Characteristics Associated With Home Health Care Referral After Discharge From Hospital

Most older adults prefer to recover at home, making home health care (HHC) an important alternative to institutional post-acute care (eg, skilled nursing, inpatient rehabilitation). Understanding factors associated with HHC referral at hospital discharge-relative to other options-can align care with patient preferences and support aging in place. This study examined individual, hospital, and community characteristics associated with HHC referral vs institutional post-acute care among Medicare beneficiaries.

Retrospective observational study.

Participants included beneficiaries referred to HHC, skilled nursing, or inpatient rehabilitation at hospital discharge in 100% Medicare fee-for-service claims, 2017-2019. Hospital characteristics came from Centers for Medicare & Medicaid Services Hospital Cost Reports, and community-level variables came from the 2017 Agency for Healthcare Research and Quality Social Determinants of Health database.

Our outcome was discharge to HHC vs institutional post-acute care (eg, skilled nursing, inpatient rehabilitation). Mixed-effects linear probability models estimated associations between individual-, hospital-, and community-level characteristics with HHC referral among Medicare beneficiaries at hospital discharge.

The study population included 11,139,222 hospital discharges among 6,287,660 Medicare beneficiaries. Older age, longer length of stay, urban dwelling, and dual-eligibility were associated with lower rates of HHC referral. Beneficiaries of color had higher rates of HHC referral than non-Hispanic White beneficiaries. Large (>400 beds), nonteaching, and safety net hospitals were associated with higher rates of HHC referral. Communities with higher percentages of racially and ethnically minoritized residents and older adults had higher rates of HHC referral. However, models explained only 13% of the variation in post-acute care referral, underscoring the limited ability of administrative claims data to capture all relevant determinants.

Referral decisions for post-acute care are influenced by individual-, hospital-, and community-level factors. As the use of HHC continues to grow, greater attention is needed to how these decisions are made to ensure equitable access to preferred and appropriate care for older adults.