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This study examines the relationship between two state Medicaid home and community-based services (HCBS) policies - number of beneficiaries (Participation) and use per beneficiary (Intensity) - and individual health expenditures. Data include the 2008-2013 Medicare Current Beneficiary Survey and state-level Medicaid HCBS indicators. Two-part generalized linear models are estimated for health expenditures by payer and dual-eligibility status. The likelihood and level of Medicare expenditures are significantly lower in states in the top quartile of Participation and Intensity. Findings suggest that state Medicaid HCBS policies may impact health expenditures, with potential spillover effects on Medicare spending.

Population aging and policies to redirect long-term care toward home- and community-based services have led to increases in Medicaid home care spending in most states. Changes in state Medicaid home care policy generosity may result from changes in the number of persons served (i.e., Participation) and/or changes in quantities of services covered (i.e., Intensity). This study measures state Medicaid home care Participation and Intensity comprehensively using latent variables, and uses those latent variables to describe changes in Medicaid home care policy generosity over time and across states. Yearly state-level data from the Medicaid Statistical Information System (1999-2012) are analyzed using exploratory and confirmatory factor analyses. Between 1999 and 2012, 29 states expanded both Participation and Intensity, whereas six states reduced both. In the remaining states, a trade-off occurred. Distinguishing between Medicaid home care Participation and Intensity deserves attention, as expansions along these two dimensions represent potentially different implications for beneficiaries.

Objective: To determine whether Medicaid home care spending reduces the proportion of the disabled elderly population who do not get help with personal care., Data Sources: Data on Medicaid home care spending per poor elderly person in each state is merged with data from the Medicare Current Beneficiary Survey for 1992, 1996, and 2000. The sample (n=6,067) includes elderly persons living in the community who have at least one limitation in activities of daily living (ADLs)., Study Design: Using a repeated cross-section analysis, the probability of not getting help with an ADL is estimated as a function of Medicaid home care spending, individual income, interactions between income and spending, and a set of individual characteristics. Because Medicaid home care spending is targeted at the low-income population, it is not expected to affect the population with higher incomes. We exploit this difference by using higher-income groups as comparison groups to assess whether unobserved state characteristics bias the estimates., Principal Findings: Among the low-income disabled elderly, the probability of not receiving help with an ADL limitation is about 10 percentage points lower in states in the top quartile of per capita Medicaid home care spending than in other states. No such association is observed in higher-income groups. These results are robust to a set of sensitivity analyses of the methods., Conclusion: These findings should reassure state and federal policymakers considering expanding Medicaid home care programs that they do deliver services to low-income people with long-term care needs and reduce the percent of those who are not getting help.

Context: Although home-based health care has grown over the past decade, its effectiveness remains controversial. A prior trial of Veterans Affairs (VA) Team-Managed Home-Based Primary Care (TM/HBPC) found favorable outcomes, but the replicability of the model and generalizability of the findings are unknown., Objectives: To assess the impact of TM/HBPC on functional status, health-related quality of life (HR-QoL), satisfaction with care, and cost of care., Design and Setting: Multisite randomized controlled trial conducted from October 1994 to September 1998 in 16 VA medical centers with HBPC programs., Participants: A total of 1966 patients with a mean age of 70 years who had 2 or more activities of daily living impairments or a terminal illness, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD). Intervention Home-based primary care (n=981), including a primary care manager, 24-hour contact for patients, prior approval of hospital readmissions, and HBPC team participation in discharge planning, vs customary VA and private sector care (n=985)., Main Outcome Measures: Patient functional status, patient and caregiver HR-QoL and satisfaction, caregiver burden, hospital readmissions, and costs over 12 months., Results: Functional status as assessed by the Barthel Index did not differ for terminal (P=.40) or nonterminal (those with severe disability or who had CHF or COPD) (P=.17) patients by treatment group. Significant improvements were seen in terminal TM/HBPC patients in HR-QoL scales of emotional role function, social function, bodily pain, mental health, vitality, and general health. Team-Managed HBPC nonterminal patients had significant increases of 5 to 10 points in 5 of 6 satisfaction with care scales. The caregivers of terminal patients in the TM/HBPC group improved significantly in HR-QoL measures except for vitality and general health. Caregivers of nonterminal patients improved significantly in QoL measures and reported reduced caregiver burden (P=.008). Team-Managed HBPC patients with severe disability experienced a 22% relative decrease (0.7 readmissions/patient for TM/HBPC group vs 0.9 readmissions/patient for control group) in hospital readmissions (P=.03) at 6 months that was not sustained at 12 months. Total mean per person costs were 6.8% higher in the TM/HBPC group at 6 months ($19190 vs $17971) and 12.1% higher at 12 months ($31401 vs $28008)., Conclusions: The TM/HBPC intervention improved most HR-QoL measures among terminally ill patients and satisfaction among non-terminally ill patients. It improved caregiver HR-QoL, satisfaction with care, and caregiver burden and reduced hospital readmissions at 6 months, but it did not substitute for other forms of care. The higher costs of TM/HBPC should be weighed against these benefits.

Objectives: To examine the role of physicians in the Veteran Affairs (VA) home-based primary care (HBPC) program and to identify variables that predict whether physicians make home visits and volume of home visits made., Design: Descriptive and regression analyses of responses from a mail survey., Participants: Forty-five physicians affiliated with VA HBPC programs. MAIN SURVEY TOPICS: Self-reported work load, attitudes toward home care, reasons for home visits, administrative policies regarding physicians' role in patient care management, and time commitment to home care., Results: A majority of physicians believed strongly in the importance of home care and made home visits for reasons consistent with their training. Physician attitude toward home care and preoccupation with office or hospital practice were related to whether or not physicians made home visits. Degree of preoccupation with office practice and amount of salary support from VA HBPC were significant predictors of the number of visits made (R2 = 0.44)., Conclusions: These findings indicate that most physicians will make home visits if they believe that home care is valuable and if their time commitment is supported financially. Managed care plans that own and operate home care programs and have the capacity to transfer primary care management to physicians who derive financial support from the programs should find this information particularly relevant.

