Does Paid Versus Unpaid Supplementary Caregiving Matter in Preventable Readmissions?

Home health beneficiaries with diabetes using paid supplementary caregivers had 68% higher hazards of readmission due to urinary tract infection than those with unpaid supplementary caregivers.
Published Online: March 17, 2017
Hsueh-Fen Chen, PhD; Taiye Oluyomi Popoola, MBBS, MPH; and Sumihiro Suzuki, PhD
ABSTRACT

Objectives:
To examine the impact of paid and unpaid supplementary caregiving on preventable readmissions among Medicare home health beneficiaries with diabetes. 

Study Design: A retrospective cohort study with a home health episode as the unit of analysis. 

Methods: We gathered multiple 2009 Medicare data and national datasets (eg, Area Health Resources File). We used propensity score matching based on beneficiaries’ predisposing, enabling, and health need factors to create matched cohorts for episodes solely assisted by paid supplementary caregivers versus those solely assisted by unpaid supplementary caregivers. We applied Cox regression on the matched cohorts to estimate the 30-day preventable readmissions, including diabetes-related conditions, heart disease-related conditions, chronic obstructive pulmonary disease, urinary tract infection (UTI), pneumonia, and dehydration.

Results: Among beneficiaries (81,481) who received assistance several times during the day and night or several times during only the day, 7.34% were solely assisted by paid supplementary caregivers and 86.34% were solely assisted by unpaid supplementary caregivers. In the matched cohorts, we found that beneficiaries with paid supplementary caregivers had 68% higher hazards of readmission due to UTIs than those with unpaid supplementary caregivers.

Conclusions: The Medicare program is moving toward value-based purchasing and penalizing home health agencies with poor quality of care. It is critical for home health professionals to invite paid and unpaid supplementary caregivers to initiate care plans and assess their competence. Policies that support unpaid supplementary caregivers can also assist caregivers to care for their loved ones and prevent them from using expensive hospital resources. 

Am J Manag Care. 2017;23(3):e82-e88
Takeaway Points
  • Among beneficiaries who received assistance several times during the day and night or several times during only the day, 7.34% and 86.34% were assisted solely by paid and unpaid supplementary caregivers, respectively. 
  • Beneficiaries with diabetes and paid supplementary caregivers had a 68% higher hazard of readmission due to urinary tract infections than those with unpaid supplementary caregivers. 
  • The Medicare program is moving toward value-based purchasing. It is critical for home health professionals to invite paid and unpaid supplementary caregivers to initiate care plans and assess their competence. Policies supporting unpaid supplementary caregivers can reduce beneficiaries’ used of expensive hospital resources.
Approximately 3.4 million Medicare home health beneficiaries receive professional home health services that are paid for by Medicare.1 These beneficiaries, on average, received 19 visits from home health professionals during an episode of home healthcare, defined as up to 60 days, in 2014.1 A study based on a large home health agency in New York found that in addition to receiving services from home health professionals, 83.4% of home health beneficiaries received supplementary care from informal caregivers, of which 7% were paid, in order to meet their needs.2 These paid informal caregivers (hereafter, called paid supplementary caregivers) are paid through beneficiaries and/or families out of pocket or through other programs (eg, Medicaid). 

The interpersonal relationships between home health beneficiaries and unpaid informal caregivers (hereafter, called unpaid supplementary caregivers) and the interpersonal relationships between home health beneficiaries and paid supplementary caregivers are different. Unpaid supplementary caregivers are beneficiaries’ family members, relatives, and/or friends. They have solid relationships with their patients and understand what patients need without requiring much communication whereas paid supplementary caregivers are introduced by home health agencies and have no prior relationships with the beneficiaries and/or their families. Therefore, they need to learn how to meet patients’ needs through communication that is often difficult, given a high prevalence of limitation in cognitive function among Medicare home health beneficiaries.3

Regardless of the differences in the interpersonal relationships, paid and unpaid supplementary caregivers provide emotional and social support and a wide scope of direct care to patients, ranging from necessary medical care (eg, medication dispensing and wound care) to assistance with activities of daily living (ADL) (eg, toileting and eating) and/or instrumental activities of daily living (eg, shopping and laundry).4,5 Given the scope of care activities, paid and unpaid supplementary caregivers are a vital part of a healthcare team and have a significant impact on home health beneficiaries’ health outcomes.

About 1.8 million Medicare home health beneficiaries received postacute care in 2012.1 In order to reduce readmission under the Affordable Care Act (ACA), the Medicare Payment Advisory Commission endorsed a home health financial incentive program for reducing preventable readmissions for home health agencies.1 Paid and unpaid supplementary caregivers play a critical role in caring for beneficiaries during the transition from hospitals to homes and postacute care,6 and can therefore impact the likelihood of preventable readmissions. Under a home health financial penalty program, investigating the potential difference in preventable readmissions of Medicare home health beneficiaries with these 2 types of supplementary caregivers is imperative for the home health industry.

