Relations among home- and community-based services investment and nursing home rates of use for working-age and older adults: a state-level analysis.

Objectives: I examined state-level rates of nursing home use for the period from 2000 to 2007.

Methods: I used multivariate fixed-effects models to examine associations between state sociodemographic, economic, supply, and programmatic characteristics and rates of use.

Results: Nursing home use declined among older adults (aged ≥65 years) in more than two thirds of states and the District of Columbia but increased among older working-age adults (aged 31-64 years) in all but 2 states. State characteristics associated with these trends differed by age group. Although relatively greater state investment in Medicaid home- and community-based services coupled with reduced nursing home capacity was associated with reduced rates of nursing home care for adults aged 65 years and older, neither characteristic was associated with use among older working-age adults. Their use was associated with state sociodemographic characteristics, as well as chronic disease prevalence.

Conclusions: Policy efforts to expand home- and community-based services and to reduce nursing facility capacity appear warranted. To more fully extend the Supreme Court's Olmstead decision's promise to older working-age adults, additional efforts to understand factors driving their increasing use are required.