Although widely used and recommended to prevent falls in the home, there is a gap in understanding the efficacy of home modifications (HMs) in improving the safety of older adults. This is a significant issue given the recently increased policy and funding focus of the Affordable Care Act on preventing avoidable institutionalization by investing in home and community based services. The long term goal of this project is to improve the safety of community-dwelling older adults by reducing the occurrence of falls and allowing them to successfully "age in place". The objectives of this study are to inform policy decisions through a greater understanding of (1) disparities in access to HMs, (2) the potential for HMs to reduce morbidity and health care utilization, and (3) the influence of state spending for HMs on health care utilization. The central hypothesis is that because HMs are not a benefit covered by Medicare, individuals who are socially and economically disadvantaged will have decreased access to these devices. It is also expected that the presence of HM devices in the home environment will improve safety, and that increased state funding for HMs among dual Medicare-Medicaid enrollees will decrease rates of institutionalization, as well as emergency room use and hospitalization for fall-related injuries. These hypotheses will be tested by the following three specific aims: (1) Investigate the relationship between sociodemographic and economic factors and the presence of HMs when controlling for individual health and function;(2) Determine whether HMs reduce the likelihood of future falls, fall-related emergency room visits and hospitalizations, and subsequent nursing home placement;(3) Determine whether state-level Medicaid generosity for HMs impacts the rates of future falls, fall-related emergency room visits and hospitalizations, and subsequent nursing home placement among a cohort of community-dwelling Medicare/Medicaid dual-enrollees. Each of these aims will be investigated by analyzing data from the recently released National Health and Aging Trends Study (NHATS), a nationally-representative survey of Medicare enrollees over the age of 65 with extensive information regarding the home environment, health, and functional capacity linked to data from Medicare claims and Medicaid expenditures. We will employ propensity-score based methods and state-level fixed effects to improve causal inference by controlling for the influence of confounding factors. By using datasets, methods and outcomes that have not previously been applied to this question, findings from the proposed study will inform future policy decisions regarding the expansion of coverage for HMs beyond the Medicaid population, and have the potential to influence national rates of institutionalization.
The proposed research is relevant to public health because home modifications are a low-cost intervention that can reduce rates of in-home falls and fall-related injuries, and subsequently delay or prevent institutionalization among older adults. This is relevant to the mission of AHRQ because the project investigates devices that can directly impact the safety of a vulnerable population. Also, the results of this work will inform evidence based practice, reduce unnecessary costs associated with emergency room use, hospitalization and institutionalization, and promote improved quality of care by identifying socioeconomic disparities in access to these devices.