Beyond Family Care: How Home- and Community-Based Services Complement Family Care to Reduce Unmet Care Needs and Enhance the Well-Being Among Older Adults With Disabilities
Restricted accessResearch articleFirst published online 2026
Beyond Family Care: How Home- and Community-Based Services Complement Family Care to Reduce Unmet Care Needs and Enhance the Well-Being Among Older Adults With Disabilities
Home- and community-based services (HCBS) complement informal family care and support healthy aging. While HCBS benefits are well documented, how informal family care moderates the association between HCBS and the subjective well-being (SWB) of older adults with disabilities and mediation mechanisms remain underexplored. Using 2018 China Health and Retirement Longitudinal Survey data (n = 1,812), we find that HCBS utilization is positively associated with SWB (measured by life satisfaction), with unmet care needs–reflecting person-environment incongruence–serving as a mediator. Informal family care moderates the HCBS–SWB association. The positive HCBS–SWB association is stronger among older adults with disabilities who were childless, lived alone, and had fewer family caregivers, primarily due to a greater mediation effect of unmet care needs. These findings highlight the importance of considering the structure and capacity of family care when promoting HCBS, ensuring HCBS more effectively complements family support and addresses older adults’ needs.
AnsahJ. P.ChiuC.-T.Wei-YanA. C.MinT. L. S.MatcharD. B. (2021). Trends in functional disability and cognitive impairment among the older adult in China up to 2060: Estimates from a dynamic multi-state population model. BMC Geriatrics, 21(1), 380. https://doi.org/10.1186/s12877-021-02309-4
2.
Ansari-ThomasZ. (2024). Sandwich caregiving and paid work: Differences by caregiving intensity and women’s life stage. Population Research and Policy Review, 43(1), 8. https://doi.org/10.1007/s11113-023-09852-5
3.
ArpinoB.BordoneV.BalboN. (2018). Grandparenting, education and subjective well-being of older Europeans. European Journal of Ageing, 15(3), 251–263. https://doi.org/10.1007/s10433-018-0467-2
4.
BakerL. A.CahalinL. P.GerstK.BurrJ. A. (2005). Productive activities and subjective well-being among older adults: The influence of number of activities and time commitment. Social Indicators Research, 73(3), 431–458. https://doi.org/10.1007/s11205-005-0805-6
5.
BarczykD.KredlerM. (2019). Long-term care across Europe and the United States: The role of informal and formal care. Fiscal Studies, 40(3), 329–373. https://doi.org/10.1111/1475-5890.12200
6.
BaronR. M.KennyD. A. (1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173–1182. https://doi.org/10.1037//0022-3514.51.6.1173
7.
BauerA.KnappM.WistowG.PerkinsM.KingD.IemmiV. (2017). Costs and economic consequences of a help-at-home scheme for older people in England. Health and Social Care in the Community, 25(2), 780–789. https://doi.org/10.1111/hsc.12372
8.
BeachS. R.SchulzR. (2017). Family caregiver factors associated with unmet needs for care of older adults. Journal of the American Geriatrics Society, 65(3), 560–566. https://doi.org/10.1111/jgs.14547
9.
BolandL.LégaréF.PerezM. M. B.MenearM.GarvelinkM. M.McIsaacD. I.Painchaud GuérardG.EmondJ.BrièreN.StaceyD. (2017). Impact of home care versus alternative locations of care on elder health outcomes: An overview of systematic reviews. BMC Geriatrics, 17(1), 20. https://doi.org/10.1186/s12877-016-0395-y
10.
BonsangE. (2009). Does informal care from children to their elderly parents substitute for formal care in Europe?Journal of Health Economics, 28(1), 143–154. https://doi.org/10.1016/j.jhealeco.2008.09.002
11.
