State Support for Home and
Community-Based Services and
Elderly Well-Being
Naoko Muramatsu, Ph.D
University of Illinois at Chicago
AcademyHealth Annual Research Meeting, Chicago IL
June 28, 2009
This research, “State Long-term Care Policy and Elderly Well-Being (SLOTEC)”, was supported
by the National Institute on Aging (R01 AG021648). The SLOTEC research team included
Richard T. Campbell, Hong Yin, Ruby Hoyem, Chris Ross, and Martha Jacob.
Home & Community-Based Services
(HCBS)

U.S. has made progress towards
expanding HCBS.


Personal care, adult-day care, nutrition and
transportation services, etc.
Intended to help persons with disabilities
avoid institutionalization.
States Vary in HCBS Support

Funding sources
Medicaid (state plan, waiver)
 Older Americans Act
 Social Services Block Grants
 State general funds


HCBS expenditures per person 65+ 2002
Average: $375
 Range: $30 (TN) - $1080 (NY)

Study Questions

Does living in a state supportive of HCBS
make a difference in elderly well-being?
1.
2.
Psychological well-being (depression)
Chance of aging in the community



↓Nursing home admission
Return to community from nursing home
Dying at home
Data

Person-level: Health and Retirement Study
(HRS) Five-wave panel data (1993-2002).

National representative samples of noninstitutionalized adults aged 70 + as of 1993
State-level: HCBS support (total HCBS $)
 County-level: LTC service availability

Analytic Approaches



Multilevel repeated measures analysis
(depressive symptoms)
Discrete-time survival analysis (nursing
home admission and discharge)
Multilevel logistic regression (chance of
dying at home)

Controls: respondents’ demographic, social,
economic, health and caregiving resources that
change over time.

Does living in a state supportive of HCBS
make a difference in elderly well-being?
1.
2.
Psychological well-being (depression)
Chance of aging in the community



↓Nursing home admission
Return to community from nursing home
Dying at home
Stress Process Model

Declining physical and cognitive function
stressful for seniors & spouse




Consistently low function: chronic stress
Recent/rapid declines: acute stress
Stress  depressive symptoms
Caregiving contexts modify stress process


Non-spouse family availability
State HCBS support
States’ HCBS & Psychological
Well-Being
Stress of functional limitations
1 Chronic stress: indiv means
• I/ADL
Depressive
Symptoms
• Cognition
(Yes/no)
2 Acute stress: changes
Resources: Care-giving Contexts
• Non-spouse care availability
• State HCBS support
1.1 State HCBS Protects Seniors from
Chronic Stress of Functional Limitations
Predicted probability of depression
.6
.5
.4
8 limitations
7
6
5
4
3
2
1
0
.3
.2
.1
0
$28
$76
$206
$561
$1230
State HCBS expenditures (logged)
Chronic stress: Intra-person means of I/ADL limitations; underlying levels of function)
Two-way interaction between state HCBS & mean ADL/IADL
1.2 State HCBS Protects Seniors from
Acute Stress of Functional Limitations
Predicted probability of depression
.4
.3
7 more limitations
6
5
4
3
2
1
0
1 less limitations
.2
.1
0
$28
$76
$206
$561
$1230
State HCBS expenditures (logged)
Acute stress: changes in I/ADL from one’s underlying level of function
Two-way interaction between state HCBS & I/ADL changes
1.3 State HCBS Protects Seniors without Family Help
Predicted probablity of depression
from Chronic Stress of Severe Cognitive Limitations
Have family help
No family help
.2
.1
0
$28
$76
$206
$561
$1230 $28
$76
$206
$561
$1230
State HCBS expenditures (logged)
90 percentile (High cognitive impairment)
75 percentile
50 percentile
20 percentile
10 percentile (Low cognitive impairment)
Three-way interaction among state HCBS, mean cognition & non-spouse family
availability

Does living in a state supportive of HCBS
make a difference in elderly well-being?
1.
2.
Psychological well-being (depression)
Chance of aging in the community



↓Nursing home admission
Return to community from nursing home
Dying at home
States’ HCBS &
Chance of Aging In Community
State-level
HCBS support
Nursing home
admission
• First
• End-of-life
County-level
health resources
Place of
death
Individual-level factors
Socio-demographic
Health & function
Family availability
Individual-level end-of-life status
Socio-demographic
Cause & timing of death
Health
Family availability
2.1 State HCBS Delays/Prevents First Nursing Home
Admission (>=90 days) among Childless Seniors
Discrete Time Survival Model (HRS, cohort born 1923 or earlier) ‘93-’02
Source: Muramatsu, et al., 2007. “Risk of Nursing Home Admission among Older Americans:
Does States’ Spending on Home and Community-Based Services Matter?” Journal of
Gerontology: Social Sciences, 62(3):S169-178.
2.2 State HCBS Support, Home Deaths, &
Community Discharges from Nursing Homes

State HCBS ↓ risk of end-of-life nursing
home relocation*

 Increased Chance of Dying at Home*

State HCBS not associated with return to
community for nursing home residents.
*Source: Muramatsu, et al. 2008. “Place of Death among Older Americans: Does State
Spending on Home- and Community-based Services Promote Home Death?” Medical
Care 46(8): 829-838.
Conclusion

Where seniors live matters for their wellbeing: living in a state with higher HCBS
support was associated with greater wellbeing among community-dwelling seniors
with functional limitations, especially
among those with limited family support.
Policy Implications



This study provides evidence for the importance
of continued state and federal efforts to sustain
and increase HCBS funding.
Aging baby boomers with fewer children.
Proportion of those who lack family caregivers
and the role of HCBS will continue to grow.
Political will is needed to prepare society for
increasing LTC needs, especially at this time of
economic hardship.