Special Article
The Use of Medicare Home Health Care Services
N Engl J Med 1996; 335:324-329August 1, 1996
- Abstract
Background
Medicare's home health care program, consisting primarily of home visits by nurses and health aides, was conceived as a means to facilitate hospital discharge. Because home health care is now one of the fastest-growing categories of Medicare expenditures, we analyzed Medicare claims data to determine current patterns of use.
Methods
We used 1993 data from Medicare's National Claims History File to examine the temporal relation between home visits and hospital discharge, as well as the number of months Medicare enrollees received home health care. To determine whether home visits replaced hospital services, we calculated population-based utilization rates, adjusted for age and sex, for enrollees living in the 310 U.S. metropolitan statistical areas and determined whether the areas with higher rates of home health care also had lower admission rates or shorter lengths of stay. Finally, we compared the geographic variation in use of home health care with that of other Medicare services.
Results
Roughly 3 million Medicare enrollees received over 160 million home health care visits in 1993. Seventy-eight percent of the visits either occurred more than a month after hospital discharge (35 percent) or were not associated with any inpatient care during the previous six months (43 percent). Home health care often represented a long-term intervention: 61 percent of the visits were to enrollees who received home health care for six months or more. We could find no evidence that home health care was substituted for hospital care; the metropolitan statistical areas with higher rates of home health care did not have fewer hospital admissions or shorter lengths of stay. There was more geographic variation in the use of home health care than in the use of other major categories of Medicare services (e.g., hospital admissions and physicians' services). Five states (all in the South) had more than 9000 visits per 1000 enrollees, and 14 states had fewer than 3000 visits per 1000 enrollees.
Conclusions
Home health care visits are used primarily to provide long-term care. There is no evidence that services provided at home replace hospital services, and the dramatic geographic variation in home visits suggests a lack of consensus about their appropriate use.
Media in This Article
Figure 2
Distribution of Visits to Medicare Enrollees According to the Number of Months Home Health Care Was Received in 1993.Figure 3
Number of Home Health Care Visits per 1000 Medicare Enrollees in the Contiguous United States in 1993.Article Activity
- Article
Medicare expenditures for home health care are growing exponentially. Home health care reimbursements grew from $2 billion in 1988 to $12.7 billion in 1994 and now account for more than 8 percent of the total budget for Medicare.1 This growth was predominantly the result of the 1988–1989 liberalization and standardization of coverage for home health care services,2 which in turn fostered a substantial increase in the number of home health agencies certified by Medicare. Between 1989 and 1995, the number of such agencies increased by more than 50 percent (from 5676 to 8747), and the number of for-profit agencies more than doubled (from 1818 to 3730).3
Home health care was originally conceived as a means to facilitate earlier hospital discharge — that is, it was to be transitional care following hospitalization.2 In fact, before 1980, Medicare regulations stipulated that only beneficiaries who had been hospitalized could receive home health services. The incentive to decrease the length of stay under the prospective-payment system helped emphasize the transitional role of home health care and encouraged hospitals to provide the service. For selected diagnosis-related groups (DRGs), there is evidence that home health care was indeed effective in decreasing the length of stay4,5 and that patients were being discharged earlier, in an earlier phase of their illness.6
The potential role for home health care greatly expanded during the 1980s.2 In 1980, the requirement that home visits be restricted to enrollees who had recently been hospitalized was eliminated, and home health care began to be used more broadly. Toward the end of the decade, the medicare manual for home health agencies was revised in response to litigation. Two changes were critical: first, coverage could no longer be denied solely because a patient had a chronic disease; and second, a physician's prescription of home health care services could no longer be rejected unless objective clinical evidence contradicted the order.
These changes set the stage for rapid growth. Although earlier studies have documented an increase in the number of home health care visits7,8 and geographic variation in expenditures for these services,5 clinicians may not be familiar with the current levels and patterns of use. We analyzed 1993 Medicare claims data to determine, first, the extent to which home health care services have moved beyond the provision of transitional care; second, whether there is strong evidence that home health care replaces other health care services; and third, the current geographic variation in the use of home health care.
