There is an enormous hidden population of older adults in America suffering behind closed doors largely because they aren't strong or well enough to leave their homes, for healthcare or anything else. This is among the worrisome findings of a study being published this week in JAMA Internal Medicine.
"The homebound population of older adults is 50 percent larger than the nursing home population in this country but almost completely invisible," says senior author Sarah Szanton, PhD, ANP, FAAN, associate professor and PhD program director at the Johns Hopkins School of Nursing. "Only 11 percent receive homebound medical care, and the others may receive no care or intermittent care."
In "The Epidemiology of the Homebound in the United States," Szanton, Katherine A. Ornstein, PhD, MPH, of the Icahn School of Medicine at Mount Sinai, and colleagues look at the community-dwelling Medicare population, which they estimate to be about 2 million people. They explain that most older adults want to age at home, but with the ability to come and go as they wish. Being homebound means being trapped, unable to leave without considerable help. "This lack of capacity may be partially or fully remediated by the availability of personal assistance."
From the study:
"In 2011, the prevalence of the homebound was 5.6%, including an estimated 395,422 people who were completely homebound and 1,578,984 who were mostly homebound. … Completely homebound individuals were more likely to be older, female, non-White and have less education and income than the non-homebound population, to have more chronic conditions, and to have been hospitalized in the last 12 months. Only 11.9 % of completely homebound individuals reported receiving primary care services at home."
Co-authors of the study include Bruce Leff, MD, of the Johns Hopkins Schools of Nursing, Medicine, and Public Health; Kenneth Covinsky, MD, and Christine Ritchie, MD, MSPH, of the University of California San Francisco; Alex D. Federman, MD, MPH, of the Icahn School of Medicine at Mount Sinai; Laken Roberts of the Hopkins School of Nursing; and Amy S. Kelley, MD, MSHS, and Albert L. Siu, MD, MSPH, of Mount Sinai and the James J. Peters Veterans Affairs Medical Center.
The authors point to evidence of success and cost-savings through the Patient Protection and Affordable Care Act, which has spurred the development of new health service delivery models to serve the homebound, including the Independence at Home demonstration program and multidisciplinary home-based primary care programs that deliver medical and social services.
Szanton is also the driving force behind an intervention called CAPABLE - for Community Aging in Place, Advancing Better Living for Elders - which involves home visits with an occupational therapist, a registered nurse, and a handyman who work together with older adults to identify mobility and self-care issues in their homes and inexpensively fix or modify them.
"Medicare defines homebound status in the context of determining patient eligibility to receive services under the Part A skilled home health care benefit. Such patients must (1) be under a doctor's care, (2) need skilled services, (3) receive services from a Medicare-approved home health agency, and (4) because of illness or injury, need the aid of supportive devices, special transportation, or assistance from another person to leave their home or have a condition for which leaving the home is medically contraindicated. Our conceptual approach to defining homebound status focused on the individual's ability to leave the home. A measure based on eligibility for Medicare services may not reflect the number of people who are, in fact, unable to leave the home."
"Our findings can inform improvements in clinical and social services for these individuals," the report in JAMA Internal Medicine concludes.
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