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Background: Interest in home-based care is increasing among Medicare Advantage (MA) plans. The epidemiology of homebound MA beneficiaries is unknown., Objective: To determine the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national MA plan., Design: Cross-sectional., Setting: National MA plan., Participants: Humana MA beneficiaries in 2022 ( n  = 2 435 519)., Measurements: Homebound status was assessed via in-home assessment using previously defined categories: homebound (never or rarely left home in the past month), semihomebound (left home with assistance, had difficulty, or needed help leaving home), and not homebound. Demographic, clinical, health service use, and mortality outcomes were compared by homebound status., Results: In 2022, the overall prevalence of homebound beneficiaries was 22.0% (8.4% of beneficiaries were homebound, and 13.6% were semihomebound). In adjusted models, female sex (odds ratio [OR], 1.36 [95% CI, 1.35 to 1.37), low-income status or dual eligibility for Medicare and Medicaid (OR, 1.56 [CI, 1.55 to 1.57]), dementia (OR, 2.36 [CI, 2.33 to 2.39]), and moderate to severe frailty (OR, 4.32 [CI, 4.19 to 4.45]) were predictive of homebound status. In multivariable logistic regression, homebound status was associated with increased odds of any emergency department visit (OR, 1.14 [ CI, 1.14 to 1.15]), any inpatient hospital admission (OR, 1.44 [CI, 1.42 to 1.46]), any skilled-nursing facility admission (OR, 2.18 [CI, 2.13 to 2.23]), and death (OR, 2.55 [CI, 2.52 to 2.58])., Limitation: The study period overlapped the tail end of the COVID-19 pandemic, and data were derived from a single national MA plan, which limits generalizability., Conclusion: Overall homebound prevalence in a national MA plan was 22.0% and was independently associated with increased health service use and mortality. Study findings can inform strategic initiatives to identify and manage care for homebound beneficiaries., Primary Funding Source: Humana, under a collaborative research agreement with Johns Hopkins University., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M24-0011.

Objectives: Homebound patients are older and suffer from multiple comorbidities, and many experienced difficulties getting vaccinated because of their inability to routinely leave the home due to health and function. Home-based primary care (HBPC) programs offer vaccination at home to reach this high-risk population. We evaluated an urban HBPC program's COVID-19 vaccination campaign to explore whether home-based vaccination can reduce inequity in vaccine administration or improve vaccine efforts., Design: We conducted a cross-sectional study to examine characteristics of homebound patients who were vaccinated through an HBPC program or were vaccinated elsewhere., Setting and Participants: We analyzed 795 patients enrolled in the HBPC program who were eligible for vaccination at home in 2021., Methods: We collected vaccination data from patients, demographic data from the electronic medical record, and neighborhood-level characteristics for each patient based on census tract., Results: Homebound patients vaccinated by HBPC were significantly more likely than homebound patients vaccinated outside of the program to have a history of dementia (P = .003), live in public housing (P < .001), have Medicaid (P = .005), be enrolled in HBPC for longer (P = .03), and live in neighborhoods with higher proportions of immigrants (P = .022), lower English proficiency (P = .007), lower computer usage (P = .001), and greater poverty (P < .001)., Conclusion and Implications: Home-based vaccination campaigns may help lower-resourced patients get vaccinated by mitigating logistic barriers and using the influence of trusted patient-provider relationships established through HBPCs., (Copyright © 2024 Post-Acute and Long-Term Care Medical Association. Published by Elsevier Inc. All rights reserved.)

The growing homebound population may particularly benefit from video telehealth. However, some patients do not have the ability or resources to successfully use this modality. This report presents the experience of a large urban home-based primary care program disseminating cellular-enabled tablets with basic instruction to a subset of its patients who would not otherwise have had the ability to engage in video telehealth. Program goals included: increasing the number of patients able to engage in video encounters and leveraging technology to help achieve greater equity. While 123 homebound patients received devices for telehealth, only one-third successfully utilized them. We identified multiple barriers to telehealth utilization beyond physical access to a device, including a lack of skill. Efforts to increase video encounters among patient groups who are less experienced with technology cannot simply rely on device provision or basic instruction but must include reinforced learning strategies combined with ongoing technical assistance.

Background: Homebound status is a final common pathway for people with a variety of diseases and conditions. There are 7 million homebound older adults in the United States. Despite concerns regarding their high healthcare costs and utilization and limited access to care, the unique subsets within the homebound population are understudied. Better understanding of distinct homebound groups may enable more targeted and tailored approaches to care delivery. Therefore, in a nationally representative sample of homebound older adults we used latent class analysis (LCA) to examine distinct homebound subgroups based on clinical and sociodemographic characteristics., Materials and Methods: Using data from the National Health and Aging Trends Study (NHATS) 2011-2019, we identified 901 newly homebound persons (defined as never/rarely leaving home or leaving home only with assistance and/or difficulty). Sociodemographic, caregiving context, health and function, and geographic covariates were derived from NHATS via self-report. LCA was used to identify the existence of distinct subgroups within the homebound population. Indices of model fit were compared for models testing 1-5 latent classes. Association between latent class membership and 1 year mortality was examined using a logistic regression., Results: We identified four classes of homebound individuals differentiated by their health, function, sociodemographic characteristics, and caregiving context: (i) Resource constrained (n = 264); (ii) Multimorbid/high symptom burden (n = 216); (iii) Dementia/functionally impaired (n = 307); (iv) Older/assisted living (n = 114). One year mortality was highest among the older/assisted living subgroup (32.4%) and lowest among the resource constrained (8.2%)., Conclusions: This study identifies subgroups of homebound older adults characterized by distinct sociodemographic and clinical characteristics. These findings will support policymakers, payers, and providers in targeting and tailoring care to the needs of this growing population., (© 2023 The American Geriatrics Society.)