Methods
We analyzed 1993 data in the National Claims History File, which is maintained by the Health Care Financing Administration. The standard 1 percent random sample was used for selected national analyses, whereas the full file was used for geographic analyses. We also determined the use of hospitals and skilled-nursing facilities and employed previously analyzed data on physicians' services.9
Definition of a Visit
Our primary measure of the use of home health care services was the number of visits, as opposed to the number of recipients or episodes of care.10 To reflect the resources expended as directly as possible, we weighted the data on visits according to the costs of various categories of home health services. Medicare uses six categories for payments. Most visits fall into two categories: skilled-nursing care, which accounts for 42 percent of visits, and care provided by home health aides, which accounts for 47 percent; the other four categories are physical therapy, which accounts for 8 percent, and speech therapy, occupational therapy, and medical social services, which account for 3 percent. We developed a relative-value unit for each category, which was based on the ratio of the average national reimbursement for that category (e.g., about $83 for a visit by a nurse and about $41 for a visit by a health aide) to the average cost of all home visits (about $64).11 Thus, a visit by a nurse counted as 1.3 visits (83 ÷ 64), whereas a visit by a health aide counted as 0.64 visit (41 ÷ 64). All the data on visits reported here reflect this refinement.
Claims Data
Claims for home health care include information on the number of visits; the visit category; the prescribing physician's unique provider identification number; the diagnostic code in the International Classification of Diseases, Ninth Revision; the enrollee's identification number; and the dates of visits. Because the original reason for offering home health care was to facilitate hospital discharge, we used the enrollee's identification number and dates of visits to link home health care claims to the most recent hospital discharge. To determine the temporal relation between home visits and hospitalization in a single year, we restricted this analysis to visits in the second half of 1993 and documented hospital discharges in the six months preceding the visits.
Home health care claims were aggregated for each beneficiary to create a user-level file. With this file, we determined the distribution of visits on the basis of the number of months in which beneficiaries received services. We also created user-level files for the use of hospitals and skilled-nursing facilities.
Population-Based Analyses
The three user-level files were merged with the Health Care Financing Administration's Denominator File to calculate population-based rates for the use of home health care services, hospitals, and skilled-nursing facilities. Because claims from health maintenance organizations (HMOs) are filed irregularly, HMO enrollees were excluded from the analysis. The unit of analysis was the metropolitan statistical area, as defined by the Bureau of the Census. There are 310 such areas in the United States. Use of services was ascribed to the geographic area where the enrollee resided rather than to the place where the service was delivered. Indirect standardization was used to adjust the data according to the age and sex of the enrollees.
We then investigated whether home health care served as a substitute for hospital care (Table 1Table 1
Correlations between Home Health Care and Care Provided in a Hospital or Skilled-Nursing Facility, According to 1993 Medicare Claims Data.). We further analyzed hospitalizations to determine whether home health care shortened the length of hospital stays (using visits within 10 days after discharge) or was a substitute for admission (using all visits). To increase the chances of detecting the use of home health care to shorten the length of stay, we performed an analysis restricted to DRGs frequently associated with home visits within 10 days after discharge. Whereas 17 percent of all hospital discharges were followed by home visits within 10 days, the 18 DRGs in this subanalysis were associated with home visits after at least 35 percent of the discharges (i.e., the DRGs were at least twice as likely to involve subsequent home health care). Similarly, to increase the chances of detecting the use of home health care as a substitute for admission, we performed an analysis restricted to DRGs for which hospitalization is highly variable (i.e., the decision to admit the patient is particularly subject to the physician's discretion).12,13 We also examined the use of home health care as a possible substitute for care provided in skilled-nursing facilities. Because Medicare coverage for care in a skilled-nursing facility is limited to conditions related to prior hospitalization (20 days are covered in full, with a substantial copayment for the next 80 days), we restricted the analysis to home health care visits within 2 months after hospital discharge.
Finally, we examined the geographic variation in the use of home health care and compared it with the geographic variation in the use of other Medicare services.
Results
Of the 33.4 million Medicare enrollees not enrolled in HMOs, roughly 3 million (9 percent) received a total of over 160 million home health care visits in 1993. Two thirds of these visits were prescribed by generalist physicians (internists, family practitioners, or general practitioners). The recipients of home health care were older than the nonrecipients and were more likely to be female and poor.
