Abstract
BACKGROUND/OBJECTIVES: Home health (HH) is a major type of home-based skilled care available to Medicare beneficiaries. We examined the association between living situation (home alone, home with others, and assisted living (AL) residence) and utilization and functional outcomes among Medicare HH recipients. DESIGN: Analysis of national data from the Outcome and Assessment Information Set, HH Compare, Medicare claims, and Area Health Resource Files. SETTING: Medicare-certified HH agencies in the United States. PARTICIPANTS: National population of Medicare beneficiaries ≥65 years old who received HH care in CY 2017 (N = 6,637,496). MEASUREMENTS: Outcomes included time-to-event measures of hospitalization and emergency department (ED) visits, and improvement in activities of daily living (ADL) from the start to the end of the HH admission. RESULTS: AL residents (12%) and patients living alone at home (24%) had longer survival time without hospitalization and ED visits than patients living with others at home (64%). Adjusting for covariates and HH agency-level random effects, and compared with patients living with others, AL residents had lower risk of hospitalization (hazard ratio (HR) = 0.85, P < .001) and ED visit (HR = 0.92, P < .001); however, less ADL improvement (β = 0.29 (29% less of total independence in one ADL)); and patients living alone had lower risk of hospitalization (HR = 0.94, P < .001) and ED visit (HR = 0.93, P < .001), yet more ADL improvement (β = -0.15 (15% more of total independence in one ADL)). CONCLUSION: In the national population of Medicare HH recipients, patients living with others at home had the highest risk of hospitalization and ED visits, whereas AL residents had the lowest risk of hospitalization and patients living alone at home had the lowest risk of ED visits, meaning that combined support from HH and AL reduces acute care admissions. Evidence-based interventions are needed for HH patients living with others at home to avoid unnecessary acute care use.