title: The effects of state-level expenditures for home- and community-based services on the risk of becoming a long-stay nursing home resident after hip fracture.
abstract: CONCLUSIONS
  This study measures the effect of spending policies for long-term care services on the risk of becoming a long-stay nursing home resident after a hip fracture. Relative spending on community-based services may reduce the risk of long-term nursing home residence. Policies favoring alternative sources of care may provide opportunities for older adults to remain community-bound.
  
  
  BACKGROUND
  This study aims to understand how long-term care policies affect outcomes by investigating the effect of state-level spending for home- and community-based services (HCBSs) on the likelihood of an individual's nursing home placement following hip fracture.
  
  
  METHODS
  This study uses data from the 5% sample of Medicare beneficiaries from 2005 to 2010 to identify incident hip fractures among dual-eligibility, community-dwelling adults aged at least 65 years. A multilevel generalized estimating equation (GEE) model estimated the association between an individual's risk of nursing home residence within 1 year and the percent of states' Medicaid long-term support service (LTSS) budget allocated to HCBS. Other covariates included expenditures for Title III services and individual demographic and health status characteristics.
  
  
  RESULTS
  States vary considerably in HCBS spending, ranging from 17.7 to 83.8% of the Medicaid LTSS budget in 2009. Hip fractures were observed from claims among 7778 beneficiaries; 34% were admitted to a nursing home and 25% died within 1 year. HCBS spending was associated with a decreased risk of nursing home residence by 0.17 percentage points (p 0.056).
  
  
  CONCLUSIONS
  Consistent with other studies, our findings suggest that state policies favoring an emphasis on HCBS may reduce nursing home residence among low-income older adults with hip fracture who are at high risk for institutionalization.
authors.affiliation: Department of Health Care Organization and Policy, University of Alabama at Birmingham School of Public Health, RPHB 330K, 1720 2nd Ave S, Birmingham, AL, 35294-0022, USA. jblackburn@uab.edu.
authors.forename: J
authors.initials: J
authors.lastname: Blackburn
authors.affiliation: Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham School of Medicine, 933 19th Street South, CH19 218, Birmingham, AL, 35294-2041, USA.
authors.forename: J L
authors.initials: JL
authors.lastname: Locher
authors.affiliation: Department of Health Policy and Management, School of Public Health, 306 SPH Administration Building, Texas A&M University, College Station, TX, 77843-1266, USA.
authors.forename: M A
authors.initials: MA
authors.lastname: Morrisey
authors.affiliation: Department of Health Care Organization and Policy, University of Alabama at Birmingham School of Public Health, RPHB 330K, 1720 2nd Ave S, Birmingham, AL, 35294-0022, USA.
authors.forename: D J
authors.initials: DJ
authors.lastname: Becker
authors.affiliation: Department of Health Care Organization and Policy, University of Alabama at Birmingham School of Public Health, RPHB 330K, 1720 2nd Ave S, Birmingham, AL, 35294-0022, USA.
authors.forename: M L
authors.initials: ML
authors.lastname: Kilgore
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003153:Community Health Services / Q000191:economics*; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006291:Health Policy / Q000191:economics; D006620:Hip Fractures / Q000191:economics / Q000534:rehabilitation*; D006699:Home Care Services / Q000191:economics; D006707:Homes for the Aged / Q000706:statistics & numerical data; D006801:Humans; D007326:Institutionalization / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D008134:Long-Term Care / Q000191:economics; D008297:Male; D008484:Medicaid; D006278:Medicare; D009735:Nursing Homes / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods; D014481:United States
keywords: HCBS; Hip fracture; Long-term care; Medicaid; Medicare