Relation between Home Visits and Hospital Discharge
Figure 1Figure 1
Relation between Home Health Care Visits and Hospital Discharges within the Previous Six Months among Medicare Enrollees in 1993. shows that most home health care visits took place long after hospital discharge, if they were preceded by hospitalization at all. Less than a quarter of home visits (22 percent) were preceded by a hospital stay within 30 days. Nearly half the visits (43 percent) were not associated with an inpatient stay in the previous six months. Thus, only a small proportion of home visits could have been made for the purpose of easing the transition from hospital to home.The data in Figure 2Figure 2
Distribution of Visits to Medicare Enrollees According to the Number of Months Home Health Care Was Received in 1993. show that home visits were often part of a long-term intervention. Almost two thirds of the visits (61 percent) were to enrollees who received six or more months of home health care, whereas only 4 percent were to enrollees who received such care for a month or less. The bulk of the visits involved a relatively small number of enrollees: 30 percent of the recipients had more than 50 visits each and accounted for three quarters of all the visits. The majority of the diagnoses reported in home health care claims were chronic conditions (such as diabetes and cardiovascular disease), providing further evidence that home visits often represent long-term care (data not shown).Home Health Care as a Substitute for Other Services
It is possible that home health visits were substituted for other health care services — in other words, increased use of home health care visits was associated with decreased use of other Medicare services. Table 1 shows the correlation coefficients for home health care visits and measures of the use of hospitals and skilled-nursing facilities. A negative correlation coefficient would indicate that increased use of home health care was associated with decreased use of other services, suggesting a substitution of home care for these other services. The only evidence of substitution for hospital care was in the analysis of length of stay with respect to 18 DRGs frequently associated with home health care after discharge; this correlation was weak and not statistically significant. All other correlations between home health care and hospital care were positive, suggesting that metropolitan statistical areas with high rates of hospitalization also have high rates of home health care. The association between the use of home health care and the use of skilled-nursing facilities was not significant.
Geographic Variation
Figure 3Figure 3
Number of Home Health Care Visits per 1000 Medicare Enrollees in the Contiguous United States in 1993. shows the number of home health care visits per 1000 Medicare enrollees in each state. Utilization rates tended to be highest in the South and lowest in the upper Midwest. Five states had more than 9000 visits per 1000 enrollees: Tennessee (13,460 visits), Mississippi (12,350), Louisiana (11,130), Alabama (9990), and Georgia (9230); three states had fewer than 2000 visits per 1000 enrollees: Minnesota (1825), Hawaii (1744), and South Dakota (1425).Figure 4Figure 4
Coefficient of Variation for Major Categories of Medicare Services. shows that there was considerably more variation in expenditures for home health care than in expenditures for other categories of Medicare services. With the metropolitan statistical area as the unit of analysis, the coefficient of variation for home health visits greatly exceeded the coefficients of variation for services provided by hospitals, physicians, and skilled-nursing facilities. This dramatic variation suggests that there is no national consensus on whether and, if so, how often to use home health care.Discussion
Although easing the transition from the hospital to the home was the original purpose of Medicare's home health care program, the results of our analysis show that this purpose actually accounts for a small proportion of home health care expenditures. Furthermore, our analysis raises questions about how successful this program is in reducing expenditures for other services. Even when we focused the analysis on the DRGs for which home health care is most frequently prescribed after discharge, there was no obvious evidence that home health care visits resulted in shorter hospital stays. And despite the evidence that home care provided to severely disabled veterans14 and elderly patients with congestive heart failure15 may lower hospital costs, metropolitan statistical areas with high rates of home health care visits also have high rates of hospital use, in terms of both length of stay and rate of admission.
In fact, in terms of resources expended, home health care in 1993 was no longer predominantly linked to acute care. Most visits were to recipients who had not recently been hospitalized, who received visits over extended periods, and who were treated for chronic conditions. Thus, home health care has become primarily a form of long-term care.
The provision of long-term care represents a new role for the Medicare program. Although the program has covered services in skilled-nursing facilities, they are not the services most clinicians would associate with conventional long-term institutional care. The nursing home services covered must be related to a prior hospitalization and must be limited in duration. Coverage for home health care visits has no such restrictions, however, allowing the visits to be used for the provision of long-term care.
What kind of long-term care is provided through home health visits? Whereas some visits may involve intravenous therapies and assistance with complex therapeutic regimens, others may serve as an alternative to a trip to a medical facility for simple diagnostic tests (e.g., phlebotomy) or therapy (e.g., dressing changes). Home health aides have played an increasingly large part in the provision of home care2 and now account for almost half the visits. These visits may also provide companionship and assistance with personal hygiene or household chores. Home health care may thus be a way to institutionalize societal “caring” and may be, at best, only tangentially related to medical care. Such visits may thus substitute for care previously provided by family members or friends.
We found considerable geographic variation in the use of home care. The magnitude of the variation (almost 10 times as many visits per 1000 Medicare enrollees in the state with the highest use as in the state with the lowest use) makes it extremely unlikely that the disease burden is the only explanation.
