Integrated Home- and Community-Based Services Improve Community Survival Among Independence at Home Medicare Beneficiaries Without Increasing Medicaid Costs

OBJECTIVES To determine the effect of home-based primary care (HBPC) for frail older adults, operating under Independence at Home (IAH) incentive alignment on long-term institutionalization (LTI). DESIGN Case-cohort study using HBPC site, Medicare administrative data, and National Health and Aging Trends Study (NHATS) benchmarks. SETTING Three IAH-participating HBPC sites in Philadelphia, PA, Richmond, VA, and Washington, DC. PARTICIPANTS HBPC integrated with long-term services and supports (LTSS) cases (n = 721) and concurrent comparison groups (HBPC not integrated with LTSS: n = 82; no HBPC: n = 573). Cases were eligible if enrolled at one of the three HBPC sites from 2012 to 2015. Independence at Home-qualified (IAH-Q) concurrent comparison groups were selected from Philadelphia, PA; Richmond, VA; and Washington, DC. INTERVENTION HBPC integrated with LTSS under IAH demonstration incentives. MEASUREMENTS Measurements include LTI rate and mortality rates, community survival, and LTSS costs. RESULTS The LTI rate in the three HBPC programs (8%) was less than that of both concurrent comparison groups (IAH-Q beneficiaries not receiving HBPC, 16%; patients receiving HBPC but not in the IAH demonstration practices, 18%). LTI for patients at each HBPC site declined over the three study years (9.9%, 9.4%, and 4.9%, respectively). Costs of home- and community-based services (HCBS) were nonsignificantly lower among integrated care patients ($2151/mo; observed-to-expected ratio = .88 [.68-1.09]). LTI-free survival in the IAH HBPC group was 85% at 36 months, extending average community residence by 12.8 months compared with IAH-q participants in NHATS. CONCLUSION HBPC integrated with long-term support services delays LTI in frail, medically complex Medicare beneficiaries without increasing HCBS costs.