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Home, but Homebound After Traumatic Brain Injury: Risk Factors and Associations With Nursing Home Entry and Death
Raj G Kumar1, Mary Louise Pomeroy2, Katherine A Ornstein2
1Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York.
Objective:
To examine risk factors associated with homeboundness 1-year after traumatic brain injury (TBI) and to explore associations between homebound status and risk of future mortality and nursing home entry.
Design:
Secondary analysis of a longitudinal prospective cohort study.
Setting:
TBI Model Systems centers.
Participants:
Community-dwelling TBI Model Systems participants (n=6595) who sustained moderate-to-severe TBI between 2006 and 2016, and resided in a private residence 1-year postinjury.
Interventions:
Not applicable.
Main Outcome Measures:
Homebound status (leaving home ≤1-2d per week), 5-year mortality, and 2- or 5-year nursing home entry.
Results:
In our sample, 14.2% of individuals were homebound 1-year postinjury, including 2% who never left home. Older age, having less than a bachelor's degree, Medicaid insurance, living in the Northeast or Midwest, dependence on others or special services for transportation, unemployment or retirement, and needing assistance for locomotion, bladder management, and social interactions at 1-year postinjury were associated with being homebound. After adjustment for potential confounders and an inverse probability weight for nonrandom attrition bias, being homebound was associated with a 1.69-times (95% confidence interval, 1.35-2.11) greater risk of 5-year mortality, and a nonsignificant but trending association with nursing home entry by 5 years postinjury (RR=1.90; 95% confidence interval, 0.94-3.87). Associations between homeboundness and mortality were consistent by age subgroup (±65y).
Conclusions:
The negative long-term health outcomes among persons with TBI who rarely leave home warrants the need to re-evaluate home discharge as unequivocally positive. The identified risk factors for homebound status, and its associated negative long-term outcomes, should be considered when preparing patients and their families for discharge from acute and postacute rehabilitation care settings. Addressing modifiable risk factors for homeboundness, such as accessible public transportation options and home care to address mobility, could be targets for individual referrals and policy intervention.
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