Background: Homebound older adults are medically complex and often have difficulty accessing outpatient medical care. Home-based primary care (HBPC) may improve care and outcomes for this population but data from randomized trials of HBPC in the United States are limited., Methods: We conducted a randomized controlled trial of HBPC versus office-based primary care for adults ages ≥65 years who reported ≥1 hospitalization in the prior 12 months and met the Medicare definition of homebound. HBPC was provided by teams consisting of a physician, nurse practitioner, nurse, and social worker. Data were collected at baseline, 6- and 12-months. Outcomes were quality of life, symptoms, satisfaction with care, hospitalizations, and emergency department (ED) visits. Recruitment was terminated early because more deaths were observed for intervention patients., Results: The study enrolled 229 patients, 65.4% of planned recruitment. The mean age was 82 (9.0) years and 72.3% had dementia. Of those assigned to HBPC, 34.2% never received it. Intervention patients had greater satisfaction with care than controls (2.26, 95% CI 1.46-3.06, p < 0.0001; effect size 0.74) and lower hospitalization rates (-17.9%, 95% CI -31.0% to -1.0%; p = 0.001; number needed to treat 6, 95% CI 3-100). There were no significant differences in quality of life (1.25, 95% CI -0.39-2.89, p = 0.13), symptom burden (-1.92, 95% CI -5.22-1.37, p = 0.25) or ED visits (1.2%, 95% CI -10.5%-12.4%; p = 0.87). There were 24 (21.1%) deaths among intervention patients and 12 (10.7%) among controls (p < 0.0001)., Conclusion: HBPC was associated with greater satisfaction with care and lower hospitalization rates but also more deaths compared to office-based primary care. Additional research is needed to understand the nature of the higher death rate for HBPC patients, as well as to determine the effects of HBPC on quality of life and symptom burden given the trial's early termination., (© 2022 The American Geriatrics Society.)

Introduction: Seriously ill people with dementia living at home may be particularly vulnerable to disruptions in their care during times of crisis. The study sought to describe care experiences of those receiving home-based primary care in New York City during the COVID-19 pandemic and compare the experiences of people with and without dementia., Methods: We conducted a retrospective review of all electronic medical record notes between March 1, 2020 and December 30, 2020 among a sample of home-based primary care recipients (n = 228), including all deaths that occurred in the spring of 2020. Drawing from administrative records and using an abstraction tool that included both structured (e.g., documented COVID-19 exposure) and unstructured (e.g., text passage describing caregiver burden) data, we identified salient COVID-19 related care experiences and identified and categorized major disruptions in care., Results: Both people with and without dementia experienced significant disruptions of paid caregiving, family caregiving, and home-based services during the COVID-19 pandemic. While the paid caregivers of people with dementia reported more burden to the home-based primary care team as compared to people without dementia, we found little evidence of differences in quantity or type of COVID-19 related disruptions relative to dementia status., Discussion: While those with dementia have distinct care needs, our findings emphasize the way that dementia may be one piece of a larger clinical picture of serious illness. In order to support all patients with high care needs in crisis, we need to understand the interdependence of clinical care, long-term care, and family caregiving support for older adults and view dementia within the larger context of serious illness and care need., (© 2022 The American Geriatrics Society.)

