Integrated Home- and Community-Based Services Improve Community Survival Among Independence at Home Medicare Beneficiaries Without Increasing Medicaid Costs

J Am Geriatr Soc. 2019 Jul;67(7):1495-1501. doi: 10.1111/jgs.15968. Epub 2019 May 10.


Objectives: To determine the effect of home-based primary care (HBPC) for frail older adults, operating under Independence at Home (IAH) incentive alignment on long-term institutionalization (LTI).

Design: Case-cohort study using HBPC site, Medicare administrative data, and National Health and Aging Trends Study (NHATS) benchmarks.

Setting: Three IAH-participating HBPC sites in Philadelphia, PA, Richmond, VA, and Washington, DC.

Participants: HBPC integrated with long-term services and supports (LTSS) cases (n = 721) and concurrent comparison groups (HBPC not integrated with LTSS: n = 82; no HBPC: n = 573). Cases were eligible if enrolled at one of the three HBPC sites from 2012 to 2015. Independence at Home-qualified (IAH-Q) concurrent comparison groups were selected from Philadelphia, PA; Richmond, VA; and Washington, DC.

Intervention: HBPC integrated with LTSS under IAH demonstration incentives.

Measurements: Measurements include LTI rate and mortality rates, community survival, and LTSS costs.

Results: The LTI rate in the three HBPC programs (8%) was less than that of both concurrent comparison groups (IAH-Q beneficiaries not receiving HBPC, 16%; patients receiving HBPC but not in the IAH demonstration practices, 18%). LTI for patients at each HBPC site declined over the three study years (9.9%, 9.4%, and 4.9%, respectively). Costs of home- and community-based services (HCBS) were nonsignificantly lower among integrated care patients ($2151/mo; observed-to-expected ratio = .88 [.68-1.09]). LTI-free survival in the IAH HBPC group was 85% at 36 months, extending average community residence by 12.8 months compared with IAH-q participants in NHATS.

Conclusion: HBPC integrated with long-term support services delays LTI in frail, medically complex Medicare beneficiaries without increasing HCBS costs.

Keywords: community survival; home- and community-based care; independence at home; provider managed care.

Publication types

  • Multicenter Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Community Health Services / economics*
  • Female
  • Frail Elderly
  • Health Services for the Aged / economics*
  • Home Care Services / economics*
  • Humans
  • Independent Living / economics*
  • Male
  • Medicaid / economics*
  • Medicare / economics*
  • Primary Health Care / economics*
  • Quality of Health Care
  • Survival Rate
  • United States / epidemiology