Geographic Disparities in Hospital Readmissions Among Older Adults in Public Home Care

Background/Purpose: Scholars have recognized the importance of community resources for hospital readmissions. Limited empirical studies, however, examine the extent to which the number and the kind of long term care organizations in neighborhoods are associated with hospital readmissions. Growing evidence is the role of place in shaping disparities in the delivery and quality of health care. Thus, this study aims: first, to document the geographically-differentially distributed long-term care infrastructures for older adults’ community-based care, and second, to examine whether living in neighborhood with high number of long term cares reduce the number of hospital readmissions using Medicaid-funded home care beneficiaries.

Methods: This study utilized Michigan interRAI-HC (2008-2013), an enumerative database of persons in the state who qualify for federal and state funded home and community-based care programs. A comprehensive clinical assessment information was concatenated with census data using clients’ residential ZIP codes. This study focused on the sample of older adults (60+) in Medicaid Waivers and case management programs, who have hospitalized at any time during observations.

The main dependent variable of interest was multiple episodes of hospitalization—the number of times during the last 90 days if clients have inpatient acute hospital with overnight stay. Independent variables at neighborhood level included number of organizations in sectors: assisted living, nursing home, home health care, and social service organizations. A composite measure that sums total number of organizations, and the number of organizations in each sector was tested as separate predictors.

Multilevel negative binomial model was applied to account for the nature of outcome (i.e. count) data and individuals clustered in the neighborhood. The assessment was based on any two waves of assessment that are equivalent to the 3-months of follow-up and test hospital readmissions in a 3-months span. This study also included a wide range of sociodemographic, social support, and health (e.g. morbidity) variables at both neighborhood- and individual-levels.

Results: The results indicate that older adults living in area with high number of nursing home in residential area reduces the number of hospital readmissions. The possible mechanisms explaining this association are informal and formal coordination efforts (e.g. referrals) across acute care and long term care organizations (Coleman, 2003), and institutional competition among long term care organizations that may directly increase the quality of care in home care (Grabowski & Hirth, 2003), all of which may in turn reduce hospital readmissions.

Conclusions and Implications:

Starting in October 2012, Center for Medicare and Medicaid had begun reducing payments to hospitals with high rates of all-cause readmission for certain conditions under Hospital Readmissions Reduction Program. In a recent health policy context that directly directed toward to reduce hospital admissions, we are likely to overburden the responsibility of readmissions to the hospitals and individuals and their families if we do not consider the role of long term care infrastructure in which older individuals are resided. Examining geographic disparities in hospital readmissions among public home care population is critical to identify effective interventions that involve service coordination and placed-based solutions.