Why Do Elders Leave Home Care and Enter Nursing Facilities?

Abstract

History of Home Care: Home care enables elders and disabled adults to thrive at home and avoid nursing facility placement. Home care services are diverse and include visiting nurses, homemakers, and personal care assistants. Early health insurance systems provided for a limited suite of home care services, and later home care use accelerated. Home care is often “pitched” as a less costly alternative to nursing facility care, although early demonstration projects failed to document cost savings. Nonetheless, home care utilization continues to grow nationwide, and federal and state home care systems allow millions of Americans to remain in their communities. Massachusetts in particular has been a state leader in progressive home care policies. Student Role: While earning an MPH, I interned with the Massachusetts Executive Office of Elder Affairs. With a goal to strengthen home care services in Massachusetts, I conducted a chart review of elders and disabled adults living in Massachusetts who discontinued home care services after entering nursing facilities. I continued scholarly work on home care policy after returning to the Medical School with a historical analysis of American home care policies. Methods: I extracted key quantitative and qualitative data for a geographically representative sample of 108 former home care consumers (who were not nursing home eligible at the time they received home care services), including: program details, caregiver characteristics, medical co-morbidities, recent falls, recent hospitalizations, request for nursing facility placement, home care agency involvement in discharge planning, steps taken to prevent or delay placement, and key themes surrounding home care discontinuation. Results: Former home care consumers often (70%) had multiple informal supports, and caregivers were infrequently (16%) stressed. Most consumers had medical conditions in three or more bodily systems and took nine or more medications. About half (48%) had recently fallen and most (76%) were recently hospitalized. Consumers and family members requested placement about half (49%) of the time, and home care agencies participated in post-rehabilitation discharge planning only 37% of the time. Clear steps were taken to prevent or delay nursing facility placement in 28% of cases. Discussion: Hospitalizations led to rehabilitation followed by nursing facility placement for most consumers. Home care agencies struggle to communicate with rehabilitation case managers and are frequently excluded from discharge planning. I suggest potential strategies to improve inter-organizational communication, as well as tackle caregiver stress and senior housing insecurity.