The purpose of this study was to compare the likelihood of 30-day preventable readmissions among Medicare home health beneficiaries with diabetes who received care from unpaid supplementary caregivers with that of those who received care from paid supplementary caregivers. We chose diabetes because it is the most common disease (one-third) among Medicare home health beneficiaries,7 and diabetes significantly contributes to disabilities, such as blindness and amputation,8 that are associated with high demands for caregiving. 

Conceptual Framework         

We used Andersen’s Behavior Model of Health Services Use as a guiding framework for our statistical modeling.9 The Andersen model stated that healthcare utilizations and outcomes are a function of patients’ predisposing (eg, gender, race/ethnicity), enabling (eg, living alone), and health need factors (eg, ADL, cognitive disorders), as well as the characteristics of healthcare organizations and communities. This model fits our study well because evidence shows that the decision of whether to hire a paid caregiver depends on beneficiaries’ predisposing, enabling, and health need factors.10,11 Additionally, supplementary caregivers—one of the beneficiaries’ enabling factors—are part of the healthcare delivery team12 likely to affect beneficiaries’ health outcomes (eg, preventable readmissions).2,13 Lastly, the characteristics of organizations and communities are associated with beneficiaries’ health outcomes.14-16    

We applied Andersen’s framework in 2 stages: 1) we used beneficiaries’ predisposing, enabling, and health need factors to estimate the propensity of beneficiaries solely assisted by paid supplementary caregivers and those solely assisted by unpaid supplementary caregivers to construct a matched cohort10,11; and 2) we applied Cox regression on the matched cohort to estimate the difference in time to first 30-day preventable readmissions between these 2 groups, after controlling for the covariates. The conceptual framework is presented in the Figure

METHODS

Data Sources 

Based on the conceptual framework, we utilized several 2009 national datasets in the study. We extracted variables for beneficiary’s predisposing, enabling, and health need factors from several Medicare claim and assessment files discussed in our previous studies.17,18 (Operational definitions are provided in the eAppendix for review; eAppendices are available at ajmc.com.) The American Hospital Association (AHA) Annual Survey and Provider of Services (POS) file provide the characteristics (eg, ownership) of hospitals and home health agencies, respectively. Finally, the Area Health Resources File (AHRF) and Primary Care Service Area (PCSA) database from HHS provide the characteristics of communities where patients reside. 

Study Design and Sample

We conducted a retrospective cohort study with home health episode for postacute care as the unit of analysis. We identified episodes of postacute care—defined as receiving home health services within 14 days of hospital discharge1,16,19—by merging the Medicare Provider Analysis and Review (MedPAR) that provides the date of hospital discharge and the Outcome Assessment Information Set (OASIS) that provides the start date of home healthcare, recommended by the literature.19

In order to achieve our study aim, we used several criteria to select our study sample. First, beneficiaries must have received assistance several times during the day and night or several times only during the day. The OASIS B1 version provides the frequency of assistance (M0370),20 which allowed us to exclude beneficiaries who received assistance once daily or less, whose health outcomes are less likely to be significantly affected by supplementary caregivers. Second, beneficiaries could not be dual eligible because their family members could be paid supplementary caregivers under the Medicaid program. As discussed previously about interpersonal relationships, these family members as unpaid supplementary caregivers are quite different from the paid supplementary caregivers who are paid out of pocket by the beneficiaries and/or their families and do not have prior relationships to the beneficiaries and their families. We used the Master Beneficiary Summary File to determine dual eligibility and excluded these individuals from our study sample. Third, beneficiaries must solely rely on paid or unpaid supplementary caregivers (we provided detailed explanation in the subsection of “Paid and Unpaid Supplementary Caregivers”). Finally, beneficiaries must have been 65 years or older and enrolled in the fee-for-service (FFS) program.

Study Variables         

Paid and unpaid supplementary caregivers. We used 2 assessment codes from the OASIS B1 version to identify beneficiaries with solely paid or unpaid supplementary caregivers. The assessment code M0360 provides information regarding which primary caregiver is taking the lead responsibility.21 The categories of primary informal caregivers in code M0360 include a spouse or significant other, daughter or son, other family member, friend, neighbor, member of the community or church members, or paid helper.21 The assessment code M0350A-M0350E (M0350A indicates that beneficiaries did not have an assisting individual) provides information on whether assisting individuals were paid (M0350B) or unpaid helpers (M0350C-M0350E).22 

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