Abstract
People with disorders of dementia experience cognitive, behavioral and psychiatric syndromes, require increasing support, and their care needs are complex and multidimensional. Nearly one-third of home health care patients in the U.S. have moderate to severe cognitive impairment, yet unique patterns of service use and cost have not been well examined. Objective: This study makes novel comparisons of home health care service use and cost between patients with moderate-to-severe cognitive impairment and those with little-to-no cognitive impairment. The goal is to determine whether an association exists between cognitive impairment status and home health care service volume, type, readmission, duration, and cost, both in the general home health care population and within each of four categories of primary source of service payment, including Medicare, Medicaid, private insurance, and self-pay. Methods: This study uses nationally-representative home health care data from the most recent and final (2007) National Home and Hospice Care Survey, consisting of 3,309 home health care patients nested within 595 agencies. This study compares service use and cost between patients with moderate-to-severe cognitive impairment and those with little-to-no cognitive impairment, as well as variations in the relationships between cognitive status and service utilization and cost by primary source of payment. Results: On average, those with moderate-to-severe cognitive impairment receive services for 111 more days, including about three more medical and two more non-medical service visits, and are 8% more likely to be readmitted to home health care. Additional costs of service that are associated with significantly greater durations and intensities of service are more likely to be incurred on multiple occasions because of readmission. The most influential factor in determining service costs is the insurance program used to pay for services. Conclusion: These findings suggest that patients with moderate-to-severe cognitive impairment may require services which are estimated to cost between 45% and 179% more than the services provided to those who have little-to-no cognitive impairment, on average, depending on primary source of payment. The rapid aging of the population, coupled with the considerable complications associated with dementia care, lends particular urgency to the need for intervention, program development, and policy change in this arena.