Missed Home Health Care in Older Adults with Dementia: Identifying Drivers, Outcomes, and Costs

Project Summary/Abstract The overarching goal of this R01 proposal “Missed Home Health Care in Older Adults with Dementia: Identifying Drivers, Outcomes, and Costs” is to identify key drivers and mitigators of missed home health care (HHC), test whether missed HHC is related to clinical outcomes and costs, and identify best practices to reduce missed HHC for vulnerable older adults with Alzheimer’s Disease and Related Dementias (ADRD). Home health care provides key in-home supports, including nursing and therapies, for older adults with ADRD and their caregivers following hospitalization. However, approximately one-third of patients never receive HHC that is planned following hospitalization, and rates of missed HHC may be even higher in adults with dementia. Missed HHC may be related to a shrinking number of HHC agencies, limited HHC access in disadvantaged or rural communities, patients declining HHC services, and/or payer-related factors such as prior authorizations. Missed HHC is associated with adverse outcomes including higher hospital readmissions, mortality, and costs, yet outcomes for older adults with ADRD who have missed HHC after hospital discharge are unknown. We propose using a mixed methods approach to: (1) Identify correlates of missed home health care following hospital discharge in older adults with dementia (quantitative);(2) Characterize drivers and mitigators of missed home health care from the perspectives of hospitalists, discharge planners, home health care clinicians, caregivers and older adults with ADRD (qualitative); and (3) Test if missed HHC is associated with higher readmissions, mortality, and/or healthcare costs after discharge for older adults with ADRD (quantitative). Our investigator team has expertise with qualitative, quantitative, and mixed methods in the HHC setting and includes experts in geriatrics, ADRD, and health economics using Medicare and Medicare Advantage data. Our work is guided by both the Conceptual Framework to Guide Intervention Research Across the Trajectory of Dementia Caregiving and the Practical, Robust Implementation and Sustainability Model (PRISM) framework. This innovative work will advance understanding of missed HHC for patients with ADRD, which will be critical as post-acute care continues to shift from facilities to the home, Medicare Advantage enrollment continues to grow, and the number of adults with ADRD continues to surge. This proposal is responsive to high-priority topic areas described in NOT-AG-21-046, including care transitions from hospital to home settings with attention to timeliness and availability of HHC to support caregivers for older adults with ADRD. Ultimately, we aim to leverage key findings to develop interventions and policy recommendations that will reduce missed HHC and improve clinical outcomes for older adults with ADRD and their caregivers.