Objectives: Homebound persons living with dementia may have increased difficulty accessing needed care in the community. This study identifies factors associated with becoming homebound among a national sample of Medicare beneficiaries with newly identified dementia., Design: Prospective cohort analysis., Setting and Participants: We used the National Health and Aging Trends Study (NHATS) 2011-2018 to identify community-dwelling older adults at the time of a new dementia diagnosis (n = 939). Dementia status was determined based on cognitive testing and self and proxy reporting., Methods: We compared characteristics of homebound (ie, those who never or rarely left home) and non-homebound participants at the time of dementia identification. Among non-homebound participants, we used a Fine-Gray subdistribution hazard model to identify factors associated with becoming homebound over follow-up (median follow-up 4 years), accounting for competing risks of death and moving to a nursing home., Results: 20% of individuals with newly identified dementia were homebound and this group was more functionally impaired, medically complex, and socioeconomically disadvantaged as compared to the non-homebound. Over time, depression [subhazard ratio (SHR) 2.19, 95% CI 1.36, 3.54], living in an assisted living facility (SHR 2.60, 95% CI 1.35, 4.97), and Hispanic ethnicity (SHR 1.91, 95% CI 1.05, 3.47) were associated with becoming homebound., Conclusions and Implications: Most adults are not homebound at the time of dementia diagnosis. Identifying and addressing modifiable factors like depression may slow progression to homebound status and enable persons living with dementia to access needed care in the community. In order to accommodate diverse individual and family preferences for long-term care, robust systems of home-based clinical and long-term care are necessary for those who do become homebound., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: One in 20 older adults in the United States is homebound and rarely/never leaves home. Although being homebound decreases the quality of the lived experience of individuals with serious illnesses, little is known about the frequency or likelihood of transitions in or out of homebound status. The objective of this study was to characterize the probability of transitions to and from homebound status among older adults and examine the relationship between dementia status and homebound transitions., Methods: Using 2011-2018 data from the National Health and Aging Trends Study (NHATS), a nationally representative longitudinal study of aging in the United States, we identified 6375 community-dwelling Medicare beneficiaries. Homebound status (independent, semi-homebound (leaving home but with difficulty or help), homebound (rarely or never leaving home), nursing home resident, dead) was assessed annually via self-report. Transition probabilities across states were assessed using a multistate Markov model., Results: Less than half of homebound individuals remain homebound (probability = 41.5% [95% CI: 39.2%, 43.5%]) after 1 year. One out of four dies (24% [22.3%, 26.0%]) and there is a low probability (3.2% [2.5%, 4.1%]) of transition to a nursing home. Dementia status was associated with increased risk of progression from independence to homebound status (HR: 1.83 [1.01, 3.34]). Dementia was consistently associated with increased probabilities of transitions to death including a two-fold increased hazards of progression from homebound to death (HR: 2.18 [1.69, 2.81]). Homebound individuals with dementia have a 34.2% [25.8%, 48.1%] probability of death in 5 years, compared with 17.4% [13.7%, 24.3%] among those without dementia., Discussion: Dementia is associated with greater risk of transitioning across homebound states. There is a greater need to support home-based care for patients with dementia, especially as the ongoing COVID pandemic has raised concerns about the need to invest in alternative models to nursing home care., (© 2021 The American Geriatrics Society.)

Background: Homebound older adults have heightened risks for isolation and negative health consequences, but it is unclear how COVID-19 has impacted them. We examine social contact and mood symptoms among previously homebound older adults during the COVID-19 pandemic., Design/setting: Cross-sectional analysis using data from the National Health and Aging Trends Study (NHATS), a nationally-representative longitudinal study of aging in the USA., Participants: A total of 3,112 community-dwelling older adults in 2019 who completed the COVID-19 survey in the summer/fall of 2020., Measurements: Homebound status was defined via self-report as rarely/never leaving home or leaving the house with difficulty or help in the prior month. We measured limited social contact during COVID-19 (in-person, telephone, video or email contacts

Homebound older adults are a highly vulnerable population, yet little is known about their experiences with healthcare during the COVID-19 pandemic. We interviewed patients in home-based primary care (HBPC) in New York City by telephone in May and June of 2020. Interviews covered social supports, household activities, self-care, and medical care, and asked participants to compare current with prepandemic experiences. Among 70 participants, 37% were Black and 32% were Hispanic. Disruptions in the home included greater difficulty accessing paid caregivers (13.9%) and food (35.3%) than before the pandemic, and unaddressed household chores (laundry, 81.4%; food preparation, 11.4%). Black study participants were more likely than White and Hispanic participants to report disruptions in accessing medical care (13 [50.0%] vs. 3 [14.3%] vs. 6 [27.3%], respectively, p = 0.02), as well as food preparation and medication taking. Black patients in HBPC are at risk of disparities in healthcare and social support during the COVID-19 pandemic., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background/objectives: Approximately 2 million people, or 6% of older adults in the United States, are homebound. In cross-sectional studies, homebound older adults have high levels of morbidity and mortality, but there is little evidence of longitudinal outcomes after becoming homebound. The aim of this research is to prospectively assess over 6 years the dynamics of homebound status, ongoing community residence, and death in a population of community-dwelling older adults who are newly homebound., Design/setting: Prospective cohort study using 2011-2018 data from the National Health and Aging Trends Study (NHATS), an annual, nationally-representative longitudinal study of aging in the United States., Participants: Two hundred and sixty seven newly homebound older adults in 2012., Measurements: Homebound status was defined via self-report as living in the community but rarely/never leaving home in the prior month. Semi-homebound was defined as leaving the house only with difficulty or help., Results: One year after becoming newly homebound, 33.1% remained homebound, 22.8% were completely independent, 23.8% were semi-homebound, 2.2% were in a nursing home, and 18.0% died. Homebound status is highly dynamic; 6 years after becoming homebound, 13.5% remained homebound and 65.0% had died. Recovering from being homebound at 1 year was associated with younger age and lower baseline rates of receiving help with activities of daily living, in particular, with bathing., Conclusion: Homebound status is a dynamic state. Even if transient, becoming homebound is strongly associated with functional decline and death. Identifying newly homebound older adults and developing interventions to mitigate associated negative consequences needs to be prioritized., (© 2021 The American Geriatrics Society.)