BulamuN.KaambwaB.GillL.CameronI.McKechnieS.FiebigJ.GradyR.RatcliffeJ. (2017). Impact of consumer-directed care on quality of life in the community aged care sector. Geriatrics and Gerontology International, 17(10), 1399–1405. https://doi.org/10.1111/ggi.12872
12.
ChanN.AnsteyK. J.WindsorT. D.LuszczM. A. (2010). Disability and depressive symptoms in later life: The stress-buffering role of informal and formal support. Gerontology, 57(2), 180–189. https://doi.org/10.1159/000314158
13.
ChenL.FanH.ChuL. (2019). The hidden cost of informal care: An empirical study on female caregivers’ subjective well-being. Social Science & Medicine, 224(2), 85–93. https://doi.org/10.1016/j.socscimed.2019.01.051
14.
ChenQ.AmanoT.ParkS.KimB. (2019). Home and community-based services and life satisfaction among homebound and poor older adults. Journal of Gerontological Social Work, 62(7), 708–727. https://doi.org/10.1080/01634372.2019.1639094
ChiuT.-Y.YuH.-W.ChenY.-M. (2022). Continuous use of home care services and functional performance: A population-based approach. Journal of Applied Gerontology: The Official Journal of the Southern Gerontological Society, 41(3), 736–743. https://doi.org/10.1177/07334648211032419
17.
ChongN.AkobirshoevI.CaldwellJ.KayeH. S.MitraM. (2022). The relationship between unmet need for home and community-based services and health and community living outcomes. Disability and Health Journal, 15(2), Article 101222. https://doi.org/10.1016/j.dhjo.2021.101222
18.
ChuL.JolyE.MoisanM.-G. (2023). Child-to-parent intergenerational support and its association with subjective well-being among older adults: A cross-national comparison of American and Korean parents. Wellbeing, Space and Society, 5(13–14), Article 100177. https://doi.org/10.1016/j.wss.2023.100177
DienerE.EmmonsR. A.LarsenR. J.GriffinS. (1985). The satisfaction with life scale. Journal of Personality Assessment, 49(1), 71–75. https://doi.org/10.1207/s15327752jpa4901_13
22.
DienerE.LucasR. E.OishiS. (2002). Subjective well-being: The science of happiness and life satisfaction. In SnyderC. R.LopezS. J. (Eds.), Handbook of positive psychology (pp. 63–73). Oxford University Press.
23.
DuprazJ.HenchozY.Santos-EggimannB. (2020). Formal home care use by older adults: Trajectories and determinants in the Lc65+ cohort. BMC Health Services Research, 20(1), 22. https://doi.org/10.1186/s12913-019-4867-6
24.
EichlerT.HoffmannW.HertelJ.RichterS.WuchererD.MichalowskyB.DreierA.ThyrianJ. R. (2016). Living alone with dementia: Prevalence, correlates and the utilization of health and nursing care services. Journal of Alzheimer's Disease: JAD, 52(2), 619–629. https://doi.org/10.3233/JAD-151058
25.
FengZ.GlinskayaE.ChenH.GongS.QiuY.XuJ.YipW. (2020). Long-term care system for older adults in China: Policy landscape, challenges, and future prospects. Lancet (London, England), 396(10259), 1362–1372. https://doi.org/10.1016/S0140-6736(20)32136-X
26.
FerrisR. E.GlicksmanA.KlebanM. H. (2016). Environmental predictors of unmet home-and community-based service needs of older adults. Journal of Applied Gerontology: The Official Journal of the Southern Gerontological Society, 35(2), 179–208. https://doi.org/10.1177/0733464814525504
27.
FonsecaC.TeixeiraM.CaetanoA. P.RodriguesP. F. S. (2024). Life satisfaction, well-being, and happiness in older adults with and without formal support. Revista Portuguesa de Investigação Comportamental e Social: RPICS, 10(1), 8. https://doi.org/10.31211/rpics.2024.10.1.333
28.
