Facilitators of home and community-based service use by urban African American elders

Factors Associated with the Utilization of Home and Community-Based Services (HCBS) Among Older Adults: A Systematic Review of the Last Decade

Home and community-based services (HCBS) for older adults have been promoted worldwide to address the growing problems of aging. This systematic review included 59 studies published from 2013 to 2023 to explore factors influencing the utilization of HCBS among older adults. The review identified 15 common factors grouped into four levels of influence: individual, inter-relationship, community, and social contextual levels. The findings suggest that HCBS utilization is a dynamic process influenced by multiple factors at different levels. Gerontological social work should incorporate ecological thinking to improve practice and strengthen caregiver-recipient relationships.

Home and Community-Based Service Use Varies by Health Care Team and Comorbidity Level of Veterans with Dementia

Home and community-based services (HCBSs) such as home care and adult day centers are vital to supporting adults with dementia in community settings. We investigated whether HCBS use (use of both home care and adult day, use of one service, and use of neither service) varied between adults receiving care from three types of health-care teams with case management from social workers and nurses, and by comorbidity level, using 2019 data of 143,281 patients with dementia in the Veterans Health Administration. We compared HCBS use by patients' type of case-managed team (Home-Based Primary Care, geriatrics-based primary care, and dementia-focused specialty care) to patients in none of these teams, stratified by patients' non-dementia comorbidities (<4 or ≥4). Each type of health-care team was associated with both home care and adult day services, at each level of comorbidity. Home-Based Primary Care was most consistently associated with other forms of HCBS use, followed by Dementia Clinics and geriatrics-based primary care, for patients with ≥4 non-dementia comorbidities. Our findings suggest that case management in primary and specialty care settings is a contributor to the use of critical community supports by patients with the most complex needs.

Access to Community Support Services among Older Adults in Social Housing in Ontario

Community support services are an integral enabler of aging in place. In social housing, older adult tenants struggle to access these services because of the siloed nature of housing and health services. This study examined the provision of government-funded community support services to 83 seniors’ social housing buildings in Toronto, Ontario. Although there were 56 different agencies operating within the buildings, only about one third of older tenants were actually receiving services. There was a subset of services that were available in more than 80 per cent of the buildings, and the most widely accessed services were food supports, crisis intervention, transportation, caregiver support, and hearing/vision care. There were also many cases in which multiple agencies offered duplicative services within the same building, suggesting that there are opportunities for improving service coordination. Practice recommendations for increasing access to community support services among low-income older adults in social housing are provided.

Relationships between reablement-embedded home- and community-based service use patterns and functional improvement among older adults in Taiwan

For its second decade, Taiwan's National 10-Year Long-Term Care Plan launched a policy of reinforcing home- and community-based services (HCBSs) with a focus on reablement. This study aimed to (1) identify the distinct service use patterns of reablement-embedded HCBS and (2) examine the effects of these service patterns on functional improvements among older care recipients, including among groups with different levels of care needs. We collected 2018 data from the Long-Term Care Service Management System for care recipients in one county located in central Taiwan (N = 4735). Three recipient groups were assigned based on level of care needs. We included data on use of the following services: reablement, home care, respite care, applications for assistive devices and home environmental modifications, transportation to medical appointments and community-based services. Outcome variables were measured by change scores between successive assessments of activities of daily living (ADL) and instrumental activities of daily living (IADL). Latent class analysis and multivariate linear regression analyses were used to analyse relationships between use patterns, participant subgroups and outcomes. Four subgroups of HCBS use patterns were found. Care recipients with low care needs had greater potential to improve their physical function in ADL through reablement-embedded HCBS. Care recipients in the groups with low and high care needs showed overall benefits in functional improvements in ADL and IADL from personal care-based HCBS. Care recipients in the community-based and multiple services-based use pattern subgroups showed the least improvement in physical function. Our study indicates that the effects of reablement-embedded HCBS use strategies may vary among older adults with different levels of care needs. We recommend further research to examine how to design HCBS with a reablement focus to better fit the needs of those with moderate and high levels of care needs.

Community environment moderates the relationship between older adults' need for and utilisation of home- and community-based care services: The case of China

This study explores the moderating influence of perceived and objective community environments on the relationship between older adults' home- and community-based care (HCBC) needs and their actual utilisation of such care. We selected 5,668 older adults in two cities in China and adopted latent class analysis to descriptively explore the patterns of their HCBC need and utilisation. Structural equation modelling was used to determine factors related to the patterns of need and utilisation of HCBC services, and to explore the moderating roles that the perceived and objective community environments had on the effect of long-term care need on its utilisation. The results descriptively showed that older adults' patterns of HCBC need and utilisation appear to be embedded within two broader latent categories: a high-need/use group and a low-need/use group. Among participants who were satisfied with their community or who lived in areas with high accessibility to HCBC services, HCBC need could predict HCBC use. Our integrated conceptual framework proved to be applicable, thus enriching the theoretical models in explaining HCBC-related behaviours. The results have strong implications for urban planners, policymakers, and programme managers who seek to support older people and provide elderly care services in communities.