Background/objectives: COVID-19 required rapid innovation throughout the healthcare system. Home-based primary care (HBPC) practices faced unique challenges maintaining services for medically complex older populations for whom they needed to adapt a traditionally hands-on, model of care to accommodate restrictions on in-person contact. Our aim was to determine strategies used by New York City (NYC)-area HBPC practices to provide patient care during the first wave of the COVID-19 pandemic with the goal of informing planning and preparation for home-based practices nationwide., Design: Cross-sectional qualitative design using semi-structured interviews., Setting: HBPC practices in the NYC metro area during spring 2020., Participants: HBPC leadership including clinical/medical directors, program managers, nurse practitioners/nursing coordinators, and social workers/social work coordinators (n = 13) at 6 NYC-area practices., Measurements: Semi-structured interviews explored HBPC practices' COVID-19 care delivery challenges, adaptations, and advice for providers. Interviewers probed patient care, end-of-life care, telehealth, community-based services and staffing. Interviews were recorded and transcribed. Data were analyzed through a combined inductive and deductive thematic approach., Results: Participants described care delivery and operational adaptations similar to those universally adopted across healthcare settings during COVID-19, such as patient outreach and telehealth. HBPC-specific adaptations included mental health services for patients experiencing depression and isolation, using multiple modalities of patient interactions to balance virtual care with necessary in-person contact, strategies to maintain patient trust, and supporting team connection of staff through daily huddles and emotional support during the surge of deaths among long-standing patients., Conclusion: NYC-area HBPC providers adapted care delivery and operations rapidly during the height of the COVID-19 pandemic. Keeping older, medically complex patients safe in their homes required considerable flexibility, transparency, teamwork, and partnerships with outside providers. As the pandemic continues to surge around the United States, HBPC providers may apply these lessons and consider resources needed to prepare for future challenges., (© 2020 The American Geriatrics Society.)

Importance: A large and growing population of older adults with multimorbidity, cognitive impairment, and functional disability live in the community, but many never or rarely leave their homes. Being homebound is associated with decreased access to medical services, poor health outcomes, and increased mortality. Yet, it is unknown what factors, in particular socioeconomic factors, are associated with new onset of homebound status., Objective: To evaluate the association between income and risk of becoming homebound., Design: Observational cohort study using 2011 to 2018 data from the National Health and Aging Trends Study, a nationally representative sample of Medicare beneficiaries aged 65 years and older., Setting: Population-based study in the United States., Participants: A total of 7,042 initially nonhomebound community-dwelling older adults., Exposure: Total annual household income at baseline (in 2011) measured via self-report., Outcome: Annual measure of homebound status, defined as leaving home an average of 1 d/wk or less., Results: Over 7 years, 15.81% of older adults in the lowest income quartile (≤$15,003) became homebound, compared with only 4.64% of those in the highest income quartile (>$60,000). In a competing risks analysis accounting for risks of death and nursing home admission, and adjusted for clinical and demographic characteristics, those in the lowest income quartile had a substantially higher subhazard of becoming homebound than those in the highest income quartile (1.65; 95% confidence interval = 1.20-2.29). Moreover, we see evidence of a gradient in risk of homebound status by income quartile., Conclusion and Relevance: Our work demonstrates that financial resources shape the risk of becoming homebound, which is associated with negative health consequences. In the context of existing income disparities, more support is needed to assist older adults with limited financial resources who wish to remain in the community., (© 2020 The American Geriatrics Society.)

The homebound population relies on both paid and family caregivers to meet their complex care needs. In order to examine the association between intensity of caregiving support and leaving the home, we identified a population of community-dwelling, homebound Medicare beneficiaries age ≥65 (n = 1,852) enrolled in the 2015 National Health and Aging Trends Study and measured the support they received from paid and family caregivers. Those who had ≥20 h of caregiving support per week had 50% less odds of being "exclusively homebound" (rarely or never leave home) (OR 0.56, p < .01). Policies that facilitate increased support for family caregivers and better access to paid caregivers may allow homebound individuals who would otherwise be isolated at home to utilize existing community-based long-term care services and supports.

Millions of older Americans are homebound and may benefit from home-based medical care. We characterized the receipt of this care among community-dwelling, fee-for-service Medicare beneficiaries ages sixty-five and older surveyed in the National Health and Aging Trends Study between 2011 and 2017. Five percent of those surveyed received any home-based medical care between 2011 and 2017 (mean follow-up time per person was 3.4 years), and 75 percent of home-based medical care recipients were homebound. Only 11 percent of the total homebound population (approximately 4.4 million fee-for-service Medicare beneficiaries in 2017) received any home-based medical care between 2011 and 2017. Receipt of home-based medical care was more common among homebound beneficiaries living in metropolitan areas and assisted living facilities, which suggests that geographic factors create operational efficiencies for home-based medical care practices that may improve their financial sustainability within the fee-for-service reimbursement setting. The significant unmet needs of this high-need, high-cost population and the known health and cost benefits of home-based medical care should spur stakeholders to expand the availability of this care.