Three factors may contribute to the variation observed. First, the variation in home health care services may be explained in part by local nursing home practices. Our study is limited in its ability to determine the extent to which home visits serve as a substitute for nursing home care. Although we did not find any evidence that home visits were substituted for care provided by skilled-nursing facilities, most nursing home care is paid for either out of pocket or by state Medicaid programs, and these expenditures are not included in our data. We examined the discharge destinations of hospitalized patients admitted from home to determine the proportion discharged to nursing homes and used these data as a proxy for overall use of nursing home care. There was a weak negative correlation between the use of home health care and the proportion of discharges to nursing homes. Although most of the reports in the literature have questioned the effectiveness of home health care as a substitute for nursing home care,16-19 the results of a recent trial suggest that a comprehensive geriatric assessment followed by infrequent home visits can reduce the use of nursing homes.20
Second, the geographic variation may in part reflect state Medicaid policy. Medicare expenditures for home health visits may be a mirror image of Medicaid expenditures for such visits. The five states with the highest home-visit rates in our analysis of Medicare data indeed have fairly low rates of Medicaid spending on home and community-based care, as reported in the State Long-Term Care Profiles Report. 21 When we examined this relation in all 50 states, however, we found that little of the variation in the Medicare expenditures was explained by the Medicaid expenditures. Because the Medicaid data provide only a crude estimate of state services provided to the elderly, the role of state policies in determining the use of the Medicare home health care program remains uncertain.
Finally, some of the geographic variation may be the result of business practices. Over half the recipients of home health care in the five highest-use states are served by for-profit agencies, which is roughly twice the national average.22 For-profit agencies have been shown to provide considerably more visits per episode of care than other agencies.23 Furthermore, because of budget cuts, home health care claims are less and less likely to be reviewed by Medicare.23 There has been growing concern about fraud in the industry (with recent convictions on the charge24,25), the prevalence of which may vary geographically.
Pressures on providers and patients are likely to result in further increases in the use of home health care in the future. Given the large reservoir of needs that nurses may identify during home visits, it may be difficult to stop such care. As other health care providers begin to focus on providing services that meet quantifiable standards of efficacy, home health care nurses may focus on the need for human contact, which is difficult to quantify. The demand for home health care may be reinforced by increasingly complex outpatient regimens that can be administered only through home visits. And because there are few disincentives for such services and no out-of-pocket costs, controlling expenditures may be very difficult, particularly given active advertising and the value placed on care received in the comfort of one's own home.26,27
Controlling the growth of home health care will ultimately require that physicians either live with rigid rules (e.g., visits allowed only within the first month after discharge, with no more than 50 visits per enrollee per year) or take a more active role in determining the need for such care. Currently, physicians may view their role as simply signing the required form and may be only vaguely aware that it is they, not nurses, who authorize home health care. A more active role on the part of physicians, however, will require information on when and how best to use home care. Equally important will be a social consensus about exactly what constitutes health care.
Supported by a grant (Cooperative Agreement No. 95-C-90401) from the Health Care Financing Administration to the Maine Medical Assessment Foundation. Dr. H.G. Welch is the recipient of a Veterans Affairs Career Development Award in health services research and development.
The views expressed here are those of the authors and do not necessarily represent the views of the institutions with which they are affiliated.
We are indebted to Xiaoqang Ren and Joe McGoldrick for programming assistance and to Robert Pritchard, M.D., Genevieve Kenny, Ph.D., and Andrew Dodds, M.D., for their critique of the manuscript.
Source Information
From the Veterans Affairs Medical Center, White River Junction, Vt. (H.G.W.); the Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, N.H. (H.G.W., D.E.W.); the Maine Medical Assessment Foundation, Augusta (D.E.W.); Maine Medical Center, Portland (D.E.W.); and the Urban Institute, Washington, D.C. (W.P.W.).
Address reprint requests to Dr. H.G. Welch at the Veterans Affairs Outcomes Group (111B), Veterans Affairs Medical Center, White River Junction, VT 05009.
- References
References
1
House Committee on Ways and Means. Overview of entitlement programs. Washington, D.C.: Government Printing Office, 1994. (Publication no. WMCP:103-27.)
2
Helbing C ,Sangl JA ,Silverman HA . Home health agency benefits. Health Care Financ Rev1992;125-1483
Halamandaris VJ. Basic statistics about home care 1995. Washington, D.C.: National Association for Home Care, 1995.
4
Kenney GM . Understanding the effects of PPS on Medicare home health use. Inquiry 1991;28:129-139
Web of Science | Medline5
Kenney GM ,Dubay LC . Explaining area variation in the use of Medicare home health services. Med Care 1992;30:43-57
CrossRef | Web of Science | Medline6
Shaughnessy PW ,Kramer AM . The increased needs of patients in nursing homes and patients receiving home health care. N Engl J Med 1990;322:21-27
Full Text | Web of Science | Medline7
Bishop C ,Skwara KC . Recent growth of Medicare home health. Health Aff (Millwood) 1993;12:95-110
CrossRef | Web of Science | Medline8
Mauser E ,Miller NA . A profile of home health users in 1992. Health Care Financ Rev 1994;16:17-33
Web of Science | Medline9
Welch WP, Verrilli DK. Geographic variation in the use of Medicare physician services: a databook to support state health care reform efforts. Washington, D.C.: Urban Institute, 1995. (Working paper no. 6433-004-02.)
