Rural-Urban Disparities in Access to Home- and Community-Based Services and Supports: Stakeholder Perspectives From 14 States

Perceived helpfulness of caregiver support resources: Results from a state-wide poll

Objective

Our goal was to identify specific types of services desired by caregivers and determine subgroups most interested in each service type.

Methods

Caregiving questions were added to a state-wide poll conducted in a majority-rural state. Those who identified as caregivers (n = 428) were asked to report on the helpfulness of 6 domains of services. Descriptive analysis and logistic regressions were conducted.

Results

Top resources caregivers identified as potentially helpful included hands-on services (33.9%), help coordinating care from multiple providers (21.5%), help with finances (18.9%), and help managing emotional stress (17.8%). Only 15% indicated no caregiver resources would be helpful. Younger caregivers endorsed several service domains as more helpful than older caregivers; caregivers reporting higher stress were more likely to endorse most domains as helpful.

Conclusion

Data reinforces the overwhelming need to offer caregiver services. Navigation and integrated and tailored service models may be beneficial to help caregivers identify and access appropriate services within healthcare systems.

Innovation

This study uses an innovative approach to identifying needs of caregivers, who are often invisible within the healthcare system. Our findings suggest a paradigm shift is needed to broaden the scope and depth of services offered to caregivers.

Unmet Needs and Factors Impacting Home- and Community-Based Service Use Among Rural Appalachian Caregivers of People With Alzheimer's and Dementia

Family caregivers of persons with Alzheimer's disease and related dementias (ADRD) living in rural areas face significant health and healthcare challenges. Limited research, however, has explored factors shaping their use of home- and community-based services (HCBS). This study identifies unmet needs among caregivers of people with ADRD in rural Western North Carolina and highlights contextual factors that facilitate HCBS use. Nineteen qualitative interviews were conducted with 21 family caregivers and 1 person with ADRD between 2021 and 2022. Thematic analyses revealed unmet needs among caregivers for information, service navigation, and caregiving support. HCBS use was shaped by multiple factors including illness needs, cultural beliefs, preferences for home-based care, and place-based resources. These findings suggest that culturally tailored HCBS are needed to support people with ADRD and their caregivers in rural Appalachian communities, especially those which facilitate access to paid caregiving, clearly communicate program eligibility requirements, and emphasize service availability.

County-Level Enrollment in Medicare Advantage Plans Offering Expanded Supplemental Benefits

Importance

Since 2019 and 2020, Medicare Advantage (MA) plans have been able to offer supplemental benefits that address long-term services and supports (LTSS) and social determinants of health (SDOH).

Objective

To examine the temporal trends and geographic variation in enrollment in MA plans offering LTSS and SDOH benefits.

Design, Setting, and Participants

This cross-sectional study used publicly available data to examine changes in beneficiary enrollment and plan offerings of LTSS and SDOH benefits from the benefits data from the second quarter of each year and other data from April of each year except 2024, for which the first quarter was the latest for benefits data and January the latest for other data at the time of analysis. Multivariable linear regression models for each type of benefit were used to investigate associations between county characteristics and enrollment in 2024. Analyses were stratified for (1) Dual Eligible Special Needs Plans (D-SNPs) that exclusively enroll dual-eligible beneficiaries and (2) non-D-SNPs.

Main Outcomes and Measures

The percentage of MA enrollees in plans offering LTSS or SDOH benefits at the county level.

Results

This study included 2 631 697 D-SNP and 20 114 506 non-D-SNP enrollees in 2020, which increased to 5 494 426 and 25 561 455, respectively, in 2024. From 2020 to 2024, the percentage of D-SNP enrollees in plans offering SDOH benefits increased from 9% to 46%, whereas the percentage fluctuated between 23% and 39% for LTSS benefits. There was an increase in non-D-SNP enrollees with LTSS (from 9% to 22%) and SDOH (from 4% to 20%) benefits from 2020 to 2023, which decreased in 2024. In 2024, the most offered LTSS benefit was in-home support services, and the most offered SDOH benefit was food and produce. The percentage of enrollees with these benefits varied across counties in 2024. In multivariable linear regression models, among D-SNPs, enrollment in plans offering any SDOH benefits was higher in counties with greater MA penetration (coefficient, 5.0 percentage points [pp] per 10-pp change; 95% CI, 2.1-7.9 pp), in urban counties (coefficient, 7.2 pp vs rural counties; 95% CI, 3.8-10.6 pp), in counties with greater enrollment in fully integrated D-SNPs (coefficient, 3.0 pp per 10-pp change; 95% CI, 2.2-3.9 pp), and in counties in states with approved Medicaid home- and community-based services waivers for individuals 65 years or older or those with disabilities (coefficient, 10.8 pp; 95% CI, 4.0-17.6 pp). Enrollment in D-SNPs offering LTSS benefits was also higher in counties with greater MA penetration (coefficient, 5.9 pp per 10-pp change; 95% CI, 2.4-9.5 pp), urban vs rural counties (coefficient, 4.6 pp; 95% CI, 1.1-8.1 pp), and counties with greater enrollment in fully integrated D-SNPs (coefficient, 3.0 pp per 10-pp change; 95% CI, 2.1-3.9 pp) in addition to counties with greater social vulnerability scores (coefficient, 1.4 pp per 10-pp change; 95% CI, 0.3-2.5 pp).

Conclusions and Relevance

In this cross-sectional study of MA plans and enrollees, an increase in enrollment was most consistent in D-SNPs offering SDOH benefits compared with LTSS benefits and in D-SNPs compared with non-D-SNPs. Geographic variation in enrollment patterns highlights potential gaps in access to LTSS and SDOH benefits for rural MA beneficiaries and dual-eligible enrollees living in counties with lower enrollment in fully integrated D-SNPs and states with more limited Medicaid home- and community-based services coverage.

Building on and tailoring to: Adapting a cancer caregiver psychoeducational intervention for rural settings

INTRODUCTION

Rural cancer caregivers experience obstacles in accessing services, obtaining respite, and ensuring their care recipients receive quality care. These challenges warrant opportunities to participate in evidence-based behavioral intervention trials to fill support gaps. Adaptation to rural settings can facilitate appropriate fit, given higher caregiver service needs and unique challenges. We present findings from the adaptation process of a psychoeducational intervention designed to support cancer caregivers in rural settings.

