State Spending on Home and Community-Based Services and Rates of Low-Care Residents in Nursing Homes

TL;DR

Higher state spending on home and community-based services is linked to fewer low-care residents in nursing homes, but this effect is weaker in high-cost states.

Contribution

This study identifies a novel association between state HCBS spending and reduced low-care nursing home use, with a nuanced interaction based on state cost levels.

Findings

High HCBS spending states had 1.08 fewer percentage points of low-care residents in nursing homes.

The effect of HCBS spending on low-care residents is stronger in low-cost states compared to high-cost states.

In high-cost states, high HCBS spending was associated with a slight increase in low-care residents.

Abstract

States are increasingly investing in home & community-based services (HCBS) to support older adults “aging in place” and prevent unnecessary nursing home (NH) admission of individuals with low care needs. This observational study examined associations between state HCBS spending (i.e. the percent of state Medicaid long-term care dollars spent on HCBS) and “low care” nursing home use in 2021 using the AARP LTSS State Scorecard and LTCFocus. In linear regression models controlling for state and NH characteristics, we estimated the association of state tertile of HCBS spending with percent of low-care residents in U.S. NHs (n = 14,105). The final model included an interaction between average state NH cost and HCBS spending. Compared to NHs in lowest-HCBS spend states, NHs in the highest-spend HCBS tertile had 1.08 percentage points (95% CI: -2.15, -0.01) fewer low-care residents. There was a significant interaction between state median NH cost and HCBS spending. In low-cost states, adjusted mean of low-care residents was 11.0% (95% CI: 10.55, 11.46) in lowest HCBS tertile, and 9.92% (95% CI: 9.47, 10.04) in highest HCBS tertile. In high-cost states, adjusted mean of low-care residents was 7.47% (95% CI: 6.94-8.00) in lowest HCBS tertile, and 9.93% (95% CI: 9.01-10.84) in highest HCBS tertile. Higher state HCBS spending is associated with a lower prevalence of low-care NH residents, but this relationship is attenuated in higher-NH cost states. Further research is needed to examine specific HCBS waiver-covered services associated with reducing NH admissions for low-care residents.