10
Goldberg HB ,Schmitz RJ . Contemplating home health PPS: current patterns of Medicare service use. Health Care Financ Rev 1994;16:109-130
Web of Science | Medline11
Health Care Financing Administration
Medline12
Wennberg JE ,McPherson K ,Caper P . Will payment based on diagnosis-related groups control hospital costs? N Engl J Med 1984;311:295-300
Full Text | Web of Science | Medline13
Soule DN, Keller RB, Wennberg DE. Variations in admission rates and the implied appropriateness of hospital admissions. In: Health of Maine's hospitals: patterns of utilization and cash flow: final report to the Commonwealth Fund. Augusta: Maine Health Information Center, 1993:16-25.
14
Hughes SL ,Cummings J ,Weaver F ,Manheim LM ,Conrad KJ ,Nash K . A randomized trial of Veterans Administration home care for severely disabled veterans. Med Care 1990;28:135-145
CrossRef | Web of Science | Medline15
Rich MW ,Beckham V ,Wittenberg C ,Leven CL ,Freedland KE ,Carney RM . A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995;333:1190-1195
Full Text | Web of Science | Medline16
Gaumer GL ,Birnbaum H ,Pratter F ,Burke R ,Franklin S ,Ellingson-Otto K . Impact of the New York Long-Term Home Health Program. Med Care 1986;24:641-653
CrossRef | Web of Science | Medline17
Kemper P . The evaluation of the National Long Term Care Demonstration. 10. Overview of the findings. Health Serv Res 1988;23:161-174
Web of Science | Medline18
Swan JH ,Benjamin AE . Medicare home health utilization as a function of nursing home market factors. Health Serv Res 1990;25:479-500
Medline19
Weissert WG ,Hedrick SC . Lessons learned from research on effects of community-based long-term care. J Am Geriatr Soc 1994;42:348-353
Web of Science | Medline20
Stuck AE ,Aronow HU ,Steiner A , et al. A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community. N Engl J Med 1995;333:1184-1189
Full Text | Web of Science | Medline21
Ladd RC, Kane RL, Kane RA, Nielsen WJ. State long-term care profiles report. Minneapolis: National LTC Mentoring Program, Institute for Health Services Research, University of Minnesota, 1995.
22
Delfosse R. Hospice and home health agency characteristics: United States, 1991. Vital and health statistics. Series 13. No. 120. Washington, D.C.: Government Printing Office, 1995. (DHHS publication no. (PHS) 95-1781.)
23
General Accounting Office. Medicare home health utilization expands while program controls deteriorate: report to the Chairman, Special Committee on Aging. U.S. Senate, March 1996. Washington, D.C.: Government Printing Office, 1996. (Publication no. GAO/HEHS-96-16.)
24
Bureau of National Affairs. Executives for home health agency convicted for defrauding Medicare. Medicare Report. No. 6. August 11, 1995:959-60.
25
Idem. ABC Home Health Care Services, owner convicted of Medicare fraud. Medicare Report. No. 7. February 9, 1996:158-9.
