Dataset Information

Occupational Therapy in Medicaid Home and Community-Based Services Waivers.

ABSTRACT: Medicaid Home and Community-Based Services (HCBS) 1915(c) waivers are the largest provider of long-term services and supports for people with intellectual and developmental disabilities (IDDs). In this study, we explored how HCBS IDD waivers projected providing occupational therapy services in Fiscal Year (FY) 2015.Medicaid HCBS IDD waivers across the nation gathered from the Centers for Medicare and Medicaid Services were qualitatively and quantitatively analyzed to determine how they projected providing occupational therapy services in terms of service expenditures and utilization.In FY 2015, $14.13 million of spending was projected for occupational therapy services of 7,500 participants. However, there was large heterogeneity across states and services in terms of total projected spending, spending per participant, and reimbursement rates.Comparisons across states strengthen the profession's ability to assert the value of its services. These findings can help identify best practices and can advocate for the refinement of state occupational therapy programs.

SUBMITTER: Friedman C

PROVIDER: S-EPMC5807402 | biostudies-literature | 2018 Mar/Apr

REPOSITORIES: biostudies-literature

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Occupational Therapy in Medicaid Home and Community-Based Services Waivers.

Friedman Carli C VanPuymbrouck Laura L

The American journal of occupational therapy : official publication of the American Occupational Therapy Association 20180301 2

<h4>Objective</h4>Medicaid Home and Community-Based Services (HCBS) 1915(c) waivers are the largest provider of long-term services and supports for people with intellectual and developmental disabilities (IDDs). In this study, we explored how HCBS IDD waivers projected providing occupational therapy services in Fiscal Year (FY) 2015.<h4>Method</h4>Medicaid HCBS IDD waivers across the nation gathered from the Centers for Medicare and Medicaid Services were qualitatively and quantitatively analyze ...[more]

PMID: 29426389

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Project description:ObjectiveTo provide the first plausibly causal national estimates of health outcomes for older dual-eligible recipients of Medicaid HCBS relative to nursing home care and to explore possible mechanisms for the effect.Data sourcesWe use 2005 and 2012 Medicaid Analytic eXtract (MAX), a national compilation of Medicaid claims, merged with Medicare claims to identify hospital admissions, our main outcome variable.Study designWe model the effects of HCBS using a longitudinal instrumental variables framework. To address the endogeneity of HCBS receipt, we instrument for it using the county percentage of nonelderly long-term care users who receive HCBS. The percentage of nonelderly users is highly predictive of HCBS use for an elderly beneficiary, but because the instrument was derived from a separate population, the exclusion restriction is unlikely to be violated.Population studied1,312,498 older adults (65+) dually enrolled in Medicaid and Medicare and are using long-term care. We also examine heterogeneity of effects by race/ethnicity and the presence of dementia.Principal findingsHCBS users have 10 percentage points higher (P < .01) annual rates of hospitalization than their nursing home counterparts when selection bias is addressed; rates of potentially avoidable hospitalizations are 3 percentage points higher (P < .01). These differences persist across races, dementia status, and intensity of HCBS spending.ConclusionsShifting Medicaid long-term care funding for older adults from nursing homes to HCBS, while well-motivated, results in the unintended consequence of substantially higher hospitalization rates for older dual eligibles. The quality and/or quantity of services may be inadequate for some HCBS recipients. Hospitalizations are costly to Medicare but also to the HCBS recipient in terms of stress and risks. Although consumer preferences to remain at home may outweigh poor outcomes of HCBS, the full costs and benefits need to be considered. HCBS outcomes-not just expansion-need more attention.

Project description:ObjectiveMedicaid-funded long-term services and supports are increasingly provided through home- and community-based services (HCBS) to promote continued community living. While an emerging body of evidence examines the direct benefits and costs of HCBS, there may also be unexplored synergies with Medicare-funded post-acute care (PAC). This study aimed to provide empirical evidence on how the use of Medicaid HCBS influences Medicare PAC utilization among the dually enrolled.Data sourcesNational Medicare claims, Medicaid claims, nursing home assessment data, and home health assessment data from 2016 to 2018.Study designWe estimated the relationship between prior Medicaid HCBS use and PAC (skilled nursing facilities [SNF] or home health) utilization in a national sample of duals with qualifying index hospitalizations. We used inverse probability weights to create balanced samples on observed characteristics and estimated multivariable regression with hospital fixed effects and extensive controls. We also conducted stratified analyses for key subgroups.Data extraction methodsThe primary sample included 887,598 hospital discharges from community-dwelling duals who had an eligible index hospitalization between April 1, 2016, and September 30, 2018.Principal findingsWe found HCBS use was associated with a 9 percentage-point increase in the use of home health relative to SNF, conditional on using PAC, and a meaningful reduction in length of stay for those using SNF. In addition, in our primary sample, we found HCBS use to be associated with an overall increase in PAC use, given that the absolute increase in home health use was larger than the absolute decrease in SNF use. In other words, the use of Medicaid-funded HCBS was associated with a shift in Medicare-funded PAC use toward home-based settings.ConclusionOur findings indicate potential synergies between Medicaid-funded HCBS and increased use of home-based PAC, suggesting policymakers should cautiously consider these dynamics in HCBS expansion efforts.