METHODS

We adapted Reblin's CARING intervention, designed for neuro-oncology, to target caregivers of rural cancer patients across cancer sites. First, we conducted formative work to determine the unmet social and supportive care needs rural cancer caregivers faced. We used the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) to guide the modifications. To conduct the adaptation, we elicited feedback through qualitative interviews of seven caregivers and three cancer hospital staff and thematic analysis to inform intervention modifications. Our qualitative study was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ).

RESULTS

Interviews revealed that service access was a pressing need, along with financial (e.g., treatment costs, employment challenges) and geographic barriers (e.g., distance to treatment, road conditions). We modified content, training, and context using the FRAME-IS steps. Changes enhanced fit through the following adaptations: changes to social support domains, session content, interventionist training, resource offerings, screening and recruitment processes, and virtual delivery.

DISCUSSION

Challenges to establishing successful psychosocial oncology interventions may be improved through participant-centered approaches and implementation science. Additional systemic challenges, including lack of systematic documentation of caregivers, persist and may especially disadvantage under-represented and underserved groups, such as rural dwellers. The enCompass intervention is undergoing ongoing single-arm pilot of rural cancer patient/caregiver dyads targeting caregiver coping self-efficacy and patient/caregiver distress (Clinical Trials #NCT05828927).

Key Informants' Visions and Solutions to Improve Home- and Community-Based Services for Older Adults and Persons With Dementia

Recent decades have seen state successes in rebalancing Medicaid long-term care from institutional care (e.g., nursing homes) into home and community settings. However, significant barriers can prevent access to home and community-based services (HCBS) among older adults and persons with dementia. Qualitative research on potential innovations and solutions in the contemporary context with attention to a wider range of state-level policy contexts is limited. Drawing on interviews with 49 key informants including state Medicaid officials, HCBS providers, and advocates for persons with dementia across 11 states, we examined perceived solutions to barriers. Key informants articulated a range of potential solutions and innovations, ranging from tangible or realized policy changes to 'magic wand' solutions. Policy research has typically focused on the former; excluding the latter may miss opportunities to envision and design a more effective long-term care system for persons living with dementia and older adults.

Home health utilization in the Veterans Health Administration: Are there rural and urban differences?

PURPOSE

Growing numbers of older adults need home health care, yhese services may be more difficult to access for rural Veterans, who represent one-third of Veterans Health Administration (VA) enrollees. Our objective was to examine whether home health use differs within VA based on rurality.

METHODS

We examined national VA administrative data for 2019-2021 (January 1, 2019 to December 31, 2021) among Veterans ages ≥65 years. Using descriptive and multivariable analyses, we assessed whether rural versus urban Veterans differed in (1) the likelihood of using any home health and (2) for those who received ≥1 visit, number of visits received.

RESULTS

Among home health users (n = 107,229, 33.1% rural), rural and urban Veterans were similar in age (77.0 vs. 77.2 years). Rural Veterans were less likely to be highly frail (38.9% rural vs. 40.4% urban) or diagnosed with dementia (13.5% vs. 17.6%). After adjusting for Veterans' characteristics, rural Veterans were more likely to receive any home health (odds ratio: 1.10; 95% confidence interval [CI]: 1.07, 1.13). Among Veterans who received ≥1 home health visit, rurality was associated with considerably fewer expected visits (incident rate ratio: 0.70; 95% CI: 0.68, 0.72).

CONCLUSIONS

Although rural Veterans were more likely than urban Veterans to receive any home health services, they received considerably fewer home health visits. This difference may represent an access issue for rural Veterans. Future research is needed to identify reasons for these differences and develop strategies to ensure rural Veterans' care needs are equitability addressed.

Community Hospital Interventions Addressing the Medical and Social Needs of Patients : Patient Perspectives From the CHART Investment Program

High utilizers of acute care in nonurban settings are at risk for poor health outcomes. Much of Massachusetts is nonurban, with many residents experiencing limited access to health care providers, fragmented health care services, inadequate housing, and low health literacy. This study examines patient perspectives on the Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program, a state-based grant program focused on advancing community hospitals toward value-based care. We found that CHART staff engaged patients in care coordination and patient advocacy, promoted patient agency and health literacy, and provided socioemotional support. These findings may help inform future program development around meeting the medical and social needs of high utilizers of health care services.

Dementia Care in Rural Appalachia: Multilevel Analysis of Individual- and County-Level Factors

BACKGROUND AND OBJECTIVES

Home- and community-based services (HCBS) are underutilized, despite offering significant health benefits to both care recipients and caregivers. Drawing upon Andersen's extended behavioral model of health services use, we examined individual- and county-level factors influencing HCBS utilization for dementia care in rural Appalachia.

RESEARCH DESIGN AND METHODS

We analyzed data from telephone interviews with 123 dementia family caregivers in rural Appalachian counties (Mage = 64.7, SDage = 12.2). Multilevel analyses were conducted to examine the effects of individual-level and county-level factors on the use of home-based services (home healthcare and personal care services) as well as community-based services (adult day care and transportation services).

RESULTS

Results indicated that caregivers' receipt of informal support from family or friends was associated with more use of home-based services (B = 0.42, p = .003). Conversely, longer travel times to service providers were linked to use of fewer community-based services (B = -0.21, p < .001). Residing in counties with more home health agencies was associated with higher utilization of home-based services (B = 0.41, p = .046). However, higher county tax expenditures for HCBS were not linked to home-based or community-based service use.

DISCUSSION AND IMPLICATIONS

Findings suggest that informal support in caring for the person living with dementia enables HCBS use in rural Appalachia. In contrast, limited geographic accessibility and service availability can impede HCBS use in rural regions. Policymakers are urged to allocate direct public funding to service providers to expand service availability in underresourced rural regions.

