Place of death among older Americans: does state spending on home- and community-based services promote home death?

Med Care. 2008 Aug;46(8):829-38. doi: 10.1097/MLR.0b013e3181791a79.


Background: The majority of Americans die in institutions although most prefer to die at home. States vary greatly in their proportion of home deaths. Although individuals' circumstances largely determine where they die, health policies may affect the range of options available to them.

Objective: To examine whether states' spending on home- and community-based services (HCBS) affects place of death, taking into consideration county health care resources and individuals' family, sociodemographic, and health factors.

Methods: Using exit interview data from respondents in the Health and Retirement Study born in 1923 or earlier who died between 1993 and 2002 (N = 3362), we conducted discrete-time survival analysis of the risk of end-of-life nursing home relocation to examine whether states' HCBS spending would delay or prevent end-of-life nursing home admission. Then we ran logistic regression analysis to investigate the HCBS effects on place of death separately for those who relocated to a nursing home and those who remained in the community.

Results: Living in a state with higher HCBS spending was associated with lower risk of end-of-life nursing home relocation, especially among people who had Medicaid. However, state HCBS support was not directly associated with place of death.

Conclusions: States' generosity for HCBS increases the chance of dying at home via lowering the risk of end-of-life nursing home relocation. State-to-state variation in HCBS spending may partly explain variation in home deaths. Our findings add to the emerging encouraging evidence for continued efforts to enhance support for HCBS.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Aged, 80 and over
  • Community Health Services / economics
  • Community Health Services / statistics & numerical data*
  • Death*
  • Humans
  • Logistic Models
  • Nursing Homes / economics
  • Nursing Homes / statistics & numerical data*
  • Nursing Homes / trends
  • Residence Characteristics*
  • Terminal Care*