title: Volume of home- and community-based services and time to nursing-home placement.
abstract: OBJECTIVE
  The purpose of this study was to determine whether the volume of Home- and Community-Based Services (HCBS) that target Activities of Daily Living disabilities, such as attendant care, homemaking services, and home-delivered meals, increases recipients' risk of transitioning from long-term care provided through HCBS to long-term care provided in a nursing home.
  
  
  METHODS
  Data are from the Indiana Medicaid enrollment, claims, and Insite databases. Insite is the software system that was developed for collecting and reporting data for In-Home Service Programs.
  
  
  METHODS
  Enrollees in Indiana Medicaid's Aged and Disabled Waiver program were followed forward from time of enrollment to assess the association between the volume of attendant care, homemaking services, home-delivered meals, and related covariates, and the risk for nursing-home placement. An extension of the Cox proportional hazard model was computed to determine the cumulative hazard of nursing-home placement in the presence of death as a competing risk.
  
  
  RESULTS
  Of the 1354 Medicaid HCBS recipients followed in this study, 17% did not receive any attendant care, homemaking services, or home-delivered meals. Among recipients who survived through 24 months after enrollment, one in five transitioned from HCBS to a nursing-home. Risk for nursing-home placement was significantly lower for each five-hour increment in personal care (HR=0.95, 95% CI=0.92-0.98) and homemaking services (HR=0.87, 95% CI=0.77-0.99).
  
  
  CONCLUSIONS
  Future policies and practices that are focused on optimizing long-term care outcomes should consider that a greater volume of HCBS for an individual is associated with reduced risk of nursing-home placement.
authors.affiliation: Purdue University.
authors.forename: Laura P
authors.initials: LP
authors.lastname: Sands
authors.affiliation: Indiana University School of Medicine.
authors.forename: Huiping
authors.initials: H
authors.lastname: Xu
authors.affiliation: Purdue University ; Regenstrief Center for Healthcare Engineering.
authors.forename: Joseph
authors.initials: J
authors.lastname: Thomas
authors.affiliation: Harvard Medical School.
authors.forename: Sudeshna
authors.initials: S
authors.lastname: Paul
authors.affiliation: Purdue University.
authors.forename: Bruce A
authors.initials: BA
authors.lastname: Craig
authors.affiliation: Indiana University School of Medicine.
authors.forename: Marc
authors.initials: M
authors.lastname: Rosenman
authors.affiliation: MDwise Hoosier, Indianapolis.
authors.forename: Caroline C
authors.initials: CC
authors.lastname: Doebbeling
authors.affiliation: Indiana University School of Medicine ; Indiana University Center for Health Services and Outcomes Research ; Regenstrief Institute, Inc.
authors.forename: Michael
authors.initials: M
authors.lastname: Weiner
mesh_terms: D000203:Activities of Daily Living; D000367:Age Factors; D000368:Aged; D003153:Community Health Services / Q000706:statistics & numerical data*; D005260:Female; D006701:Home Nursing / Q000706:statistics & numerical data*; D006801:Humans; D007196:Indiana / Q000453:epidemiology; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D009735:Nursing Homes / Q000706:statistics & numerical data*; D012737:Sex Factors; D013997:Time Factors; D014481:United States
keywords: Aged and Disabled; Home and Community Based Care; Medicaid; Nursing Home; Waivers