Nursing home closures and access to post-acute care and long-term care services in rural areas

PURPOSE

Nursing home closures have raised concerns about access to post-acute care (PAC) and long-term care (LTC) services. We estimate the additional distance rural residents had to travel to access PAC and LTC services because of nursing home closures.

METHODS

We identify nursing home closures and the availability of PAC and LTC services in nursing homes, home health agencies, and hospitals with swing beds using the Medicare Provider of Services file (2008-2018). Using distances between ZIP codes, we summarize distances to the closest provider of PAC and LTC services for rural and urban ZIP codes with nursing home closures from 2008 to 2018 and no nursing homes in 2018.

FINDINGS

Compared to urban ZIP codes, rural ZIP codes experiencing nursing home closure had higher distances to the closest nursing home providing PAC (6.4 vs. 0.94 miles; p < 0.05) and LTC services (7.2 vs. 1.1 miles; p < 0.05), and these differences remain even after accounting for the availability of home health agencies and hospitals with swing beds. Distances to the closest providers with PAC and LTC services were even higher for rural ZIP codes with no nursing homes in 2018. About 6.1%-15.7% of rural ZIP codes with a nursing home closure or with no nursing homes had no PAC or LTC providers within 25 miles.

CONCLUSIONS

Nursing home closures increased distances to nursing homes, home health agencies, and hospitals with swing beds for rural residents. Access to PAC and LTC services is a concern, especially for rural areas with no nursing homes.

The need for multilevel supportive care infrastructure for cancer caregivers

Communication with cancer caregivers occurs in the broader multilevel context of oncology care. Improving communication with caregivers requires changes across multiple levels of this context.

Older Adults' Unmet Needs at the End of Life: A Cross-Country Comparison of the United States and England

Objectives: This study aimed to compare the end-of-life (EOL) experiences in concentration with place of death, for older adults in the U.S. and England. Methods: Weighted comparative analysis was conducted using harmonized Health and Retirement Study and English Longitudinal Study of Ageing datasets covering the period of 2006-2012. Results: At the EOL, more older adults in the U.S. (64.14%) than in England (54.09%) had unmet needs (I/ADLs). Home was the main place of death in the U.S. (47.34%), while it was the hospital in England (58.01%). Gender, marital status, income, place of death, previous hospitalization, memory-related diseases, self-rated health, and chronic diseases were linked to unmet needs in both countries. Discussion: These findings challenge the existing assumptions about EOL experiences and place of death outcomes, emphasizing the significance of developing integrated care models to bolster support for essential daily activities of older adults at the EOL.

State home and community-based services expenditures and unmet care needs in the United States: Has everyone benefitted equally?

OBJECTIVE

To test whether the impacts of Medicaid's Home and Community-Based Services (HCBS) expenditures have been equitable.

DATA SOURCES AND STUDY SETTING

This is a secondary data analysis. We linked annual data on state-level Medicaid HCBS expenditures with individual data from U.S. Health and Retirement Study (HRS; 2006-2016).

STUDY DESIGN

We evaluated the association between state-level HCBS expenditure quartiles and the risk of experiencing challenges in basic or instrumental activities of daily living (I/ADLs) without assistance (unmet needs for care). We fitted generalized estimating equations (GEE) with a Poisson distribution, log link function, and an unstructured covariance matrix. We controlled demographics, time, and place-based fixed effects and estimated models stratified by race and ethnicity, gender, and urbanicity. We tested the robustness of results with negative controls.

DATA COLLECTION/EXTRACTION METHODS

Our analytic sample included HRS Medicaid beneficiaries, aged 55+, who had difficulty with ≥1 I/ADL (n = 2607 unique respondents contributing 4719 person-wave observations).

PRINCIPAL FINDINGS

Among adults with IADL difficulty, higher quartiles of HCBS expenditure (vs. the lowest quartile) were associated with a lower overall prevalence of unmet needs for care (e.g., Prevalence Ratio [PR], Q4 vs. Q1: 0.91, 95% CI: 0.84-0.98). This protective association was concentrated among non-Hispanic white respondents (Q4 vs. Q1: 0.82, 95% CI: 0.73-0.93); estimates were imprecise for Hispanic individuals and largely null for non-Hispanic Black participants. We found no evidence of heterogeneity by gender or urbanicity. Negative control robustness checks indicated that higher quartiles of HCBS expenditure were not associated with (1) the risk of reporting I/ADL difficulty among 55+ Medicaid beneficiaries, and (2) the risk of unmet care needs among non-Medicaid beneficiaries.

CONCLUSION

The returns to higher state-level HCBS expenditures under Medicaid for older adults with I/ADL disability do not appear to have been equitable by race and ethnicity.

The relationship between Medicaid policy and realized access to home- and community-based services

Medicaid funding for home- and community-based services (HCBS) has increased substantially in recent decades. Prior research has investigated the effects of this expansion on outcomes for individuals as well as costs to Medicaid, often using state policy as a proxy for access to HCBS or implicitly assuming that more generous policies affect outcomes through access, an assumption that may not hold. In this study, using survey data linked to Medicaid claims, we assess the extent to which common measures of state Medicaid HCBS generosity correspond to increased individual use of HCBS among older adults with potential needs. We find several measures to have strong predictive power, but only with relatively large changes in policy generosity. Our findings imply that increased funding of HCBS is not sufficient to ensure access to services and that researchers should be careful when using state policy generosity as a proxy for access.

Spatial Analysis of Home and Community-Based Services and Number of Deaths Among Older Adults in Taiwan

This study examined the geographical distribution of home- and community-based services (HCBS) resources in Taiwan's Long-Term Care 2.0 policy and explored its association with the number of deaths among older adults. The main outcome of the study was determination of the number of deaths among older adults in townships (N = 346) in 2021. The results showed that home-based HCBS had a significant positive association with mortality among older adults; moreover, community-based and complementary services, which are highly clustered within a township and among its neighbors, exert a significant protective effect on mortality among older adults. Stratified analyses showed a significantly lower mortality among older adults using adult foster care and transportation services, but a significantly higher mortality among older adults using home-based professional care and respite care services, after considering the sociodemographic characteristics of older adults, urbanization, and the number of long-term care resources in the spatial analysis.

