Three Essays on Post-Acute and Long-Term Care for Older Adults

The U.S. population is aging rapidly. It is therefore critical to better understand the organization and performance of care systems that serve older adults. This dissertation empirically evaluates the delivery, utilization, and quality of care in post-acute and long-term care settings, two key components of the U.S. health care system for older adults. Chapter One estimates the causal effects of delays in post-acute care on patient outcomes in the home setting using national Medicare claims data. Leveraging an instrumental variable approach to address endogeneity, I find that such delays increase mortality within 30 days of hospital discharge and reduce the probability of functional improvement over the course of the home health episode. These results underscore the significance of the timely initiation of post-acute care for patient outcomes. Chapter Two studies the interaction between skilled home health care and home-based long-term care among Medicare and Medicaid dual-eligible older adults. The analysis reveals substitution between these two services, highlighting the need to address gaps in long-term care provision in the home setting. Exploiting variation in policies that relaxed nursing home visitation bans during the COVID-19 pandemic across states and over time, Chapter Three analyzes how these policies affected mortality among nursing home residents. I show that allowing nursing home visitation by designated family members or friends under controlled circumstances reduces both non-COVID-19 and COVID-19 deaths. These results suggest that social interaction and informal caregivers are essential to the well-being of older adults in institutional settings. In summary, these studies address gaps in the existing evidence and inform policy discussions on improving the delivery and quality of post-acute and long-term care for older adults.