Background:: Many older adults are homebound due to chronic illness and suffer from significant symptoms, including pain. Home-based primary and palliative care (HBPC), which provides interdisciplinary medical and psychosocial care for this population, has been shown to significantly reduce symptom burden. However, little is known about how pain is managed in the homebound., Objective:: This article describes pain management for chronically, ill homebound adults in a model, urban HBPC program., Design/measurements:: This was a prospective observational cohort study of newly enrolled HBPC patients, who completed a baseline Edmonton Symptom Assessment System (ESAS) survey during the initial HBPC visit (N = 86). Baseline pain burden was captured by ESAS and pain severity was categorized as none, mild, or moderate-severe. All pain-related assessments and treatments over a 6-month period were categorized by medication type and titration, referrals to outside providers, procedures, and equipment., Results:: At baseline, 55% of the study population had no pain, 18% had mild pain, and 27% had moderate-severe pain. For those with moderate-severe pain at baseline (n = 23), prescriptions for pharmacological treatments for pain, such as opiates and acetaminophen, increased during the study period from 48% to 57% and 52% to 91%, respectively. Nonpharmacological interventions, including referrals to outside providers such as physical therapy, procedures, and equipment for pain management, were also common and 67% of the study population received a service referral during the follow-up period., Conclusions:: Pharmacological and nonpharmacological treatments are widely used in the setting of HBPC to treat the pain of homebound, older adults.

Nurse practitioner (NP) co-management involves an NP and physician sharing responsibility for the care of a patient. This study evaluates the impact of NP co-management for clinically complex patients in a home-based primary care program on hospitalizations, 30-day hospital readmissions, and provider satisfaction. We compared preenrollment and postenrollment hospitalization and 30-day readmission rates of home-bound patients active in the Nurse Practitioner Co-Management Program within the Mount Sinai Visiting Doctors Program (MSVD) (n = 87) between January 1, 2012, and July 1, 2013. Data were collected from electronic medical records. An anonymous online survey was administered to all physicians active in the MSVD in July 2013 (n = 13).After enrollment in co-management, patients have lower annual hospitalization rates (1.26 vs. 2.27, p = .005) and fewer patients have 30-day readmissions (5.8% vs. 17.2%, p = .004). Eight of 13 physicians feel "much" or "somewhat" less burned out by their work after implementation of co-management. The high level of provider satisfaction and reductions in annual hospitalization and readmission rates among high-risk home-bound patients associated with NP co-management may yield not only benefits for patients, caregivers, and providers but also cost savings for institutions.

By providing more frequent provider visits, prompt responses to acute issues, and care coordination, nurse practitioner (NP) co-management has been beneficial for the care of chronically ill older adults. This paper describes the homebound patients with high symptom burden and healthcare utilization who were referred to an NP co-management intervention and outlines key features of the intervention. We compared demographic, clinical, and healthcare utilization data of patients referred for NP co-management within a large home-based primary care (HBPC) program (n = 87) to patients in the HBPC program not referred for co-management (n = 1027). A physician survey found recurrent hospitalizations to be the top reason for co-management referral and a focus group with nurses and social workers noted that co-management patients are typically those with active medical issues more so than psychosocial needs. Co-management patients are younger than non-co-management patients (72.31 vs. 80.30 years old, P < 0.001), with a higher mean Charlson comorbidity score (3.53 vs. 2.47, P = 0.0001). They have higher baseline annual hospitalization rates (2.27 vs. 0.61, P = 0.0005) and total annual home visit rates (13.1 vs. 6.60, P = 0.0001). NP co-management can be utilized in HBPC to provide intensive medical management to high-risk homebound patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: To determine the association between homebound status and mortality., Design: Cross-sectional., Setting: Annual, in-person interviews., Participants: A nationally representative sample of community-dwelling, Medicare beneficiaries aged 65 and older enrolled in the National Health and Aging Trends Study between 2011 and 2013 (N = 6,400)., Measurements: Two-year mortality and prevalence of homebound status in the year before death are described using three categories of homebound status: homebound (never or rarely left home in the last month), semihomebound (left home with assistance, needed help or had difficulty), and nonhomebound (left home without help or difficulty)., Results: In unadjusted analyses, 2-year mortality was 40.3% in homebound participants, 21.3% in those who were semihomebound and 5.8% in those who were nonhomebound. Homebound status was associated with greater 2-year mortality, adjusted for sociodemographic characteristics, comorbidities, and functional status (hazard ratio = 2.08; 95% confidence interval = 1.63-2.65, P < .001). Half of older community-dwelling Medicare beneficiaries were homebound in the year before death., Conclusion: Homebound status is associated with greater risk of death independent of functional impairment and comorbidities. To improve outcomes for homebound older adults and the many older adults who will become homebound in the last year of life, providers and policymakers need to extend healthcare services from hospitals and clinics to the homes of vulnerable individuals., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Purpose: Participation in social and community activities that require leaving one's home is important to older adults; however, many older adults have difficulty or are unable to leave their dwellings, and little is known from national samples about issues related to remaining active outside the home or the barriers faced by these older adults., Design and Methods: We used the National Health and Aging Trends Study, a nationally representative study of older adults (n = 7197), to understand the following: (1) the importance that homebound and semi-homebound adults place on involvement in social or community activities, (2) their current level of involvement, and (3) reported barriers to participation., Results: Despite the heavy burden of functional limitations, depression, pain, and falls, homebound adults reported that activities outside the home were important to them ranging from 25.2 % (attend clubs) to 70.0 % (visit family). Similarly, semi-homebound older adults had a strong interest in such participation, including visiting friends and family (81.8 %), attending religious services (72.6 %), and going out for enjoyment (72.5 %). Many homebound adults reported health (42.9-64.1 % depending on the activity) and transportation (12.2-18.2 %) as barriers to participation. Semi-homebound adults also identified health (23.8-41.0 %) and transportation (6.5-10.2 %) as participation barriers., Implications: This information can be useful in designing community programs that will foster meaningful social and community engagement for older adults, which may improve their quality of life.

