Factors Associated With Initial Type of Long-Term Services and Supports Among Dual-Eligible Beneficiaries

OBJECTIVE: To examine the association between individual characteristics and type of initial long-term services and supports (LTSS) among older adults receiving Medicaid home- and community-based services (HCBS) or nursing home (NH) care. DESIGN: Cohort study of traditional Medicare beneficiaries surveyed between 2002 and 2009 linked with Medicare and Medicaid administrative files through 2018. SETTING AND PARTICIPANTS: The study population includes 581 dual-eligible individuals aged ≥65 at the time of initial LTSS use. Study population was predominantly Black (67.1%), female (69.0%), and with a household income below $15,000/year (78.3%). METHODS: Initial HCBS and long-term NH use were identified using Medicaid data and Minimum Data Set (MDS) nursing home assessments. Sociodemographic factors were identified using the Southern Community Cohort Study (SCCS) survey dataset. Chronic conditions and prior health care use were identified using traditional Medicare claims. A multivariate logistic model predicted whether individuals initiated LTSS with HCBS use, adjusting for individual-level covariates and state and year fixed effects. RESULTS: Half of the sample (N = 291) initiated LTSS with HCBS and the other half (N = 290) initiated with NH use between 2008 and 2018. Factors associated with a higher likelihood of initiating LTSS with HCBS included Black race [marginal effect (ME), 0.13; 95% CI, 0.05-0.21] and female sex (ME, 0.19; 95% CI, 0.12-0.26). Factors associated with higher likelihood of initiating LTSS with NH instead of HCBS included older age, Alzheimer's disease and related dementias (ADRD) diagnosis, recent hospitalization, and higher education levels. Among individuals with ADRD, several factors-Black race, living with others, and prior emergency room use-were associated with higher likelihood of initiating LTSS with HCBS and prior hospitalization was associated with initial NH use. CONCLUSION AND IMPLICATIONS: Among dual-eligible older adults initiating LTSS, factors related to more complex medical needs were associated with a higher likelihood of NH use rather than HCBS use as their initial LTSS option.