Comparison of resource utilization for Medicaid dementia patients using nursing homes versus home and community based waivers for long-term care.

BACKGROUND Medicaid waiver home and community-based long-term care services (HCBS) may provide a partial solution to the escalating costs of long-term care. Persons with dementia can have complex caregiving needs; it is unknown whether their expenditures and resource utilization differ between community-based versus institutional settings. OBJECTIVE To compare expenditures and resource utilization for Medicaid recipients with dementia who received long-term care through a nursing home versus HCBS waivers. DESIGN Twelve-month cohort study. SETTING Indiana Medicaid administrative data from 2001 through 2004. PARTICIPANTS Medicaid recipients with dementia who lived in the community 6 months before receiving long-term care through nursing homes (N = 1534) or HCBS waivers (N = 174). MEASUREMENTS Monthly inpatient and emergency department rates and total expenditures adjusted for prior use, demographics, insurance status, and comorbidities. RESULTS Adjusted rates of inpatient use were stable for nursing home patients (0.06) but significantly increased over 12 months for HCBS recipients (0.07-0.12; P = 0.048). Adjusted total expenditures increased over 12 months from $1419 to $2002 for HCBS recipients (P < 0.001), but remained stable for those in nursing homes ($3413-$3336). Long-term care expenditures were on average $1688 per month higher for those in nursing homes. CONCLUSIONS The escalation in inpatient use for HCBS waiver recipients suggests that future development of HCBS programs should consider the unique needs of persons with dementia so as to optimize their health outcomes. Despite increasing inpatient use among HCBS recipients, their overall expenditures remained significantly lower than those of nursing home patients.