Home And Community-Based Care Gets A Boost To Reduce Health Inequities For Older Populations

HCBS offers practical programs to care for senior adults in their homes and communities

A person's neighborhood and physical environment is one of six categories proven to influence health. Because many older people stay in their neighborhood for many years, they typically experience higher exposure to harmful neighborhood conditions. This is compounded for the nearly two million older adults who are entirely homebound and 5.5 million partially homebound.

In this article, we explore:

• Existing and long-standing Home and Community-based Services (HCBS) for older adults
• HCBS successful outcomes and areas for improvement
• Implications for new federal funds available to states through the American Jobs Plan

How neighborhoods impact senior health

Senior adults in economically oppressed neighborhoods are less likely to have adequate access to stores with a variety of healthy food, quality healthcare, safe housing, and health-promoting social services. According to the AHEAD Study (Asset and Health Dynamics (AHEAD), "adults ages 70 and older living in economically disadvantaged neighborhoods are more likely than peers living in wealthier neighborhoods to report being in poor health." Research published in the American Journal of Preventative Medicine found that, while neighborhood environment is not a primary influence on older adults' health and functioning, it is an important factor.

Additionally, their communities are more likely to experience greater violence, lower social cohesion, and lower social capital, all of which are associated with poor health. Seniors in these areas are more likely to have chronic health and mobility issues and die at younger ages compared with older adults of more affluent communities.

Homebound adults have a 65% mortality rate within six years, and they are more likely than their non-homebound counterparts to be from a historically marginalized racial or ethnic group. These social and economic determinants of health create barriers for older adults to experience optimal health and receive proper and timely healthcare.

COVID-19 exacerbated existing issues and health inequities

COVID exacerbated issues and inequities that make healthcare and healthy living more challenging for older adults. In 2020, adults 70 and older were homebound twice the pre-pandemic levels, growing from about five percent in 2011-2019 to 13 percent in 2020. Homebound levels for Black non-Hispanic individuals grew from nine percent to 22% and from 16.7% to 34.% among Hispanic/Latino individuals.

While telehealth use accelerated during the pandemic, research shows it didn't help homebound older adults very much. Although 75% of homebound older adults had a cell phone, more than 50% did not have a computer or use the Internet. This lack of access and technology caused more seniors to go to the emergency department when traditional care channels weren't available, which exposed more seniors to hospital-based COVID infections.

Existing HCBS programs and models

There are several established home and community-based health programs in the U.S. Some HCBS programs have been around for several decades and have measurable outcomes on senior health and well-being. Home and Community-based Services include a variety of medical, support, and social help for older adults in their own homes or those in independent living and personal care homes.

HCBS programs may include:

• Housekeeping
• Help with shopping and laundry
• Nutrition services like meal delivery and nutrition education and screening
• Medical services in the home
• Transportation
• Home maintenance and modifications
• Care coordination to help schedule appointments
• Respite care for family caregivers

Program of all-Inclusive Care for the Elderly (PACE)

For over 30 years, PACE has offered community-based care and services to nursing home-eligible older adults, helping them age-in-place, which is the preferred living arrangement by more than 80% of seniors. Beyond personal preference, research has shown that aging at home can yield potential cost savings for Medicare and Medicaid.

In this HBCS program, seniors receive comprehensive, coordinated health and social services, including prescription drugs, physician services, transportation, home care, check-ups, as well as inpatient and nursing home stays as necessary. As of June 2022, PACE had more than 60K enrollees in 146 programs and 273 centers across 31 states.

Community aging in place, advancing better living for elders (CAPABLE)

CAPABLE is an HCBS program funded by the Center for Medicare and Medicaid Innovation (CMMI) and strives to reduce disability among low-income older adults. CAPABLE focuses on prevention and problem-solving to build skills that can keep seniors in their homes longer. The program addresses individual capacities within their home environment using an interprofessional team that includes an occupational therapist, registered nurse, and handyman. Participants set goals and work with their team over four-to-five months to improve health, independence, and safety.

