Medicare-funded home-based clinical care for community-dwelling persons with dementia: An essential healthcare delivery mechanism

Patterns of national emergency department utilization by fee-for-service Medicare beneficiaries with dementia

BACKGROUND

Individuals with Alzheimer's disease and related dementias (ADRD) often face high acute care clinical utilization and costs with unclear benefits in survival or quality of life. The emergency department (ED) is frequently the site of pivotal decisions in these acute care episodes. This study uses national Medicare data to explore this population's ED utilization.

METHODS

Retrospective cohort study of persons aged ≥66 years enrolled in traditional Medicare with a Chronic Condition Warehouse diagnosis of dementia. Primary 1-year outcome measures included ED visits with and without hospitalization, ED visits per 100 days alive, and health-care costs. A multivariate random effects regression model (clustered by county of residence), adjusted for sociodemographics and comorbidities, examined how place of care on January 1, 2018, was associated with subsequent ED utilization.

RESULTS

In 2018, 2,680,006 ADRD traditional Medicare patients (mean age 82.9, 64.2% female, 9.4% Black, 6.2% Hispanic) experienced a total of 3,234,767 ED visits. Over half (52.2%) of the cohort experienced one ED visit, 15.5% experienced three or more, and 37.1% of ED visits resulted in hospitalization. Compared with ADRD patients residing at home without services, the marginal difference in ED visits per 100 days alive varied by location of care. Highest differences were observed for those with hospitalizations (0.48 visits per 100 days alive, 95% confidence interval [CI] 0.47-0.49), skilled nursing facility (rehab/skilled nursing facility [SNF]) stays (0.27, 95% CI 0.27-0.28), home health stays (0.25, 95% CI 0.25-0.26), or observation stays (0.82, 95% CI 0.77-0.87). Similar patterns were observed with ED use without hospitalization and health-care costs.

CONCLUSIONS

Persons with ADRD frequently use the ED-particularly those with recent hospitalizations, rehab/SNF stays, or home health use-and may benefit from targeted interventions during or before the ED encounters to reduce avoidable utilization and ensure goal-concordant care.

Healthcare contact days among older adults living with dementia

BACKGROUND

For older adults with dementia and their care partners, accessing health care outside the home involves substantial time, direct and indirect costs, and other burdens. While prior studies have estimated days spent by these individuals in or out of hospitals and nursing homes, ambulatory care burdens are likely substantial yet poorly understand. Therefore, we characterized "health care contact days"-days spent receiving ambulatory or institutional care-in this population.

METHODS

We used 2019 Medicare Current Beneficiary Survey data linked to claims for community-dwelling, ≥65-year-old adults with dementia in Traditional Medicare. We measured contact days including ambulatory days (with an office visit, test, imaging, procedure, or treatment) and institutional days (spent in an emergency department, hospital, skilled nursing facility, or hospice facility). We described variation and patterns in contact days. Using multivariable Poisson regression, we identified sociodemographic and clinical factors associated with contact days.

RESULTS

In weighted analyses, 887 older adults with dementia (weighted: 2.9 million) had mean (SD) 31.1 (33.7) total contact days/year, of which 21.7 (20.6) were ambulatory. Ten percent had ≥68 contact days in the year. One-third (34%) of ambulatory contact days involved multiple services. In multivariable models, receipt of more ambulatory contact days was associated with younger age (65-74 reference vs. -32.3% [95% CI: -42.2%, -20.7%] for 85+), higher income (>200% Federal Poverty Level [FPL] reference versus -16.6% [95% CI: -26.7%, -5.0%] for ≤200% FPL), and lack of functional impairment (reference versus -14.6% [95% CI: -23.7%, -4.4%]). Each additional chronic condition was associated with 8.2% (95% CI: 6.7%, 9.8%) more ambulatory contact days.

CONCLUSIONS

Older adults with dementia spent 31 days a year accessing care which was mostly ambulatory. These days varied widely by both clinical and sociodemographic factors. These results highlight the need to reduce patient burden through strategies such as reducing unneeded care, coordinating care, and shifting care to home settings through telemedicine and home care.

Drivers of Community-Entry Home Health Care Utilization Among Older Adults

OBJECTIVES

A growing proportion of Medicare home health (HH) patients are "community-entry," meaning referred to HH without a preceding hospitalization. We sought to identify factors that predict community-entry HH use among older adults to provide foundational information regarding care needs and circumstances that may prompt community-entry HH referral.

DESIGN

Nationally representative cohort study.

