Changes in nursing home use following Medicaid-supported expanded access to home- and community-based services for older adults with dementia
Open accessAbstract
Importance: New York State's Medicaid managed long-term care (MLTC) program expanded access to home- and community-based services, providing an alternative to nursing home care for people with dementia. Between 2012 and 2015, the state implemented mandatory MLTC for dual Medicare and Medicaid enrollees requiring more than 120 days of community-based long-term care. Objective: To evaluate changes in nursing home use among older adults with dementia following MLTC implementation. Design, Setting, and Participants: This cohort study used longitudinal data from January 1, 2011, to December 31, 2019, from the Minimum Data Set and Medicare administrative data. The study sample included New York State Medicare beneficiaries 65 years and older with dementia. New York City residents were excluded due to insufficient pre-study period data. Data were analyzed from January 1, 2011, to December 31, 2019. Exposure: Mandatory MLTC enrollment. Main Outcomes and Measures: Longitudinal models were used to evaluate changes in annual days of nursing home use following the staggered implementation of MLTC across 13 regions of the state. Two models were estimated: (1) a logistic regression model for any nursing home use in a given year and (2) a linear regression model of total nursing home days, conditional on any nursing home use. Models included annual event-time indicators specified as years until or since MLTC implementation. To capture MLTC effects for dual enrollees relative to non-dual Medicare enrollees, models included interaction terms for dual enrollment and event-time indicators. Results: This sample included 463 947 Medicare beneficiaries with dementia who lived in New York State between 2011 and 2019 (50.2% younger than 85 years; 64.4% women). Implementation of MLTC was associated with lower odds of nursing home use among dual enrollees, ranging from 8% lower odds 2 years post implementation (adjusted odds ratio, 0.92 [95% CI, 0.86-0.98]) to 24% lower odds 6 years post implementation (adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]). Compared with a scenario of no MLTC, MLTC implementation was associated with an 8% reduction in annual days of nursing home use between 2013 and 2019 (mean, -5.6 [95% CI, -6.1 to -5.1] days per year). Conclusions and Relevance: The findings of this cohort study suggest that implementation of mandatory MLTC in New York State was associated with less nursing home use among dual enrollees with dementia and that MLTC may help prevent or delay nursing home placement among older adults with dementia.
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More supportive policy environments, such as the Netherlands' government-funded nursing homes or Medicaid alternatives in the United States, were reported to ease financial strain and promote smoother transitions into home or community-based care.
“In contrast, more supportive policy environments, such as the Netherlands’ government-funded nursing homes or Medicaid alternatives in the United States, were reported to ease financial strain and promote smoother transitions into home or community-based care (Groenvynck et al., 2022; Harrison et al., 2023).”
From Mind the gap: a systematic review of barriers, facilitators, and experiences of care transitions for people living with dementia and their informal caregivers. (2026) · cites this paper as Harrison et al., 2023
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- Authors
- Harrison, J. M., Sheng, F., Josberger, R. E., Liu, H. H., Stone, P. W., Luchsinger, J. A., & Dick, A. W.
- Affiliations
- RAND Corporation (US)
- New York State Department of Health (US)
- NutritionQuest (United States) (US)
- Columbia University (US)
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
- Corresponding author
- Harrison, Jordan M.
- Venue
- JAMA Network Open
- Publisher
- American Medical Association (AMA)
- Published
- 2023-07-10
- Volume
- 6
- Issue
- 7
- Pages
- e2322520
- ISSN
- 2574-3805 (ISSN-L)
- PMC
- PMC10334251
- OpenAlex
- W4383710627
- Cited by
- 7
- References
- 22
- Citations by year
- 2026: 1 · 2025: 5 · 2024: 1
- FWCI
- 2.46
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JAMA Network Open (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health
- National Institute on Aging (R21AG069787, K24AG045334)
- Topics
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Keywords
- nursing home use, home and community-based services, dementia, older adults, long-term care, New York State, policy implementation, Medicare beneficiaries, Minimum Data Set, New York City
- MeSH terms
- Aged, Community Health Services, Dementia, Female, Medicare, Humans, Male, Medicaid, New York City, Nursing Homes, United States, Cohort Studies
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