Christine Ritchie, MD, MSPH, Mongan Institute Center for Aging and Serious Illness, Harvard Medical School and Bruce Leff, MD, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine
Older adults who are homebound are often socially isolated, have unmet care needs, suffer from high mortality, and are invisible to health systems. Homebound older adults are also more likely to be people of color or socially and economically disadvantaged. Our current system of home-based clinical care exacerbates these disparities. To reduce these disparities, we need to identify people who are homebound and ensure that all who cannot access traditional office-based clinical care can receive it where they live and receive it equitably. This blog post highlights the epidemiology and characteristics of homebound older adults, inequities faced by this population, how the COVID-19 pandemic exacerbated these inequities, and a vision to reimagine health care delivery in this country to improve health equity for this population.
Epidemiology and Characteristics of Homebound Older Adults
Being homebound is common among older adults. Using nationally representative data, we found that approximately two million older adults are completely homebound and another 5.5 million are partially homebound and have difficulty or need help to get out of their homes. The homebound population is a high-need, high-cost, vulnerable group. They are more likely than their non-homebound counterparts to be from a minority racial or ethnicity group, unmarried and without a partner, and have low educational attainment and low income. In terms of health status, they are more likely to have low levels of self-reported health, depressive symptoms, and/or dementia, and to have been recently hospitalized. Becoming homebound is associated with an astonishing 65 percent six-year mortality rate.
Inequities Faced by People Who Are Homebound and Frail Older Adults
People who are homebound and frail older adults who face serious inequity in access to traditional ambulatory primary care are mostly invisible to health systems. In a study of subgroups of the most medically complex Kaiser Permanente Northern California members, insured by a variety of payers, frail older adults were found to have the highest mortality rate at 24 percent ― even higher than the active cancer patient subgroup. Frail older adults also have the second highest rate of hospital use (34 percent), the lowest rate of seeing a primary care physician, and the highest rate of not having any outpatient medical visits (27 percent) among the different subgroups. In other words, many frail and likely homebound older adults were not getting the basic primary care they needed and therefore were getting disruptive high-cost hospital care that they likely didn’t want because it was their only recourse. From the perspectives of value-based health care and equity, this is disconcerting. Frail older adults are precisely the people who experience the highest level of preventable health care costs. An estimated 50 percent of preventable Medicare costs are incurred by frail older adults and most of these costs are due to preventable hospitalizations.
Home-based primary care, which provides ongoing longitudinal care in the home for people who cannot access traditional ambulatory care due to functional limitations or mental illness, is not yet ubiquitous in the U.S. Only 12 percent of the two million individuals who are completely homebound receive primary medical care in their homes. The availability of this limited supply of home-based primary care is not distributed equitably; it is concentrated in urban metropolitan areas. It is more available to people in assisted living facilities than individuals in their homes and more available to white populations than to Black or Latinx populations. It is useful to compare the availability of primary care of homebound people to people who are residents of nursing homes. While there are about two million completely homebound older adults, there are about 1.4 million nursing home residents in the U.S. A 2016 study found that about seven times more primary care providers (34,000 of them) visited nursing facilities than visited patients at home. The volume of nursing facility visits also greatly exceeds that of home visits. Internal medicine physicians, for example, made about eight million nursing facility visits, but only about half a million home visits in 2012. Medicare paid those providers $500 million for nursing facility visits, but only $50 million for home visits. Clearly, changes are needed to ensure that frail older adults who want to live in their homes can receive the same level of primary care as individuals receiving care in nursing homes.
Making home-based primary care available to ALL frail older adults will require better value-based incentives to encourage provision of this type of care. Value-based care ideally rewards health care providers for delivering quality care to patients and improving health outcomes for populations at a lower cost. Unfortunately, inequity for homebound older adults receiving home-based primary care is also evident in Medicare value-based care programs. A potentially important opportunity for home-based primary care practices to enter into value-based care is to leverage performance payments available through the Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS). Performance payments through MIPS are predicated on eligible providers participating in quality reporting using CMS-specified quality measures. A quality measure numerator specifies whether a certain process of care or outcome has been achieved; the denominator defines whether a quality measure can be applied to a certain patient population. Some CMS measures lack home visit evaluation and management codes in their denominators, rendering them unusable by home-based medical care providers and leaving a vulnerable patient population outside the realm of value-based care. We reviewed all the CMS 2019 MIPS quality measures and found that fully 50 percent of CMS MIPS measures potentially applicable to patients receiving home-based medical care lack home visit codes in their denominators, effectively excluding them from federal value-based care initiatives and further marginalizing the population and the clinicians who care for them. In addition, measures used to judge quality of care for Medicare Advantage beneficiaries should include measures that are suitable for older adults with multiple chronic conditions and functional limitations and don’t create perverse incentives for inappropriate care.
COVID-19 Exacerbated Health Care Inequity for People Who Are Homebound and Older Adults
The COVID-19 pandemic uncovered ageism and revealed multiple cracks in the foundation of U.S. health care delivery. It laid bare the risks associated with a health care system that generally provides fragmented and reactive care and ties health service delivery to brick-and-mortar health care facilities. Hospitals, skilled nursing facilities, assisted living facilities, and nursing homes became sites of greater COVID-19 risk, increased social isolation due to restricted visitation, and death.
In a recent analysis looking at homebound status among adults 70 and older, we found that during the pandemic in 2020, homebound prevalence more than doubled, from approximately five percent in 2011-2019 to 13 percent in 2020. This increase was particularly great among minority populations with homebound status increasing among Black non-Hispanic individuals from nine percent to 22.6 percent and among Hispanic/Latino individuals from 16.7 percent to 34.5 percent.
The explosion in the use of telehealth during the pandemic helped to maintain medical care for many in the U.S.; not so much for homebound older adults. When COVID-19 struck, while only a quarter of homebound older adults lacked a cell phone, more than half did not have a computer or go online. Our brick-and-mortar health care facilities quickly resorted to video visits when in-person visits were discontinued. For the disproportionate number of homebound older adults without easy online access, virtual care proved wholly inadequate. For frail older adults already disconnected from regular ambulatory care, their only recourse when they fell ill was to go to the emergency department, a choice many did not want to make. COVID-19 showed us that our technology-enabled solution to health care, while acceptable to healthy or resourced populations, was inadequate for seriously ill high-risk populations such as the homebound population.
A Vision for the Future
We have the opportunity to reimagine a highly coordinated, truly patient-centered, distributed, and decentralized health care delivery model — the central locus being in the home and community — and less dependent on brick-and-mortar health care facilities. It would leverage decades of research in home- and community-based care delivery models, advances in data management, technology, supply chain, logistics, and payment models.
This new distributed model would weave together complementary types of home-based care — not just hospital at home or home-based primary care, but the whole toolkit of home-based longitudinal, acute, and episodic care. It would also integrate with non-medical home-based skilled and social support services. This new approach could help alleviate health care disparities and inequities by caring for patients in their preferred setting by trusted agents. It would improve access to care and help make care more affordable for patients and our society.
To do this will require innovation, learning communities to assure quality, thoughtful tests of change, investment by funders, and policy changes. All of these are within reach. Conversion to this approach to health is a matter of will, a willingness to allocate resources differently, and to give up the comfort and control of care that we have provided on our terms.
We need to reimagine health service delivery and move the locus of care to the home. This is an equity issue. This home- and community-based continuum will truly provide high-value, person-centered care at home or in a setting that feels like home. Let’s learn from COVID-19, push against ageism, and reimagine the way we provide care.