Changes in service use and unmet needs in home- and community- based services in the United States during the COVID-19 pandemic

Background: More than 4 million older adults in the United States use publicly funded home-and community-based services (HCBS) which were disrupted during the COVID-19 pandemic. There is paucity of empirical evidence of how service disruptions influenced consumer needs in different types of HCBS. Therefore, we evaluate changes in service use and consumer-reported unmet service needs in HCBS during the COVID-19 pandemic (2021–2022) versus pre-pandemic (2018–2019), to inform future public health emergency (PHE) preparedness. Methods: We analyzed repeated cross-sectional survey data from the National Core Indicators- Aging and Disability Adult Consumer Survey in two survey waves, 2018–2019 and 2021–2022. We included community-dwelling, older HCBS consumers (age ≥ 65 years; n = 7143) from 11 states that participated in both survey waves. We measured service use and consumer-reported unmet needs as outcomes for six commonly used HCBS including personal care, homemaker, meal delivery, adult day, transportation, and caregiver respite/support. Using logistic regression, we calculated adjusted odds ratios (aOR) and 95% confidence interval (CI) to evaluate changes in outcomes during versus pre-pandemic, adjusting for demographics, health-related variables, and self- versus proxy-response, with random intercepts for each state. Results: Compared to 2018–2019, during 2021–2022, odds of service use increased for personal care (aOR, 1.24; 95% CI, 1.09, 1.40) and caregiver respite/support (aOR, 1.28; 95% CI, 1.00, 1.63) but decreased for homemaker services (OR, 0.69; 95% CI, 0.60, 0.79) and meal delivery (aOR, 0.81; 95% CI, 0.70, 0.93). During the PHE, odds of unmet service needs increased for personal care (aOR, 1.23; 95% CI, 1.03, 1.46) and meal delivery (aOR, 1.26; 95% CI, 1.01, 1.56), and decreased for caregiver respite/support (aOR, 0.49; 95% CI, 0.35, 0.70). Conclusions: During the PHE, simultaneous increase in services use and unmet service needs for some HCBS (e.g. personal care) suggests that temporary PHE measures taken were insufficient to offset the demand for those services. For caregiver respite/support, increased service use and decreased unmet service needs suggests that the temporary PHE measures for caregiver support may have offset a rise in service demand. These findings can inform evaluations of temporary PHE policies for HCBS and disaster preparedness efforts for future PHEs. Clinical trial number: Not applicable.