Impact of home healthcare reform on place of death for people with dementia: A nationwide cohort study accounting for cultural factors of impending death discharge.

Abstract

BACKGROUND: Although home is frequently the preferred place of death, little is known regarding how home healthcare (HHC) influences this outcome for people with dementia (PWD), particularly within Asian contexts. This study investigates the impact of HHC and its 2016 "Integrated Home-Based Medical Care" reform on home death in Taiwan, explicitly accounting for the cultural phenomenon of "impending death discharge." METHODS: This nationwide retrospective cohort study utilized Taiwan's National Health Insurance Research Database. We identified PWD decedents from 2011 to 2022 and conducted a nested case-control analysis. Cases (home deaths) and controls (hospital deaths) were matched 1:1 using propensity scores to balance demographics and health status. HHC models included pre-2016 primary HHC, post-2016 primary HHC, and the reformed "HBPC Plus" (Home-Based Primary Care Plus). The outcome was adjusted to include patients discharged terminally to die at home, reflecting distinctive cultural practices. RESULT(S): Among 209,468 decedents, 95,594 were selected after matching. Overall, HHC use was associated with higher odds of home death (adjusted odds ratio [aOR]: 1.17; 95% CI: 1.13-1.21). The reformed HBPC Plus program showed the strongest association compared to pre-2016 primary HHC (aOR: 1.63; 95% CI: 1.34-1.98). Crucially, this association strengthened further when accounting for impending death discharge (aOR: 1.82; 95% CI: 1.40-2.35). Higher visit frequency and services from hospital-based teams were also significantly linked to home death. CONCLUSION(S): HHC significantly increases the likelihood of home death among PWD in culturally influenced contexts. The 2016 reform, particularly the HBPC Plus program, proved highly effective. Policy components like flexible visit frequencies and enhanced hospital-physician coordination appear vital for supporting end-of-life care at home, offering key insights for policy planning in aging societies.