Association for Public Policy Analysis & Management

People with dementia (PWD) are among the highest spenders in the US health care system, experiencing high rates of hospitalizations, outpatient and emergency department visits, and long-term care placement. Among older adults dually-eligible for Medicare and Medicaid, Medicaid spending among those with dementia is three times as high as those without dementia. System fragmentation of medical and non-medical services, and poor continuity of care impacts the ability of PWD and their caregivers to engage appropriately and constructively with the health care system. The Maximizing Independence for People With Dementia (MIND) at Home program is a care coordination program for PWD and their caregivers. A randomized pilot trial of this program showed a significant delay in time to all-cause transition from home of almost 9 months among participants over a median of 26 months, compared to augmented usual care. Through a Health Care Innovation Award funded by CMMI, a larger study of the MIND at Home program was conducted to evaluate the effects of a care coordination program for PWD and their caregivers on health care spending. We evaluate the impact of MIND at Home on PWD and their caregivers on total Medicaid spending, as well as by service type. A difference-in-difference analysis of Medicaid spending among MIND at Home participants and matched controls from two-year pre-enrollment to five quarters of the intervention period using population-averaged linear regression with panel data. Spending differences are also analyzed by type of service. This analysis uses Medicaid claims data for 120 dually-eligible MIND participants and 374 propensity score-matched controls living in Baltimore, Maryland and surrounding counties. The results of the regression analysis showed total Medicaid spending per quarter among participants is lower compared to controls in the intervention period compared to the pre-enrollment period. Nearly all of the savings come from slower growth in Medicaid inpatient spending and long-stay nursing home spending for participants compared to controls. Participants saw changes in the distribution of their spending in the intervention period to increased home and community-based services and physician services, and decreased inpatient and outpatient services. MIND at Home dementia care coordination program resulted in both a reduction in total Medicaid spending and a redistribution of spending away from costly and potentially unnecessary acute care towards services like home and community-based services and physician services that better support PWD living in the community. Federal and State Medicaid programs, as a funder of both health care and long-term services and supports for qualifying, low-income individuals with physical or cognitive impairment, or provider organizations at full financial risk for health and LTSS spending such as Fully Integrated Duals Eligible Special Needs Plans (FIDE SNPs) would benefit from adopting care coordination activities like those provided through the MIND at Home program.