Rural caregivers' preparedness for detecting and responding to the signs of worsening health conditions in recently hospitalised patients at risk for readmission: a qualitative descriptive study

OBJECTIVES

This study aimed to explore informal rural caregivers' perceived preparedness to detect and respond to the signs of worsening health conditions in patients recently discharged from hospital and at risk for readmission.

DESIGN

A qualitative descriptive design and semistructured interviews were used. Data were thematically analysed.

SETTING

Data collection occurred in 2018 and 2019 in rural communities in Southwestern and Northeastern Ontario, Canada.

PARTICIPANTS

The study included sixteen informal caregivers who were all family members of a relative discharged from hospital at high risk for readmission following hospitalisation mostly for a medical illness (63%). Participants were mostly women (87.5%), living with their relative (62.5%) who was most often a parent (56.3%).

RESULTS

Three themes were identified: (1) warning signs and rural communities, (2) perceived preparedness, and (3) improving preparedness. The first theme elucidates informal caregivers' view that they needed to be prepared because they were taking over care previously provided by hospital healthcare professionals yet lacked accessible medical help in rural communities. The second theme captures informal caregivers' perceptions that they lacked knowledge of how to detect warning signs and how to respond to them appropriately. The last theme illuminates informal caregivers' suggestions for improving preparation related to warning signs.

CONCLUSIONS

Informal caregivers in rural communities were largely unprepared for detecting and responding to the signs of worsening health conditions for patients at high risk for hospital readmission. Healthcare professionals can anticipate that informal caregivers, particularly those whose relatives live far from medical help, need information on how to detect and respond to warning signs, and may prioritise their time to this aspect of postdischarge care for these caregivers.

"I can't imagine having to do it on your own": a qualitative study on postoperative transitions in care from the perspectives of older adults with frailty

BACKGROUND

Adults aged 65 and older have surgery more often than younger people and often live with frailty. The postoperative transition in care from hospital to home after surgey is a challenging time for older adults with frailty as they often experience negative outcomes. Improving postoperative transitions in care for older adults with frailty is a priority. However, little knowledge from the perspective of older adults with frailty is available to support meaningful improvements in postoperative transitions in care.

OBJECTIVE

To explore what is important to older adults with frailty during a postoperative transition in care.

METHODS

This qualitative study used an interpretive description methodology. Twelve adults aged ≥ 65 years with frailty (Clinical Frailty Scale score ≥ 4) who had an inpatient elective surgery and could speak in English participated in a telephone-based, semi-structured interview. Audio files were transcribed and analyzed using thematic analysis.

RESULTS

Five themes were constructed: 1) valuing going home after surgery; 2) feeling empowered through knowledge and resources; 3) focusing on medical and functional recovery; 4) informal caregivers and family members play multiple integral roles; and 5) feeling supported by healthcare providers through continuity of care. Each theme had 3 sub-themes.

CONCLUSION

Future programs should focus on supporting patients to return home by empowering patients with resources and clear communication, ensuring continuity of care, creating access to homecare and virtual support, focusing on functional and medical recovery, and recognizing the invaluable role of informal caregivers.

The Role of Place in Person- and Family-Oriented Long-Term Services and Supports

Policy Points Little attention to date has been directed at examining how the long-term services and supports (LTSS) environmental context affects the health and well-being of older adults with disabilities. We develop a conceptual framework identifying environmental domains that contribute to LTSS use, care quality, and care experiences. We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain; increased neighborhood social and economic deprivation are highly associated with experiencing adverse consequences due to unmet need, whereas availability and generosity of the health care and social services delivery environment are inversely associated with participation restrictions in valued activities. Policies targeting local and state-level LTSS-relevant environmental characteristics stand to improve the health and well-being of older adults with disabilities, particularly as it relates to adverse consequences due to unmet need and participation restrictions.

CONTEXT

Long-term services and supports (LTSS) in the United States are characterized by their patchwork and unequal nature. The lack of generalizable person-reported information on LTSS care experiences connected to place of community residence has obscured our understanding of inequities and factors that may attenuate them.

METHODS

We advance a conceptual framework of LTSS-relevant environmental domains, drawing on newly available data linkages from the 2015 National Health and Aging Trends Study to connect person-reported care experiences with public use spatial data. We assess relationships between LTSS-relevant environmental characteristic domains and person-reported care adverse consequences due to unmet need, participation restrictions, and subjective well-being for 2,411 older adults with disabilities and for key population subgroups by race, dementia, and Medicaid enrollment status.

FINDINGS

We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, public assistance, social cohesion) are highly associated with experiencing adverse consequences due to unmet care needs. Measures of the health care and social services delivery environment (e.g., Medicaid Home and Community-Based Service Generosity, managed LTSS [MLTSS] presence, average direct care worker wage, availability of paid family leave) are inversely associated with experiencing participation restrictions in valued activities. Select measures of the built and natural environment (e.g., housing affordability) are associated with participation restrictions and lower subjective well-being. Observed relationships between measures of LTSS-relevant environmental characteristics and care experiences were generally held in directionality but were attenuated for key subpopulations.

CONCLUSIONS

We present a framework and analyses describing the variable relationships between LTSS-relevant environmental factors and person-reported care experiences. LTSS-relevant environmental characteristics are differentially relevant to the care experiences of older adults with disabilities. Greater attention should be devoted to strengthening state- and community-based policies and practices that support aging in place.

Family Ties at End-of-Life: Characteristics of Nursing Home Decedents With and Without Family

Background

Little is known about nursing home (NH) residents' family characteristics despite the important role families play at end-of-life (EOL).

Objective

To describe the size and composition of first-degree families (FDFs) of Utah NH residents who died 1998-2016 (n = 43,405).

Methods

Using the Utah Population Caregiving Database, we linked NH decedents to their FDF (n = 124,419; spouses = 10.8%; children = 55.3%; siblings = 32.3%) and compared sociodemographic and death characteristics of those with and without FDF members (n = 9424).

