Frail seniors getting supports and services at home are more likely to be hospitalized than those living in nursing homes, even though those in nursing facilities are often sicker than those in the community, according to a new study in the June issue of the journal Health Services Research (behind a paywall).
The study finds that seniors receiving care at home face both preventable and non-preventable hospitalizations at significantly higher rates than nursing home residents. These elders were at greater risk of hospitalization for potentially preventable conditions, according to the paper by Andrea Wysocki of Brown University; Bob Kane, Ezra Golberstein, Bryan Dowd, and Tetyana Shipee of the University of Minnesota; and Terry Lum of the University of Hong Kong. These conditions include congestive heart failure, pneumonia, dehydration, and urinary tract infections.
The study may be the first that compares rates of preventable hospitalizations among frail elders living at home with those living in nursing homes. It is important because so many people prefer care at home and because states are increasingly shifting care of those eligible for both Medicare and Medicaid (called dual eligibles) into home and community-based care.
The authors acknowledge the preference of many for home-based care, but warn that those higher rates of preventable hospitalizations may be a “hidden cost” of that choice.
Most recent studies either looked at preventable hospitalizations only among those living at home or did not distinguish between those in nursing homes and those in Medicaid HCBS programs. A 2012 study by Edith Walsh, Josh Wiener, and others found that about one-third of those dually eligible for Medicare and Medicaid were hospitalized in 2005, and about 40 percent of those were potentially preventable.
Wysocki, Kane and colleagues looked at those over 65 who were participating in home and community-based care (HCBS) programs in seven states under Medicaid. The data are from 2003-2005.
The authors carefully corrected for important differences between dual eligibles living at home and those in nursing homes. In general, nursing home residents were older, more likely to be white, more likely to have dementia, and more likely to be eligible for Medicaid based on medical need rather than poverty.
The study does not say why those living at home are at greater risk of hospitalization, but the authors note the story can be very complicated.
For example, nursing homes are a more medical setting, with nurses and aides available to regularly check on a resident’s health status (and some better access to physicians). Thus, they should be able to treat or even prevent many acute episodes, such as urinary tract infections, without sending a resident to the hospital.
Yet, some facilities still hospitalize patients at high rates for reasons ranging from poor staff training to fear of legal liability. In a 2012 article for Health Progress, I described some of these causes, and potential solutions.
In contrast, those living at home are normally cared for by family members with limited assistance from home health aides and infrequent access to either RNs or physicians. It may be that better medical care, in the form of house calls, community health centers, or other services, could reduce many of those preventable hospitalizations. Better training and more support for family caregivers could help as well.
Another important issue: While potentially preventable hospitalizations are often used as a proxy for quality, the reality is much more complicated. And, as the authors report, they were not able to determine whether the relatively low percentage of hospitalizations from nursing homes was the result of better care at those facilities or poor judgment involving residents who should have been sent to the hospital.
The study was also unable to examine the impact of patient choice. For instance, there were no data on do-not-hospitalize orders requested by patients.
Finally, nobody knows how the recent shift of many dual eligibles to managed care changes the relative likelihood of preventable hospitalizations. However, managed care organizations have strong financial incentives to keep all their members at home rather than in nursing facilities, and keep them out of the hospital.
The study does not suggest that frail elders are better off in nursing homes than at home. Far from it. But it does provide an important warning about the risks of home care.