Comparing Outcomes Among Medicaid Home and Community-Based Service Users: Private Homes vs. Assisted Living...

To compare outcomes of Medicaid home and community-based services (HCBS) users residing in a private home vs. in an assisted living facility among dually eligible individuals aged 65 or older.

Medicaid HCBS occurred either in private homes or assisted living facilities in 883 counties in 39 states in the United States from 2016 to 2019. We used an instrumental variable (IV) approach to account for unmeasured factors that might confound the association between HCBS settings and outcomes. Our IV was the monthly proportion of HCBS users in a private home (vs. in an assisted living facility) in surrounding counties within the same state. We examined four outcomes: hospitalizations, emergency department visits, days at home, and Medicare spending.

We used Medicare and Medicaid claims linked at the individual level. Our sample included dually eligible individuals aged 65 or older, enrolled in Medicare fee-for-service plans, who used HCBS either in a private home or an assisted living facility, between 2016 and 2019.

Our sample included 8,140,213 person-months from 383,607 individuals, of whom 85% lived at home and 15% in assisted living facilities. Compared to those in assisted living facilities, in-home HCBS users were 1.3 percentage points more likely to be hospitalized each month (95% CI: 0.8-1.8) and had 0.3 fewer days at home per month (95% CI: -0.4 to -0.1). In an analysis using a sample matched on observed person-months, HCBS users at home had higher likelihoods of hospitalizations and emergency department visits, fewer days at home, and higher Medicaid spending.

Overall, in-home HCBS users were more likely to experience adverse health events than those in assisted living facilities, suggesting that policymakers should consider improving care for HCBS users in private homes.