Older adults who qualify for both Medicare and Medicaid and have more complex health needs are more likely to begin long-term services and supports (LTSS) in nursing homes rather than through home- and community-based services (HCBS), according to new research published in February in the Journal of the Post-Acute and Long-Term Care Medical Association.
The study examined 581 adults age 65 and older living in Southern Community Cohort Study states. All participants had at least three consecutive months of full Medicaid coverage before initiating LTSS between January 2007 and December 2018.
By 2018, the group was nearly evenly divided: 49.9% (290 individuals) began care through HCBS, while 50.1% (291 individuals) entered a nursing home.
However, researchers found clear differences in who entered which setting.
Black beneficiaries and women were more likely to start services in home- and community-based programs. In contrast, older participants, those recently hospitalized, individuals with higher education levels, and especially those diagnosed with Alzheimer’s disease and related dementias (ADRD) were more likely to initiate care in a nursing home.
The findings suggest that beneficiaries with more complex medical needs tend to enter institutional settings.
A prior ADRD diagnosis emerged as one of the strongest predictors of nursing home entry. The authors noted that this may reflect the higher level of supervision and hands-on care required by individuals with cognitive impairment. At the same time, dementia itself may present barriers to navigating and securing HCBS benefits.
“If HCBS expansions are to be successful, Medicaid programs need strong evidence on whether HCBS programs are reaching individuals whose long-term care needs can be managed at home,” the authors wrote. They added that cognitive impairment may make it harder for beneficiaries to identify available services and complete approval processes.
The researchers said future studies should examine whether HCBS programs without waitlists — including certain state plan services and waiver programs — are more effective at reaching dual-eligible beneficiaries with significant health needs.
As states continue to invest in expanding home-based care, the findings raise questions about whether the most medically vulnerable seniors are being adequately served outside institutional settings.