FreedmanV. A.CornmanJ. C.CarrD.LucasR. E. (2019). Time use and experienced wellbeing of older caregivers: A sequence analysis. The Gerontologist, 59(5), e441–e450. https://doi.org/10.1093/geront/gny175
29.
FriedmanM. M.BowdenV. R.JonesE. G. (2003). Family nursing: Research, theory & practice. (5th ed.). Prentice Hall.
30.
FuY.ChuiE. W. T. (2020). Determinants of patterns of need for home and community-based care services among community-dwelling older people in urban China: The role of living arrangement and filial piety. Journal of Applied Gerontology: The Official Journal of the Southern Gerontological Society, 39(7), 712–721. https://doi.org/10.1177/0733464819871875
31.
FuY.GuoY. (2022). Community environment moderates the relationship between older adults’ need for and utilisation of home- and community-based care services: The case of China. Health and Social Care in the Community, 30(5), e3219–e3232. https://doi.org/10.1111/hsc.13766
32.
GlinskayaE.FengZ. (2018). Options for aged care in China: Building an efficient and sustainable aged care system. World Bank Publications.
33.
GuD.VloskyD. (2008). Long-term care needs and related issues in China. In GarnerJ. B.ChristiansenT. C. (Eds.), Social sciences in health care and medicine (pp. 52–84). Nova Science Publishers.
34.
HayesA. F. (2017). Introduction to mediation, moderation, and conditional process analysis, second edition: A regression-based approach. Guilford Publications.
35.
HazzanA. A.PloegJ.ShannonH.RainaP.OremusM. (2015). Caregiver perceptions regarding the measurement of level and quality of care in Alzheimer’s disease. BMC Nursing, 14(1), 54. https://doi.org/10.1186/s12912-015-0104-8
36.
HeS.CraigB. A.XuH.CovinskyK. E.StallardE.ThomasJ.IIIHassZ.SandsL. P. (2015). Unmet need for ADL assistance is associated with mortality among older adults with mild disability. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 70(9), 1128–1132. https://doi.org/10.1093/gerona/glv028
37.
HeY.WeiB.LiY. (2023). The impact of using community home-based elderly care services on older adults’ self-reported health: Fresh evidence from China. Frontiers in Public Health, 11, Article 1257463. https://doi.org/10.3389/fpubh.2023.1257463
38.
HerbersD. J.MulderC. H. (2017). Housing and subjective well-being of older adults in Europe. Journal of Housing and the Built Environment, 32(3), 533–558. https://doi.org/10.1007/s10901-016-9526-1
39.
HoefmanR. J.van ExelJ.BrouwerW. B. (2013). Measuring the impact of caregiving on informal carers: A construct validation study of the CarerQol instrument. Health and Quality of Life Outcomes, 11(1), 173. https://doi.org/10.1186/1477-7525-11-173
40.
HuB.WangJ. (2019). Unmet long-term care needs and depression: The double disadvantage of community-dwelling older people in rural China. Health and Social Care in the Community, 27(1), 126–138. https://doi.org/10.1111/hsc.12630
41.
HuangZ.XuT.ZhangR.ZhangX.WangS.ZhangJ.YangQ.FuY.GuiJ.ZhangX.ChenC. (2023). The relationship between home and community-based healthcare services utilization and depressive symptoms in older adults in rural China: A moderated mediation model. BMC Public Health, 23(1), 1014. https://doi.org/10.1186/s12889-023-15590-2
42.
IparraguirreJ. L. (2020). Reductions in local government spending on community-based social care and unmet social care needs of older people in England. The Journal of the Economics of Ageing, 17, Article 100126. https://doi.org/10.1016/j.jeoa.2017.07.001
43.
JinF.ChenT. (2025). Community nursing on subjective well-being of the elderly: Evidence from CLASS data. BMC Nursing, 24(1), 757. https://doi.org/10.1186/s12912-025-03205-7
44.
