Home and Community-based Services Coordination for Homebound Older Adults in Home-based Primary Care

Gregory J. Norman*, Amy J. Wade, Andrea M. Morris and Jill C. Slaboda

Background: Medically complex vulnerable older adults often face social challenges that affect compliance with
their medical care plans, and thus require home and community-based services (HCBS). This study describes how
non-medical social needs of homebound older adults are assessed and addressed within home-based primary care
(HBPC) practices, and to identify barriers to coordinating HCBS for patients.

Methods: An online survey of members of the American Academy of Home Care Medicine (AAHCM) was
conducted between March through November 2016 in the United States. A 56-item survey was developed to
assess HBPC practice characteristics and how practices identify social needs and coordinate and evaluate HCBS.
Data from 101 of the 150 surveys received were included in the analyses. Forty-four percent of respondents were
physicians, 24% were nurse practitioners, and 32% were administrators or other HBPC team members.
Results: Nearly all practices (98%) assessed patient social needs, with 78% conducting an assessment during the
intake visit, and 88% providing ongoing periodic assessments. Seventy-four percent indicated ‘most’ or ‘all’ of their
patients needed HCBS in the past 12 months. The most common needs were personal care (84%) and medication
adherence (40%), and caregiver support (38%). Of the 86% of practices reporting they coordinate HCBS, 91%
followed-up with patients, 84% assisted with applications, and 83% made service referrals. Fifty-seven percent
reported that coordination was ‘difficult.’ The most common barriers to coordinating HCBS included cost to patient
(65%), and eligibility requirements (63%). Four of the five most frequently reported barriers were associated with
practices reporting it was ‘difficult’ or ‘very difficult’ to coordinate HCBS (OR from 2.49 to 3.94, p-values < .05).

Conclusions: Despite the barriers to addressing non-medical social needs, most HBPC practices provided some level
of coordination of HCBS for their high-need, high-cost homebound patients. More efforts are needed to implement
and scale care model partnerships between medical and non-medical service providers within HBPC practices.

Keywords: Home-based primary care, Community-based services, Care coordination, Homebound