Growth in the prevalence of dementia will intensify the challenges of delivering appropriate care to persons with dementia (PWD) and their family caregivers. Consistent with care preferences and evidence of cost savings, long-term care is shifting away from institutional care facilities to the home setting. PWD are increasingly living at home throughout the course of their illness, typically with multiple comorbid illnesses requiring concurrent management. The increasing delivery of home-based clinical care holds promise for supporting PWD and their family caregivers by allowing clinicians to address the complex social, environmental, medical, and safety concerns that emerge for this population. This project will critically enhance our understanding of the lives of persons with dementia by focusing on two key components of Medicare home-based clinical care delivery: (1) home-based medical care provided by physicians, physician assistants and nurse practitioners and (2) skilled home health care provided by professionals (e.g., nurses, physical therapists) on an episodic basis for homebound individuals. Using two longitudinal cohorts, the Health and Retirement Study (HRS) and the National Health and Aging Trends Study (NHATS), linked to Medicare claims and geospatial data, this project will document the utilization of home-based clinical services among PWD living in the community (Specific Aim 1), evaluate disparities in receipt of home-based clinical services (Specific Aim 2), and examine the consequences of these services (Specific Aim 3). Utilizing rich longitudinal cohorts, administrative data, geospatial analysis, and rigorous methods, this project examines disparities in home-based care delivery while considering key factors such as gender, function and coexisting illness burden. We will also evaluate the consequences of use of these services for patients and families. Such information will guide care delivery for this vulnerable population in the context of a growing shift towards person-centered, home-based care. Our results will inform the evolution of home-based medical care and skilled home health care policy. They will also instruct the larger context of home-based care delivery by offering insights on what fosters high quality care for persons with dementia. The proposed analyses can serve as a platform for future investigations examining best practices for serving PWD and their caregivers. Most importantly, the knowledge generated by this proposed study is an important step in developing and expanding services to support the growing numbers of PWD.
