Medicaid HCBS Caregiver Payment Policy and Post-Discharge Visits Among Dual-Eligible Older Adults With ADRD

To examine the association between state Home- and Community-Based Services (HCBS) caregiver payment policies and timely follow-up visits (in-person and telehealth) within 14 days of hospital discharge among Medicare-Medicaid dual-eligible older adults with dementia.

We categorized state HCBS caregiver payment policies into three groups: no caregiver payment, payment eligible for other friends/family, and payment eligible for two caregiver types (legally responsible relatives or other friends/family). The primary outcome was the mode of follow-up visit within 14 days post-hospital discharge (in-person, telehealth, or no visit). We used multinomial logistic regression with hospital random effects, adjusting for individual- and area-level and HCBS factors. Marginal effects were estimated.

We analyzed 2021 Medicare claims data linked with publicly available datasets. The analytic cohort comprised 51,633 dual-eligible Medicare beneficiaries with dementia who were hospitalized and discharged to the community in 2021.

State HCBS caregiver payment policies were significantly associated with the mode of timely follow-up visits. Compared to states without providing caregiver payments, states providing payments to two caregiver types had a 6.8 percentage point higher probability (p < 0.01) of timely in-person visits but a 3.2 percentage point lower probability (p < 0.01) of timely telehealth visits. Similar, though smaller, significant differences were observed between states that provided payments to only other family or friends and those with no caregiver payments. Other HCBS generosity measures, as well as racial, ethnic, and geographic locations, were also associated with the mode of post-discharge visits.

Providing financial support to family caregivers through state HCBS policies may increase the rate of timely post-discharge visits, primarily driven by an increase in in-person visits. The effects were particularly prominent among states that allow payments to both types of caregivers.