(P76) Structural Inequities in Outcomes for Dually-Medicare/Medicaid Enrolled Assisted Living Residents

Introduction/

Objective: To examine the association between the concentration of residents dually enrolled in Medicare and Medicaid in assisted living (AL) communities and residents’ risk of hospitalization and long-term nursing home (NH) admission.

Design/Methodology: We estimated linear regression models of the risk of each outcome in the first year of moving to AL. We adjusted for person-level clinical and demographic characteristics and fixed effects for the AL community and year. The exposure was a resident’s dual status interacted with the AL duals concentration: no-duals, low-duals [<=50%] (reference group), and majority-duals [>50%]. Medicare data from 2008–2017 and a national directory of licensed ALs. Sample included 538,275 traditional Medicare enrollees whose ZIP code indicated they moved to a large (25+ beds) AL during the study period.

Results: Overall, 12-month risks of hospitalization were higher for duals compared to non-duals (0.40 vs 0.32 per year, respectively; p= < 0.001), even after adjustment for demographic and clinical characteristics. In models with AL fixed effects, non-duals’ risk of hospitalization did not differ significantly with levels of duals concentration. Among dual-eligible residents, risk of hospitalization was 0.033 higher in a majority-duals AL than a low-duals AL, representing a 7.5% increase in the risk of hospitalization (p < 0.001).Duals had a higher risk of long-term NH transition than non-duals (0.077 vs 0.026, respectively; p< 0.001). For non-duals, moving to a no-duals AL lowered the risk of long-term NH admission by -0.002 compared to low-duals AL, a 7% decrease (P < 0.001), and majority-duals AL increased the risk by .012 (p=0.007), a 47% increase. For non-duals, moving to a majority-duals AL was not significantly associated with NH transition. For duals, however, moving to a majority-duals AL decreased the risk of long-term NH admission by -.0029, a 21% decrease, compared to a low-duals AL (p < 0.001).

Conclusion/

Discussion: Duals in AL have higher risk of hospitalization and NH admission than non-duals. For duals and non-duals, moving to an AL with a high concentration of duals conferred excess risk of hospitalization. Among duals, higher concentration of duals in AL decreases the risk of long-term NH admission. The higher rates of hospitalization among non duals in high-duals ALs suggest that quality may be a concern in communities that specialize in care for duals. However, because duals who are supported by Medicaid home- and community-based service funding require NH level of care, high-duals ALs may be better equipped to provide more comprehensive care as an alternative care to NH. It is also possible that if low-dual ALs have higher out-of-pocket costs or fewer Medicaid beds, then dual residents may be more likely to transfer to NHs because of financial reasons.