The Impact of Hcbs (Home and Community-Based Services) on Loneliness Among Older Adults: The Mediating Role of Social Participation

Background: HCBS plays a crucial role in helping older adults interact with their communities. Studies suggest HCBS can reduce social barriers and increase participation among seniors. Considering that social participation helps alleviate loneliness, HCBS may indirectly reduce loneliness, but empirical evidence remains scarce. We examined HCBS’s effect on loneliness and social participation’s mediating role among adults aged 65-74.

Methods: We utilized the NCI-AD (2022–2023) dataset, applying propensity score matching (using social participation as the primary variable) and generalized structural equation modeling (GSEM). Individuals living in institutional settings were excluded from the analysis. The final sample included 766 community-dwelling older adults (mean age = 68.86). We used three models to evaluate HCBS outcomes. Model 1 examined individual service effects, showing how distinct services impact loneliness and social participation. Model 2 investigated service combinations using a seven-pattern typology, exploring potential synergistic effects. Model 3 assessed long-term service use (1 year or more), offering a longitudinal perspective. To understand user characteristics, we conducted additional analysis using t-tests and chi-square analyses to examine user characteristics within the matched group (while PSM balance testing confirms group differences and bias in variables before and after matching, our additional analysis aims to identify the specific characteristics of users for services with statistically significant effects).

Results: In Model 1, transportation services significantly increased loneliness (β=0.284, SE=0.140), while case management services significantly decreased loneliness (β=-0.175, SE=0.085). Model 2 found no statistically significant direct impacts on loneliness or social participation. Model 3 found that delivered meal services significantly decreased social participation (β=-0.552, SE=0.181), and transportation services continued to significantly increase loneliness (β=0.869, SE=0.311). Among service patterns, personal care only services significantly increased social participation for long-term users (β=3.590, SE=1.254). Additional analysis results revealed that transportation services were primarily used by individuals with low daily living support needs, with higher usage among elderly individuals not living with family. Case management services demonstrated that users with higher social activity participation were more likely to use these services. Long-term meal delivery service users mostly struggled with forming relationships with friends and family. Long-term personal care service users were predominantly from households not living with family.

Conclusions: First, our research found that transportation and meal support services did not positively impact social participation and, in some cases, had negative effects on older adults' social outcomes. Transportation services, while enabling mobility, unexpectedly increased loneliness possibly because they may facilitate solo trips without meaningful social interaction, highlighting that physical mobility alone doesn't guarantee social connection. These services should be provided alongside other services to enhance participation for individuals struggling with family and social connections. Second, if case management and personal care services are improved, they have the potential to promote social participation and alleviate loneliness. Case management services should be expanded for older adults with lower social participation, rather than for those already socially active. Additionally, personal care services should go beyond providing physical assistance and be complemented with services that can help build friendships to actively promote social participation and reduce loneliness.