Perceived barriers to oral health care among the homebound

Michael S. Strayer, DDS, MS

Perceived barriers to oral health care among the homebound

Questionnaires and oral examina- tions were completed on 50 clients of a social service agency which pro- vides home-based services to functionally dependent elderly. Nearly 61% of all respondents classified their oral health as frall/poor, and 82% reported a perceived need for some oral health care. When asked if they considered themselves homebound, 60% reported being homebound from 1-10 years (mean = 4.7 years). Two or more home services were received by 80% of the homebound group compared with just 45% of the not-homebound group. Paying for dental care, transportation dim- culties, and poor health were the most frequently identified barriers that limited access to oral health care.

inked with the growth of the elderly population is the relationship between increasing age

and the presence of multiple chronic pathologies.' Although comprising about 12% of the population, the elderly account for 27% of hospital discharges* and 33% of the US personal health care expenditure^.^ With the most rapid population growth occurring among the oldest age cohort, it is expected that by the turn of the century more than 50% of the elderly will be over the age of 75.4 Berk et aL5 have reported that nearly 30% of this population (over the age of 75) have chronic health problems that limit daily activities.

the community over the age of 65 have limitations with at least one Activity of Daily Living (ADL), one Instrumental Activity of Daily Living (IADL), or with walking6 Defined as the functional dependent, these elderly are impaired by chronic debil- itating physical, mental, and/or emo- tional problems that make it difficult to live independently. These functional limitations result in an increasing number of individuals who are institutionalized or homebound due to the loss of independence. It is esti- mated that 13% of community- dwelling elderly experience ADL limitations6 These ADL limitations are comparable with those experienced by 90% of nursing home resi- d e n t ~ . ~

The community-dwelling functionally dependent elderly and their caregivers prefer noninstitutionalized approaches to care which utilize home-based services.s To avoid insti-

Over five million persons living in

tutionalization, community-dwelling functionally dependent elderly are more frequent users of home-based services which can include: home health aids, homemaker services, visiting nurses, physical therapy, and home-delivered meals. These services are viewed as the preferred and low- cost alternative to nursing home care.9 While more elderly choose to remain in their own homes with the assistance of home-based services, little is known about the oral health needs of these community-dwelling functionally dependent elderly or their access to oral health care.

The elderly are retaining more of their natural dentition and experien- cing increasing rates of dental disease.lOJ1 However, the relationship between subjective oral health needs and barriers to receiving oral health care among the functionally dependent and homebound elderly is not well-documented. Previously identified barriers to receiving oral health care among the elderly include: functional status, medical status, transportation difficulties, financing oral health care, previous patterns of dental utilization, knowl- edge and use of available oral health care services, and perceived oral health status.12-16

The objectives of this study were, first, to describe the perceived homebound status, perceived oral health status, perceived oral health need, and barriers to receiving dental care for a little-studied population consist- ing of functionally dependent elderly living in the community receiving home-based support services. A sec- ond objective was to examine the

Speclal Care In Dentlstry, Vol 15 No 3 1995 113

Table 1. Characteristics of community-dwelling elderly receiving home-based services.

Homebound Not Homebound

(n = 30) (n = 20)

Gender (YO) Male

Female

Race (%)

White

Other

Medical Status (YO)

Excellent/Good

Fair/Poor

Mean Age (SD)

Mean Number of Years of

Education Completed (SD)

17

83

45

55

60

40

25

75

58

42

60

40

73.2 (t 14.3) 70.8 (k 13.0)

10.8 (k 4.3) 12.4 (+ 2.2)

Mean Number of Visits to

Physician/Past Year (SD)

10.1 (k 11.5) 8.7 (+ 6.7)

Mean Number of Home

Services Received (SD)a

2.5 (+ 0.91) 1.6 (+ 1.0)

aWilcoxon Rank Sum Test, p < 0.01.

relationship between perceived homebound status and barriers to care (represented by functional limitations). It was expected that those elderly who consider themselves homebound would report having poorer oral health and would per- ceive more barriers to accessing oral health care.

Methods Subjects for this study were clients of a social service agency providing home-based services to functionally dependent individuals. The social service agency serves an urban Midwestern city with clients repre- senting all socioeconomic segments

of the community. Confidentiality issues concerning the use of the agency client roster precluded select- ing a random sample of subjects for this study. Therefore, the project director met with the social service agency staff to identify clients willing to participate in this study. Each vol- unteer subject consented to a home- administered questionnaire and oral examination which was completed by the project director.

Factors associated with classifying individuals as homebound include: being older, more dependent on measures of physical function, more likely to have used in-home services, and having visited a physician within the

preceding 12 months.17 Functional status (ADL’s and number of home- based services) and perceived barriers to receiving oral health care were obtained so that the subjects’ relationship to perceived homebound status could be examined. Variables per- taining to perceived barriers to oral health care for the elderly have been previously described.l2-I5 Questions addressing use of dental services were adapted from a previous study on dental needs of homebound individuals.l8 Perceived medical status was determined by response to the question, ”Compared to others your age, how would you rate your general health?” Response choices were: excellent, good, fair, poor. This question has been used extensively in a longitudinal panel study of the functionally dependent elderly in Massachu~etts.~~ All data collected were considered confidential and were used in aggregate form for data analysis only. Subjects were informed of oral conditions which required treatment and were referred to a local program which provided in-home oral health care services.

