Post-Acute Care Use and Functional Outcomes for Medicaid-Funded Home and Community Based Services Users with and without Alzheimer’s Disease and Related Dementias

Dissertation Committee

Evan S. Cole, PhD, Research Associate Professor, Department of Health Policy & Management (Committee Chair)
Howard B. Degenholtz, PhD, Professor, Department of Health Policy & Management
Coleman Drake, PhD, Associate Professor, Department of Health Policy and Management
Kristina E. Rudd, MD, MPH, Assistant Professor, Department of Critical Care Medicine

Abstract

Medicaid-funded Home and Community-Based Services (HCBS) support over 4 million individuals in the U.S., particularly as policies shift toward home-based rather than institutional care. HCBS now comprises 57% of long-term services and supports (LTSS) spending. Among HCBS users, individuals with Alzheimer’s Disease or Related Dementias (ADRD) face a heightened risk of nursing facility placement, though HCBS support may help prevent this outcome.

This dissertation explores how serious illness, disability, and ADRD impact post-acute care and functional recovery for Medicaid-funded HCBS users. Aim 1 examines mortality and readmission differences among seriously ill HCBS users with and without ADRD using logistic regression. Mortality odds are significantly higher at 30-, 60-, and 90-days post-discharge for those with ADRD, though readmission rates show no significant difference. Additionally, there is no significant difference in spending all 30 days post-discharge alive and at home between ADRD and non-ADRD individuals. Aim 2 evaluates functional changes pre- and post-hospitalization. Using a pre-post weighted scoring linear regression, we observe that both groups experience functional declines, but findings indicate no significant interaction between ADRD and post-hospitalization functional outcomes. Aim 3 investigates a composite binary outcome of mortality or long-term nursing facility placement by 100 days post-discharge using logistic regression. These findings collectively are informative for the design of targeted interventions to enhance care transitions to timely post-acute services so that individuals can remain in their communities.