Older Adults' Demand for Integrated Care and Its Influencing Factors: A Scoping Review

Introduction:

Integration has become a major concern for governments, healthcare and aged care systems in many countries. However, the research on and implementation of integrated care in China started relatively late, and there is no review on the needs of older adults with regard to integrated care and the influencing factors. Therefore, this paper aims to provide a scoping review by searching, evaluating, and summarizing the Chinese and international literature on the need for and the factors influencing integrated care for older people. In addition, this review highlights evidence of the gap between China and the world in integrated care.

Methods:

Using a framework proposed by Arksey and O’Malley, a systematic search of 12 domestic and international databases was conducted. Of the 890 original studies retrieved, those that met the established inclusion criteria were screened and scored using the Ekman quality assessment tool. The qualitative description method was used to summarize the demand for integrated care for older adults and the influencing factors.

Results:

A total of 49 papers were included. These studies were from eleven countries on five continents (most commonly China and the US) and were mostly cross-sectional quantitative studies that surveyed the integrated care needs of older people living in homes/communities or long-term care facilities. The analysis shows that existing research on the integrated care needs of older people in China adopts a single perspective and is inadequate and unsystematic in its assessment; the integrated care needs of older adults and the factors influencing them are multifaceted; and both in China and internationally, the community-home care scenario most consistently meets the needs and expectations of older adults.

Conclusion:

Although there is no uniform definition of integrated care in China or abroad and each country has its own national definition and system of integrated care, there are certain commonalities regarding the needs of older adults and the factors that influence them across countries. Our research reveals a gap between China and the international community in terms of integrated care.

Social factors influencing utilization of home care in community-dwelling older adults: a scoping review

BACKGROUND

Older adults want to live at home as long as possible, even in the face of circumstances that limit their autonomy. Home care services reflect this emergent preference, allowing older adults to 'age in place' in familiar settings rather than receiving care for chronic health conditions or ageing needs in an institutionalized setting. Numerous social factors, generally studied in isolation, have been associated with home care utilization. Even so, social circumstances are complex and how these factors collectively influence home care use patterns remains unclear.

OBJECTIVES

To provide a broad and comprehensive overview of the social factors influencing home care utilization; and to evaluate the influence of discrete social factors on patterns of home care utilization in community-dwelling older adults in high-income countries.

METHODS

A scoping review was conducted of six electronic databases for records published between 2010 and 2020; additional records were obtained from hand searching review articles, reference lists of included studies and documents from international organisations. A narrative synthesis was presented, complemented by vote counting per social factor, harvest plots and an evaluation of aggregated findings to determine consistency across studies.

RESULTS

A total of 2,365 records were identified, of which 66 met inclusion criteria. There were 35 discrete social factors grouped into four levels of influence using a socio-ecological model (individual, relationship, community and societal levels) and grouped according to outcome of interest (home care propensity and intensity). Across all studies, social factors consistently showing any association (positive, negative, or equivocal in pattern) with home care propensity were: age, ethnicity/race, self-assessed health, insurance, housing ownership, housing problems, marital status, household income, children, informal caregiving, social networks and urban/rural area. Age, education, personal finances, living arrangements and housing ownership were associated with home care intensity, also with variable patterns in utilization. Additional community and societal level factors were identified as relevant but lacking consistency across the literature; these included rurality, availability of community services, methods of financing home care systems, and cultural determinants.

CONCLUSION

This is the first literature review bringing together a wide range of reported social factors that influence home care utilization. It confirms social factors do influence home care utilization in complex interactions, distinguishes level of influences at which these factors affect patterns of use and discusses policy implications for home care reform.

Use of Informal Support as a Predictor of Home- and Community-Based Services Utilization

OBJECTIVES

Home- and community-based services (HCBS) help older adults remain living safely in their homes by delaying or preventing the need for institutionalization. This analysis is guided by the Andersen Behavioral Model of Health Services Use to examine the association between informal support and use of HCBS.

METHOD

Health and Retirement Study data from 2011 and 2012 are used in the bivariate analyses and multivariate logistic regression models to examine differences in HCBS utilization among extremely vulnerable older adults who have informal caregivers and those who do not.