Results

Compared to NH decedents with FDF (78.3%), those without (21.7%) were more likely to be female (64.7% vs. 57.1%), non-White/Hispanic (11.2% vs. 4.2%), less educated (<9th grade; 41.1% vs. 32.4%), and die in a rural/frontier NH (25.3% vs. 24.0%, all p < 0.001). Despite similar levels of disease burden (Charlson Comorbidity score 3 + 37.7% vs. 38.0%), those without FDF were more likely to die from cancer (14.2% vs. 12.4%), Chronic Obstructive Pulmonary Disease (COPD) (6.0% vs. 4.0%), and dementia (17.1% vs. 16.6%, all p < 0.001), and were less likely to have 2+ hospitalizations at EOL (20.5% vs. 22.4%, p < 0.001).

Conclusions

Among NH decedents, those with and without FDF have different sociodemographic and death characteristics-factors that may impact care at EOL. Understanding the nature of FDF relationship type on NH resident EOL care trajectories and outcomes is an important next step in clarifying the role of families of persons living and dying in NHs.

Rural disparities in use of family and formal caregiving for older adults with disabilities

BACKGROUND

As federal and state policies rebalance long-term care from institutional settings to home- and community-based settings, reliance on formal (paid) and family (unpaid) caregivers for support at home nationally has increased in recent years. Yet, it is unknown if use of formal and family care varies by rurality.

METHODS

Using the Health and Retirement Study, we describe patterns in receipt of combinations of formal and family home care and self-reported expectation of nursing home use by rurality among community-dwelling adults aged 65+ with functional limitations from 2004 to 2016.

RESULTS

Older adults residing in rural areas are more likely to receive any family care than those in urban areas. From 2004 to 2016, a higher proportion of older adults in rural areas receive care from family caregivers exclusively while a lower proportion receive care from formal caregivers exclusively. When examining older adults in urban areas, we find the opposite - a higher proportion of urban adults rely exclusively on formal care and a lower proportion rely exclusively on family care in 2016 compared to 2004.

CONCLUSION

We find that national estimates of sources of caregiving and their changes over time mask significant heterogeneity in uptake by rurality. Understanding how older adults in rural areas are, or are not, receiving home-based care compared to their urban peers and how these patterns are changing over time is the first step to informing supports for family and formal caregivers.

Who Will Care for Rural Older Adults? Measuring the Direct Care Workforce in Rural Areas

Using the 2021 Occupational Employment and Wage Statistics (OEWS) dataset, we calculate the ratio of direct care workers relative to the population of older adults (ages 65+) across rural and urban areas in the US. We find that there are, on average, 32.9 home health aides per 1000 older adults (age 65+) in rural areas and 50.4 home health aides per 1000 older adults in urban areas. There are, on average, 20.9 nursing assistants per 1000 older adults in rural areas and 25.3 nursing assistants per 1000 older adults in urban areas. There is substantial regional variation. Greater investment needs to be made in improving wages and job quality for direct care workers to attract workers to these critical occupations, especially in rural areas where the need for direct care is greater.

Rates of nursing home closures were relatively stable over the past decade, but warrant continuous monitoring

For years, nursing home closures have been a concern for the industry, policymakers, consumer advocates, and other stakeholders. We analyzed data from 2011 through 2021 and did not find persistent increases in the closure rates. Closures were relatively stable from 2011 to 2017, averaging 118 facilities (0.79%) per year and increasing to 143 (0.96%) in 2018 and 200 (1.34%) in 2019. Closures decreased during the COVID-19 pandemic, averaging 133 facilities in 2020 and 2021 (0.90%). Medicaid-only nursing facilities had higher closure rates than Medicare-only skilled-nursing facilities and dually certified nursing homes. The Census regions (divisions) of the South (West South Central) and Northeast (New England) had the highest closure rates, while the South (South Atlantic and East South Central) had the lowest rates. Facility characteristics associated with increased closure risk included smaller size, lower occupancy rate, urban location, no ownership changes, lower inspection survey ratings, higher staffing ratings, higher percentages of non-White residents and Medicaid residents, lower percentages of Medicare residents and residents with severe acuity, and location in states with more nursing home alternatives. Additional research should examine the impact of closures on resident outcomes and access to care.

Changes in Nursing Home Use Following Medicaid-Supported Expanded Access to Home- and Community-Based Services for Older Adults With Dementia

Importance

New York State's Medicaid managed long-term care (MLTC) program expanded access to home- and community-based services, providing an alternative to nursing home care for people with dementia. Between 2012 and 2015, the state implemented mandatory MLTC for dual Medicare and Medicaid enrollees requiring more than 120 days of community-based long-term care.

Objective

To evaluate changes in nursing home use among older adults with dementia following MLTC implementation.

Design, Setting, and Participants

This cohort study used longitudinal data from January 1, 2011, to December 31, 2019, from the Minimum Data Set and Medicare administrative data. The study sample included New York State Medicare beneficiaries 65 years and older with dementia. New York City residents were excluded due to insufficient pre-study period data. Data were analyzed from January 1, 2011, to December 31, 2019.

Exposure

Mandatory MLTC enrollment.

Main Outcomes and Measures

Longitudinal models were used to evaluate changes in annual days of nursing home use following the staggered implementation of MLTC across 13 regions of the state. Two models were estimated: (1) a logistic regression model for any nursing home use in a given year and (2) a linear regression model of total nursing home days, conditional on any nursing home use. Models included annual event-time indicators specified as years until or since MLTC implementation. To capture MLTC effects for dual enrollees relative to non-dual Medicare enrollees, models included interaction terms for dual enrollment and event-time indicators.

Results

This sample included 463 947 Medicare beneficiaries with dementia who lived in New York State between 2011 and 2019 (50.2% younger than 85 years; 64.4% women). Implementation of MLTC was associated with lower odds of nursing home use among dual enrollees, ranging from 8% lower odds 2 years post implementation (adjusted odds ratio, 0.92 [95% CI, 0.86-0.98]) to 24% lower odds 6 years post implementation (adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]). Compared with a scenario of no MLTC, MLTC implementation was associated with an 8% reduction in annual days of nursing home use between 2013 and 2019 (mean, -5.6 [95% CI, -6.1 to -5.1] days per year).

