Racial, ethnic, and income inequities in functional improvement within and between home health agencies

Objective: To quantify racial, ethnic, and income-based disparities in home health (HH) patients’ functional improvement within and between HH agencies (HHAs). Data Sources: 2016-2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data. Study Design: We use a multinomial-logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five-category outcome; (1) discharged with functional improvement; (2) discharged without functional improvement; (3) death while still a patient; (4) transfer to inpatient setting; and (5) still using HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins. Principal Findings: Of the 3+ million Medicare beneficiaries with a HH start-of-care assessment in 2016, 69% experienced functional improvement at discharge, 7% were discharged without functional improvement, 0.4% died, 20% were transferred to an inpatient setting, and 4% continued using HH. Adjusting for selected individual-level characteristics, Black and low-income HH patients had a lower adjusted rate of functional improvement at discharge (-1.1pp (95% CI: -1.4, -0.7) -4.4pp; (95% CI: -4.6, -4.1), respectively), as compared to their White and higher income counterparts. Additionally, Black, Hispanic/Latine, and low-income HH patients were all more likely to be discharged without functional improvement (1.2pp (95% CI: 0.9, 1.4), 1.2pp (95% CI: 0.7, 1.7), 0.5pp (95% CI:0.4, 0.6), respectively) compared to their White and higher income counterparts. After including HHA fixed effects, the differences for Black and Hispanic/Latine HH patients are generally mitigated. However, outcome disparities for all low-income HH patients persists within HHAs. Conclusions: A large part of the overall disparity in functional outcomes among Black, Hispanic/Latine, and low-income home health patients is attributable to agencies’ characteristics; therefore, improving access to higher quality HH services for our most vulnerable HH patients is imperative to improve outcomes.
LCC Working Paper Series