CMMI's Accountable Health Communities

CMMI is completing its five-year pilot in 29 community-bridge organizations, testing various service delivery approaches that link Medicare and Medicaid beneficiaries within the same geographic area with services that can address health-related social needs like housing, food, utilities, transportation, and interpersonal violence. Similarly, CMMI's Accountable Care Organizations (ACOs) hire community navigators and partner with social service agencies to link older adults with social services.

Older Americans Act (OAA)

Established in 1965, OAA established authority for grants to states to provide community planning services, fund research projects, and train personnel in the field of aging. Today, OAA encompasses a national network of 56 state agencies on aging, 618 area agencies on aging, nearly 20K service providers, 281 Tribal organizations, and 1 Native Hawaiian organization representing 400 Tribes. Through these organizations, seniors receive a host of social and nutrition services.

Community-based care create positive outcomes and opportunities for improvement

HCBS programs, like PACE and CAPABLE, have documented improvements in the health and well-being of older adults whose population is on track to increase to 20% of the U.S. adult population by 2025. Currently, healthcare is not prepared for this surge in senior adults.

PACE program impact and barriers to scale

Studies have revealed that compared to individuals who opt out of a PACE program, those who stay in the PACE program have fewer and shorter nursing home stays and experience lower hospitalization rates, greater overall survival, less depression, and increased social interaction.

Participants and their family caregivers value the program's focus on independence and person-centered care. They appreciate having one source for services, including transportation, pharmacy, and health care providers.

Barriers to the PACE program included poor information dissemination, particularly among Black and Latino older adults. Many individuals didn't trust what they heard about the program and all the resources and benefits, mainly because the program covered prescriptions, transportation, and co-pays without any cost. The cost of PACE can be prohibitive for those who do not qualify for Medicaid. And some didn't want to lose access to their primary care provider. Lastly, some participants cited inadequate sensitivity to cultural, language, and disability differences and that the program lacked cultural diversity.

CAPABLE program impact and barriers to scale

Because the CAPABLE program focuses on prevention and problem-solving with practical, time-bound goals, it has been shown to decrease hospitalization and nursing home stays. Research has also shown that the program has generated a 6X+ return on investment with $3,000 in program costs per participant yielding $30,000 in medical cost savings. Since it is a team-based, goal-oriented program, it enhances motivation and self-efficacy. Lastly, it was shown to improve self-care for 75% of participants over the course of the five-month program.

Neighborhood sense of community

Not all positive changes come from federal- or state-funded programs. Some socioeconomically disinvested neighborhoods have built a strong sense of community, including higher investment in supportive services, ongoing community participation, and environments conducive to socializing and physical activity. Research has shown that mutual support and strong social ties within some predominately Black and Hispanic neighborhoods may help ameliorate some health consequences of living in a historically marginalized neighborhood.

American Jobs Plan includes new funding for home and community-based services

In March 2021, the current administration announced that the American Jobs Plan included $400B to expand access to Medicaid HCBS, as well as strengthen the direct care workforce. The HCBS Infrastructure Improvement Program offers permanent federal Medicaid matching funds if states elect to participate and can meet requirements.

While most home and community-based services programs are provided through Medicaid, they are not covered by other payers or Medicare. States must opt-in to offer Medicaid HCBS as part of their plan benefits. When participating, they can also provide needed services to specific populations, expand income and asset limits, and set enrollment caps.

More than $50B currently goes toward HCBS for older adults and people with physical disabilities. These services could be expanded further, including self-directed services, expanding PACE, Medicare Advantage (MA) Supplemental Benefits, telehealth expansion, and subsidized rental housing for older people, primarily through the U.S. Department of Housing and Urban Development's (HUD) 's Section 202 housing program.

While the U.S. has a long history of providing home and community-based services to older adults, the accelerated growth of the senior population and the need to provide care for people living longer with chronic illnesses and disabilities make HCBS funding and workforce critical. These community supports have the opportunity to impact social determinants and reverse long-standing health disparities.

If you would like to discover how to address the unique needs of older adults better and how your services and care are delivering what they want and need, turn to RTI Health Advance. We can ensure that your strategies, programs, policies, and operations match your intention for person-centric care. We can also assess the impact of interventions focused on senior adults and their effects on care quality, population health, and health equity to determine these programs' economic and community value.

Learn more about RTI Health Advance and connect with us.