Context: Homebound adults experience significant symptom burden., Objectives: To examine demographic and clinical characteristics associated with high symptom burden in the homebound, and to examine associations between symptom burden and time to hospitalization, nursing home placement, and death., Methods: Three hundred eighteen patients newly enrolled in the Mount Sinai Visiting Doctors Program, an urban home-based primary care program, were studied. Patient sociodemographic characteristics, symptom burden (measured via the Edmonton Symptom Assessment Scale), and incidents of hospitalization, nursing home placement, and death were collected via medical chart review. Multivariate Cox proportional hazards models were used to analyze the effect of high symptom burden on time to first hospitalization, nursing home placement, and death., Results: Of the study sample, 45% had severe symptom burden (i.e., Edmonton Symptom Assessment Scale score >6 on at least one symptom). Patients with severe symptom burden were younger (82.0 vs. 85.5 years, P < 0.01), had more comorbid conditions (3.2 vs. 2.5 Charlson score, P < 0.01), higher prevalence of depression (43.4% vs. 12.0%, P < 0.01), lower prevalence of dementia (34.3% vs. 60.6%, P < 0.01), and used fewer hours of home health services (73.6 vs. 94.4 hours/wk, P < 0.01). Severe symptom burden was associated with a shorter time to first hospitalization (hazard ratio = 1.51, 95% CI 1.06-2.15) in adjusted models but had no association with time to nursing home placement or death., Conclusion: The homebound with severe symptom burden represents a unique cohort of patients who are at increased risk of hospitalization. Tailored symptom management via home-based primary and palliative care programs may prevent unnecessary health care utilization in this population., (Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Importance: Increasing numbers of older, community-dwelling adults have functional impairments that prevent them from leaving their homes. It is uncertain how many people who live in the United States are homebound., Objectives: To develop measures of the frequency of leaving and ability to leave the home and to use these measures to estimate the size of the homebound population in the US population., Design, Setting, and Participants: Cross-sectional data from the National Health and Aging Trends Study collected in 2011 in the contiguous United States. Participants were a nationally representative sample of 7603 noninstitutionalized Medicare beneficiaries 65 years and older., Main Outcomes and Measures: We defined homebound persons as those who never (completely homebound) or rarely (mostly homebound) left the home in the last month. We defined semihomebound persons as those who only left the home with assistance or had difficulty or needed help leaving the home. We compared demographic, clinical, and health care utilization characteristics across different homebound status categories., Results: In 2011, the prevalence of homebound individuals was 5.6% (95% CI, 5.1%-6.2%), including an estimated 395,422 people who were completely homebound and 1,578,984 people who were mostly homebound. Among semihomebound individuals, the prevalence of those who never left home without personal assistance was 3.3% (95% CI, 2.8%-3.8%), and the prevalence of those who required help or had difficulty was 11.7% (95% CI, 10.9%-12.6%). Completely homebound individuals were more likely to be older (83.2 vs 74.3 years, P < .001), female (67.9% vs 53.4%, P < .006), and of nonwhite race (34.1% vs 17.6%, P < .001) and have less education and income than nonhomebound individuals. They also had more chronic conditions (4.9 vs 2.5) and were more likely to have been hospitalized in the last 12 months (52.1% vs 16.2%) (P < .001 for both). Only 11.9% of completely homebound individuals reported receiving primary care services at home., Conclusions and Relevance: In total, 5.6% of the elderly, community-dwelling Medicare population (approximately 2 million people) were completely or mostly homebound in 2011. Our findings can inform improvements in clinical and social services for these individuals.

Objectives: To assess the oral health status, use of dental care, and dental needs of homebound elderly adults and to determine whether medical diagnoses or demographic factors influenced perceived oral health., Design: Cross-sectional analysis., Setting: Participants' homes in New York City., Participants: Homebound elderly adults (N = 125)., Measurements: A trained dental research team conducted a comprehensive clinical examination in participants' homes and completed a dental use and needs survey and the Geriatric Oral Health Assessment Index., Results: Participants who reported a high level of unmet oral health needs were more likely to be nonwhite, although this effect was not significant in multivariate analysis. Individual medical diagnoses and the presence of multiple comorbidities were not associated with unmet oral health needs., Conclusion: The oral health status of homebound elderly adults was poor regardless of their medical diagnoses. High unmet oral health needs combined with strong desire to receive dental care suggests there is a need to improve access to dental care for this growing population. In addition to improving awareness of geriatricians and primary care providers who care for homebound individuals, the medical community must partner with the dental community to develop home-based programs for older adults., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

The growing population of homebound adults increasingly receives home-based primary care (HBPC) services. These patients are predominantly frail older adults who are homebound because of multiple medical comorbidities, yet they often also have psychiatric diagnoses requiring mental health care. Unfortunately, in-home psychiatric services are rarely available to homebound patients. To address unmet psychiatric need among the homebound patients enrolled in our large academic HBPC program, we piloted a psychiatric in-home consultation service. During our 16-month pilot, 10% of all enrolled HBPC patients were referred for and received psychiatric consultation. Depression and anxiety were among the most common reasons for referral. To better meet patients' medical and psychiatric needs, HBPC programs need to consider strategies to incorporate psychiatric services into their routine care plans.