JuddC. M.KennyD. A. (1981). Process analysis: Estimating mediation in treatment evaluations. Evaluation Review, 5(5), 602–619. https://doi.org/10.1177/0193841X8100500502
45.
KadowakiL.WisterA. V.ChappellN. L. (2015). Influence of home care on life satisfaction, loneliness, and perceived life stress. Canadian Journal on Aging / La Revue Canadienne Du Vieillissement, 34(1), 75–89. https://doi.org/10.1017/S0714980814000488
46.
KimB.ParkS.Bishop-SaucierJ.AmorimC. (2017). Community-based services and depression from person-environment fit perspective: Focusing on functional impairments and living alone. Journal of Gerontological Social Work, 60(4), 270–285. https://doi.org/10.1080/01634372.2017.1310166
47.
KimY.KimS.JeongS.ChoS. G.HwangS. (2019). Poor people and poor health: Examining the mediating effect of unmet healthcare needs in Korea. Journal of Preventive Medicine and Public Health, 52(1), 51–59. https://doi.org/10.3961/jpmph.18.162
48.
KoP.-C.MöhringK. (2021). Chipping in or crowding-out? The impact of pension receipt on older adults’ intergenerational support and subjective well-being in rural China. Journal of Cross-Cultural Gerontology, 36(2), 139–154. https://doi.org/10.1007/s10823-020-09422-8
49.
KolodziejI. W. K.CoeN. B.Van HoutvenC. H. (2022). The impact of care intensity and work on the mental health of family caregivers: Losses and gains. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 77(Supplement_1), S98–S111. https://doi.org/10.1093/geronb/gbac031
50.
KomisarH. L.FederJ.KasperJ. D. (2005). Unmet long-term care needs: An analysis of medicare-medicaid dual eligibles. Inquiry: A Journal of Medical Care Organization, Provision and Financing, 42(2), 171–182. https://doi.org/10.5034/inquiryjrnl_42.2.171
51.
KumagaiN. (2017). Distinct impacts of high intensity caregiving on caregivers’ mental health and continuation of caregiving. Health Economics Review, 7(1), 15. https://doi.org/10.1186/s13561-017-0151-9
52.
LämåsK.BöleniusK.SandmanP.-O.BerglandÅ.LindkvistM.EdvardssonD. (2020). Thriving among older people living at home with home care services—A cross-sectional study. Journal of Advanced Nursing, 76(4), 999–1008. https://doi.org/10.1111/jan.14307
53.
LawtonM. P. (1985). The elderly in context: Perspectives from environmental psychology and gerontology. Environment and Behavior, 17(4), 501–519. https://doi.org/10.1177/0013916585174005
54.
LawtonM. P.NahemowL. (1973). Ecology and the aging process. In EisdorferC.LawtonM. P. (Eds.), The psychology of adult development and aging (pp. 619–674). American Psychological Association.
55.
LiuJ.WeiW.PengQ.XueC. (2021). What can buffer the impact of social support on Chinese older adults’ life satisfaction?Journal of Applied Gerontology: The Official Journal of the Southern Gerontological Society, 40(10), 1260–1271. https://doi.org/10.1177/0733464820917876
56.
MacKinnonD. P.WarsiG.DwyerJ. H. (1995). A simulation study of mediated effect measures. Multivariate Behavioral Research, 30(1), 41–62. https://doi.org/10.1207/s15327906mbr3001_3
57.
MaoX.HanW.-J. (2018). Living arrangements and older adults’ psychological well-being and life satisfaction in China: Does social support matter?Family Relations, 67(4), 567–584. https://doi.org/10.1111/fare.12326
MoralesM. J.RobertS. A. (2022). Examining consequences related to unmet care needs across the long-term care continuum. Journals of Gerontology Series B, 77(SUPPL 1), S63. https://doi.org/10.1093/geronb/gbab210
60.