Conclusions and Relevance

The findings of this cohort study suggest that implementation of mandatory MLTC in New York State was associated with less nursing home use among dual enrollees with dementia and that MLTC may help prevent or delay nursing home placement among older adults with dementia.

Barriers to Service Use Among Dementia Family Caregivers in Rural Appalachia: Implications for Reducing Caregiver Overload

Although the benefits of home- and community-based services (HCBS) to support the needs of older adults are well-established, researchers have persistently reported service underutilization by dementia caregivers to assist them with their caregiving responsibilities. Using the Health Behavior Model and Conservation of Resources Theory, the aim of the current study was to understand what barriers prevent caregivers from using HCBS and the toll it takes on them. Utilizing a sample of 122 rural family caregivers (74% female, 87% white, Mage = 64.86 years) of persons living with dementia (PLwD), simultaneous ordinary least square regressions were employed to understand the association between barriers to service use and the current use of support services and personal services, and concurrently on caregiver role overload. Financial barriers, caregiver's reluctance to use services, and their capability of seeking services were associated with lower use of support services. After controlling for need and enabling factors, caregivers who used more support services, and those who reported system complexities to using support services experienced higher role overload. Financial barriers, system complexities, and caregivers' reluctance also affected the use of personal care services. Despite the use of personal services, caregivers of PLwD with greater needs and fewer enabling factors experienced higher role overload. Study findings suggest that reducing system complexities of HCBS and improving prevention and intervention efforts to facilitate caregivers' awareness of HCBS are needed to address lack of service use and reduce caregiver overload.

Paid Family Caregiving for Children With Medical Complexity

OBJECTIVES

We evaluated Colorado's paid family caregiver certified nursing assistant (CNA) program by assessing stakeholders' perceptions of the model's strengths and potential areas for improvement.

METHODS

A professional bilingual research assistant conducted key informant interviews of English- and Spanish-speaking certified nursing assistant (CNA) family caregivers (FCs), primary care providers, and pediatric home health administrators of children with medical complexity in the family caregiver CNA program. Interview questions focused on the program's benefits, drawbacks, and implications for the child and caregiver's quality of life. Transcripts were coded and analyzed, and themes summarizing program benefits and disadvantages were identified.

RESULTS

Semistructured interviews were completed by phone with 25 FCs, 10 home health administrators, and 10 primary care providers between September 2020 and June 2021. Overall, the program was highly valued and uniformly recommended for prospective families. Perceived benefits included: (1) fulfilling the desire to be a good parent, (2) providing stable and high-quality home health care, (3) benefitting the child's health and wellbeing, and (4) enhancing family financial stability. Perceived drawbacks included: (1) FCs experiencing mental and physical health burdens, (2) difficult access for some community members, (3) extraneous training requirements, and (4) low program visibility.

CONCLUSIONS

Given the perceived benefits of the family CNA program, the model may be considered for future dissemination to other communities. However, additional research and program improvements are needed to help make this a more equitable and sustainable home health care model for children with medical complexity.

Barriers and Facilitators to Home- and Community-Based Services Access for Persons With Dementia and Their Caregivers

OBJECTIVES

The United States has seen increasing shifts toward home- and community-based services (HCBS) in place of institutional care for long-term services and supports. However, research has neglected to assess whether these shifts have improved access to HCBS for persons with dementia. This paper identifies HCBS access barriers and facilitators, and discusses how barriers contribute to disparities for persons with dementia living in rural areas and exacerbate disparities for minoritized populations.

METHODS

We analyzed qualitative data from 35 in-depth interviews. Interviews were held with stakeholders in the HCBS ecosystem, including Medicaid administrators, advocates for persons with dementia and caregivers, and HCBS providers.

RESULTS

Barriers to HCBS access for persons with dementia range from community and infrastructure barriers (e.g., clinicians and cultural differences), to interpersonal and individual-level barriers (e.g., caregivers, awareness, and attitudes). These barriers affect the health and quality of life for persons with dementia and may affect whether individuals can remain in their home or community. Facilitators included a range of more comprehensive and dementia-attuned practices and services in health care, technology, recognition and support for family caregivers, and culturally competent and linguistically accessible education and services.

DISCUSSION

System refinements, such as incentivizing cognitive screening, can improve detection and increase access to HCBS. Disparities in HCBS access experienced by minoritized persons with dementia may be addressed through culturally competent awareness campaigns and policies that recognize the necessity of familial caregivers in supporting persons with dementia. These findings can inform efforts to ensure more equitable access to HCBS, improve dementia competence, and reduce disparities.

Identifying Barriers to Post-Acute Care Referral and Characterizing Negative Patient Preferences Among Hospitalized Older Adults Using Natural Language Processing

Our objective was to detect common barriers to post-acute care (B2PAC) among hospitalized older adults using natural language processing (NLP) of clinical notes from patients discharged home when a clinical decision support system recommended post-acute care. We annotated B2PAC sentences from discharge planning notes and developed an NLP classifier to identify the highest-value B2PAC class (negative patient preferences). Thirteen machine learning models were compared with Amazon's AutoGluon deep learning model. The study included 594 acute care notes from 100 patient encounters (1156 sentences contained 11 B2PAC) in a large academic health system. The most frequent and modifiable B2PAC class was negative patient preferences (18.3%). The best supervised model was Extreme Gradient Boosting (F1: 0.859), but the deep learning model performed better (F1: 0.916). Alerting clinicians of negative patient preferences early in the hospitalization can prompt interventions such as patient education to ensure patients receive the right level of care and avoid negative outcomes.

Making a Bad Situation Worse: Examining the Challenges Facing Rural Home Care Workers

This study examines the unique challenges facing rural home care workers. Semi-structured interviews were undertaken between July 2021 and February 2022 with 23 participants that have experience in rural home care delivery. The major challenge confronting rural home care workers involved distance and transportation. This challenge emerged due to long distance between clients, unreliable vehicles, inadequate reimbursement, and inclement weather. In turn, this challenge exacerbated three other types of challenges facing rural home care workers: workforce challenges that consisted of a persistent labor shortage and shorter visits that forced workers to rush through tasks, client isolation due to the social and physical seclusion of households, and the poor working conditions of home care work more broadly. Without policy interventions that respond to these particular challenges, the care gap in rural areas can be expected to grow.

