Home-Health and Hospice Care -- United States, 1992

An estimated 9.5 million persons in the United States have difficulty performing basic life activities because of mental or physical health conditions (1). In recent years, an increasing range of home-care services -- including home-health care and hospice care -- have been created for persons requiring long-term care, and access to such care has been increased through public programs such as Medicare and Medicaid (2). To better characterize the use of these services in the United States, CDC's National Center for Health Statistics conducted the 1992 National Home and Hospice Care Survey (NHHCS), the first survey of home-health agencies and hospices and their patients. This report presents preliminary findings from the survey.

During September-December 1992, CDC used a three-stage probability sample design to survey 1500 agencies and approximately 14,000 patients that were selected from among 8036 agencies either classified by the 1991 National Health Provider Inventory as providing home-health or hospice care (3) or newly opened for business from November 1991 through June 1992. Differences are significant at the 0.05 level. Home-Health Care

On any day during the survey period, an estimated 1,237,100 patients received care from approximately 7000 home-health agencies in the United States (4). Most patients were female (67%) and married (33%) or widowed (36%); the average age was 70 years, and 75% were aged greater than or equal to 65 years (Table_1).

Most (55%) home-health patients received assistance in at least one of the activities of daily living (ADLs) crucial to independent community living (i.e., bathing, dressing, transferring in or out of a bed or chair, using the toilet, or eating). Approximately half (51%) received assistance in bathing; 44%, dressing; 33%, transferring in or out of a bed or chair; 24%, using the toilet; and 14%, eating. On average, agency staff assisted patients with 1.7 ADLs.

In addition to assistance in self-care activities, home-health patients received a variety of restorative, therapeutic, and social services. The most common of these were skilled nursing services (80%), personal care (45%), physical therapy (15%), homemaker/companion services (11%), social services (9%), and medications (8%).

First-listed diagnoses on admission to the agency varied among home-health patients. The most frequent diagnoses included heart disease (International Classification of Diseases, Ninth Revision, Clinical Modification {ICD-9-CM} codes 391-392.0, 393-398, 402-404, 410-416, and 420-429) (12%), diabetes mellitus (ICD-9-CM code 250) (8%), arthropathies and related disorders (ICD-9-CM codes 710-719) (6%), malignant neoplasms (ICD-9-CM codes 140-208 and 230-234) (6%), cerebrovascular disease (ICD-9-CM codes 430-436) (6%), essential hypertension (ICD-9-CM code 401) (4%), and fractures (ICD-9-CM codes 800-829) (4%). These diagnoses accounted for 46% of all first-listed diagnoses.

During the 12 months preceding the survey, there were approximately 3,066,300 discharges from the care of home-health agencies. Reasons for discharge were improvement or stabilization of the condition causing enrollment (52%); transfer to a nursing home, hospital, or some other health facility (17%); death (8%); and discharge for some other reason (23%). Patients may have had more than one discharge during the year. The average length of service before discharge was 94 days. Hospice Care

Hospice care provides palliative and supportive services that enhance the quality of life of terminally ill patients and their families. On any day during the survey period, an estimated 1000 hospices in the United States provided care to approximately 47,200 patients (4); 77% were aged greater than or equal to 65 years (average age on admission: 71 years). When compared with home-health patients, higher proportions of hospice patients were male (45%) and married (49%) (Table_1). In addition, hospice patients were more likely to receive skilled nursing services (86%), social services (52%), medications (33%), counseling (30%), and physician services (20%). Hospice patients usually were admitted with specific diagnoses; 65% of hospice patients were admitted with a first-listed diagnosis of malignant neoplasms, and 10% were admitted with a diagnosis involving heart disease. Eighty-seven percent of hospice patients received care in private or semiprivate residences; 8% received care in short-stay hospitals, nursing homes, or other health facilities.

During the 12 months preceding the survey, an estimated 207,000 patients were discharged from hospices; of these, 91% died while receiving hospice care. The average completed length of service before discharge was 60 days. Reported by: Long-Term Care Statistics Br, Div of Health Care Statistics, National Center for Health Statistics, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that home-health agencies and hospices play an increasing role in providing care to the population requiring long-term care. In addition to providing long-term maintenance care, home-health agencies provide skilled rehabilitative and therapeutic services (5). Hospice was first introduced in the United States in 1974, and these findings are among the first national estimates for hospice patients.

Since 1965, when Title XVIII (Medicare) of the Social Security Act was enacted, Medicare coverage of home-health services has been limited to post-acute care, focusing on recuperative care rather than long-term maintenance care. In 1992, 90% of home-health agency patients received services from agencies certified by Medicare (4). Medicare added hospice benefits in 1983, and by 1992, 92% of hospice patients were in hospices certified by Medicare (4).

The findings in this report indicate that home-health agencies primarily provide skilled rehabilitative and therapeutic services or "medically oriented" home care. In 1987, estimated annual national expenditures for medically oriented home-health care were $5 billion (6), while estimated annual expenditures for home-health care, including care provided by homemakers and personal-care providers, were $11.6 billion (2). Medically oriented home-health care represents less than half of formal home-health services rendered to the long-term-care population.

Home-health care is the fastest growing segment of the health-care system. In 1991, expenditures for home-health care increased 29% over 1990 (6). The findings in this report can be used to monitor changes in the use of these services and in the range of services and types of patients using these services.

References

1. LaPlante MP. People with disabilities in basic life activities in the U.S. {Disability statistics abstract no. 3}. Washington, DC: US Department of Education, National Institute on Disability and Rehabilitation Research, 1992.

