Addressing Social Drivers of Health in Homebound Older Adults
By Rachel Zimmer
Over 35 million of the nearly 50 million adults age 65 and over in 2017 lived either alone or with a spouse or partner, with projected single-person households age 80+ expected to rise to over to 10.1 million in 2038 (Joint Center for Housing Studies of Harvard University, 2019).
The COVID-19 pandemic has disproportionately impacted older adults, with 8 out of 10 COVID-19 related deaths involving older adults with comorbid conditions (Centers for Disease Control and Prevention [CDC], 2020).
Because of their higher risk of complications associated with COVID-19, older adults have largely been self-isolating since March, even beyond those in the general population. In addition, the pandemic is causing increased economic uncertainty for many older adults.
The isolation and threat of morbidity and mortality associated with the pandemic has caused significant disruption in the lives of many older adults, causing change in daily activities and isolation from caregivers, friends, and family members on whom many older adults rely.
Many adult day centers have closed temporarily, putting more responsibility of care on the caregivers who were already showing evidence of burden, even prior to the pandemic. Also, many older adults and their caregivers are under increased financial strain due to job loss.
In many cases, older adults are facing economic uncertainty due to loss of financial assets and a net decrease in housing values (Cohen et al., 2020).
Prior to the pandemic, the Joint Center for Housing Studies of Harvard University (2019) found an additional 2.4 million of the poorest senior citizens in the United States will have no access to affordable housing by 2038 if trends of financial strain in older adults continue.
Social Drivers of Health
Social drivers of health are defined by the World Health Organization (WHO, 2020) as "circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness.
These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics." WHO identifies reorienting the health sector toward reducing health inequities as part of the Global Plan of Action. These include a person's access to food, housing, transportation, safety, and education. Social drivers are strong indicators of disease complications, including mortality, and are considered responsible for many health inequities (WHO, 2020).
Social drivers of health affect a wide range of outcomes in older adults, including health, quality of life, social isolation, and mental health (CDC, 2020). If not addressed, they cause upstream effects that impact an individual's health care. For example, if a patient suffers from financial insecurity and does not have food subsidies, they may have to decide whether to buy medications or food on a weekly basis.
This reality is becoming a more common occurrence in the older adult population. Nearly 5.5 million older adults reported being food insecure in 2019, with this number expected to grow (Feeding America, 2020; U.S. Department of Agriculture, 2014).
In addition, the number of people age 62 and older living in emergency shelters and transitional housing has risen by over 69% over the last decade (Joint Center for Housing Studies of Harvard University, 2019).
Another sobering report published by Culhane and colleagues (2019) predicts the number of elderly people experiencing homelessness in the United States will nearly triple in the next 10 years.
Strategies to Address Social Drivers for Older Adults
House Call providers are well suited to assess and address social drivers of health for their patients. A survey of members of the American Academy of Home Care Medicine in 2016 found 98% of practices reported assessing the patient's social needs, while 83% of the practices reported filling out service referrals.
The practices cited difficulties in addressing social drivers of health for patients, with barriers such as costs and eligibility requirements (Norman et al., 2018). Also, House Call programs include care transition interventions to address social drivers and healthcare access. Care transition interventions are an important service to provide to older adults, as they reduce patient costs while also improving outcomes and reducing 30-day readmissions (Boutwell, et al., 2016; De Jonge et al., 2014).
For example, an NP-led home visit within 48-72 hours of hospital discharge was shown to reduce readmissions, leading to a 48.2% reduction in the readmission rate (Smith et al., 2016; Verhaegh et al., 2014).
Encouragingly, many healthcare institutions across the country are finding ways to help patients who are struggling with social drivers of health through innovative strategies that also include increasing access to technology.
In Baltimore, a population health team developed several supports for high-risk older adults during the pandemic, including increased support to help with access to medications from local pharmacies, to healthy meals, and by the provision of technological support for older adults to access telehealth. Federal funding has also provided additional support for community-based organizations to help address food insecurity and access to health foods for older adults. In addition, many older adults are learning to use technology to order groceries for delivery from their local grocery stores.
For patients who need access to food, the healthcare team may need assistance in applying for SNAP or other community-based services, depending on the patient's functional status and comfort with technology.
For older adults, the continuation of stable housing is an important contributor to reducing health and nursing services and hospitalization costs (Culhane et al., 2019). There are several recommended approaches healthcare teams can take to prevent homelessness in older adults, including case management services for those who need ongoing, modest rental assistance, and helping patients gain access to resources such as rental vouchers through the housing authority.
Other suggested interventions include early intervention for decreased mobility with increased home nurse and palliative care support for older adults who suffer with chronic illness and are at higher risk of hospitalization (Culhane et al., 2019).
In summary, the pandemic has highlighted the impact social drivers of health have on all populations, but especially need to be addressed for older adults who are the frailest. House Call providers are well known for their ability to fully assess the needs of older persons, particularly those who are more isolated or those with limited mobility and cognitive decline/dementia, in order to provide person-centered support.
Teams should work with caregivers and older adults to ensure community-based services and supports are in place for older persons, including social and legal services, despite physical distancing measures. Screening for social drivers of health is a first step, opening the door for conversation and provision of individualized options for support.
Rachel Zimmer, DNP, AGPCNP
rbrandin@wakehealth.edu
References
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- Centers for Disease Control and Prevention (CDC). (2020). People at increased risk for severe illness. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html
- Cohen, M., Taveres, A., Silberman, S., & Popham, L. (2020). Economic insecurity for older adults in the presence of the COVID-19 pandemic: What can we learn from the most recent major economic downturn? https://d2mkcg26uvg1cz.cloudfront.net/wp-content/uploads/2020-C19-DG06_COVID-19-Issue-Brief_4-14.pdf
- Culhane, D., Treglia, D., Byrne, T., Metraux, S., Kuhn, R., Doran, K., … Schretzman, M. (2019). The emerging crisis of aged homelessness: Could housing solutions be funded by avoidance of excess shelter, hospital, and nursing home costs? https://www.aisp.upenn.edu/wp-content/uploads/2019/01/Emerging-Crisis-of-Aged-Homelessness-1.pdf
- De Jonge, K.E., Jamshed, N., Gilden, D., Kubisiak, J., Bruce, S.R., & Taler, G. (2014). Effects of home-based primary care on Medicare costs in high-risk elders. Journal of the American Geriatrics Society, 62(10), 1825-1831.
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