The sampling method utilized for this project dictated that nonparamet- ric measures of data analysis be used. The Wilcoxon rank sum test was used for the analysis of continuous variables, and Fisher’s exact text was used for nominal variables. This group of community-dwelling functionally dependent elderly had received an in-home assessment and were deemed to need assistance with at least one home-based service from the social service agency. The volunteers represented less than one per- cent of the social service agency clients (approximately 5000), who can be characterized as female, 75 years old, and with incomes less than $7,500. The volunteers approximate the overall distribution of county social service agency clients for gender, age, and income. However, the results of this study should be used with caution, since this population may reflect a skewed sample, and therefore the results may not be generalizable to other community- dwelling elderly who are functionally

114 Special Care in Dentistry, Vol15 No 3 1995

dependent or homebound.

Results This group of community-dwelling functionally dependent elderly were receiving at least one home-based service through a social service agency. When asked if they considered themselves to be homebound, 60% reported being homebound, and 40% indicated that they were not. Individuals reported being homebound for from 1-10 years (4.7 -c 2.9 years). Table 1 presents respondent characteristics for each group. There were no differences in respondent characteristics with the exception of number of home services received. The homebound group reported receiving 2.5 home-based services us. just 1.6 home-based services for the non-homebound group.

The number of home-based services received is a measure of homebound status.17 The types and distribution of home-based services received by all respondents are shown in Fig 1. The homebound group made more frequent use of all home-based services except for the homemaker service. Just 45% of the not-homebound group used two or more home-based services, while 90% of the homebound group reported using two or more home-based services. Another measure of homebound status is the need for assistance with ADL's and transportation diffi~u1ties.l~ Assistance with bathing, with dressing, and transportation difficulties were the three ADL's in which a significantly higher proportion of the homebound group needed assistance (Table 2). When the level of assistance needed with ADL's was separated into three cate- gories (those needing no assistance with any ADL, those needing assistance with one or two ADL's, or those needing assistance with three or more ADL's), homebound respondents required assistance with significantly more ADL's (Table 3).

Dental health characteristics of these individuals have previously been reported. There was no difference in mean number of teeth present, coronal DFT, or root DFT

Visiting Nurse

Home Health Aid

Horn em aker

Home Delivered

i I

67%

90%

Meals 0% 20% 40% 60% 80% 100%

Figure 1. A comparison of home services received by homebound status.

I Difficulty Locating

Den tist

Transportation 39.3%

40% Flnancing

13.3% I11 Health

.7%

Office Access

0% 10% 20% 30% 40% 50%

Figure 2. Perceived barriers to receiving oral health care by homebound status.

between groups.20 To assess perceived oral health status, each respondent rated his or her oral health (poor or excellent), need for oral health care (none to a lot), and primary method of paying for oral health care. Nearly 61% of all respondents rated their oral health as fair or

poor, with just 18% indicating no perceived need for oral health care. However, there was no difference in perceived oral health, perceived need for oral health care, or method of paying for oral health care between the homebound and not-homebound groups (Table 4). Just 26% of respon-

Special Care In Dentistry, Vol15 No 3 1995 115

Table 2. Activities of Daily Living by homebound status.


(n = 30) (n = 20)

Need H e b Moving. about the House

Yes 30

No 70

Need Assistance with Dressing. YO^ Yes

No

Need Assistance with Bathing (Yay

Yes

No

Need Assistance with Eating (”/orb

Yes

No

47

53

79

21

13

87

Need Assistance with Personal Hvgiene

Yes 47

No 53

15

85

10

90

40

60

0

100

35

65

Transportation (%y Able to go out 0 70

Unable to go out 100 30

aFisher’s Exact Test, p c 0.001 bFisher’s Exact Test, n.s.

dents had been to the dentist in the past two years, and nearly 45% had not visited the dentist in six or more years.

Correlations between oral health characteristics and perceived oral need and general health were examined. Perceived need for oral care and number of teeth present (r = 0.27925, p = 0.0495) were moderately correlat- ed, with individuals having a greater number of teeth more likely to report a need for dental care. As perceived need for oral care increases, perceived dental health worsens (r = -0.4867, p = 0.006). No significant relationships were noted among den-

tal utilization, perceived oral need, oral health status, and perceived general health status.

Paying for oral health care services was the most frequently identified barrier to receiving oral health care among all functionally dependent elderly surveyed. Transportation and poor health were the next most frequently cited barriers (Fig 2). While 80% of these community- dwelling elderly reported a perceived need for some oral health care, nearly two-thirds (64%) reported paying for oral health care services out-of-pocket, and 26% relied on Medicaid for oral health care reimbursement.