MoussaM. M. (2019). The relationship between elder care-giving and labour force participation in the context of policies addressing population ageing: A review of empirical studies published between 2006 and 2016. Ageing and Society, 39(6), 1281–1310. https://doi.org/10.1017/s0144686x18000053
61.
MuramatsuN.YinH.HedekerD. (2010). Functional declines, social support, and mental health in the elderly: Does living in a state supportive of home and community-based services make a difference?Social Science & Medicine, 70(7), 1050–1058. https://doi.org/10.1016/j.socscimed.2009.12.005
62.
NewcomerR.KangT.LaPlanteM.KayeS. (2005). Living quarters and unmet need for personal care assistance among adults with disabilities. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 60(4), S205–S213. https://doi.org/10.1093/geronb/60.4.s205
63.
Osmanovic-ThunströmA.MosselloE.ÅkerstedtT.FratiglioniL.WangH.-X. (2015). Do levels of perceived stress increase with increasing age after age 65? A population-based study. Age and Ageing, 44(5), 828–834. https://doi.org/10.1093/ageing/afv078
64.
PattersonS. E.FreedmanV. A. (2025). Family structure and unmet care needs among older adults with and without dementia in the United States. The Gerontologist, 65(5), gnaf062. https://doi.org/10.1093/geront/gnaf062
65.
PattersonS. E.FreedmanV. A.CornmanJ. C.WolffJ. L. (2023). Work as overload or enhancement for family caregivers of older adults: Assessment of experienced well-being over the day. Journal of Marriage and Family, 85(3), 760–781. https://doi.org/10.1111/jomf.12909
66.
PearlinL. I.SkaffM. M. (1996). Stress and the life course: A paradigmatic alliance. The Gerontologist, 36(2), 239–247. https://doi.org/10.1093/geront/36.2.239
67.
PeeblesV.BohlA. (2014). The HCBS taxonomy: A new language for classifying home- and community-based services. Medicare & Medicaid Research Review, 4(3), E1–E17. https://doi.org/10.5600/mmrr.004.03.b01
68.
PingR.HuB.OshioT. (2024). Evaluating the impact of a pilot programme for home- and community-based services on long-term care needs among older adults in China. PLoS One, 19(11), Article e0311616. https://doi.org/10.1371/journal.pone.0311616
69.
PreacherK. J.RuckerD. D.HayesA. F. (2007). Addressing moderated mediation hypotheses: Theory, methods, and prescriptions. Multivariate Behavioral Research, 42(1), 185–227. https://doi.org/10.1080/00273170701341316
70.
RoweJ. W.KahnR. L. (1998). Successful aging. Pantheon Books.
71.
SobelM. E. (1982). Asymptotic confidence intervals for indirect effects in structural equation models. Sociological Methodology, 13(1), 290–312. https://doi.org/10.2307/270723
TseliouF.RosatoM.MaguireA.WrightD.O’ReillyD. (2018). Variation of caregiver health and mortality risks by age: A census-based record linkage study. American Journal of Epidemiology, 187(7), 1401–1410. https://doi.org/10.1093/aje/kwx384
74.
UchinoB. N. (2006). Social support and health: A review of physiological processes potentially underlying links to disease outcomes. Journal of Behavioral Medicine, 29(4), 377–387. https://doi.org/10.1007/s10865-006-9056-5
UrwinS.LauY.-S.GrandeG.SuttonM. (2021). The challenges of measuring informal care time: A review of the literature. PharmacoEconomics, 39(11), 1209–1223. https://doi.org/10.1007/s40273-021-01053-2
WangH.LiuH.WuB.HaiL. (2024). The association between trajectories of perceived unmet needs for home and community-based services and life satisfaction among Chinese older adults: The moderating effect of psychological resilience. Research on Aging, 46(2), 139–152. https://doi.org/10.1177/01640275231203608
80.
WangY.YangW. (2022). Does receiving informal care lead to better health outcomes? Evidence from China longitudinal healthy longevity survey. Research on Aging, 44(7–8), 510–518. https://doi.org/10.1177/01640275211052834
81.
