Increased use of health services and higher mortality among the homebound population

1. In this cross-sectional study, homebound beneficiaries of a large national Medicare Advantage plan had increased health care utilization and increased mortality rates.

2. Female gender, low income, dementia, and moderate to severe frailty were predictive factors for home attachment.

Evidence assessment level: 2 (Good)

Study overview: Increasing numbers of older adults experience functional impairments and chronic diseases that prevent them from leaving their homes. Homebound older adults have been shown to use primary care less relative to their morbidity burden but to use hospital, emergency department, and nursing home care more frequently than their non-homebound peers. Medicare Advantage (MA), a type of health insurance plan offered by Medicare-approved private companies, provides coverage for more than half of Medicare enrollees and has increased the use of home care. However, the epidemiology of populations participating in MA remains poorly understood. Therefore, this study aimed to examine the characteristics, utilization patterns, and mortality outcomes of homebound enrollees of Humana, a large national MA program. Overall, more than one-fifth of enrollees were found to be homebound to some degree, with female gender, low income, dementia, and moderate to severe frailty being significant predictors of homebound status. Humana’s homebound beneficiaries also had higher healthcare utilization and mortality, with higher odds of emergency room, hospital, and nursing home use. The study overlapped with the end of the COVID-19 pandemic, during which a significant increase in the prevalence of homebound status was observed. In addition, the study used data from a single MA plan, limiting the generalizability of the results. Overall, this study highlights the size and composition of this vulnerable population.

Click here to read the study in AIM

Relevant reading: Epidemiology of the homebound population in the United States

In-depth (cross-sectional study): This cross-sectional study was the largest investigation to date of homebound and epidemiology. The study included beneficiaries enrolled in plans offered by Humana who completed an in-home health and well-being assessment (IHWA) between January and December 2022, and were continuously enrolled in the plan from January 1 to December 31, 2021. Using self-reported IHWA responses, individuals were defined as homebound if they never or rarely left home, semi-homebound if they left home but were at risk of becoming homebound, or non-homebound. Of 5,722,966 active beneficiaries in 2022, 2,435,519 were eligible and 514,188 individuals completed an IHWA. Of those completing an IHWA, 113,052 were homebound to some degree (a homelessness prevalence of 22.0%), of which 69,740 (13.6%) beneficiaries were partially homebound and 43,312 (8.4%) beneficiaries were fully homebound. Being female (odds ratio (OR) 1.36; 95% confidence interval (CI) 1.35 to 1.37), having low income or dual eligibility for Medicare and Medicaid (OR 1.56; 95% CI 1.55 to 1.57), having dementia (OR 2.36; 95% CI 2.33 to 2.39), and having moderate to severe frailty (OR 4.32; 95% CI 4.19 to 4.45) were associated with homelessness. Homebound status was also associated with increased odds of emergency department visit (OR, 1.14; 95% CI, 1.14 to 1.15), inpatient hospital admission (OR, 1.44; 95% CI, 1.42 to 1.46), nursing facility admission (OR, 2.18; 95% CI, 2.13 to 2.23), and death (OR, 2.55; 95% CI, 2.52 to 2.58). In summary, this study adds to the literature describing the risk factors and consequences of the growing number of homebound adults.

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