Undocumented Dementia Diagnosis During Skilled Home Health Care: Prevalence and Associated Factors.

Background: Skilled home health (HH) is a critical source of clinical care for community-living older adults. One-third of HH patients have dementia, but poor information transfer may limit HH providers' awareness of dementia diagnosis. We determined the prevalence of undocumented dementia diagnosis among HH patients and associated care delivery patterns and clinical outcomes.

Methods: Among a 2018 national sample of Medicare HH patients, we compared those (1) without diagnosed dementia, (2) with dementia documented during HH, (3) with dementia undocumented during HH. Dementia diagnosis was determined from the Medicare Beneficiary Summary File claims-based indicator and documentation was determined via HH clinical assessments (OASIS). We measured HH care delivery and outcomes from claims and assessment data. We fit multivariable negative binomial and logistic regression models to estimate associations of dementia status and documentation with outcomes, while adjusting for patient- and HH agency-level characteristics and clustering at the HH agency level.

Results: Among 1,372,570 HH patients, 30% had diagnosed dementia. Among those with diagnosed dementia, most (69%) had this diagnosis go undocumented during HH. Compared to those with documented dementia, those with undocumented dementia had longer lengths of stay (+3.1 days; 95% CI: 6.4-7.1) and were more likely to receive physical therapy (aOR: 1.19; 95% CI: 1.16-1.22) and less likely to receive social work (aOR: 0.82; 95% CI: 0.80-0.84). Compared to those with documented dementia, those with undocumented dementia had higher odds of hospitalization (aOR: 1.20; 95% CI: 1.17-1.24) and Emergency Department use (aOR: 1.14; 95% CI: 1.11-1.17) and lower odds of discharge to self-care (aOR: 0.88; 95% CI: 0.86-0.90). Findings were robust to sensitivity analyses stratifying by cognitive symptom severity, functional impairment, clinical severity, and referral source.

Conclusions: Results suggest that HH providers often lack pertinent information regarding patients' dementia status, and patients with undocumented dementia more often experience acute care utilization.