Provision of Home-based Long-term Services and Supports to Vulnerable Populations During the COVID-19 Pandemic

BACKGROUND: Older adults and individuals with disabilities prefer to receive long-term services and supports (LTSS) in home and community-based settings (HCBS). Because HCBS is less regulated, it is challenging to identify and implement COVID-19 safety practices. The purpose of this study is to understand the delivery of home-based LTSS during the COVID-19 pandemic. METHODS: This qualitative study involved interviews with home-based Medicaid LTSS clients, direct service workers (DSWs), family caregivers, and agencies. Interviews were recorded and transcribed. Analysis included immersion, team coding, aggregating codes into themes, interpretation, and member checking. RESULTS: 43 participants were interviewed. One major theme was the flux of people increasing clients’ COVID-19 exposure. Clients’ DSWs may work for other clients or at institutional settings. Aside from periods of pandemic lockdowns and shutdowns, clients may go to day centers, appointments, or community locations. Additionally, some clients had episodes of institutional care. In group-living settings, this flux was even more complex. Another theme was the negotiation of COVID-19 safety practices between clients, family members, and DSWs within the home setting. Limitation in care emerged as a third theme, with self-directed HCBS clients at particular risk. Some DSWs felt an obligation to continue care, but many quit. Social distancing in the home environment was not always possible given the services provided, so care was often limited, and isolation of family caregivers and clients was exacerbated. A final theme was that agency support of home safety practices varied. Some tried to provide guidance, personal protective equipment, and cleaning supplies to clients and caregivers, while other were unable to provide that support. CONCLUSIONS: Our findings highlight the complexity of HCBS environments. Older adults and those with disabilities are vulnerable to COVID-19, but flux of people, negotiation of safety practices, limitations in services, and variations in support increased this population's risk.