2. Altman BM, Walden DC. Home health care: use, expenditures, and sources of payment. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1993; AHCPR publication no. (PHS)93-0040. (National Medical Expenditures Survey Research findings no. 15).

3. Delfosse R. Hospice and home health agency characteristics: 1991 National Health Provider Inventory. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, NCHS. Vital Health Stat (in press).

4. Strahan G. Overview of home health and hospice patients: preliminary data from the 1992 National Home and Hospice Care Survey. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1993. (Advance data no. 235).

5. Keenan JM, Fanale JE. Home care: past and present, problems and potential. J Am Geriatr Soc 1989;37:1076-83.

6. Letsch SW, Lazenby HC, Levit KR, Cowan CA. National health expenditures, 1991. Health Care Financing R 1992;14:1-30.

Table_1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Selected characteristics of current home-health and hospice patients --
United States, 1992 *
=========================================================================================================
                                                               Home-health               Hospice
                                                          ---------------------   ---------------------
Characteristic                                            No. patients    (%)     No. patients    (%)
-------------------------------------------------------------------------------------------------------
Average age (yrs) on admission                                      69.5                    71.4

Sex
 Male                                                        411,300    ( 33.2)       21,300    ( 45.1)
 Female                                                      825,800    ( 66.8)       25,900    ( 54.9)

Marital status
 Married                                                     413,700    ( 33.4)       23,300    ( 49.4)
 Widowed                                                     438,800    ( 35.5)       16,200    ( 34.3)
 Divorced/Separated                                           57,900    (  4.7)        2,400    (  5.0)
 Never married                                               150,300    ( 12.1)        3,100    (  6.5)
 Unknown                                                     176,500    ( 14.3)         +          +

Living arrangements
 Private/Semiprivate residence                             1,194,500    ( 96.6)       40,800    ( 86.5)
 Alone                                                       411,300    ( 33.3)        5,900    ( 12.5)
 With others                                                 773,000    ( 62.5)       34,300    ( 72.8)
 Board and care/Residential-care facility                     31,000    (  2.5)         +          +
 Health facility                                               6,000    (  0.5)        3,800    (  8.0)
 Other/Unknown                                                 +           +            +          +

Activities of daily living received help with
 Bathing                                                     629,800    ( 50.9)       26,900    ( 57.0)
 Dressing                                                    548,500    ( 44.3)       23,500    ( 49.9)
 Transferring in/out of a bed or chair                       402,100    ( 32.5)       19,800    ( 42.1)
 Using the toilet                                            301,500    ( 24.4)       17,800    ( 37.8)
 Eating                                                      171,400    ( 13.9)       13,500    ( 28.6)

Average no. activities of daily living received
 personal assistance with                                            1.7                     2.2

Selected services received during previous billing period
 Skilled nursing services                                    989,600    ( 80.0)       40,700    ( 86.3)
 Personal care                                               550,400    ( 44.5)       23,700    ( 50.3)
 Physical therapy                                            191,800    ( 15.5)         +          +
 Homemaker/Companion services                                130,000    ( 10.5)        5,000    ( 10.5)
 Social services                                             115,100    (  9.3)       24,500    ( 51.9)
 Medications                                                  99,400    (  8.0)       15,800    ( 33.4)
 Occupational therapy                                         43,300    (  3.5)         +          +
 Counseling                                                   36,900    (  3.0)       14,200    ( 30.2)
 Referral services                                            30,000    (  2.4)        2,500    (  5.3)
 High-tech care (including enterostomal therapy)              29,900    (  2.4)         +          +
 Dietary/Nutritional services                                 27,000    (  2.2)        3,100    (  6.5)
 Physician services                                           24,500    (  2.0)        9,200    ( 19.5)
 Respite care                                                  +           +           3,700    (  7.9)

Selected first-listed admission diagnoses
 Heart disease (lCD-9-CM & codes 391-392.0, 393-398,
  402-404, 410-416, 420-429)                                 153,600    ( 12.4)        4,900    ( 10.4)
 Diabetes mellitus (ICD-9-CM code 250)                        94,400    (  7.6)         +          +
 Arthropathies and related disorders (ICD-9-CM codes
  710-719)                                                    75,900    (  6.1)         +          +
 Malignant neoplasms (ICD-9-CM codes 140-208,
  230-234)                                                    73,100    (  5.9)       30,500    ( 64.7)
 Cerebrovascular disease (ICD-9-CM codes 430-436)             70,800    (  5.7)         +          +
 Essential hypertension (ICD-9-CM code 401)                   49,500    (  4.0)         +          +
 Fractures (ICD-9-CM codes 800-829)                           46,100    (  3.7)         +          +

Total @                                                    1,237,100    (100.0)       47,200    (100.0)

Discharge status
 Alive                                                     2,828,800    ( 92.3)       18,700    (  9.0)
 Dead                                                        237,500    (  7.7)      188,300    ( 91.0)

Total discharges **                                        3,066,300    (100.0)      207,000    (100.0)

Average length of service (days)                                    94.0                    59.7
-------------------------------------------------------------------------------------------------------
 * Estimates based on data from the National Home and Hospice Care Survey. For any value,
   confidence intervals do not exceed +/- 9%.
 + Unreliable (standard error >30% of estimate).
 & International Classification of Diseases, Ninth Revision, Clinical Modification.
 @ As of day before survey began.
** During the 12 months preceding the survey.
=========================================================================================================

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