As rates of institutionalization have decreased, a growing majority of patients with dementia choose to live and receive care at home, according to a new study.
Rates of home health care use among people with Alzheimer’s disease and other dementias are higher than those without, according to the study, published today in JAMA Network Open. However, the number of Medicare beneficiaries with dementia receiving home health care declined beginning in 2020.
“Although our data cannot speak to the reason for the reversal in those trends with the COVID-19 pandemic, the decreasing use of home health care is consistent with reports of widespread staffing shortages in home care agencies, which may reduce the capacity of home health agencies to meet demand for services,” the study’s authors wrote.
Researchers from the University of Pennsylvania studied traditional Medicare beneficiaries aged 68 and older who used home health care from Jan. 1, 2010, to June 30, 2022. The beneficiaries were divided into two groups: those diagnosed with dementia and those without a diagnosis.
The primary source of this care is Medicare-funded home health care, according to the study.
The study found that 28% of individuals on traditional Medicare had a dementia diagnosis. Among beneficiaries receiving home health care, those with a dementia diagnosis were more likely to be older females who were dually eligible for Medicare and Medicaid. Dementia patients most commonly initiated home health care from the community, rather than from post-acute care.
The researchers highlighted a significant overall increase in the use of home-based care over the past decade as institutional care has decreased for both post-acute and long-term care. This shift has been linked to pressures to limit Medicare spending. Alternative payment models aimed at controlling costs may drive demand for home health care as a lower-cost alternative to residential facilities. Additionally, this trend aligns with patient preferences to age in place.
“Home health care was commonly used among people with a diagnosis of dementia, particularly for community-initiated home health care,” researchers noted. “We observed that home health care usage in this population increased between 2010 and 2020 but then decreased through mid-2022. In contrast, home health care use among individuals without a dementia diagnosis was relatively low and has gradually declined.”
The study noted striking changes in home health care usage during the COVID-19 pandemic in 2020, which saw a sharp decline in the initiation of home-based care. Although there was a brief rebound in late 2020, usage declined again through mid-2022, particularly among individuals with a dementia diagnosis. Furthermore, the length of home health care episodes increased and remained significantly higher post-pandemic compared to pre-pandemic levels.
Researchers identified consistent and widespread staffing shortages in home health agencies as a possible reason for the decline in usage, as these shortages hinder the ability to meet demand. Additionally, changes to Medicare payments for home health care, effective Jan. 1, 2020, under the patient-driven groupings model (PDGM), reduced episode lengths from 60 to 30 days. This new model also adjusted payments based on clinical characteristics rather than the amount of therapy provided, resulting in decreased reimbursement for community-initiated home health care.
“Despite the increasing use of home health care during this time period, people may receive incomplete support for their home health care needs through Medicare, which is centered on needs for skilled care, or Medicaid, which entails strict asset and income tests,” researchers wrote. “Decreasing rates of home health care use since 2020 in this high-need population point to a need for ongoing monitoring of service use and outcomes for people with dementia.”