SETTING AND PARTICIPANTS

Health and Retirement Study (HRS) respondents who were aged ≥65 years, community-living, and enrolled in Medicare between 2012 and 2018 (n = 11,425 unique individuals providing 27,026 two-year observation periods).

METHODS

HRS data were linked with standardized HH patient assessments. Community-entry HH utilization was defined as incurring one or more HH episode with no preceding hospitalization or institutional post-acute care stay (determined via assessment item indicating institutional care within 14 days of HH admission) within 2 years of HRS interview. Weighted, multivariable logistic regression was used to model community-entry HH use as a function of individual, social support, and community characteristics.

RESULTS

The overall rate of community-entry HH utilization across observation periods was 13.4%. Older adults had higher odds of community-entry HH use if they were Medicaid enrolled [adjusted odds ratio (aOR) = 1.49, P = .001], had fair or poor overall health (aOR = 1.48, P < .001), 3+ activities of daily living limitations (aOR = 1.47, P = .007), and had fallen in the past 2 years (aOR = 1.43, P < .001). Compared with those receiving no caregiver help, individuals were more likely to use community-entry HH if they received family or unpaid help only (aOR = 1.81, P < .001), both family and paid help (aOR = 2.79, P < .001), or paid help only (aOR: 3.46, P < .001).

CONCLUSIONS AND IMPLICATIONS

Findings indicate that community-entry HH serves a population with long-term care needs and coexisting clinical complexity, making this an important setting to provide skilled care and prevent avoidable health care utilization. Results highlight the need for ongoing monitoring of community-entry HH accessibility as this service is a key component of home-based care for a high-need subpopulation.

Place of care in the last three years of life for Medicare beneficiaries

BACKGROUND

Most older adults prefer aging in place; however, patients with advanced illness often need institutional care. Understanding place of care trajectory patterns may inform patient-centered care planning and health policy decisions. The purpose of this study was to characterize place of care trajectories during the last three years of life.

METHODS

Linked administrative, claims, and assessment data were analyzed for a 10% random sample cohort of US Medicare beneficiaries who died in 2018, aged fifty or older, and continuously enrolled in Medicare during their last five years of life. A group-based trajectory modeling approach was used to classify beneficiaries based on the proportion of days of institutional care (hospital inpatient or skilled nursing facility) and skilled home care (home health care and home hospice) used in each quarter of the last three years of life. Associations between group membership and sociodemographic and clinical predictors were evaluated.

RESULTS

The analytic cohort included 199,828 Medicare beneficiaries. Nine place of care trajectory groups were identified, which were categorized into three clusters: home, skilled home care, and institutional care. Over half (59%) of the beneficiaries were in the home cluster, spending their last three years mostly at home, with skilled home care and institutional care use concentrated in the final quarter of life. One-quarter (27%) of beneficiaries were in the skilled home care cluster, with heavy use of skilled home health care and home hospice; the remaining 14% were in the institutional cluster, with heavy use of nursing home and inpatient care. Factors associated with both the skilled home care and institutional care clusters were female sex, Black race, a diagnosis of dementia, and Medicaid insurance. Extended use of skilled home care was more prevalent in southern states, and extended institutional care was more prevalent in midwestern states.

CONCLUSIONS

This study identified distinct patterns of place of care trajectories that varied in the timing and duration of institutional and skilled home care use during the last three years of life. Clinical, socioregional, and health policy factors influenced where patients received care. Our findings can help to inform personal and societal care planning.

Care Setting Transitions for People With Dementia: Qualitative Perspectives of Current and Former Care Partners

Care partners (CP) of people with dementia (PWD) report that decisions about care setting are aided by the support of healthcare providers. However, providers are often underprepared to offer adequate counseling. This qualitative study aimed to identify what support from providers will assist CPs in making decisions related to care setting throughout the dementia journey. We conducted semi-structured interviews with current CPs of PWD and former CPs of decedents. We utilized the constant comparative method to identify themes regarding preferences around care setting as the PWD progressed from diagnosis to end-of-life. Participants were 31 CPs, including 16 current and 15 former CPs. CPs had a mean age of 67 and were primarily white (n = 23/31), female (n = 21/31), and spouses (n = 24/31). Theme 1: Current CPs discussed overwhelming uncertainty pertaining to care setting, expressing "I don't know when I need to plan on more care," and a desire to understand "what stage we are at." Theme 2: Later in the disease, former CPs wanted guidance from healthcare providers on institutional placement ("I sure would've loved some help finding better places") or support to stay in the home ("a doctor had to come to the house"). CPs want early, specific guidance from healthcare providers related to transitions between home and long-term care. Early in the disease course, counseling geared toward prognosis and expected disease course helps CPs make plans. Later, caregivers want help identifying locations or institutionalization or finding home care resources.