The growing homebound population has many complex biomedical and psychosocial needs and requires a team-based approach to care (Smith, Ornstein, Soriano, Muller, & Boal, 2006). The Mount Sinai Visiting Doctors Program (MSVD), a large interdisciplinary home-based primary care program in New York City, has a vibrant social work program that is integrated into the routine care of homebound patients. We describe the assessment process used by MSVD social workers, highlight examples of successful social work care, and discuss why social workers' individualized care plans are essential for keeping patients with chronic illness living safely in the community. Despite barriers to widespread implementation, such social work involvement within similar home-based clinical programs is essential in the interdisciplinary care of our most needy patients.

Objective: To describe informal caregiver and patient characteristics associated with high caregiver burden in homebound elders and to examine associations between high caregiver burden and patient health care utilization at the practice level., Method: We used a cross-sectional and prospective cohort design to study 214 caregiver-patient dyads in a home-based primary care program., Results: Informal caregivers with the highest burden were more likely to help with more activities of daily living and instrumental activities of daily living and spend >40 hr/week in caregiving. Patients whose caregivers experienced the highest burden were more likely to be non-White males without 24-hr paid homecare. There were no significant independent associations between high burden and high calls, high visits, or social work involvement., Discussion: In this medically complex and highly dependent population, further study of how families and other caregivers impact health care utilization is needed.

Venous thromboembolism (VTE) is a source of morbidity and mortality for high risk populations. The incidence of VTE has been characterized in many populations, but the incidence in homebound patients, a growing demographic, is unknown. The objective of this study was to estimate the incidence of VTE occurring at home in a cohort of patients enrolled in the Mount Sinai Visiting Doctor's Program (VDP), a home-based primary care program. The medical records of patients enrolled in the VDP over a 4 year period were examined. Incident VTE in a home setting was defined as the diagnosis of any symptomatic deep vein thrombosis or pulmonary embolism that did not occur during a hospitalization, within 4 weeks of a medical hospitalization, or within 12 weeks of a hospitalization for surgery. Functional status was abstracted for all patients, when available. Of 1,910 patients active during the study period, 39 cases of at-home VTE were identified (8.0 per 1,000 person years [95 % CI = 7.6-8.3]). Of these events, 30 of 39 were confirmed by radiological testing and considered definite, and 9 were considered probable. There was no statistically significant difference in age, race, or sex between the patients with and without VTE. In conclusion the estimated incidence of symptomatic VTE in a homebound population is low. There is insufficient evidence to support routine surveillance or prophylaxis strategies for VTE in homebound patients.

Objectives: To document the degree of symptom burden in an urban homebound population., Design: Cross-sectional survey., Setting: The Mount Sinai Visiting Doctors (MSVD) program., Participants: All individuals newly enrolled in the MSVD., Measurements: Edmonton Symptom Assessment Scale (ESAS), which consists of 10 visual analogue scales scored from 0 to 10; symptoms include pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, shortness of breath, and other., Results: ESAS scores were completed for 318 participants. Most participants were aged 80 and older (68%) and female (75%); 36% were white, 22% black, and 32% Hispanic. Forty-three percent had Medicaid, and 32% lived alone. Ninety-one percent required assistance with one or more activities of daily living, 45% had a Karnofsky Performance Scale score between 0 and 40 (unable to care for self), and 43% reported severe burden on one or more symptoms. The most commonly reported symptoms were loss of appetite, lack of well-being, tiredness, and pain; the symptoms with the highest scores were depression, pain, appetite, and shortness of breath. Participants were more likely to have severe symptom burden if they self-reported their ESAS, had chronic obstructive pulmonary disease or diabetes mellitus with end organ damage, or had a Charlson Comorbidity Index greater than 3 and less likely to have severe burden if they had dementia., Conclusion: In chronically ill homebound adults, symptom burden is a serious problem that needs to be addressed alongside primary and specialty care needs., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Background: Prolonged length of stay (LOS) is a major concern for hospitalized populations at risk for adverse events. Homebound patients are at particular risk for long stays and may have unique discharge needs because of their commitment to be cared for at home despite poor functional status., Objective: The goal of this study was to describe factors contributing to long hospitalizations in the homebound population., Design: This retrospective observational pilot study included all 2007 discharges that occurred for patients at The Mount Sinai Hospital enrolled in the Mount Sinai Visiting Doctors Program., Measures: Long-stay patients were defined as those having an LOS 2 standard deviations above the mean. Hospitalization days were defined as "nonmedical" when patients medically ready for discharge remained in the hospital. Patients discharged immediately after determination of medical readiness were characterized as "medical stay" cases. The University HealthSystems Consortium Database was used to calculate expected LOS and the LOS ratio. Chart reviews were performed to describe long-stay cases as nonmedical or medical., Results: The average LOS for 479 discharges was 7.84 days, with a mean LOS Ratio of 1.23. Seventeen cases were determined to be long stays. Eight of these cases (47%) were defined as nonmedical stays. These accounted for 136 days of hospitalization and 32% of total long-stay days. The most common reason for a nonmedical stay was nursing facility placement delay., Conclusions: Nonmedical factors accounted for nearly one-third of all long-stay days in the hospitalized homebound population. Increased interdisciplinary collaboration may help address homebound patient LOS., (Copyright © 2011 Society of Hospital Medicine.)

