Seniors Moved from Nursing Homes to Home, Community Care Suffer
Long-term care at home meets desires of older
patients and can save Medicaid money
Feb. 12, 2014 What looks like a win-win for
everyone senior citizens and the Centers for Medicare & Medicaid
Services is not turning out that way, according to a new study in the
online Journal of the American Geriatrics Society. The seniors
want to age at home, rather than in nursing homes, which can save money
for Medicaid. The problem the study found was that as these older people
eligible for Medicaid and Medicare were moved into community care
there was a 40 percent greater risk of "potentially preventable"
"We are trying to move people into the community
and I think that is a really great goal, but we aren't necessarily
providing the medical support services that are needed in the
community," said Andrea Wysocki, a postdoctoral scholar in the Brown
University School of Public Health and lead author of the study.
"One of the policy issues is how do we care for not
only the long-term care needs when we move someone into home- and
community-based settings but also how do we support their medical needs
Wysocki said her finding of a higher potentially
preventable hospitalization risk for seniors who transitioned to
community- or home-based care suggests that some medical needs are not
as well addressed in community settings as they are in nursing homes.
More vigilant and effective treatment for chronic, already-diagnosed
ailments such as chronic obstructive pulmonary disease could prevent
some of the hospitalizations that occur.
There are two likely reasons why care in home and
community settings is not as effective in preventing hospitalizations,
>> Nursing homes provide round-the-clock care by
trained nurses and doctors, but workers with much less medical training
provide community- and home-care services.
>> In addition, while Medicaid pays for long-term
care, Medicare pays for medical care, meaning that Medicaid programs do
not have a built-in financial incentive to prevent hospitalizations.
Home- and community-based care is less expensive for Medicaid regardless
of the medical outcome.
Wysocki performed the analysis for her doctoral
thesis work at the University of Minnesota. She and her co-authors
looked at a set of records provided by the Centers for Medicare and
Medicaid Services of thousands of dually eligible seniors from Arkansas,
Florida, Minnesota, New Mexico, Texas, Vermont, and Washington who
entered nursing homes between 2003 and 2005.
Based on those records, Wysocki and her team
determined who made the transition to community and home care and who
stayed in the nursing home. Accounting for a wide variety of demographic
and medical factors, they then compared the rate of hospitalizations
among 1,169 seniors who transitioned to the community ("transitioners")
and 1,169 otherwise similar seniors who stayed in the nursing home ("stayers").
What Wysocki observed was that 133 transitioners
ended up hospitalized for potentially preventable reasons, while only
113 stayers did. Including "non-preventable" hospitalizations, the
numbers rose to 419 among transitioners and 297 among stayers.
Those raw numbers don't quite tell the whole story
in comparing overall hospitalization risk, however, because seniors in
the stayers group also generally took a longer time to reach that first
hospitalization than seniors in the transitioners group. Using a
standard statistical technique to account for the time difference,
Wysocki found that transitioners faced a 40-percent greater risk of
enduring a potentially preventable hospitalization and a 58-percent
greater risk of any kind of hospitalization than the stayers did.
Making care less fragmented
The study, published Jan. 2, 2014, concludes with a
clear recommendation: "Ensuring that an individual has long-term care
and medical providers and a care plan at the time of transition may keep
them out of the hospital and result in more successful long-term
Whether that happens is ultimately up to the
payers, Medicaid and Medicare. Wysocki said demonstration programs in
which the two programs work in concert, rather than separately to
address the issue are underway and merit watching.
In addition to Wysocki, the paper's other authors
are Dr. Robert Kane, Bryan Dowd, Ezra Golberstein, and Tetyana Shippee
of the University of Minnesota School of Public Health, and Terry Lum of
the University of Hong Kong.
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