Home health services for minorities in urban and rural areas with Alzheimer's and related dementia

Timely access and continuum of care in older adults with Alzheimer's Disease and Related Dementia (ADRD) is critical. This is a retrospective study on Medicare fee-for-service beneficiaries with ADRD diagnosis discharged to home with home health care following an episode of acute hospitalization. Our sample included 262,525 patients. White patients in rural areas have significantly higher odds of delay (odds ratio [OR], 1.03; 95% CI, 1.01-1.06). Black patients in urban areas (OR, 1.15; 95% CI, 1.12-1.19) and Hispanic patients in urban areas also were more likely to have a delay (OR, 1.07; 95% CI, 1.03-1.11). Black and Hispanic patients residing in urban areas had a higher likelihood of delay in home healthcare initiation following hospitalization compared to Whites residing in urban areas.

Examining the role of race and quality of home health agencies in delayed initiation of home health services for individuals with Alzheimer's disease and related dementias (ADRD)

INTRODUCTION

We examined differences in the timeliness of the initiation of home health care by race and the quality of home health agencies (HHA) among patients with Alzheimer's disease and related dementias (ADRD).

METHODS

Medicare claims and home health assessment data were used for the study cohort: individuals aged ≥65 years with ADRD, and discharged from the hospital. Home health latency was defined as patients receiving home health care after 2 days following hospital discharge.

RESULTS

Of 251,887 patients with ADRD, 57% received home health within 2 days following hospital discharge. Black patients were significantly more likely to experience home health latency (odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.11-1.19) compared to White patients. Home health latency was significantly higher for Black patients in low-rating HHA (OR = 1.29, 95% CI = 1.22-1.37) compared to White patients in high-rating HHA.

DISCUSSION

Black patients are more likely to experience a delay in home health care initiation than White patients.

Use of Home-Based Clinical Care and Long-Term Services and Supports Among Homebound Older Adults

OBJECTIVES

Describe use of home-based clinical care and home-based long-term services and supports (LTSS) using a nationally representative sample of homebound older Medicare beneficiaries.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Homebound, community-dwelling fee-for-service Medicare beneficiaries participating in the 2015 National Health and Aging Trends Study (n = 974).

METHODS

Use of home-based clinical care [ie, home-based medical care, skilled home health services, other home-based care (eg, podiatry)] was identified using Medicare claims. Use of home-based LTSS (ie, assistive devices, home modification, paid care, ≥40 hours/wk of family caregiving, transportation assistance, senior housing, home-delivered meals) was identified via self or proxy report. Latent class analysis was used to characterize patterns of use of home-based clinical care and LTSS.

RESULTS

Approximately 30% of homebound participants received any home-based clinical care and about 80% received any home-based LTSS. Latent class analysis identified 3 distinct patterns of service use: class 1, High Clinical with LTSS (8.9%); class 2, Home Health Only with LTSS (44.5%); and class 3, Low Care and Services (46.6% homebound). Class 1 received extensive home-based clinical care, but their use of LTSS did not meaningfully differ from class 2. Class 3 received little home-based care of any kind.

CONCLUSIONS AND IMPLICATIONS

Although home-based clinical care and LTSS utilization was common among the homebound, no single group received high levels of all care types. Many who likely need and could benefit from such services do not receive home-based support. Additional work focused on better understanding potential barriers to accessing these services and integrating home-based clinical care services with LTSS is needed.

Dementia's Unique Burden: Function and Health Care in the Last 4 Years of Life

BACKGROUND

Dementia is a terminal illness marked by progressive cognitive decline. This study characterized trajectories of functional status and health care use for people with and without dementia at the end of their life.

METHODS

We used the Health and Retirement Study linked with Medicare claims to generate a series of generalized linear models. Models predicted functional status and health care use for decedents with and without dementia during each month in the last 4 years of life (48 months).

RESULTS

People with dementia have high, sustained functional impairments during the entire last 4 years of life. People with dementia have the same predicted average activities of daily living score (1.92) at 17 months before death (95% confidence interval [CI]: 1.857, 1.989) as individuals without dementia at 6 months before death (95% CI: 1.842, 1.991). Dementia was associated with significantly less hospice during the final 3 months of life, with a 12.5% (95% CI: 11.046, 13.906) likelihood of hospice in the last month of life with dementia versus 17.3% (95% CI: 15.573, 18.982) without dementia. Dementia was also associated with less durable medical equipment (p < .001), less home health care (p < .005), and fewer office visits (p < .001). There were not significant differences in likelihood of hospitalization in the last 48 months with or without dementia.

