Among Medicare beneficiaries with diabetes, does post-acute home health care use reduce the risk of rehospitalization?
Creators: name: Smith, Jamie Marie
Publisher: name: No Publisher Supplied
Year: 2021

description: Diabetes affects more than one-quarter of older adults living in the United States. Patients with diabetes are at increased risk of adverse outcomes due to medication changes and exacerbated co-occurring conditions following hospitalizations. Post-acute home health care can support safe transitions home with clinical assessments, medication reconciliation, and reinforcement of self-management skills. The extent to which race/ethnicity and societal factors affect access to home health care and rehospitalization risk has not been fully explored. Therefore, the study's purpose was to 1) examine the association between race/ethnicity, hospital discharge referral, and subsequent use of home health care; and 2) explore the relationship between the timing of home health initiation and 30-day rehospitalization risk following diabetes-related hospitalizations. This dissertation was a cohort analysis of Medicare fee-for-service and Medicare Advantage beneficiaries who experienced a diabetes-related hospitalization in 2015 and were discharged home with or without home health services. The study used Medicare administrative, claims, and assessment data. The analytic approach included using multivariate logistic regression models to assess for predictors of home health referral and use within 14 days of hospital discharge. Then multivariate logistic regression models included patient demographics, clinical, and geographic variables to evaluate the relationship between the timing of home health care initiation and 30-day rehospitalizations. Inverse probability weighted propensity scores were incorporated to account for potential confounding factors.Racial/ethnic differences were uncovered in home health referral and use. In the fully adjusted models, Hispanic and American Indian/Alaska Native patients were 20% less likely to be referred to home health than white patients (p &lt;0.05). Among patients who received referrals, all racial/ethnic minority patients were less likely to receive home health care within 14-day of hospital discharge. Medicare Advantage and Medicaid Advantage/Medicaid beneficiaries were half as likely to receive services as fee-for-services patients (p &lt;0.05). The Centers for Medicare and Medicaid Services' require initial home health visits within two days of hospital discharge. The study found patients experienced increased risk of hospitalization when those visits were delayed (3-7 days) and late (8-14 days) (p &lt;0.001). The relationship between the timing of home health initiation and rehospitalization was significant across racial/ethnic groups. Asian American/Pacific Islander and American Indian/Alaska Native patients were most affected by timing; they were 6 to 7 times more likely to be rehospitalized when home health was late (p &lt;0.001). The study findings suggest systemic disparities in post-acute home health access by race/ethnicity and insurance. Furthermore, the findings provide compelling evidence that prompt home health can reduce rehospitalizations in this population. Additional work should address the systemic barriers to prompt home health care. Future research should use a racial justice lens when exploring relationships among institutional and structural determinants on post-acute services.