Discussion Although several home-based services are made available to the functionally dependent elderly, oral health care is not routinely provided. The transportation of equipment needed to provide oral health care services limits the delivery of oral health care in nontraditional settings. The demand for oral health care services among all elderly has increased during the past two decades. The elderly are retaining more of their own teeth, resulting in fewer com- pletely edentulous individuals. The retention of more natural teeth has resulted in increased caries rates and increased periodontal disease among the elderly c o h ~ r t . ~ , l ~ With the trend of retaining more natural dentition into old age expected to continue, future community-dwelling functionally dependent elderly will require greater access to oral health care.

Use of in-home services, functional status, need for assistance with ADL’s, and transportation difficulties are validated measures used opera- tionally to define individuals as h0meb0und.l~ All subjects in this project received at least one home- based service. Individuals who considered themselves homebound in this study used more home-based services, required assistance with a greater number of ADL’s, and experienced more difficulty with transportation. These findings are consistent with Gilbert et al.’s validation of factors associated with homebound status among a longitudinal panel study of frail dependent elderly in Massachusetts.17 These factors are indicative of a population that is more functionally dependent and has greater difficulty in accessing services outside the home.

One indication that the oral health needs of these functionally dependent elderly are largely unmet is the high proportion who reported a perceived need for oral health care. Nearly 90% of the homebound group reported the need for some level of oral health care. The extent of perceived oral health need recorded by this group (90%) is greater than the

116 Special Care in Dentistry, Vol15 No 3 1SSb

60% of homebound subjects reporting a perceived oral health care need in an earlier study of the homebound.21 It is important to note that numerous studies have shown perceived oral health care need among the elderly to be lower than actual clinical need.22-24 Another indication of unmet oral health care need with this population is the proportion of respondents who described their oral health as fair or poor (61%).

Perceived barriers can limit the elderly’s access to oral health care. Only 26% of all respondents reported having gone to the dentist in the past two years, while just one in five of the homebound group had gone to the dentist in the past two years. This is in contrast to national data which report that, among individuals with 11-12 years of education, approximately 41-57% had visited the dentist in the past two years.25

Frequently identified barriers to accessing oral health care among homebound populations include: cost of or paying for overall health care, difficulty with transportation, and need for physical assistance to get to the dentist.12,20,21 The proportion of this population (64%) paying for oral health care services out-of-pocket is comparable with the 74-84% reported in an earlier study.21 Substantially more individuals (26%) relied on Medicaid for dental reimbursement among this population us. just 2% from a national survey.26 Difficulty in arranging transportation continues to be identified as a barrier, consistent with a previous report.21

The anticipated growth in the functionally dependent elderly population, using home-based services to avoid institutionalization and mini- mize health costs, will place tremen- dous demands on the current health care delivery system. As state and federal governments ponder methods to control the spiraling cost of long- term care, more home-based services are offered as an alternative to institutionalization. Health care policy makers, providers, and social service agencies must be cognizant of the growing need for oral health services and the barriers which limit access to

Table 3. Level of functional deoendence bv homebound status.


(n = 30) (n = 20)

No A4ssistance with Activities 17

of Daily Living (YO) 45

Assistance with 1-2 Activities (YO) 45 45

Assistance with 3-5 Activities (Yo) 38 10

Fisher’s Exact Test, p c 0.05.

Table 4. Oral health characteristics by homebound status.


(n = 30) (n = 20)

Perceived Oral Health P/i,p Excellent /Good Fair/Poor

38

62

Perceived Need for Oral Health Care H YO^ None 23

Some 47

A Lot 30

Method of Pavment (YOp Medicaid

Self-pay

Insurance

Other

30 60

7

3

40

60

15

60

25

20

70

5

5

aFisher’s Exact Test, n.s.

oral health care among this frail dependent aging population.

Previously, little has been reported on the oral health needs of the homebound. A high perceived need for oral health care, a high proportion reporting poor perceived oral health, an increase in the number of retained natural teeth, and continued barriers to accessing care (cost and transportation) are major issues for this growing segment of frail functionally

dependent community-dwelling elderly. Although these data are not generalizable to other homebound populations, they do provide a glimpse of the problems experienced by community-dwelling functionally dependent elderly in accessing oral health care. The continued emphasis on home-based services to lower health care costs will only increase the number of elderly who will experience limited access to oral health

Speclal Care In Dentistry, Vol 15 No 3 1995 117

care services as delivered in the traditional office setting. This information can offer some insight into the need to develop state and federal policies regarding the reimbursement and delivery of oral health services to a functionally dependent elderly population unable to access oral health care services in the traditional man- ner.

Dr. Strayer is Associate Professor in the College of Dentistry, The Ohio State University, 305 W. 12th Avenue, Columbus, OH 43210.

Xis project was funded by The Ohio State University Committee on Urban Affairs and the Urban Assistance Program.

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Documents

Perceived barriers to oral health care among the homebound