CONCLUSIONS

People with dementia can functionally appear to be at end of life (EOL) for years before their death. Simultaneously, they receive less health care, particularly home health and hospice, in their last months. Models of care that target people with dementia should consider the unique and sustained burden of dementia at EOL.

Prevalence of use and characteristics of users of home-based medical care in Medicare Advantage

BACKGROUND/OBJECTIVES

Home-based medical care (HBMC) is longitudinal medical care provided by physicians, advanced practice providers, and, often, inter-professional care teams to patients in their homes. Our objective is to determine the prevalence of HBMC among older adults (≥65) insured by a Medicare Advantage (MA) plan and compare characteristics of those who receive HBMC to those who do not.

METHODS

Study used de-identified medical claims and enrollment records for MA beneficiaries during calendar years 2017 and 2018 linked with socioeconomic status data in the OptumLabs Data Warehouse. We defined a cohort of MA beneficiaries age ≥65 receiving HBMC for at least 2 months during 2017-2018, described the cohort using demographic, utilization, and comorbidity data and compared it to a 5% random sample of a population of MA beneficiaries age ≥65 not receiving HBMC (No HBMC).

RESULTS

Overall, 1.45% of the study cohort age ≥65 received HBMC. Compared to No HBMC (n = 132,147), those receiving HBMC (n = 38,800) were more likely to be: older (46.6% vs. 11.9% age 85+); female (70.8% vs. 58.5%); Black (12.3% vs. 11.3%); urban (90.3% vs. 81.3%); experience hospitalization (38.0% vs. 13.3%), emergency department visit (58.3% vs. 26.9%), ambulance trip (44.1% vs. 9.6%), skilled nursing facility (37.6% vs. 6.4%), or hospice care admission (21.1% vs. 3.5%). They also were more likely to experience a wide range of chronic conditions including dementia (58.1% vs. 5.2%), morbidity burden (Charlson score 3.4 vs. 1.8), and serious illness (77.1% vs. 29.5%). All comparisons p < 0.0001.

CONCLUSIONS

MA beneficiaries who received HBMC are older, experience greater chronic and serious illness burden, and higher levels of facility-based care than those who did not receive HBMC. MA plans need strategies to identify patients that would benefit from HBMC and develop approaches to deliver such care to this impactful, often invisible population.

Care disruptions among the homebound during the COVID-19 pandemic: An analysis of the role of dementia

INTRODUCTION

Seriously ill people with dementia living at home may be particularly vulnerable to disruptions in their care during times of crisis. The study sought to describe care experiences of those receiving home-based primary care in New York City during the COVID-19 pandemic and compare the experiences of people with and without dementia.

METHODS

We conducted a retrospective review of all electronic medical record notes between March 1, 2020 and December 30, 2020 among a sample of home-based primary care recipients (n = 228), including all deaths that occurred in the spring of 2020. Drawing from administrative records and using an abstraction tool that included both structured (e.g., documented COVID-19 exposure) and unstructured (e.g., text passage describing caregiver burden) data, we identified salient COVID-19 related care experiences and identified and categorized major disruptions in care.

RESULTS

Both people with and without dementia experienced significant disruptions of paid caregiving, family caregiving, and home-based services during the COVID-19 pandemic. While the paid caregivers of people with dementia reported more burden to the home-based primary care team as compared to people without dementia, we found little evidence of differences in quantity or type of COVID-19 related disruptions relative to dementia status.

DISCUSSION

While those with dementia have distinct care needs, our findings emphasize the way that dementia may be one piece of a larger clinical picture of serious illness. In order to support all patients with high care needs in crisis, we need to understand the interdependence of clinical care, long-term care, and family caregiving support for older adults and view dementia within the larger context of serious illness and care need.

