Home and community-based service volume and the risk of transitioning to long-term care facilities: an exploratory stratified analysis

Moving beyond the assumption of uniform protective effects of care hours, this study explored the longitudinal association between Home and Community-Based Services (HCBS) volume and the risk of transitioning to Long-Term Care (LTC) facilities across mild and severe dependence groups. A stratified analysis was employed to independently evaluate context-specific utilization. We analyzed 10,296 home care service users aged 65 and older using the National Health Insurance (NHI) ‘Elderly Cohort Database’. Survival analysis was employed to track transitions to LTC facilities between 2015 and 2019. The longitudinal associations between relevant factors (e.g., home care service hours, demographics, and socioeconomic resources) and the risk of transition were evaluated using Kaplan-Meier estimates and a stratified Weibull regression model. In general, the risk of transition tended to increase over time among home care service users. However, for older adults with mild dependence, a higher HCBS volume demonstrated an inverse association with the risk of transitioning to LTC facilities. This inverse association was not observed among the severe dependence group. These exploratory findings challenge the assumption of uniform effectiveness in HCBS provision. Higher service volume was associated with a lower institutionalization risk for mildly dependent adults, whereas a statistically significant inverse association was not detected in the smaller severe-dependence group. Policymakers should move beyond blanket expansions and develop severity-tailored resource allocation strategies.