Project description:ImportanceNew York State's Medicaid managed long-term care (MLTC) program expanded access to home- and community-based services, providing an alternative to nursing home care for people with dementia. Between 2012 and 2015, the state implemented mandatory MLTC for dual Medicare and Medicaid enrollees requiring more than 120 days of community-based long-term care.ObjectiveTo evaluate changes in nursing home use among older adults with dementia following MLTC implementation.Design, setting, and participantsThis cohort study used longitudinal data from January 1, 2011, to December 31, 2019, from the Minimum Data Set and Medicare administrative data. The study sample included New York State Medicare beneficiaries 65 years and older with dementia. New York City residents were excluded due to insufficient pre-study period data. Data were analyzed from January 1, 2011, to December 31, 2019.ExposureMandatory MLTC enrollment.Main outcomes and measuresLongitudinal models were used to evaluate changes in annual days of nursing home use following the staggered implementation of MLTC across 13 regions of the state. Two models were estimated: (1) a logistic regression model for any nursing home use in a given year and (2) a linear regression model of total nursing home days, conditional on any nursing home use. Models included annual event-time indicators specified as years until or since MLTC implementation. To capture MLTC effects for dual enrollees relative to non-dual Medicare enrollees, models included interaction terms for dual enrollment and event-time indicators.ResultsThis sample included 463 947 Medicare beneficiaries with dementia who lived in New York State between 2011 and 2019 (50.2% younger than 85 years; 64.4% women). Implementation of MLTC was associated with lower odds of nursing home use among dual enrollees, ranging from 8% lower odds 2 years post implementation (adjusted odds ratio, 0.92 [95% CI, 0.86-0.98]) to 24% lower odds 6 years post implementation (adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]). Compared with a scenario of no MLTC, MLTC implementation was associated with an 8% reduction in annual days of nursing home use between 2013 and 2019 (mean, -5.6 [95% CI, -6.1 to -5.1] days per year).Conclusions and relevanceThe findings of this cohort study suggest that implementation of mandatory MLTC in New York State was associated with less nursing home use among dual enrollees with dementia and that MLTC may help prevent or delay nursing home placement among older adults with dementia.

Project description:BackgroundIdentify the association between specific combinations of home and community-based services (HCBS) and risk of acute hospitalization.MethodsData for this study came from Pennsylvania Medicaid claims and Medicare records. This was a retrospective, observational cohort study that examined hospitalization, HCBS service use and patient characteristics between July, 2014 and December, 2016. This analysis compared risk of inpatient hospitalization risk for community dwelling disabled older adults using a range of Medicaid financed HCBS. Twelve constellations of HCBS were identified representing different combinations of common services (personal assistive services [PAS], delivered meals, and adult day care). Since HCBS users are not randomly assigned to different combinations of services, we used logistic regression to estimate the predicted probability of experiencing hospitalization conditional on the constellation of services, and adjusting for demographics, health and level of disability.ResultsThe most common constellation was people who used under four hours of PAS per person per day. This group experienced a hospitalization rate of 13.7%. however, those individuals receiving more than 4 h per person per day experienced only a 10.2% hospitalization rate. Similar trends were seen for people who used PAS in combination with home delivered meals. However, those who used adult day care experienced higher hospitalization rates as the number of hours of personal assistive service increased: increasing from 6.8% among those with under 4 h, to 8.6% among those with 8 or more hours per person per day.ConclusionUsing medium and high levels of PAS was associated with lower hospitalization risk for people who PAS alone or in combination with delivered meals. By contrast, higher levels of PAS was associated with increased hospitalization for adult day users (both alone or in combination). Policy makers should consider offering higher levels of PAS to offset potential risk of hospitalization. Future research is needed to explain the association between adult day care and risk.

Dataset Information

Occupational Therapy in Medicaid Home and Community-Based Services Waivers.

Publications

Occupational Therapy in Medicaid Home and Community-Based Services Waivers.

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