February 13, 2026
Dementia was the largest predictor of whether dually eligible Medicare and Medicaid beneficiaries were more likely to receive long-term services and supports in a home-and-community-based setting such as an assisted living community or enter a nursing home, according to the results of a study published in JAMDA.
“Our findings suggest that dementia is a large predictor of whether dual-eligible beneficiaries are more likely to enter a nursing home instead of receiving long-term services and supports in a community setting,” study co-author Laura M. Keohane, PhD, an associate professor in Vanderbilt’s Department of Health Policy, told McKnight’s Senior Living. “A nursing home may be the most appropriate choice for some older adults, but assisted living facilities and other community-based providers could also consider strategies for helping Medicaid participants with dementia and their caregivers learn about and access services that are available prior to needing nursing home care.”
A team led by researchers at Vanderbilt University looked at which sociodemographic and clinical factors were associated with initiating LTSS with HCBS versus nursing home care to determine whether HCBS reaches older adults who would benefit the most from those services. The recently published study included 581 dually eligible older adults from the Southern Community Cohort Study.
HCBS use has steadily increased over time, accounting for most total Medicaid expenditures since 2013, according to researchers. Nationally, three-fourths of all Medicaid spending is done through personal care state plans and 1915(c) waiver programs, the kinds of waivers under which assisted living operators often provide HCBS to residents who are Medicaid beneficiaries.
Separately, recently published data from the Centers for Medicare & Medicaid Services found that when it comes to Medicaid LTSS, “far fewer people” received institutional services such as those provided in nursing homes than HCBS such as those provided in assisted living communities in 2023.
In the study published in JAMDA, the investigators found that the number of first-time HCBS and nursing home users steadily increased between 2008 and 2018, with equal proportions of the study population beginning to use LTSS in an HCBS or nursing home setting.
Dually eligible beneficiaries whose initial LTSS use was in an HCBS setting were more likely to be Black, female and have a household income of less than $15,000, according to the study. In contrast, initial users of LTSS in nursing homes were more likely to have a prior diagnosis of dementia, diabetes or potential diabetes-related complications, or chronic kidney disease.
Understanding which populations are reached by LTSS rebalancing efforts can inform future policy decisions, the authors concluded.