Differences between Rural and Urban Practices in the Response to the COVID-19 Pandemic: Outcomes from the PRICOV-19 Study in 38 Countries

This paper explores the differences between rural and urban practices in the response to the COVID-19 pandemic, emphasizing aspects such as management of patient flow, infection prevention and control, information processing, communication and collaboration. Using a cross-sectional design, data were collected through the online PRICOV-19 questionnaire sent to general practices in 38 countries. Rural practices in our sample were smaller than urban-based practices. They reported an above-average number of old and multimorbid patients and a below-average number of patients with a migrant background or financial problems. Rural practices were less likely to provide leaflets and information, but were more likely to have ceased using the waiting room or to have made structural changes to their waiting room and to have changed their prescribing practices in terms of patients attending the practices. They were less likely to perform video consultations or use electronic prescription methods. Our findings show the existence of certain issues that could impact patient safety in rural areas more than in urban areas due to the underlying differences in population profile and supports. These could be used to plan the organization of care for similar future pandemic situations.

Gender-Specific Associations between Late-Life Disability and Socioeconomic Status: Findings from the International Mobility and Aging Study (IMIAS)

Disability is a dynamic process and can be influenced by a sociocultural environment. This study aimed to determine whether the associations between socioeconomic status and late-life disability differ by gender in a multi-sociocultural sample from different countries. A cross-sectional study was developed with 1362 older adults from The International Mobility in Aging Study. Late-life disability was measured through the disability component of the Late-Life Function Disability Instrument. Level of education, income sufficiency and lifelong occupation were used as indicators of SES. The results indicated that a low education level β = -3.11 [95% CI -4.70; -1.53] and manual occupation β = -1.79 [95% -3.40; -0.18] were associated with frequency decrease for men, while insufficient income β = -3.55 [95% CI -5.57; -1.52] and manual occupation β = -2.25 [95% CI -3.89; -0.61] played a negative role in frequency for women. For both men β = -2.39 [95% -4.68; -0.10] and women β = -3.39 [95% -5.77; -1.02], insufficient income was the only factor associated with greater perceived limitation during life tasks. This study suggested that men and women had different late-life disability experiences. For men, occupation and education were associated with a decrease in the frequency of participation, while for women this was associated with income and occupation. Income was associated with perceived limitation during daily life tasks for both genders.

Low Exposure to Home- and Community-Based Services Among U.S. Adults: Cause for Concern?

Home- and community-based services (HCBS) facilitate community living for older adults and persons with disabilities, but limited awareness of HCBS is a significant barrier to access. Social exposure is one potential conduit for HCBS knowledge. To understand the general population's social exposure to HCBS-that is, knowing someone who has used HCBS (including one's self)-we fielded a survey item with a nationally representative panel of U.S. adults. An estimated 53% of U.S. adults reported not knowing anyone who had used HCBS. Exposure rates were low across specific HCBS types (6%-28%). Women had greater exposure than men for eight of the 11 HCBS. We also found differences by age, racial/ethnic identity, rurality, education, and income. Increasing the general public's awareness of HCBS may facilitate access when services are needed, enhance readiness for aging in place, and increase the visibility and inclusion of older adults, persons with disabilities, and caregivers.

Aging in Rural Communities

Purpose of Review

Population aging is occurring worldwide, particularly in developed countries such as the United States (US). However, in the US, the population is aging more rapidly in rural areas than in urban areas. Healthy aging in rural areas presents unique challenges. Understanding and addressing those challenges is essential to ensure healthy aging and promote health equity across the lifespan and all geographies. This review aims to present findings and evaluate recent literature (2019-2022) on rural aging and highlight future directions and opportunities to improve population health in rural communities.

Recent Findings

The review first addresses several methodological considerations in measuring rurality, including the choice of measure used, the composition of each measure, and the limitations and drawbacks of each measure. Next, the review considers important concepts and context when describing what it means to be rural, including social, cultural, economic, and environmental conditions. The review assesses several key epidemiologic studies addressing rural-urban differences in population health among older adults. Health and social services in rural areas are then discussed in the context of healthy aging in rural areas. Racial and ethnic minorities, indigenous peoples, and informal caregivers are considered as special populations in the discussion of rural older adults and healthy aging. Lastly, the review provides evidence to support critical longitudinal, place-based research to promote healthy aging across the rural-urban divide is highlighted.

Summary

Policies, programs, and interventions to reduce rural-urban differences in population health and to promote health equity and healthy aging necessitate a context-specific approach. Considering the cultural context and root causes of rural-urban differences in population health and healthy aging is essential to support the real-world effectiveness of such programs, policies, and interventions.

Essential but Excluded: Building Disaster Preparedness Capacity for Home Health Care Workers and Home Care Agencies

COVID-19 has demonstrated the essential role of home care services in supporting community-dwelling older and disabled individuals through a public health emergency. As the pandemic overwhelmed hospitals and nursing homes, home care helped individuals remain in the community and recover from COVID-19 at home. Yet unlike many institutional providers, home care agencies were often disconnected from broader public health disaster planning efforts and struggled to access basic resources, jeopardizing the workers who provide this care and the medically complex and often marginalized patients they support. The exclusion of home care from the broader COVID-19 emergency response underscores how the home care industry operates apart from the traditional health care infrastructure, even as its workers provide essential long-term care services. This special article (1) describes the experiences of home health care workers and their agencies during COVID-19 by summarizing existing empiric research; (2) reflects on how these experiences were shaped and exacerbated by longstanding challenges in the home care industry; and (3) identifies implications for future disaster preparedness policies and practice to better serve this workforce, the home care industry, and those for whom they care.

"If I wasn't in a rural area, I would definitely have more support": social needs identified by rural cancer caregivers and hospital staff

BACKGROUND

The social needs of rural families facing cancer warrant investigation to inform psychosocial care planning and policy development.

