Many Older Americans Do Not Receive the Recommended Home Health Care After Hospitalization

A Jun Li, Mingyu Qi, Rachel M. Werner

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KEY FINDINGS

  • Only 54% of Medicare patients referred to home health care services following a hospitalization received home health care visits.
  • Black and Hispanic Medicare beneficiaries received home health at lower rates than White patients by approximately 7.3 and 9.2 percentage points, respectively.
  • Patients residing in disadvantaged neighborhoods—those in ZIP codes with high poverty and unemployment rates—received lower rates of home health care services by approximately 5 percentage points.

Home health care is one of the fastest-growing services used by patients following a hospital stay in the U.S.1-3 Patients receive health and social services within their homes to help them recover from illness or injury and to maintain their independence.4 Ensuring access to home health care has important implications for patient wellbeing and the U.S. health care system. Recent research examining the years before the implementation of the Affordable Care Act has shown that a substantial portion of Medicare patients referred to home health care after hospitalization do not receive that care.5 It is unknown whether this discrepancy has changed in more recent years as rates of home health care have increased and the use of institutional post-acute care has declined.

This brief summarizes the results of a study just published in JAMA Network Open.6 Using national data, we describe how often Medicare patients referred to home health care services after a hospital discharge received one or more home health care visits. We further examined variation in the rates of successful home health care referrals by patient sociodemographic characteristics.

Only Half of Medicare Beneficiaries Referred to Home Health Care Receive It
In 2016, more than 2.3 million Medicare patients were discharged from hospitals with home health referrals. Of these patients, only 54% received a home health visit. Even when accounting for death or institutional care following discharge, over 38% of patients never received home health care as intended by their physicians. Medicare beneficiaries enrolled in private Medicare Advantage health plans fared worse than traditional Medicare fee-for-service patients. Only about 48% of Medicare Advantage patients received home health care as compared to nearly 57% of Medicare fee-for-service patients.

Data Souce:  Estimates are from “Assessment of Receipt of the First Home Health Care Visit After Hospital Discharge Among Older Adults,” JAMA Network Open 3(9):e2015470.

Policymakers Must Address the Disparities Among Populations Receiving Home Health Care
This study indicates that despite the benefits of home health care, a substantial portion of discharged patients is unlikely to receive it. Notably, our findings suggest patients in vulnerable population groups are more likely to face consequential barriers to home health care. These disparities are doubtlessly contributing to the inequitable health care system in the U.S. Recent health care reform efforts increasingly rely on home health care as a substitute for institutional care.7-9 With this knowledge, policymakers should implement a system that ensures all patients receive the home health care that has been recommended by their physicians.

Data and Methods
This study used national Medicare data to identify patients referred to home health care upon hospital discharge and their subsequent care utilization. The study also employs data from the American Community Survey to measure ZIP code level socioeconomic characteristics. For more details about the data and methods, the full paper is available here.

References

  1. Keohane, L.M., Freed, S., Stevenson, D.G., Thapa, S., Stewart, L., & Buntin, M.B. (2018, December 10). Trends in postacute care spending growth during the Medicare spending slowdown. Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2018/dec/postacute-care-spending-growth-medicare
  2. Medicare Payment Advisory Commission. (2019). Report to the Congress: Medicare Payment Policy. http://medpac.gov/docs/default-source/reports/mar19_medpac_entirereport_sec.pdf?sfvrsn=0
  3. Cuckler, G.A., Sisko, A.M., Poisal, J.A., Keehan, S.P., Smith, S.D., Madison, A.J., Wolfe, C.J., & Hardesty, J.C. (2018). National health expenditure projections, 2017-2026: Despite uncertainty, fundamentals primarily drive spending growth. Health Affairs, 37(3), 482-492.
  4. Ellenbeck, C., Samia, L., Cushman, M.J., & Alster, K. (2008). Patient safety and quality: An evidence-based handbook for nurses. Agency for Healthcare Research and Quality.
  5. Zhu, Y. & Stearns, S.C. (2019). Post-acute care locations: Hospital discharge destination reports vs. medicare claims. Journal of the American Geriatrics Society, 68(4), 847-851.
  6. Li, J., Qi, M., Werner, R.M. (2020). Assessment of Receipt of the First Home Health Care Visit After Hospital Discharge Among Older Adults. JAMA Network Open, 3(9), e2015470.
  7. Graze, T.K., Beidler, L.B., Briggs, A.D.M., & Colla, C.H. (2019). ‘Eyes in the home’: ACOs use home visits to improve care management, identify needs, and reduce hospital use. Health Affairs, 38(6), 1021-1027.
  8. Glickman, A., Dinh, C., Navathe, A.S. (2018). The current state of evidence on bundled payments. LDI Issue Brief, 22(3), 1-5.
  9. Medicare Payment Advisory Commission. (2019). Report to the Congress: Medicare and the Health Care Delivery System. http://medpac.gov/docs/default-source/reports/jun19_medpac_reporttocongress_sec.pdf?sfvrsn=0

Acknowledgements
An author of this brief is an affiliate of the Center for Aging and Policy Studies, which receives funding from the National Institute on Aging (grant # 1P30AG066583). The study was supported by the Agency for Healthcare Research and Quality (grant # R01-HS024266, grant # R36-HS026836) and the Rackham Predoctoral Fellowship. The authors also thank Shannon Monnat and Megan Ray for edits on an earlier version of this brief.

About the Authors
Jun Li is an Assistant Professor of Public Administration and International Affairs at the Syracuse University Maxwell School of Citizenship and Public Affairs, a Faculty Associate in the Aging Studies Institute, and a Faculty Affiliate in the Center for Aging and Policy Studies (jli208@maxwell.syr.edu). Mingyu Qi is a statistical analyst at the University Pennsylvania Perelman School of Medicine. Rachel M. Werner is a Professor of Medicine at the University of Pennsylvania Perelman School of Medicine and the Robert D. Eilers Professor of Health Care Management at the Wharton School, and the Executive Director of the Leonard Davis Institute of Health Economics.