1. Optimizing Pathways of Care for Medicaid Patients with Dementia Center for Health Outcomes Research and Policy Purdue Faculty: Purdue Faculty: Laura Sands, Nursing Huiping Xu, Statistics Joseph Thomas, Pharmacy Practice Bruce Craig, Statistics Indiana School of Medicine Faculty : Indiana School of Medicine Faculty : Michael Weiner Marc Rosenman Indiana Office of Medicaid Policy and Planning : Caroline Doebbeling, Emily Hancock

2. Costs of Long-term Care Annually $132 billion are spent on long- term care Medicaid and other public sources pay for half of the cost of long-term care Long-term care consumes nearly one-third of states’ Medicaid budgets

3. Dementia Patients Have Challenging Long-Term Care Needs Half of long-term care recipients have dementia. Disability, rather than a need for 24 hour medical care, drives need for long-term care among long- term care recipients with dementia Dementia is associated with complex caregiving needs - patients in the later stages of dementia require constant supervision

4. Two Most Common Forms of Long Term Care Provided by Medicaid Nursing home care: care is provided in a medically supervised institutional setting Home based long-term care: long-term services are delivered in the patients’ home, and may include: -attendant care to help with bathing, dressing, feeding, toileting and mobility -housekeeping -home delivered meals

5. Most Patients, Families and Policy Makers Prefer Home-based Long-term Care Among Indiana Medicaid recipients with dementia, expenditures for long-term care average $1,688 per month more for nursing home care than home based long-term care. Home based long-term care allows patients to receive long-term care in a familiar and comfortable environment

6. Two Goals of Home Based Long-Term Care 1) Provide services that meets patients’ needs - Unmet need for long-term care is associated higher rates of hospital admissions among those with unmet needs compared to those with met long-term care needs 2) Reduce nursing home use - The majority of patients and their families prefer home based long-term care when appropriate care can be accessed in the community How does type and amount of home based long- term care services affect these long-term care goals for Medicaid recipients with dementia?

7. Study Design Prospective Cohort Study 285 Indiana Medicaid waiver recipients with dementia receiving community-based long-term care Assessed the association between hours of personal care, homemaking services and the number of home delivered meals and time to nursing home placement and risk for hospitalization Considered how level of ADL functioning, co- morbidities and living status may affect the association

8. Volume of Services Received by Indiana Medicaid Home and Community-Based Long-term Care Recipients with Dementia Monthly Amount of Service Half received fewer than: 75% received fewer than 90% received fewer than Hours of Personal Care 43468 Hours of Homemaking Services 007 Number of Home Delivered Meals 0717

9. More Hours of Personal Care Per Week Reduces Risk for Nursing Home Placement

10. More Hours of Personal Care and Homemaking Care Reduced Risk for Nursing Home Placement Hazard Ratio P Value 95% Hazard Ratio Confidence Limits Non-white race0.780.2260.51 - 1.17 Living alone1.780.0041.20 - 2.63 Married1.060.8430.59 - 1.90 Chronic obstructive pulmonary disease0.710.1130.46 - 1.09 Number of ADL dependencies 2 to 30.730.194 0.46 - 1.17 4 to 50.860.578 0.51 - 1.46 Informal support from friends or relatives0.930.7950.51 - 1.67 Average monthly volume of attendant care in 5-hour increment 0.950.0040.92 - 0.98 Average monthly amount of homemaking in 5-hour increment 0.790.0270.65 - 0.97 Average monthly number of home delivered meals 1.000.8010.98 - 1.03

11. Hours of Personal Care is Associated with Risk for Hospitalization Hazard Ratio P value 95% Hazard Ratio Confidence Limits Male gender2.040.00031.386 - 3.002 Chronic obstructive pulmonary disease1.2110.30940.837 - 1.750 Cerebrovascular disease1.4720.03341.031 - 2.102 Renal failure2.0980.00091.357 - 3.244 Hospitalization in prior 6 months1.6240.02161.074 - 2.455 Informal help from relatives and friends0.7560.38870.401 - 1.427 Average Monthly Number of Home Delivered Meals 0.9960.73550.973 - 1.020 Average Monthly Hour of Homemaking0.980.15090.954 - 1.007 Average Monthly Hour of Attendant Care < 49 hours0.978<.00010.968 - 0.988 49 hours or above1.0120.00541.004 - 1.021

12. Hours of Personal Care Per Week is Associated with Risk for Hospitalization

13. Conclusion Greater volume of home-based community care keeps older adults out of hospitals and nursing homes. Future research should be directed towards determining best methods for developing guidelines for the amount and type of long-term care needed to optimize disabled older adults health can long-term care outcomes.