“I Didn’t Sign Up for This”: Perspectives from Persons Living with Dementia and Care Partners on Challenges, Supports, and Opportunities to Add Geriatric Neuropalliative Care to Dementia Specialty Care

Background: In the United States, dementia specialty centers affiliated with centers of excellence for research hold promise as locations to develop innovative, holistic care in care systems otherwise siloed by discipline or payer. Objective: We conducted foundational research to inform development of patient-and family-centered palliative care interventions for dementia specialty centers. Methods: We interviewed persons living with dementia (PLWD), current, and former care partners (CP) recruited from a specialty dementia clinic and purposively selected for variation across disease syndrome and stage. A framework method of thematic analysis included coding, analytic matrices, and pattern mapping. Results: 40 participants included 9 PLWD, 16 current CPs, and 15 former CPs of decedents; 48% impacted by Alzheimer’s disease dementia. While help from family, support groups and adult day centers, paid caregiving, and sensitive clinical care were invaluable to PLWD, CPs, or both, these supports were insufficient to navigate the extensive challenges. Disease-oriented sources of distress included symptoms, functional impairment and falls, uncertainty and loss, and inaccessible care. Social and relational challenges included constrained personal and professional opportunities. The obligation and toll of giving or receiving caregiving were challenging. Clinical care challenges for PLWD and/or CPs included care fragmentation, insufficient guidance to inform planning and need for expert interdisciplinary clinical care at home. Conclusion: Findings highlight the breadth and gravity of gaps, which surpass the disciplinary focus of either behavioral neurology or palliative care alone. Results can inform the development of novel interventions to add principles of geriatrics and neuropalliative care to dementia care.

Predicting Hospice Transitions in Dementia Caregiving Dyads: An Exploratory Machine Learning Approach

Background and Objectives

Hospice programs assist people with serious illness and their caregivers with aging in place, avoiding unnecessary hospitalizations, and remaining at home through the end-of-life. While evidence is emerging of the myriad of factors influencing end-of-life care transitions among persons living with dementia, current research is primarily cross- sectional and does not account for the effect that changes over time have on hospice care uptake, access, and equity within dyads.

Research Design and Methods

Secondary data analysis linking the National Health and Aging Trends Study to the National Study of Caregiving investigating important social determinants of health and quality-of-life factors of persons living with dementia and their primary caregivers (n = 117) on hospice utilization over 3 years (2015-2018). We employ cutting-edge machine learning approaches (correlation matrix analysis, principal component analysis, random forest [RF], and information gain ratio [IGR]).

Results

IGR indicators of hospice use include persons living with dementia having diabetes, a regular physician, a good memory rating, not relying on food stamps, not having chewing or swallowing problems, and whether health prevents them from enjoying life (accuracy = 0.685; sensitivity = 0.824; specificity = 0.537; area under the curve (AUC) = 0.743). RF indicates primary caregivers' age, and the person living with dementia's income, census division, number of days help provided by caregiver per month, and whether health prevents them from enjoying life predicts hospice use (accuracy = 0.624; sensitivity = 0.713; specificity = 0.557; AUC = 0.703).

Discussion and Implications

Our exploratory models create a starting point for the future development of precision health approaches that may be integrated into learning health systems that prompt providers with actionable information about who may benefit from discussions around serious illness goals-for-care. Future work is necessary to investigate those not considered in this study-that is, persons living with dementia who do not use hospice care so additional insights can be gathered around barriers to care.

Life expectancy for community-dwelling persons with dementia and severe disability

BACKGROUND

Understanding life expectancy can help persons with dementia, their care partners, and policymakers plan for what lies ahead. We sought to determine life expectancy and predictors of mortality for community-dwelling persons with dementia and severe disability.

METHODS

Using the National Health and Aging Trends Study (NHATS) linked to Medicare claims, we identified community-dwelling respondents age 65+ who entered NHATS in 2011 with dementia and severe disability (defined as three impairments in activities of daily living), or who subsequently met criteria for dementia and then severe disability. We estimated time to death based on the timing of meeting severe disability criteria. We conducted parametric survival analyses using a Gompertz distribution to calculate risk of death and predicted median time to death. Predictors included demographic, functional, clinical characteristics, and behavioral symptoms (assessed among NHATS respondents with proxy interviews).

RESULTS

Among 842 community-dwelling persons with dementia and severe disability, 80.5% died during the study period. After adjusting for age and gender, overall predicted median time to death was 1.7 years (25th percentile 0.6, 75th percentile 3.8 years). Six notable characteristics were associated with shorter life expectancy: 1) older age (90+), with a predicted median time to death of 1.0 year (0.4, 2.1); 2) being bedbound, 1.1 years (0.4, 2.3); 3) being homebound, 1.2 years (0.5, 2.6); 4) having comorbid cancer, 1.2 years (0.5, 2.6); 5) unintended weight loss, 1.4 years (0.5, 3.1); and 6) comorbid depression, 1.5 years (0.6, 3.3).

CONCLUSIONS

Community-dwelling persons with dementia and severe disability lived a median of 1.7 years. Clinicians can use the study findings to provide anticipatory guidance to patients and care partners, and policymakers to inform design of longitudinal supportive services.