The Unmet Needs of Homebound Urban Elders: Examining the Role of Economic Security, Living Alone, and Case Management Services

Background and purpose: The relationship between economic insecurity and functional decline among older adults is well established. It has also been suggested that older adults most at risk of poor outcomes are those who live alone. Older adults who live alone face multiple challenges due to a lack of informal or financial resources often available to those living with others. A challenge facing social workers in supporting older adults in their homes is the lack of awareness of community-based supportive services, and the fragmentation of service delivery systems. Case management (CM) plays a key role in connecting homebound older adults to services, and in navigating the fragmented and confusing long-term service milieu. In New York City, approximately 18,000 older adults receive CM funded by the Older Americans Act..  The case management literature has been inconclusive in determining the effectiveness of case management services that target broad populations, but has suggested that appropriately targeted services may produce positive outcomes. This study examined whether case management mediates the relationship between economic security and unmet needs among homebound older adults.

Methods: Assessment records (N=90) were analyzed from a consortium of four case management programs serving a diverse catchment area in New York City, using a convenience sample of clients who consented to the record review (36% response rate). Approximately three-quarters of the ethnically diverse sample (78%) had received case management services in the previous six-months and two-thirds of the sample lived alone (66.7%). To determine whether case management mediates the relationship between economic security (monthly income minus housing and medical expenses) and number of unmet needs for assistance with daily living (ADL/IADL), three separate regressions were performed using the Baron and Kenny (1986) four-step approach to establishing mediation. Control variables included: living alone, age, gender, race/ethnicity, adequate informal support, and food stamp benefits.

Results: Although there was a significant relationship between economic security and unmet needs, significance was not sustained when controlling for other variables. This precluded the need to test for a mediating relationship between economic security and unmet needs. Living alone, however, remained a significant predictor of unmet needs (B = 1.37, SE = .635, p<.05). The mediating effect of case management on the relationship between living alone and unmet needs was examined and was not found to be significant. Living alone significantly predicted higher numbers of unmet needs among homebound elders, regardless of economic security, adequacy of informal support, case management use, while controlling for age, gender, race/ethnicity, and food stamp benefits.

Conclusions and implications: The findings of this study call attention to the challenges faced by older adults who live alone, despite their connection to community-based supportive services. Researchers, practitioners and policymakers need to better understand the complexities of aging in place and improve the ability to identify those with the greatest need who may benefit from case management or other long term supportive services. Indeed, more innovative approaches to traditional programming are needed to meet the needs of the growing number of older adults living alone.