Home-based services linked to functional improvement in older adults with diabetes

Older adults living with diabetes face a heightened risk of functional decline, a condition that can significantly impact their quality of life and independence. While functional status is often viewed as a static measure of health, recent research suggests it is dynamic, involving periods of both worsening and potential improvement. A new longitudinal analysis published in BMC Geriatrics examines the relationship between the use of home- and community-based services (HCBS) and transitions in functional status among this specific population. The study focuses on whether access to these services is associated with moving into or out of a state of dual functional limitation, defined as concurrent difficulties in both basic and instrumental daily activities.

The study, led by researchers Xiaowei Ying and Mingshen Lin, utilized data from the China Health and Retirement Longitudinal Study (CHARLS). This longitudinal cohort study incorporated data from 2018 and 2020 to track changes in health and functional status over time. The analysis included 1,227 adults aged 60 years and older who had been diagnosed with diabetes. By examining these two specific time points, the researchers were able to assess the directionality of functional changes, distinguishing between those who developed new limitations and those who experienced improvements in their ability to perform daily tasks.

In this context, dual functional limitation is a critical metric for assessing severe disability. It is defined as the simultaneous presence of limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL). ADLs refer to basic self-care tasks such as bathing, dressing, and eating, while IADLs involve more complex activities necessary for independent living, such as managing finances, preparing meals, and using transportation. The presence of limitations in both domains indicates a significant burden of disability that often requires substantial external support to maintain a basic standard of living.

Home- and community-based services (HCBS) represent a broad category of support designed to help individuals remain in their own homes and communities rather than in institutional settings. These services can include personal care assistance, homemaker services, and various forms of community-based support. In the study, HCBS use was assessed in 2018, serving as the exposure variable for the analysis. The researchers aimed to determine if receiving these services was associated with a lower risk of developing dual functional limitation or a higher probability of recovering from it by the 2020 follow-up.

Among the 1,227 participants in the cohort, 288 individuals, representing 23.5% of the sample, reported using HCBS during the baseline period. The researchers employed modified Poisson regression with robust sandwich variance to estimate risk ratios (RRs) for the transitions in functional status. This statistical approach is suitable for estimating risk ratios in cohort studies and provides a clear measure of the relative likelihood of transitioning between different functional states, adjusted for potential confounding factors.

The findings revealed a distinct pattern regarding the association between HCBS use and functional transitions. Specifically, the use of HCBS was not significantly associated with a transition into dual functional limitation. The estimated risk ratio for developing dual limitations was 1.01, with a 95% confidence interval ranging from 0.72 to 1.41. This result suggests that, based on this data, receiving home- and community-based services did not significantly increase or decrease the likelihood of an older adult with diabetes moving from a state of no dual limitation to one of dual limitation over the study period.

In contrast, the analysis indicated a significant association between HCBS use and the transition out of dual functional limitation. Participants who used HCBS had a higher probability of improving their functional status, with a risk ratio of 1.45 and a 95% confidence interval of 1.05 to 1.99. This finding implies that access to these services may be linked to a greater likelihood of recovering from severe dual-domain disability, although the study design limits the ability to establish a direct causal mechanism for this improvement.

A more detailed examination of the nature of this improvement provided further nuance to the results. The association between HCBS use and functional improvement was primarily observed in transitions to single-domain limitation. The risk ratio for moving from dual limitation to a state where only one domain (either ADL or IADL) was limited was 1.84, with a 95% confidence interval of 1.16 to 2.93. However, the association was not significant for the transition to complete functional independence, where no ADL or IADL limitations were present. The risk ratio for this complete restoration was 1.01, with a 95% confidence interval of 0.52 to 1.97, indicating that HCBS use was not significantly associated with a full return to independence in this cohort.

The authors conclude that among older adults with diabetes, the use of home- and community-based services is associated with a transition out of dual functional limitation, but not with a transition into it. The observed benefit appears to reflect a partial improvement in functional status, specifically a reduction from dual-domain to single-domain limitation, rather than a complete restoration of functional independence. These findings highlight the potential role of HCBS in mitigating the severity of functional decline in this vulnerable population, although the association does not imply that services prevent the initial onset of dual limitations.

This study contributes to the growing body of evidence regarding the management of functional health in older adults with chronic conditions like diabetes. By distinguishing between different directions of functional transition, the research offers insights into how community-based supports might influence the trajectory of disability. The results suggest that while HCBS may not prevent the onset of severe dual-domain limitations, they may be associated with a higher likelihood of partial recovery, potentially helping individuals maintain a degree of independence and reducing the burden of care. Further research is needed to understand the specific mechanisms through which these services influence functional outcomes and to determine if these associations hold true in other populations and healthcare settings.

Subject of Research: Geriatrics

Article Title: Home- and community-based services and transitions into and out of dual functional limitation in older adults with diabetes: a longitudinal analysis

Article References: Ying, X., & Lin, M. (2026). Home- and community-based services and transitions into and out of dual functional limitation in older adults with diabetes: a longitudinal analysis. BMC Geriatrics. https://doi.org/10.1186/s12877-026-08434-2

Image Credits: AI Generated

DOI: 10.1186/s12877-026-08434-2

Keywords: Diabetes, Functional Limitation, Home- and Community-Based Services, Older Adults, Longitudinal Study, CHARLS, BMC Geriatrics, Home-, community-based, services, transitions, dual