WangY.-C.YuH.-W.WuS.-C.ChanS.-Y.YangM.-C.LeeY.-C.ChenY.-M. (2021). The impact of different patterns of home- and community-based services on nursing home admission: National data from Taiwan. Social Science & Medicine, 270(8), Article 113679. https://doi.org/10.1016/j.socscimed.2021.113679
82.
WiestM.SchüzB.WebsterN.WurmS. (2011). Subjective well-being and mortality revisited: Differential effects of cognitive and emotional facets of well-being on mortality. Health Psychology: Official Journal of the Division of Health Psychology, American Psychological Association, 30(6), 728–735. https://doi.org/10.1037/a0023839
83.
WilsonA. (2012). Improving life satisfaction for the elderly living independently in the community: Care recipients’ perspective of volunteers. Social Work in Health Care, 51(2), 125–139. https://doi.org/10.1080/00981389.2011.602579
XuT.HuangZ.LiB.JinH.ZhangJ.YangH.HuangY.ZhangX.ChenC. (2024). Association between home and community-based services utilization and self-rated health among Chinese older adults with chronic diseases: Evidence from the 2018 China Health and Retirement Longitudinal Study. BMC Public Health, 24(1), 117. https://doi.org/10.1186/s12889-023-17535-1
86.
YangW.TanS. Y. (2021). Is informal care sufficient to meet the long-term care needs of older people with disabilities in China? Evidence from the China Health and Retirement Longitudinal Survey. Ageing and Society, 41(5), 980–999. https://doi.org/10.1017/s0144686x1900148x
87.
YangY.LeeA.-R.RappT.ChenR.GlymourM. M.TorresJ. M. (2024). State home and community-based services expenditures and unmet care needs in the United States: Has everyone benefitted equally?Health Services Research, 59(2), Article e14269. https://doi.org/10.1111/1475-6773.14269
88.
YuY.ZhangJ.SongC.PetrovicM.PeiX.ZhangW.-H. (2022). Perceived availability of home- and community-based services and self-reported depression among Chinese older adults: A cross-sectional study. Health and Social Care in the Community, 30(5), e2827–e2837. https://doi.org/10.1111/hsc.13726
89.
YueZ.XiangN.LiH.LiuE. (2021). The evolution trend of availability of China’s community-based care services and its impact on the cognitive function of elderly people: 2008-2018. International Journal for Equity in Health, 20(1), 203. https://doi.org/10.1186/s12939-021-01544-w
90.
ZengY.LinC.FangY. (2023). Factors influencing the demands for home and community-based care services among older adults living alone in China. Journal of Aging & Social Policy, 36(5), 1–17. https://doi.org/10.1080/08959420.2023.2226297
91.
ZhangW.SunH.L’HeureuxJ. (2022). The impact of caregiving length and intensity on labor force participation among middle-aged Canadians: An analysis of Canadian longitudinal study on aging data. Journal of Occupational and Environmental Medicine, 64(11), e774–e781. https://doi.org/10.1097/JOM.0000000000002696
92.
ZhangY.YeagerV. A.HouS. (2018). The impact of community-based supports and services on quality of life among the elderly in China: A longitudinal study. Journal of Applied Gerontology: The Official Journal of the Southern Gerontological Society, 37(10), 1244–1269. https://doi.org/10.1177/0733464816661945
93.
ZhuY.ÖsterleA. (2017). Rural-urban disparities in unmet long-term care needs in China: The role of the hukou status. Social Science & Medicine, 191, 30–37. https://doi.org/10.1016/j.socscimed.2017.08.025
94.
ZuverinkA.XiangX. (2020). Anxiety and unmet needs for assistance with daily activities among older adults. Journal of Aging and Health, 32(5–6), 491–500. https://doi.org/10.1177/0898264319830805
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
