Enrollees with nursing home stays tended to have either very short or very long spells of care (34 percent and 41 percent, respectively), indicating a mix of residents some of whom likely need only temporary care (for example, post-acute cases) while others will likely require access to nursing and medical services for the remainder of their lives. A significant number of enrollees with new spells (31 percent) were not enrolled in Medicaid prior to the beginning of their Medicaid-financed spell, at which point approximately half (49 percent) qualified for benefits under "other" eligibility criteria -- which include the 300 percent rule -- while most others qualified under cash assistance-related or medically needy provisions. One possible explanation for this finding is that many enrollees had incomes that were higher than the SSI standard prior to beginning their Medicaid-financed spells, and some were already residing in the nursing home, paying for services through Medicare, private insurance, or out-of-pocket.
One of the most significant findings is that a substantial minority of enrollees with new spells also used HCBS at some point during 2006 or 2007. Among those with spells of six months or less, 30 percent used HCBS prior to receiving nursing home services, while more than one in four used HCBS following discharge. This suggests the possibility that a significant number of enrollees with nursing home stays used HCBS and institutional care in an integrated fashion and therefore that single-point of entry or "no wrong door" approaches to allowing individuals to access LTSS -- as embodied by the Aging and Disability Resource Centers and other approaches -- could be particularly valuable in helping individuals and their family members navigate the system of LTC as their needs change over time.
Although the percentage of nursing home spells lasting three months or less was generally higher in states with larger investments in HCBS relative to nursing homes and higher HCBS utilization rates (and the percentage lasting 12 months or more was generally lower), these associations were not especially large. This is not surprising, given the many variables that determine both length-of-stay and HCBS use that were not considered here. It is likely that further analysis of the relationship between patterns of HCBS and nursing home use at the person-level, as explained by individual enrollees' distinct characteristics and needs, will yield results with a clearer interpretation.
Relative to the 2001-2002 period studied by Wenzlow et al. (2008), there were fewer elderly and people with disabilities enrolled in Medicaid in 2006-2007, and fewer of these individuals had either new or ongoing nursing home spells. The percentage of this population receiving care in nursing homes declined slightly in states that allocated a high proportion of their Medicaid LTC expenditures to HCBS while rising slightly in others, and the positive associations between the percentage of spells lasting less than three months and the proportion of Medicaid LTC spending allocated to HCBS (as well as the percentage of Medicaid-financed LTC recipients using HCBS) observed in the earlier study were confirmed here with the more recent data.