26
Council on Scientific Affairs, Council on Medical Education
CrossRef | Web of Science27
Campion EW . New hope for home care? N Engl J Med 1995;333:1213-1214
Full Text | Web of Science | Medline
- Citing Articles (62)
Citing Articles
1
Matthew Parsons, Hugh Senior, Ngaire Kerse, Mei-hua Chen, Stephen Jacobs, Stephen Vanderhoorn, Craig Anderson. (2012) Should Care Managers for Older Adults Be Located in Primary Care? A Randomized Controlled Trial. Journal of the American Geriatrics Society 60:1, 86-92
CrossRef2
Evelyn Hutt, Stacey J. Elder, Ron Fish, Sung-Joon Min. (2011) Regional Variation in Mortality and Subsequent Hospitalization of Nursing Residents With Heart Failure. Journal of the American Medical Directors Association 12:8, 595-601
CrossRef3
Dianne V. Liebel, Bethel Ann Powers, Bruce Friedman, Nancy M. Watson. (2011) Barriers and facilitators to optimize function and prevent disability worsening: a content analysis of a nurse home visit intervention. Journal of Advanced Nursingno-no
CrossRef4
Benjamin T. Kopp, Wei Wang, Deena J. Chisolm, Kelly J. Kelleher, Karen S. McCoy. (2011) Inpatient healthcare trends among adult cystic fibrosis patients in the U.S.. Pediatric Pulmonologyn/a-n/a
CrossRef5
Gideon A. Caplan, Anne Meller, Grad Cert. (2010) Home Care for Dying People. Journal of the American Medical Directors Association 11:1, 7-8
CrossRef6
Jennifer L. Wolff, Ann Meadow, Cynthia M. Boyd, Carlos O. Weiss, Bruce Leff. (2009) Physician Evaluation and Management of Medicare Home Health Patients. Medical Care 47:11, 1147-1155
CrossRef7
John D. FitzGerald, W. John Boscardin, Susan L. Ettner. (2009) Changes in Regional Variation of Medicare Home Health Care Utilization and Service Mix for Patients Undergoing Major Orthopedic Procedures in Response to Changes in Reimbursement Policy. Health Services Research 44:4, 1232-1252
CrossRef8
W. J. McAuley, W. Spector, J. Van Nostrand. (2009) Formal Home Care Utilization Patterns by Rural-Urban Community Residence. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 64B:2, 258-268
CrossRef9
Teija Hammar, Marja-Leena Perälä, Pekka Rissanen. (2009) Clients’ and workers’ perceptions on clients’ functional ability and need for help: home care in municipalities. Scandinavian Journal of Caring Sciences 23:1, 21-32
CrossRef10
Rachel L. Murkofsky, Karen Alston. (2009) The Past, Present, and Future of Skilled Home Health Agency Care. Clinics in Geriatric Medicine 25:1, 1-17
CrossRef11
Christine Chang, Susan S. Jackson, Tim A. Bullman, Elizabeth L. Cobbs. (2009) Impact of a Home-Based Primary Care Program in an Urban Veterans Affairs Medical Center. Journal of the American Medical Directors Association 10:2, 133-137
CrossRef12
Julie Leftwich Beales, Thomas Edes. (2009) Veteran's Affairs Home Based Primary Care. Clinics in Geriatric Medicine 25:1, 149-154
CrossRef13
Jennifer L. Wolff, Ann Meadow, Carlos O. Weiss, Cynthia M. Boyd, Bruce Leff. (2008) Medicare Home Health Patients’ Transitions Through Acute And Post-Acute Care Settings. Medical Care 46:11, 1188-1193
CrossRef14
Lori North, Linda Kehm, Katherine Bent, Timothy Hartman. (2008) Can Home-based Primary Care. The Nurse Practitioner 33:7, 39-44
CrossRef15
H. Temkin-Greener, A. Bajorska, D. B. Mukamel. (2008) Variations in Service Use in the Program of All-Inclusive Care for the Elderly (PACE): Is More Better?. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 63:7, 731-738
CrossRef16
Nihar R. Desai, Kristofer L. Smith, Jeremy Boal. (2008) The Positive Financial Contribution of Home-Based Primary Care Programs: The Case of the Mount Sinai Visiting Doctors. Journal of the American Geriatrics Society 56:4, 744-749
CrossRef17
Lacey Hartman, Stephanie L. Jarosek, Beth A. Virnig, Sara Durham. (2007) Medicare-Certified Home Health Care: Urban-Rural Differences in Utilization. The Journal of Rural Health 23:3, 254-257
CrossRef18
Barbara Pieper, Mary Sieggreen, Cheryl K. Nordstrom, Barbara Freeland, Pauline Kulwicki, Madelyn Frattaroli, Deborah Sidor, Maria Teresa Palleschi, Jerry Burns, Donna Bednarski. (2007) Discharge Knowledge and Concerns of Patients Going Home With a Wound. Journal of Wound, Ostomy and Continence Nursing 34:3, 245-253
CrossRef19
Graziano Onder, Rosa Liperoti, Manuel Soldato, Iain Carpenter, Knight Steel, Roberto Bernabei, Francesco Landi. (2007) Case Management and Risk of Nursing Home Admission for Older Adults in Home Care: Results of the AgeD in HOme Care Study. Journal of the American Geriatrics Society 55:3, 439-444
CrossRef20
M. Tousignant, N. Dubuc, R. Hébert, C. Coulombe. (2006) Home-care programmes for older adults with disabilities in Canada: How can we assess the adequacy of services provided compared with the needs of users?. Health and Social Care in the Community 0:0, 061031070510003-???