Objectives: This study examines home medical equipment (HME) receipt for 1,040 veterans considered appropriate for home health services., Methods: HME receipt was monitored for 12 months using the Department of Veterans Affairs' Prosthetics database., Results: Eighty-three percent received at least one item; averaging 7.4 items (SD = 6.8). The most common items included commodes/bath benches (9%), canes/walkers (7%), safety equipment (7%), liquid oxygen (6%), and wheelchairs (6%). Two functional status variables, home care use and race, correctly classified 69% of HME recipients. Logistic regressions were run for specific equipment; c-indices ranged from .64 to .75. Age, race, income, functional status, risk of hospital readmission, and home care use were significant predictors., Discussion: HME accounted for $4.5 billion in sales (16% of total) for medical products in 1996. As the HME market continues to expand, the characteristics of HME recipients are necessary to project future HME needs in a growing, elderly population.

Additional analyses were conducted on a recently published survey of persons with spinal cord injury (SCI) who used standing mobility devices. Frequency and duration of standing were examined in relation to outcomes using chi square analyses. Respondents (n = 99) who stood 30 minutes or more per day had significantly improved quality of life, fewer bed sores, fewer bladder infections, improved bowel regularity, and improved ability to straighten their legs compared with those who stood less time. Compliance with regular home standing (at least once per week) was high (74%). The data also suggest that individuals with SCI could benefit from standing even if they were to begin several years after injury. The observation of patient benefits and high compliance rates suggest that mobile standing devices should be more strongly considered as a major intervention for relief from secondary medical complications and improvement in overall quality of life of individuals with SCI.

Given the greatly decreased length of hospital stays, concern about the transition from hospital to home has increased. This descriptive study focused on a sample of hospitalized patients discharged to home with home care services. Patient and caregiver interviews revealed that satisfaction with home care services was positively related to receipt of information from the home care staff about medications, equipment/supplies, and self-care. Caregiver burden was inversely related to receiving this information. Recommendations for improving the transition from hospital to home included providing more information, more reassurance and emotional support, and more household assistance. Several possible methods of implementing these recommendations are proposed.

All admissions to a 1,100-bed Department of Veterans Affairs (VA) hospital were screened to identify 171 terminally ill patients with informal caregivers who were then randomly assigned to VA hospital-based team home care (HBHC, N = 85) or customary care (N = 86). Patient functioning, and patient and caregiver morale and satisfaction with care were measured at baseline, one month, and six months. Health services utilization was monitored over the six-month study period and converted to cost. Findings included no differences in patient survival, activities of daily living (ADL), cognitive functioning, or morale, but a significant increase in patient (p = .02) and caregiver (p = .005) satisfaction with care at one month. A substitution effect of HBHC was seen. Those in the experimental group used 5.9 fewer VA hospital days (p = .03), resulting in a $1,639 or 47 percent per capita saving in VA hospital costs (p = .02). As a result, total per capita health care costs, including HBHC, were $769 or 18 percent (n.s.) lower in the HBHC sample, indicating that expansion of VA HBHC to serve terminally ill veterans would increase satisfaction with care at no additional cost.

Home health care is uniformly accepted by patients, caregivers, health professionals, policymakers, and the public as a desirable way to provide care to disabled individuals and the frail elderly. Given the lack of positive impact of home care upon functional status, cost, and nursing home use, as well as documented additional cost, future research must focus upon positive aspects from past experiences. Careful targeting of patients most likely to benefit from this care has produced better results. Satisfaction with care has been shown consistently. Managed home health care may have the potential, especially the impact of physician involvement with team care on hospital use, to contain costs. The intuitive belief that home care is beneficial and a worthwhile expense, held by policymakers and health care professionals alike, needs to be fully researched by studies that carefully examine the wide spectrum of home care benefits for disabled or chronically ill individuals in relation to varying cost levels that the population and health care system can absorb. The challenge is here, and those who believe in home care need to make use of the results of these previous, rather nonsupportive studies. Additional research is needed to measure the impact of active physician participation in the team care provision of home care services and the impact of managed home care on the cost of hospital care in the population most at risk for recurrent hospitalization. This same research must document not only more effective targeting of individuals, but also the maintenance of increased satisfaction with care--strongest motive for the need to prove the cost-effectiveness of home care.

This randomized study screened hospital admissions to all wards except Psychiatry and Spinal Cord Injured during a 3-year period to identify 233 severely disabled patients (2 impairments on the Katz Index of ADL) and caregivers who were willing to participate in a pretest-multiple posttest trial of the Hines VA Hospital-based Home Care (HBHC) Program. Patient functional status, morale, and satisfaction with care were measured at baseline, 1 month and 6 months post discharge. Caregiver satisfaction and morale were assessed at the same time periods. All health care services used by both groups were tracked over the 6-month period and converted to cost. Findings include improved 1-month satisfaction with care (P = 0.04) and improved 6-month cognitive functioning (P = 0.04) among HBHC patients and improved 1-month (P = 0.04) and 6-month satisfaction with care (P less than 0.01) among their caregivers. A nonsignificant 10% decrease in net cost of care, was found in the treatment group, largely due to lower use of private sector hospital care.