Post-acute care transitions and outcomes among Medicare beneficiaries with dementia: Associations with race/ethnicity and dual status

Objective: To evaluate how post-acute care (PAC) transitions affect minority older adults with Alzheimer's disease or related dementia (ADRD), and the extent to which dual Medicare-Medicaid eligibility may attenuate or exacerbate disparities in PAC outcomes. We examined: (1) PAC referrals by race/ethnicity and dual status; (2) individual, hospital, and market-level factors associated with PAC; (3) the association between PAC and outcomes. Data Sources/Study Setting: We used the following secondary data: Master Beneficiary Summary File (MBSF), Medicare Provider Analysis and Review (MedPAR), Minimum Data Set (MDS), Area Health Resource File (AHRF), hospital Provider of Services (POS) file, and the area deprivation index (ADI). Study Design: This observational study consisted of 619,262 community-residing Medicare fee-for-service (FFS) beneficiaries with ADRD who had a hospital stay in 2017. Data Collection/Extraction Methods: PAC discharge was to skilled nursing facilities (SNF), home health care (HHC) agencies or home without services. Outcomes were 30-day readmission and death. Multinomial logistic regressions with hospital random effects (RE), stratified by dual eligibility, were fit. Principal Findings: Dual-related differences were significantly larger than race/ethnicity differences in PAC transitions. For example, the difference in the probability of SNF transitions between White and Black patients was 3.2% and 6.8%-points for non-duals and duals, respectively. The difference between non-dual/dual White patients was 21.6% points, and among Black patients 18.0%-points. The adjusted risk of 30-day readmission was 5.6 percentage point higher among non-duals discharged to SNF, compared to home, but such risk among duals was not statistically significantly different. The adjusted probabilities of 30-day mortality were larger for duals and non-duals who transitioned to SNF, compared to those discharged home. Conclusions: PAC referrals and the resulting outcomes for Medicare beneficiaries with ADRD are associated with multi-level variables that need to be incorporated in discharge decision making. KEYWORDS Alzheimer's disease or dementia, mortality, post-acute care, readmissions What is known on this topic? * Hospitals and insurers have been shifting post-acute care (PAC) from institutional care settings to home. * Overall, for Medicare beneficiaries, studies have indicated that discharge to home health was associated with higher readmission rates. * Little is known about PAC transitions among community-dwelling Medicare beneficiaries with dementia and their impact on outcomes. What does this study add? * We found differences in PAC transitions to be more pronounced by dual status than by race/ethnicity. * PAC outcomes for hospital readmissions were not statistically significant by race/ethnicity but were by dual status. * Interventions to improve PAC transitions and outcomes for Medicare beneficiaries with ADRD should specifically consider differences duals versus non-duals in care needs and access.
1 | INTRODUCTION Post-acute care (PAC) provided in a skilled nursing home (SNF) or at home with services from a home health care (HHC) agency has been common among Medicare [...]