CrossRef21
Kristofer L. Smith, Katherine Ornstein, Theresa Soriano, David Muller, Jeremy Boal. (2006) A Multidisciplinary Program for Delivering Primary Care to the Underserved Urban Homebound: Looking Back, Moving Forward. Journal of the American Geriatrics Society 54:8, 1283-1289
CrossRef22
L A Szczech, P S Klassen, B Chua, S S Hedayati, M Flanigan, W M McClellan, D N Reddan, R A Rettig, D L Frankenfield, W F Owen. (2006) Associations between CMS's Clinical Performance Measures project benchmarks, profit structure, and mortality in dialysis units. Kidney International 69:11, 2094-2100
CrossRef23
Sandra Peterson, Evelyn Shapiro, Noralou P. Roos. (2005) Regional Variation in Home Care Use in Manitoba. Canadian Journal on Aging / La Revue canadienne du vieillissement 24:S1, 69
CrossRef24
Byung-Kwang Yoo, Jay Bhattacharya, Kathryn M. McDonald, Alan M. Garber. (2004) Impacts of Informal Caregiver Availability on Long-term Care Expenditures in OECD Countries. Health Services Research 39:6p2, 1971-1992
CrossRef25
Carolyn Wei Zhu. (2004) Effects of the Balanced Budget Act on Medicare Home Health Utilization. Journal of the American Geriatrics Society 52:6, 989-994
CrossRef26
Gabriel Picone, R. Mark Wilson, Shin-Yi Chou. (2003) Analysis of hospital length of stay and discharge destination using hazard functions with unmeasured heterogeneity. Health Economics 12:12, 1021-1034
CrossRef27
Theodore J Iwashyna, Nicholas A Christakis. (2003) Marriage, widowhood, and health-care use. Social Science & Medicine 57:11, 2137-2147
CrossRef28
Elizabeth A. Madigan, Susan Tullai-McGuinness, Richard H. Fortinsky. (2003) Accuracy in the outcomes and assessment information set (OASIS): Results of a video simulation. Research in Nursing & Health 26:4, 273-283
CrossRef29
Daren K. Heyland, Joan Tranmer, C.J. O'Callaghan, Amiram Gafni. (2003) The seriously ill hospitalized patient: Preferred role in end-of-life decision making?. Journal of Critical Care 18:1, 3-10
CrossRef30
Peter W. Shaughnessy, David F. Hittle, Kathryn S. Crisler, Martha C. Powell, Angela A. Richard, Andrew M. Kramer, Robert E. Schlenker, John F. Steiner, Nancy S. Donelan-McCall, James M. Beaudry, Kendra L. Mulvey-Lawlor, Karen Engle. (2002) Improving Patient Outcomes of Home Health Care: Findings from Two Demonstration Trials of Outcome-Based Quality Improvement. Journal of the American Geriatrics Society 50:8, 1354-1364
CrossRef31
Susan M. C. Payne, David L. DiGiuseppe, Negussie Tilahun. (2002) The Relationship of Post-acute Home Care Use to Medicaid Utilization and Expenditures. Health Services Research 37:3, 683-710
CrossRef32
David G. Fairchild, Joanne Hogan, Rebecca Smith, Michelle Portnow, David W. Bates. (2002) Survey of Primary Care Physicians and Home Care Clinicians. An Assessment of Communication and Collaboration. Journal of General Internal Medicine 17:4, 253-261
CrossRef33
Zuzka V. Blasi, Ann C. Hurley, Ladislav Volicer. (2002) End-of-Life Care in Dementia: A Review of Problems, Prospects, and Solutions in Practice. Journal of the American Medical Directors Association 3:2, 57-65
CrossRef34
Sarah B. Laditka, Mary Fischer, Kevin B. Mathews, Janine M. Sadlik, Mark E. Warfel. (2002) There's No Place Like Home: Evaluating Family Medicine Residents' Training in Home Care. Home Health Care Services Quarterly 21:2, 1-17
CrossRef35
BARBARA E. MILLEN, JAMES C. OHLS, MICHAEL PONZA, AUDREY C. McCOOL. (2002) The Elderly Nutrition Program. Journal of the American Dietetic Association 102:2, 234-240
CrossRef36
Michael E. Chernew, William G. Weissert, Richard A. Hirth. (2001) Heterogeneity of Risk in a Managed Home Health Care Population. Medical Care 39:9, 1002-1013
CrossRef37
Carolyn E. Adams, Yvonne Michel. (2001) Correlation Between Home Health Resource Utilization Measures. Home Health Care Services Quarterly 20:3, 45-56
CrossRef38
Korbin Liu, Sharon K. Long, Heidi Kapustka. (2001) Interactions Between Medicare and Medicaid Home Care in Connecticut: Responses to the 1997 BBA. Home Health Care Services Quarterly 20:3, 75-88
