Medicaid Long-term Care Policies and Rates of Nursing Home Successful Discharge to Community

Objectives: Successful discharge of nursing home (NH) residents to community has been reported in Nursing Home Compare (NHCompare) as a quality indicator, yet it is likely influenced by the availability of home- and community-based services (HCBS). Medicaid NH reimbursement rates and bed-hold policies have been shown to be related to quality of care, which may also affect successful discharge. This study explores the relationship of state Medicaid long-term care policies and successful discharge. Design: Longitudinal study of Medicaid policies and NHCompare successful discharge rates over 3 time periods, 2014-2015, 2015-2016, and 2016-2017, using generalized estimating equation models. Setting and participants: 11,694 unique NHs. Measures: Risk-adjusted rates of successful discharge were downloaded from NHCompare. Truven's “Medicaid Expenditures for Long-term Services and Supports” reports provided states' expenditures on HCBS and NHs. Details of bed-hold policies in 2014 were obtained from the Medicaid and CHIP Payment and Access Commission. Data on NH and market characteristics were extracted from LTCFocUs.org and Area Health Resources File. Results: The national average-adjusted successful discharge rates were 49.7%, 56.8%, and 56.2% in 2014-2015, 2015-2016, and 2016-2017, respectively. In 2015, states spent between 30.6% (Mississippi) and 82.2% (Oregon) on HCBS, with an overall average of 53.1%. States reimbursed NHs, on average, $185.7 per resident day. Five percent increase in Medicaid spending for HCBS was statistically significantly associated with 0.47% higher successful discharge rates. Compared to NHs in states with reimbursement rates in the first quartile (≤$152), NHs in the second ($153-$178), third ($179-$212), and fourth (≥$213) quartiles were associated with 2.33%, 1.86%, and 1.15% higher successful discharge rates (all P <. 01). Results were stronger in states without bed-hold policies. Conclusions/Implications: This study provides promising evidence to state governments that shifting expenditures from institutions to communities as well as more generous reimbursements to NHs may improve quality of care in NHs.