RESULTS

For extremely vulnerable older adults who report difficulties with any instrumental or basic activities of daily living, use of HCBS is not strongly associated with access to informal caregivers. However, for this same population of extremely vulnerable older adults, those who live alone have roughly 3 times the odds of using any HCBS compared to those who do not live alone.

DISCUSSION

Among already vulnerable older adults, this study revealed that living alone is an important enabling factor of the Andersen Behavioral Model as applied in HCBS research. Further investigation is needed to see if more resources should be allocated to senior centers and local providers to identify vulnerable older adults who live alone and may have unmet needs.

Determinants of Patterns of Need for Home and Community-Based Care Services Among Community-Dwelling Older People in Urban China: The Role of Living Arrangement and Filial Piety

This study aims to identify older people’s home- and community-based care (HCBC) service need patterns and explore the role of living arrangement and filial piety in affecting such patterns. A total of 556 older people were selected in Beijing, China. Latent class analysis and multinomial logistic regression were adopted to identify the service need patterns and the influencing factors. A three-class model of service need patterns was explored (high-needs group, moderate-needs group, and low-needs group). Living arrangement was related to HCBC service need patterns. Compared with the high-needs group, those living with at least two family members were more likely to express low needs or moderate needs. Living arrangement was a moderator for the effect of filial piety on HCBC needs. Greater recognition of the effects of living arrangement and filial piety should enrich the Andersen model and provide a robust stimulus for long-term care policy development and for service delivery and social work.

Use of Home- and Community-Based Services in Taiwan’s National 10-Year Long-Term Care Plan

We aimed to understand the relationships between care recipients’ profiles and home- and community-based services (HCBS use patterns. Data were from the 2010 to 2013 Long-Term Care Service Management System in Taiwan ( N = 78,205). We used latent class analysis and multinomial logistic regression analyses. Three HCBS use patterns were found. Care recipients who lived alone, lived in less urbanized areas, and had instrumental activities of daily living disabilities were more likely to be in the home-based personal care group. Those in the home-based personal and medical care group were more likely than others to have a primary caregiver. Care recipients who had poorer abilities at basic activities of daily living and cognitive function, better household income, and lived in a more urbanized area were more likely to be in the non-personal care multiple services group. The findings suggest that policymakers alleviate barriers to accessing various patterns of HCBS should be encouraged.

Unmet service needs evaluated by case managers among disabled patients on hemodialysis in Japan

Background

This study aimed to investigate the levels of unmet needs for home and community-based services (HCBS) evaluated by case managers (CMs) among disabled patients on hemodialysis (DPHD) and to examine factors related to unmet needs. Unmet needs for HCBS were defined as situations in which patients do not use or underuse HCBS despite needing them. Candidates for the factors relating to unmet needs for HCBS included three dimensions: predisposing, enabling, and need factors.

Methods

Self-administrated questionnaires were collected from 391 CMs of DPHD certified with long-term care insurance. These were introduced by the dialysis facilities that a member of the Japanese Association of Dialysis Physicians belonged to. CMs were asked questions about their management of each individual case. HCBS included home help, visiting nursing, daycare, and short stay.

Results

The prevalence of unmet needs for each HCBS ranged from 32% for home help to 48% for short stay. Barriers to service usage in the patients were associated with unmet needs for all four services. The patients with more severe cognitive malfunction were more likely to have unmet needs for visiting nursing and short stay. Heavier burden with caregiving was associated with more likelihood of unmet needs for home help and short stay.

Conclusion

CMs need to monitor unmet needs after coordinating HCBS for DPHD and need to encourage HBCS use among patients with impaired cognitive function and caregivers with heavier caregiving burdens.

Trajectories of Community-Based Service Use: The Importance of Poverty and Living Arrangements

This study examined how older adults' living arrangements and poverty status affected their use of in-home health, functional, and out-of-home services over time. Using eight waves of data from the Korea Welfare Panel Study, we employed a logistic mixed-effect model to analyze how poverty and living arrangements affect community-based service use. Living-alone older adults and elder-only couples were more likely than co-residing households to use services. Elder-only couples, when poor, were more likely to use in-home and out-of-home services over time. Understanding predictors of community-based service use over time enables researchers and policymakers to better understand the process of aging-in-place.

Home Modifications among Community-Dwelling Older Adults: A Closer Look at Race and Ethnicity

This study investigated racial and ethnic differences in home modification use. Data from the 2011 National Health and Aging Trends Study were used (n=6,764). Compared with non-Hispanic Whites, Hispanics were less likely to have a grab bar (odds ratio (OR) = 0.6), bath seat (OR = 0.8), or raised toilet (OR = 0.6). Non-Hispanic Blacks were less likely to have a grab bar (OR = 0.7) or bath seat (OR = 0.7) than non-Hispanic Whites, but more likely to have a raised toilet (OR = 1.3). English proficiency largely explained ethnic differences, while health status partially accounted for racial disparities.

