Transitioning From Community-Based to Institutional Long-term Care: Comparing 1915(c) Waiver and PACE Enrollees.
To compare the risk of long-term nursing home (NH) admission and the level of functional and cognitive impairment at the time of long-term NH admission in the Program of All-Inclusive Care for the Elderly (PACE) and in 1915(c) aged and aged and disabled waiver programs.



Cohorts of new waiver and PACE enrollees in 12 states were identified (in 2005-2007) and followed (through 2009) using the Medicaid Analytic Extract and the Minimum Data Set. Individual-level outcomes of interest were time from waiver or PACE enrollment to long-term (90+ days) NH admission and functional (29-point activities of daily living [ADL]) and cognitive (7-point Cognitive Performance Scale [CPS]) impairment at NH admission. An overall measure of impairment was also created and categorized as low (ADL < 17 and CPS < 3) versus high (ADL ≥ 17 or CPS ≥ 3). The key independent variable was enrollment in PACE versus waiver program. County-level covariates were included. Analyses employed multivariable models including competing risk proportional hazard and linear and logistic regressions.



Compared with waiver enrollees, PACE enrollees had 31% lower risk of long-term NH admission (p < .001). At NH admission, they were overall significantly (p < .0001) more cognitively impaired (0.34 point), with 55% higher odds of severe (CPS ≥ 4) cognitive impairment (p < .001) and 45% higher odds of having overall high impairment (p = .003).



PACE may be more effective than 1915(c) aged and aged and disabled waiver programs in reducing long-term NH use and may be particularly well suited to supporting cognitively impaired individuals, enabling them to remain in the community longer.
Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York.
Micah
M
Segelman
Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, New York.
Xueya
X
Cai
National PACE Association, Alexandria, Virginia.
Christine
C
van Reenen
Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York.
Helena
H
Temkin-Greener
D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D003071:Cognition; D060825:Cognitive Dysfunction; D003153:Community Health Services; D005260:Female; D006299:Health Services for the Aged; D006801:Humans; D007326:Institutionalization; D008134:Long-Term Care; D008297:Male; D008484:Medicaid; D009735:Nursing Homes; D010360:Patient Transfer; D012306:Risk; D012720:Severity of Illness Index; D014481:United States
Dual eligible beneficiaries; Home- and Community-based Care and Services; Long-term care