Older adults are vulnerable to both coronavirus disease 2019 (COVID-19) and the secondary effects of the pandemic.¹⁾ Given the lack of effective pharmacological treatment, home isolation has been recommended to prevent infection,²⁾ which raises concerns regarding the secondary effects on older people living in the community, including reduced physical activity, social isolation, and reduced access to home care services.³–⁵⁾

Older people living in the community face additional challenges related to reduced home care.^6,7) Even in facilities in which no outbreaks have occurred, home care has been reduced or suspended because employees are required to stay home to prevent the spread of infection and thus are unable to provide care.^8,9) Families are reluctant to send older people to long-term care (LTC) facilities,⁸⁾ which causes confusion and stress not only to clients but also to family caregivers. The symptoms of people with dementia may also be aggravated by disruptions in their usual lifestyle and prolonged indoor living.^1,10) Furthermore, a significant decrease in user numbers negatively affects home LTC provider businesses.¹¹⁾ However, little is known about how reduced use affects home care.⁷⁾

In Japan, the Ministry of Health, Labour and Welfare restricted visits to clients in LTC facilities from February 24, 2020, before a steep increase in the number of cases.¹²⁾ In early March, the first outbreak at an adult day service was identified, following which other LTC providers in the area were required to close.⁹⁾ In late March, the number of infections increased, and on April 1, the government's expert panel recommended suspending or restricting day care services for persons with disability.¹³⁾ A survey of home LTC providers conducted in April showed that 25.6% of respondents had experienced decreases of income of 20% or more in March compared to those in February.¹¹⁾ On April 7, a state of emergency was declared for seven prefectures, which was gradually expanded. One percent or more of the adult day services for people with disabilities were closed during this period.¹⁴⁾ A total of 39 LTC facilities had experienced outbreaks by May 9.¹⁵⁾

This study investigated the reduced use of home LTC services using data from an urgent survey of LTC providers in Japan. Reduced usage in this study included both client cancellations (i.e., users voluntarily refraining from using the service) and service contraction (i.e., service providers reducing service availability). To evaluate the magnitude of the effects on home care, we compared the impact of home care services to that of institutional services and assessed which of these home care services were more likely to be affected. The research questions were as follows. (1) Were home LTC services more likely to experience reduced usage than institutional LTC services during the COVID-19 pandemic? Which home LTC services were the most affected? (2) To what extent did reduced usage affect user numbers and provider revenues for each service?

Home care was more likely to experience reduced usage than institutional care. It is difficult to suspend services for clients in an LTC facility and move them back to their homes or to another facility. In addition, clients in institutional care facilities had lower activities of daily living (ADLs) than those using home care; thus, it may have been difficult for them to postpone their admission and continue home care. This may have prevented reduced institutional usage especially that associated with client cancellation. We estimated that reduced institutional usage reduced revenues by 1.4%–1.9%. This was lower than that for home care, and reduced usage was assumed to occur in a limited number of patients.

In this study, 72% of home care providers experienced client cancellations, a rate significantly higher than that for institutional services. Although the government did not recommend avoiding the use of home-based services in general, clients may have perceived that the risk of infection from home care services exceeded the benefits of using them. In addition to health anxiety and risk to loved ones, regular media use and social media use were identified as predictors of fear related to COVID-19.¹⁷⁾ While the media are critical for conveying information to the public and promoting preventive behavior, information should be conveyed without sensationalism or disturbing images to avoid generating excessive fear.¹⁸⁾ The World Health Organization has also recommended that individuals limit seeking information from the media to about twice a day.¹⁹⁾ Additionally, service providers may have failed to adequately inform clients of the services’ benefits and risks of service suspension. The purpose of LTC insurance is to provide health, medical, and welfare benefits for services necessary for clients to lead independent lives and maintain their dignity.²⁰⁾ In this study, service providers were concerned about a potential decline in ADLs (68.9% of respondents were concerned), fewer opportunities to go out and socialize (59.2%), cognitive function decline (58.1%), increased burden on family caregivers (57.3%), and physical inactivity (42.3%).¹⁶⁾ Emerging evidence has shown that community-dwelling older adults experienced negative effects on anxiety, depression, sleep quality, and physical activity during the period of social isolation due to COVID-19.²¹⁾ Insufficient communication on why home services are necessary and how they contribute to clients’ health may have led to substantial underutilization. To avoid excessive client cancellations in future pandemics, it may be necessary to agree with clients and their families on the necessity and benefits of the regular use of home care services.

Among home care services, adult day services were more likely to experience reduced usage. Adult day service embeds social contact in its process.^22,23) Because clients often stay in the same place and eat at the same time in adult day services, it may have been difficult to take measures to prevent infection. Furthermore, since clients of adult day services have lower care needs on an average than short stay service clients, adult day services may have been temporarily replaced by informal caregiving or perceived as less necessary. The average increase in the number of home visit service users suggests that some clients reduced their use of adult day services and replaced these services with home visit services. Service contraction was more likely to occur in short stay services; however, as they were mostly located in LTC institutions with residents at higher risks of severe illness, they adopted more stringent preventive measures.

The adult day service experienced the largest impact on user numbers and revenue following reduced usage. We estimated that service contraction caused a 12.0% decrease in user numbers and a 7.2% decrease in revenue. Since the average profit ratio is 3.1% for all LTC providers and 3.3% for adult day service,²⁴⁾ a revenue reduction exceeding 10% could be critical. In this study, 19.9% of respondents reported increased expenditures related to additional infection control materials/equipment and working hours;¹⁶⁾ thus, the impact on the profit ratio was likely greater. Home care providers are smaller enterprises than institutional care providers and therefore are likely to have less financial capacity. Although the proportion of service contractions was lower than that of client cancellations, it was much higher than the proportion of infected cases among service providers and users, suggesting that services were contracted in a fairly precautionary manner. As the pandemic continues, there has been progress in infection control training, including standard precautions and stocking of infection prevention items in home services. These efforts should continue to ensure service continuity as much as possible during future pandemics.

This study was conducted with an emphasis on timeliness, which limited the representativeness of the sample. It was difficult to survey facilities in crisis situations or that were closed due to outbreaks. Nevertheless, the results of the survey of care managers¹⁶⁾ also demonstrating that adult day services most commonly experienced service contraction, followed by short stay services and home-visiting services, suggests that this tendency is reliable.

The rates of change in client numbers and revenue are less reliable because the respondents were asked to retrospectively indicate the changes from the previous year. In addition, the rate of change was based on April data, while the usage restrictions were based on data at the time of the response (May 12–22); thus, there is a time gap. The results of this study should be followed up with further analyses of LTC insurance records and ongoing administrative survey data. Prolonged reduced usage may cause deterioration of physical and psychological outcomes, regardless of the COVID-19 situation. The potential long-term impact on the older population requires further investigation. In addition, the data did not include the condition of the affected clients (e.g., care level). This topic also requires further exploration as older people with higher care levels may be more vulnerable to the negative effects of service reduction.