Impact of HCBS Spending on Nursing Home Admissions for 1915(c) Waiver Enrollees

We examined whether higher levels of Medicaid Home and Community Based Services (HCBS) spending were associated with: 1) lower risk of long-term NH admission and 2) higher functional/cognitive impairment at admission.

Methods

The Medicaid Analytic Extract Personal Summary File (24 states) and the NH Minimum Dataset were merged at the beneficiary level.

Individual-level outcomes of interest were time from HCBS waiver enrollment to long-term (90+ days) NH admission, functional (29 point Activities of Daily Living [ADL]) and cognitive (7 point Cognitive Performance Scale [CPS]) impairment at admission. An overall measure of impairment was also created and categorized as low (ADL<17 and CPS<3) vs other states.

Key independent variable was state-level average monthly HCBS spending per waiver enrollee, adjusted using area wage index. Individual, county, and state-level covariates were included.

We employed proportional hazards regressions with county clustering, mixed models with county random effects, and logit models with county random effects.

158,358 dual-eligible beneficiaries, age 65+, who entered 1915(c) aged or aged and disabled waiver programs in 24 states April 2005 - December 2007, were followed through 2009. 27,692 experienced subsequent long-term NH admission.

Results

An additional $1000 per month in average HCBS spending on waiver enrollees was associated with a 12% lower risk of long term NH admission (p=0.01), 0.91 higher functional impairment at admission (p<0.0001), and 15% lower odds of having overall low impairment at admission (p=0.001).

Higher per enrollee HCBS spending for waiver enrollees is associated with lower risk of, and greater impairment at, long-term NH admission.