Home Health Produces Worse Outcomes for Sicker Seniors Than Skilled Nursing

While governments and payers increasingly incentivize the provision of long-term care at home instead of in skilled nursing facilities, data about outcomes remains few and far between — with one group of researchers finding that some high-acuity patients fare worse in the community setting.

Based on 2012 claims data, a team from the University of Chicago determined that dual-eligible seniors with dementia in the home had higher rates of hospitalization than those who had received care in an institutional setting, such as a nursing home.

“Thus, among sicker people — those with dementia — home and community-based services were associated with worse outcomes than nursing facility care,” the researchers wrote in a study published this week in the July issue of the journal Health Affairs.


That trend was reversed for relatively healthier patients, the team noted, though on the whole, the rate of hospitalizations — a key marker of resident outcomes — was largely consistent across settings.

“Beneficiaries who used either institutional services or HCBS alone had similar rates of overall hospitalizations and potentially avoidable hospitalizations, even though institutional service users tended to be older, have more chronic conditions, and have higher mortality rates,” researchers Rebecca Gorges, Prachi Sanghavi, and R. Tamara Konetzka wrote.

In addition, the researchers observed certain discrepancies based on the race and ethnicity of the seniors studied, all of whom qualified for both Medicare and Medicaid coverage. For instance, among people both with and without dementia, black seniors had the highest rates of hospitalizations among those who received care in the community, while spending was greatest for non-Hispanic whites.


The upshot, in the academics’ view, isn’t that one setting is objectively better or worse; rather, the team argues that the relative dearth of solid data on the differences between in-home and institutional care

“These results have several policy implications. First, the high rates of hospitalizations among users of only home and community-based services suggest that outcomes of HCBS need additional scrutiny, especially for members of racial/ethnic minority groups and people with serious health issues such as dementia,” the team noted.

The efficacy of home care as a replacement for SNF services remains hotly contested in the industry, with a variety of initiatives designed to send residents home — or bypass the skilled nursing facility entirely. New York State, for instance, recently offered $27 million to organizations that identify nursing home residents who could shift to the community setting, while Medicare Advantage plans and bundled payment programs have routinely attempted to reduce health care costs by clamping down on lengths of stay at nursing homes.

But George Hager, CEO of national nursing home chain Genesis HealthCare (NYSE: GEN), has repeatedly insisted that health plans and government payers have moved as many people as possible into the home setting, challenging people to go into any of his facilities and identify people who could safely receive care at home.

“I think those things have reached a point of equilibrium, and that we’re beginning to see some marginal growth in total census,” Hager said earlier this year. “I’m less concerned about migration out of our setting or diversion away from our setting.”

While calling for more research, the University of Chicago team concluded that strong access to all types of care will be necessary to ensure quality outcomes for seniors.

“The high rates of institutional service use among elderly, dual-eligible beneficiaries with dementia suggest that institutional care may be required or even preferred by some beneficiaries and their families because of high needs for intensive long-term care that might not be met in the home setting,” they wrote. “Even as HCBS options are expanded, the need for access to high-quality nursing facilities should remain on the agenda as policy makers consider ways to improve the long-term care options available to Medicaid beneficiaries.”

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