• Laura P Sands, Huiping Xu, Michael Weiner, Marc B Rosenman, Bruce A Craig, and Joseph Thomas.
• School of Nursing, Purdue University, West Lafayette, Indiana 47907-2069, USA. lsands@purdue.edu
• Med Care. 2008 Apr 1;46(4):449-53.

BackgroundMedicaid waiver home and community-based long-term care services (HCBS) may provide a partial solution to the escalating costs of long-term care. Persons with dementia can have complex caregiving needs; it is unknown whether their expenditures and resource utilization differ between community-based versus institutional settings.ObjectiveTo compare expenditures and resource utilization for Medicaid recipients with dementia who received long-term care through a nursing home versus HCBS waivers.DesignTwelve-month cohort study.SettingIndiana Medicaid administrative data from 2001 through 2004.ParticipantsMedicaid recipients with dementia who lived in the community 6 months before receiving long-term care through nursing homes (N = 1534) or HCBS waivers (N = 174).MeasurementsMonthly inpatient and emergency department rates and total expenditures adjusted for prior use, demographics, insurance status, and comorbidities.ResultsAdjusted rates of inpatient use were stable for nursing home patients (0.06) but significantly increased over 12 months for HCBS recipients (0.07-0.12; P = 0.048). Adjusted total expenditures increased over 12 months from $1419 to $2002 for HCBS recipients (P < 0.001), but remained stable for those in nursing homes ($3413-$3336). Long-term care expenditures were on average $1688 per month higher for those in nursing homes.ConclusionsThe escalation in inpatient use for HCBS waiver recipients suggests that future development of HCBS programs should consider the unique needs of persons with dementia so as to optimize their health outcomes. Despite increasing inpatient use among HCBS recipients, their overall expenditures remained significantly lower than those of nursing home patients.

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