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Multicenter Study
. 2019 Jul;67(7):1495-1501.
doi: 10.1111/jgs.15968. Epub 2019 May 10.

Integrated Home- and Community-Based Services Improve Community Survival Among Independence at Home Medicare Beneficiaries Without Increasing Medicaid Costs

Girish Valluru  1 , Jean Yudin  2   3 , Christine L Patterson  4 , Joanna Kubisiak  5 , Peter Boling  4   3 , George Taler  3   6   7 , Karl Eric De Jonge  3   6   7 , Steve Touzell  8 , Ann Danish  8 , Katherine Ornstein  9 , Bruce Kinosian  2   3   10   11   12
Affiliations
Multicenter Study

Integrated Home- and Community-Based Services Improve Community Survival Among Independence at Home Medicare Beneficiaries Without Increasing Medicaid Costs

Girish Valluru et al. J Am Geriatr Soc. 2019 Jul.

Abstract

Objectives: To determine the effect of home-based primary care (HBPC) for frail older adults, operating under Independence at Home (IAH) incentive alignment on long-term institutionalization (LTI).

Design: Case-cohort study using HBPC site, Medicare administrative data, and National Health and Aging Trends Study (NHATS) benchmarks.

Setting: Three IAH-participating HBPC sites in Philadelphia, PA, Richmond, VA, and Washington, DC.

Participants: HBPC integrated with long-term services and supports (LTSS) cases (n = 721) and concurrent comparison groups (HBPC not integrated with LTSS: n = 82; no HBPC: n = 573). Cases were eligible if enrolled at one of the three HBPC sites from 2012 to 2015. Independence at Home-qualified (IAH-Q) concurrent comparison groups were selected from Philadelphia, PA; Richmond, VA; and Washington, DC.

Intervention: HBPC integrated with LTSS under IAH demonstration incentives.

Measurements: Measurements include LTI rate and mortality rates, community survival, and LTSS costs.

Results: The LTI rate in the three HBPC programs (8%) was less than that of both concurrent comparison groups (IAH-Q beneficiaries not receiving HBPC, 16%; patients receiving HBPC but not in the IAH demonstration practices, 18%). LTI for patients at each HBPC site declined over the three study years (9.9%, 9.4%, and 4.9%, respectively). Costs of home- and community-based services (HCBS) were nonsignificantly lower among integrated care patients ($2151/mo; observed-to-expected ratio = .88 [.68-1.09]). LTI-free survival in the IAH HBPC group was 85% at 36 months, extending average community residence by 12.8 months compared with IAH-q participants in NHATS.

Conclusion: HBPC integrated with long-term support services delays LTI in frail, medically complex Medicare beneficiaries without increasing HCBS costs.

Keywords: community survival; home- and community-based care; independence at home; provider managed care.

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Conflict of interest statement

Conflicts of Interest: All authors except Katherine Ornstein, Joanna Kubisiak, and Girish Valluru are employed by organizations involved in the study. George Taler, Peter Boling, and Bruce Kinosian are faculty members at the Independence at Home Learning Collaborative. Bruce Kinosian is treasurer of the American Academy of Home Care Medicine (AAHCM); George Taler and Jean Yudin are members of the Public Policy Committee of the AAHCM. Bruce Kinosian is chair of the Clinical and Operational Data Analysis Committee of the National PACE Association.

Figures

Figure 1.
Figure 1.
(A) Comparison of long-term institutionalization (LTI) rates among Mid-Atlantic Consortium (MAC) Independence at Home (IAH) patients (54 with LTI exit) and 455 IAH -qualified (IAH-Q) National Health and Aging Trends Study (NHATS) respondents (74 with LTI exit), conditional on survival. MAC IAH patients had their community exit due to LTI delayed on average by 12.8 months. (B) Patient survival in the community, conditional on survival. MAC IAH patients (blue) compared with IAH-Q NHATS respondents (orange) with LTI or death as competing risks. The 721 MAC IAH patients had 61.3% of their potential days alive in the community, compared with the national IAH-Q NHATS cohort (56.8%), or 34 925 extra days (equivalent to 95 person-years).
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References

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