CrossRef39
Elizabeth A. Madigan, Donna Schott, Carol R. Matthews. (2001) Rehospitalization Among Home Healthcare Patients: Results of a Prospective Study. Home Healthcare Nurse 19:5, 298-305
CrossRef40
P Coyte. (2000) Costs and outcomes associated with alternative discharge strategies following joint replacement surgery: analysis of an observational study using a propensity score. Journal of Health Economics 19:6, 907-929
CrossRef41
Alexis A. Wilson. (2000) Normative Treatment Guidelines in Home Care: Building the Case. Home Healthcare Nurse 18:9, 574-578
CrossRef42
Jane E. Mahoney, Jan Eisner, Tom Havighurst, Shelly Gray, Mari Palta. (2000) Problems of Older Adults Living Alone After Hospitalization. Journal of General Internal Medicine 15:9, 611-619
CrossRef43
Neville Board, Nicholas Brennan, Gideon A. Caplan. (2000) A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients. Australian and New Zealand Journal of Public Health 24:3, 305-311
CrossRef44
Jack Hadley, David Rabin, Andrew Epstein, Susan Stein, Carolyn Rimes. (2000) Posthospitalization Home Health Care Use and Changes in Functional Status in a Medicare Population. Medical Care 38:5, 494-507
CrossRef45
Magnus A. Björkgren, Brant E. Fries, Lisa R. Shugarman. (2000) A RUG-III Case-Mix System for Home Care. Canadian Journal on Aging / La Revue canadienne du vieillissement 19:S2, 106-125
CrossRef46
Cheryl E. Woodson, Joe Feinglass, Rael Slavensky. (1999) Physicians' Capability in Home Health Practice: Home Health Nurses' Perceptions. Home Health Care Services Quarterly 17:4, 25-37
CrossRef47
David Mechanic. (1999) The changing elderly population and future health care needs. Journal of Urban Health 76:1, 24-38
CrossRef48
Iglehart, John K.. (1999) Medicare. New England Journal of Medicine 340:4, 327-332
Full Text49
Cindy Parks Thomas, Susan M. C. Payne. (1998) Home Alone: Unmet Need for Formal Support Services Among Home Health Clients. Home Health Care Services Quarterly 17:2, 1-20
CrossRef50
(1998) A Tale of Two Walls. Journal of General Internal Medicine 13:10, 718-719
CrossRef51
Susan M. C. Payne, Cindy Parks Thomas, Tanya Fitzpatrick, Manar Abdel-Rahman, Herbert L. Kayne. (1998) Determinants of Home Health Visit Length. Medical Care 36:10, 1500-1514
CrossRef52
Tom J. Wachtel, David R. Gifford. (1998) Eligibility for Home Care Certification What Clinicians Should Know. Journal of General Internal Medicine 13:10, 705-709
CrossRef53
Diana J. Torrez, Carroll Estes, Karen Linkens. (1998) The Impact of a Decade of Policy on Home Health Care Utilization. Home Health Care Services Quarterly 16:4, 35-56
CrossRef54
Campion, Edward W., . (1997) Can House Calls Survive?. New England Journal of Medicine 337:25, 1840-1841
Full Text55
Meyer, Gregg S., Gibbons, Robert V., . (1997) House Calls to the Elderly — A Vanishing Practice among Physicians. New England Journal of Medicine 337:25, 1815-1820
Full Text56
Lisa S Krivickas, Lauren Shockley, Hiroshi Mitsumoto. (1997) Home care of patients with amyotrophic lateral sclerosis (ALS). Journal of the Neurological Sciences 152, s82-s89
CrossRef57
Michael J. O'Sullivan, Beverly Volicer. (1997) Factors Associated with Achievement of Goals for Home Health Care. Home Health Care Services Quarterly 16:3, 21-34
CrossRef58
Richard H. Fortinsky, Elizabeth A. Madigan. (1997) Home Care Resource Consumption and Patient Outcomes: What Are the Relationships?. Home Health Care Services Quarterly 16:3, 55-73
CrossRef59
Marc P. Freiman, Nancy Breen. (1997) The Use of Home Care by Cancer Patients: A Multivariate Analysis. Home Health Care Services Quarterly 16:1-2, 3-19
CrossRef60
Iglehart, John K.. (1997) Health Issues, the President, and the 105th Congress. New England Journal of Medicine 336:9, 671-676
Full Text61
Mark E. Miller, W. Pete Welch, Herbert S. Wong. (1997) Exploring the Relationship Between Inpatient Facility and Physician Services. Medical Care 35:2, 114-127
CrossRef62
(1997) Medicare Home Health Care Services. New England Journal of Medicine 336:3, 226-228
Full Text
- Letters
