Becoming Homebound

The following is cross-posted at Public Health Post and is by Katherine Ornstein, PhD, Melissa Garrido, PhD (@GarridoMelissa), and Katelyn Ferreira, MPH. Dr. Ornstein is Director of Research for the Institute for Care Innovations at Home at Mount Sinai and Associate Professor  at the Icahn School of Medicine at Mount Sinai. Dr. Garrido is Associate Director of the Partnered Evidence-based Policy Resource Center (PEPReC) at the Boston VA Healthcare System, U.S. Department of Veterans Affairs, and a Research Associate Professor at Boston University School of Public Health. Ms. Ferreira is a Research Program Manager at Mount Sinai.

The Covid-19 pandemic has resulted in millions of Americans becoming homebound — having limited social contacts and accessing medical care, groceries, and other needs from within their homes. But for many older Americans, being homebound (i.e., never or rarely leaving home) is already the norm.  Our previous work estimated that, in 2011, two million older Americans were homebound—more than the number of people who live in nursing homes.

Homebound adults often have multiple chronic illnesses, difficulties with activities like bathing and dressing, high rates of depression, and few people on whom they can rely for assistance. They also have a higher risk of death than non-homebound individuals with similar characteristics. The practical realities of being homebound, like difficulty accessing routine medical care and inability to engage in valued activities, may contribute to poor outcomes.

Yet there is limited research examining what factors contribute to becoming homebound. In particular, we do not know what social and economic factors lead to becoming homebound. To fill this gap, our team conducted a study examining the association between income and becoming homebound. We used nationally representative data from the National Health and Aging Trends Study (NHATS), an annual survey of adults 65 or older. We looked at participants’ annual household income during the first year of NHATS (2011), and we divided the range of responses into quartiles (< $15,003, $15,004-$30,000, $30,001-$60,000, > $60,000). We then followed non-homebound participants for seven years (2011-2018) to see whether they became homebound.

Participants with higher incomes were less likely to become homebound. In the seven-year study period, 15.81% of older adults in the lowest income quartile became homebound, compared with 11.31% in the next lowest quartile, 6.88% in the second highest, and only 4.64% those in the highest. Membership in the lowest quartile continued to predict homebound status even after accounting for demographics, health status, having a caregiver, and other events (nursing home placement and death).

There are several potential explanations for this relationship. Lower-income older adults may be more vulnerable to the diseases, impairments, and disabilities that lead to becoming homebound. They may also be less likely to have resources for accommodating or overcoming these disabilities. For example, people with lower incomes might not be able to afford assistive devices (like electric wheelchairs) or home modifications (like ramps) that would help them be able to leave their homes.

This evidence that income can help predict who may become homebound is useful for prevention and for meeting the needs of people who are already unable to leave their homes. In the context of wide income disparities in the United States, programs that provide equipment, home modifications, caregiver support, and other assistance for individuals of low or mid-range incomes may allow those individuals to leave their homes more often and avoid becoming homebound.

People who do become homebound must have access to the care and resources they need. Alongside home-based medical care and interventions like Community Aging in Place – Advancing Better Living for Elders (CAPABLE), remote options for healthcare delivery — including telehealth and video visits — can help meet the needs of this population. While the Covid-19 pandemic has led to massive strides in remote-care delivery, we must ensure that the concerns of homebound patients regarding telemedicine are addressed and that they are not left behind as healthcare changes. As health professionals, we need to collaborate in new and creative ways with entities that provide broadband, design assistive technology, and promote digital literacy. Efforts to connect homebound people with health-promoting resources could help not only to address their medical needs, but also to facilitate their social engagement and participation in valued life activities.

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