Ageing well in the right place: partnership working with older people

Purpose

The provision of home and community supports can enable people to successfully age-in-place by improving physical and mental health, supporting social participation and enhancing independence, autonomy and choice. One challenge concerns the integration of place-based supports available as older people transition into affordable housing. Sustainable solutions need to be developed and implemented with the full involvement of communities, service organizations and older people themselves. Partnership building is an important component of this process. The purpose of this paper is to detail the intricacies of developing partnerships with low-income older people, local service providers and nonprofit housing associations in the context of a Canadian housing development.

Design/methodology/approach

A community-based participatory approach was used to inform the data collection and partnership building process. The partnership building process progressed through a series of democratized committee meetings based on the principles of appreciative inquiry, four collaboration cafés with nonprofit housing providers and four community mapping workshops with low-income older people. Data collection also involved 25 interviews and 15 photovoice sessions with the housing tenants. The common aims of partnership and data collection were to understand the challenges and opportunities experienced by older people, service providers and nonprofit housing providers; identify the perspectives of service providers and nonprofit housing providers for the provision and delivery of senior-friendly services and resources; and determine actions that can be undertaken to better meet the needs of service providers and nonprofit housing providers in order to help them serve older people better.

Findings

The partnership prioritized the generation of a shared vision together with shared values, interests and the goal of co-creating meaningful housing solutions for older people transitioning into affordable housing. Input from interviews and photovoice sessions with older people provided material to inform decision making in support of ageing well in the right place. Attention to issues of power dynamics and knowledge generation and feedback mechanisms enable all fields of expertise to be taken into account, including the experiential expertise of older residents. This resulted in functional, physical, psychological and social aspects of ageing in place to inform the new build housing complex.

Research limitations/implications

The time and effort required to conduct democratized partnerships slowed the decision-making process.

Originality/value

The findings confirm that the drive toward community partnerships is a necessary process in supporting older people to age well in the right place. This requires sound mechanisms to include the voice of older people themselves alongside other relevant stakeholders. Ageing well in a housing complex requires meaningful placemaking to include the functional, physical, psychological and social aspects of older people’s everyday life in respect to both home and community.

Characteristics of Older Georgians Receiving Older Americans Act Nutrition Program Services and Other Home- and Community-Based Services: Findings from the Georgia Aging Information Management System (GA AIMS)

This descriptive study examined characteristics of older Georgians receiving Older Americans Act Nutrition Program Services and other home- and community-based services (HCBS) using state aging administrative data (N = 31,341, mean age: 76.6 ± 9.2 y, 71.2% female, 52.3% White). Home-delivered meals (HDM) was used most frequently. The characteristics of older Georgian HCBS participants varied by the type and number of HCBS received. Those receiving HDM and other in-home and caregiving services were more likely to show poorer sociodemographic, economic, and functional characteristics, and food insecurity. Those receiving multiple HCBS were most vulnerable, but showed lower level of food insecurity than those receiving single HCBS, suggesting potential combined benefits of receiving multiple programs. This study underscores the importance of documenting dynamic needs for HCBS, especially HDM, among vulnerable older adults as part of standard administrative process to identify those at high risk of institutionalization, optimize HCBS delivery and coordination, and maximize HCBS benefits.

[Health and social services used by the rural elderly]

OBJECTIVES

To describe the use of health and social services, and to analyze the influence of functional capacity for Instrumental Activities of Daily Living (IADL) and other factors in their use.

METHOD

Cross-sectional study in a non-institutionalized population older than 64 years old in a basic rural health area of Zaragoza.

DEPENDENT VARIABLES

use of different health and social services. Main independent variable: functional capacity for IADL according to the Lawton-Brody. Confounding variables: sociodemographic, physical exercise, comorbidity, self-perceived health, walking aids, social resources and economic resources (OARS-MAFQ). The relationship between the use of services and functional capacity for IADL was assessed using crude OR (ORC) and adjusted (adjusted OR) with CI95% by means of multivariate logistic regression models.

RESULTS

The use of social and health services increased with age and worse functional capacity for IADL. The increased use of health services was related with bad stage of health, limited social and economic resources, physical inactivity and female. The increased use of home help services was related with limited social resources, low education level and male. Regular physical activity and using walking aids were associated with greater participation in recreational activities.

CONCLUSIONS

The probability of using social and health services increased in older people with impaired functional capacity for IADL. The specific use of them changed according to differences in health, demographic and contextual features.