Seasonal influenza vaccination is recommended for all persons aged ≥50 years to reduce influenza related morbidity and mortality, but vaccination coverage among community-dwelling elderly remains low. Homebound elderly receiving home-based primary care (HBPC) have fewer barriers to vaccination than other community-dwelling elderly. The Mount Sinai Visiting Doctors (MSVD) program provides HBPC to homebound elderly in New York City. This study assessed seasonal influenza vaccination coverage within an urban HBPC program and identified factors associated with vaccine refusal. A cross-sectional analysis of data from the 2008-2009 influenza season was completed and influenza vaccination coverage was assessed. The association between social, demographic and health-related characteristics and vaccine refusal was evaluated using bivariate analysis and multivariable logistic regression. Of 689 people aged >65 eligible for influenza vaccination, 578 (84%) accepted and 111 (16%) refused vaccination. In multivariable analysis, vaccine refusal was positively associated with female gender (adjusted odds ratio [AOR] = 1.85, 95% confidence interval [CI] 1.02, 3.35), black race (AOR = 2.04, 95% CI 1.28, 3.25), and living alone (AOR = 1.71, 95% CI 1.10, 2.67), and negatively associated with dementia (AOR = 0.59, 95% CI 0.37, 0.91). Seasonal influenza vaccine coverage in the MSVD program was high compared to nursing home and community-dwelling elderly. Offering patients vaccination at home without additional expense will likely improve vaccine coverage among urban homebound elderly. Understanding why vaccine refusal rates are higher among females, black patients, and those living alone should guide interventions to increase vaccine acceptance among this population.

Homebound older adults may receive suboptimal care during hospitalizations and transitions home or to postacute settings. This 2-year study describes a nurse practitioner (NP)-led transitional care program embedded within an existing home-based primary care (HBPC) program. The transitional care pilot program was designed to improve coordination and continuity of care, reduce readmissions, garner positive provider feedback, and demonstrate financial benefits through shorter length of stay, lower cost of inpatient stay, and better documentation of patient complexity. A detailed mixed-methods evaluation was conducted to characterize the hospitalized homebound population and investigate provider feedback and program feasibility, effectiveness, and costs. Length of stay (LOS), case-mix index, and admission-related financial costs were compared before and after the intervention using a pre-post design. Structured focus groups were conducted with inpatient and primary care providers to collect feedback on the usefulness of and satisfaction with the program. The program improved communication between home-based primary care providers and inpatient providers of all disciplines and facilitated the timely and accurate transfer of critical patient information. The intervention failed to decrease hospital LOS and readmission rate significantly for people who were hospitalized. The financial implications were reassuring, although future studies are necessary. This model of a NP-led program may be feasible for enhancing inpatient management and transitional care for older adults in HBPC programs and should be considered to augment the HBPC care model., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

The Mount Sinai Visiting Doctors program, a joint program of Mount Sinai Medical Center's Departments of Medicine and Geriatrics, is a large multidisciplinary teaching, research, and clinical care initiative serving homebound adults in Manhattan since 1995. Caring for more than 1,000 patients annually, the physicians of Visiting Doctors make more than 6,000 urgent and routine visits each year, making it the largest program of its kind in the country. Services include 24-hour physician availability, palliative care, social work case management, collaboration with nursing agencies, and in-home specialty consultation. The program serves many individuals who have previously received inadequate and inconsistent medical care. Patients are referred by social service agencies, localphysicians, and hospitals and are primarily frail older individuals with complex needs. Funded by Mount Sinai and private support, the program serves as a major teaching site for medical nursing, and social work trainees interested in home-based primary care.

The coming decades will see a dramatic rise in the number of homebound adults. These individuals will have multiple medical conditions requiring a team of caregivers to provide adequate care. Home-based primary care (HBPC) programs can coordinate and provide such multidisciplinary care. Traditionally, though, HBPC programs have been small because there has been little institutional support for growth. Three residents developed the Mount Sinai Visiting Doctors (MSVD) program in 1995 to provide multidisciplinary care to homebound patients in East Harlem, New York. Over the past 10 years, the program has grown substantially to 12 primary care providers serving more than 1,000 patients per year. The program has met many of its original goals, such as helping patients to live and die at home, decreasing caregiver burden, creating a home-based primary care training experience, and becoming a research leader. These successes and growth have been the result of careful attention to providing high-quality care, obtaining hospital support through the demonstration of an overall positive cost-benefit profile, and securing departmental and medical school support by shouldering significant teaching responsibilities. The following article will detail the development of the program and the current provision of services. The MSVD experience offers a model of growth for faculty and institutions interested in starting or expanding a HBPC program.

The authors discuss the use of telemedicine during the COVID-19 pandemic. They mention the increase in telehealth appointments by the elderly and homebound, the issues of race and socioeconomics in the use of telehealth technology, and the need to factor that usage into patient care.