Disparities in Unmet Care Needs and Long-Term Care Transitions Among Older Renters Versus Homeowners

Background/Purpose: Unaddressed personal care needs of community-dwelling older adults lead to increased risk of worsened health, institutionalization, and death. Older renters are more likely to experience unmet care needs due to fewer economic resources, higher levels of housing instability, and less control over their physical environment compared to homeowners. Yet few studies have examined the relationships between renting versus owning, health, unmet needs, and their potential consequences. The primary objective of this study is to test whether older renters are at increased risk of death or transitioning out of community residence due to unmet needs. Better understanding these relationships can help social workers effectively target services and inform proactive policy approaches that promote equitable access to the full range of long-term care options for vulnerable older adults.

Methods: The National Health and Aging Trends Study (NHATS) collects data annually from a nationally representative sample of Medicare beneficiaries ages 65 and older taken from the Medicare enrollment database with oversamples of black older adults and the oldest old. Among community-dwelling older adults in the 2011 NHATS (N=3,313), we examined predictors of their transitions from the community to independent living, assisted living, a nursing home, or death after five years (2016 NHATS). Unmet need was determined if a respondent had difficulty or reported insufficient help with at least one of twelve self-care, household, or mobility activities. Weighted multinomial stepwise logistic regression models were used to estimate residence type (or mortality) in 2016 regressed on unmet need, renter status, sociodemographic covariates, and health characteristics in 2011. An interaction term between unmet need and renter status was also examined. Standard errors were corrected to account for the NHATS’ complex sample design.

Results: In 2011, 57% of renters compared to 43% of homeowners reported an unmet need (χ² =33.9, p<0.001). By 2016, 82% of renters with unmet needs compared to 90% of homeowners with unmet needs remained in the community (p<0.001). Controlling for sociodemographic and health characteristics, being a renter increased the average probability of transitioning to independent living by 0.02 (p<0.05) and to a nursing home by 0.03 (p<0.01). Holding all else constant, renters were also more likely than homeowners to transition to a nursing home rather than assisted living (p<0.05). Although renters have more unmet needs than homeowners, renter status did not moderate the association between unmet need and transition to a residential setting or death five years later. 

Conclusions/Implications: Since older renters have a greater prevalence of unmet care needs and are at greater risk of transition out of community residence, social work interventions should specifically target older renters as an at-risk group. Future research should examine how personal preference, geographic access, and housing stability contribute to differences in long-term care use among renters and homeowners. Collaboration between researchers, the aging network and housing advocates can help identify policy changes to ensure older renters have equitable access to the full range of long-term care options.