Was Digitalization In In-Home Supportive Services Associated with Service Utilization?

Background

There are two sides of digitalization. While it improves services efficiency, transparency, and accountability (Ariyadi & Akbar, 2025), prior studies show that the shift to digital access in health and social care can worsen disparities for older adults with limited income, education, digital literacy, or cognitive resources (Yang et al., 2024) Yet, little is known about how these dynamics affect In-Home Supportive Services (IHSS), which uniquely serves low-income, highly vulnerable older adults. This study examines whether transitioning IHSS from a paper-based to an electronic system of timesheet approval in 2020 decreased the service utilization among low-income older adults and which subgroup is disproportionately impacted.

Methods

This study employed a mixed-methods design. Quantitative analyses used individual-level IHSS administrative data from a California county (N=6,700) from 2016 to 2024, including descriptive statistics, paired t-tests, and a multiple regression model. Service utilization is measured by the ratio of actual paid hours to authorized hours. The qualitative component consisted of semi-structured interviews with IHSS participants (N=7), which explored experiences with the system transition, perceived challenges, and strategies used to maintain service continuity.

Results

Overall service utilization was high: mean service utilization was 97.02% before the electronic system transition and 97.32% after. Higher use percentages mean fewer unclaimed hours. A paired t-test among 6,700 clients indicated a 0.3% (p<0.001) decrease in unclaimed hours post-digitalization. Multiple regression showed that having a family caregiver is a protective factor, while mobility limitations and living alone were associated with higher increases in unclaimed hours after the change. Race and ethnicity were not significant predictors of service utilization change. However, Chinese and Russian primary languages were positively related to service use.

Qualitative findings showed that participants from different backgrounds adjusted well to the system change. Participants who disliked the electronic system successfully used phone-based options or received caregiver help to approve timesheets. Participants who reported unmet needs and/or service gaps had limited mobility, lived alone, and had caregivers who were unrelated to them. Russian-speaking participants expressed no difficulty with the electronic system transition and reported no unmet needs.

Quantitative and qualitative findings converged to show that participants’ IHSS services were not negatively impacted by the electronic system switch. However, participants with mobility limitations and those who lived alone showed less service utilization, while family caregiver relationships and Russian as the primary language emerged as protective factors.

Conclusion and Implications

Contrary to widely held expectations that digitization amplifies inequities (Hwang et al., 2024), the data showed statistical, but not clinically meaningful change in the service utilization post-digitalization. Caregiver support and phone alternatives appear to mitigate the impacts of system switch—consistent with sociotechnical recommendations emphasizing flexible, user-centered designs and supportive ecosystems (Rabbani et al., 2026). Limitations of this study include a small qualitative sample size and missing key variables in quantitative data (e.g., education level). Other factors, rather than the system switch alone, may explain the positive changes. Future research should include the impact of education level and explore other metrics of challenges and successes related to service utilization.