In-Home Care

Citation: Sands, L. P., Xu, H., Thomas, J., 3rd, Paul, S., Craig, B. A., Rosenman, M., Doebbeling, C. C., & Weiner, M. (2012). Volume of home- and community-based services and time to nursing-home placement. Medicare & medicaid research review, 2(3), mmrr.002.03.a03.

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  • | Peer Reviewed Article


The purpose of this study was to determine whether the volume of Home- and Community-Based Services (HCBS) that target Activities of Daily Living disabilities, such as attendant care, homemaking services, and home-delivered meals, increases recipients’ risk of transitioning from long-term care provided through HCBS to long-term care provided in a nursing home.

Data Sources:

Data are from the Indiana Medicaid enrollment, claims, and Insite databases. Insite is the software system that was developed for collecting and reporting data for In-Home Service Programs.

Study Design:

Enrollees in Indiana Medicaid’s Aged and Disabled Waiver program were followed forward from time of enrollment to assess the association between the volume of attendant care, homemaking services, home-delivered meals, and related covariates, and the risk for nursing-home placement. An extension of the Cox proportional hazard model was computed to determine the cumulative hazard of nursing-home placement in the presence of death as a competing risk.

Principal Findings:

Of the 1354 Medicaid HCBS recipients followed in this study, 17% did not receive any attendant care, homemaking services, or home-delivered meals. Among recipients who survived through 24 months after enrollment, one in five transitioned from HCBS to a nursing-home. Risk for nursing-home placement was significantly lower for each five-hour increment in personal care (HR=0.95, 95% CI=0.92-0.98) and homemaking services (HR=0.87, 95% CI=0.77–0.99).


Future policies and practices that are focused on optimizing long-term care outcomes should consider that a greater volume of HCBS for an individual is associated with reduced risk of nursing-home placement.