METHODS

Using purposive sampling, we interviewed 24 rural caregivers and 17 hospital staff from an academic cancer center in the U.S. South. Social needs were defined as the support needed to effectively provide informal caregiving across economic, physical, interpersonal, and service domains. We used the framework method to code and synthesize findings.

FINDINGS

Caregiver economic and physical needs were interconnected and most pressing, including common examples of distance to care and transportation barriers. Caregivers desired additional support from the health system, insurance providers, and community resources. Staff identified similar need patterns and gaps in health system capacity.

CONCLUSIONS

Rural cancer caregivers experience multiple unmet social needs. Supportive interventions for this population will benefit from flexible implementation and multilevel, multisector approaches. In particular, interventions that address financial hardship and limited internet access are needed.

Rural-urban differences in family and paid caregiving utilization in the United States: Findings from the Cornell National Social Survey

PURPOSE

While rates of family caregiving and paid caregiving are increasing, how often they occur together ("shared care") and whether utilization varies geographically are unknown. We examined differences in family and paid caregiving utilization by rurality and region in the United States.

METHODS

The 2020 Cornell National Social Survey is an annual cross-sectional telephone-based survey of a random sample of 1,000 US adults. Participants were asked if they have been a family caregiver, including if they provided care alongside a paid caregiver. Rural-Urban Commuting Area Codes and Census areas classified rurality and region. The association between residence and the prevalence of caregiving was determined with multivariable Poisson regression.

FINDINGS

Among 857 participants with geographic and caregiving data, 11.8% (n = 101) were rural dwellers and 34.2% were family caregivers. Rural residence (vs urban) was associated with a higher prevalence of family caregiving (PR: 1.59 [1.22, 2.06]), and Western residence (vs Northeast) was associated with a lower prevalence of family caregiving (PR: 0.63 [0.46, 0.87], P = .01). Forty percent of family caregivers shared care with a paid caregiver. There was no significant difference in shared care by rural residence in unadjusted (31.8% rural vs 43.1% urban, P = .22) or adjusted models (PR: 0.85 [0.51, 1.41], P = .53).

CONCLUSIONS

Although family caregiving was more prevalent in rural areas and certain regions, shared care did not differ by rurality or region. Studies are needed to understand why rural residents do more family caregiving without additional support from paid caregivers, and what the implications are for caregivers and care recipients.

System- and Individual-Level Barriers to Accessing Medical Care Services Across the Rural-Urban Spectrum, Washington State

Background:

Residents of rural areas face barriers beyond geography and distance when accessing medical care services. The purpose of this study was to characterize medical care access barriers across several commonly used classifications of rurality.

Methods:

Washington State household residents completed a mixed-mode (paper/online) health care access survey between June 2018 and December 2019 administered to a stratified random sample of ZIP codes classified as urban, suburban, large rural, and small rural (4-tier scheme). For analyses, rurality was also classified into 2-tier schemes (rural/urban) based on ZIP code and county. Respondents reported availability of medical care services and system- and individual-level barriers to accessing services. Logistic regression models estimated the odds of reporting system- or individual-level barriers in accessing medical care services across rurality (4- and 2-tier schemes), adjusting for respondent characteristics, and weighted to account for survey design.

Results:

About 617 households completed the survey (25.7% response rate). Compared to urban residents (across all 3 schemes), more rural residents reported traveling to a distant city or town for medical care (P < .001). Rurality was significantly associated with increased odds of facing system-level barriers. Respondents from small rural areas had greater odds access barriers for primary care (OR 7.31, 95% CI 1.84-29.09) and having no primary care provider (OR 11.37, 95% CI 3.03-42.75) compared to urban respondents. Individual-level barriers were not associated with rurality.

Conclusions:

To improve healthcare access across the rural-urban spectrum, policymakers must consider system-level barriers facing rural populations.

Intersections of Personal Assistance Services for Rural Disabled People and Home Care Workers' Rights

It is very difficult to find and keep workers to provide home-based care for disabled people, especially in rural places. There is a tension between the rights of disabled people and the rights of home-based personal care workers. In this brief review, we explore the intersections of historical and social forces that shaped federal-level policies for both disability rights and the rights of personal care workers, as well as the current state of the policies. This paper provides a narrow focus on federal policies relevant to both groups, while also considering how the urbancentric nature of advocacy and policymaking has failed to address important issues experienced by rural people. In addition to briefly reviewing relevant federal policies, we also explore sources of support and resistance and how urbanormativity, ableism, and sexism intersect to influence how the needs of people with disabilities and their personal care workers are conceptualized and addressed. We conclude with recommendations for how to better address the needs of rural people with disabilities using home-based personal care services and the workers who provide them.

Socio-Spatial Disparities in County-Level Availability of Aging and Disability Services Organizations

Aging and disability services are essential for supporting older adults in living independently in their homes and communities as they age. Applying theoretical perspectives of community gerontology and spatial inequality, we use county-level data (N=3142) from the National Neighborhood Data Archive (NaNDA) and the American Community Survey to explore if and how availability of aging and disability services organizations varies across the rural-urban continuum and across compositional characteristics of counties. Results show that rural counties are significantly more likely to be aging and disability services deserts. Stratified models show that poverty rates and relative shares of non-Hispanic Blacks are positively associated with greater odds of aging and disability services deserts across rural and urban counties, but divergent findings appear for county-level shares of Hispanics. These findings are discussed as well as implications for research, policy, and practice on equitable access to aging and disability services.

Fewer potentially avoidable health care events in rural veterans with self-directed care versus other personal care services

BACKGROUND

Rural residents face more barriers to healthcare access, including challenges in receiving home- and community-based long-term services, compared to urban residents. Self-directed services provide flexibility and choice in care options and may be particularly well suited to help older adults with multiple chronic conditions and functional limitations who reside in rural areas remain independent and live in the community.

METHODS

We conducted a retrospective observational study to understand whether differences in health outcomes between Veteran-Directed Care (VDC), a self-directed Veterans Health Administration (VHA)-paid care program, and other VHA-paid home- and community-based personal care services vary in rural/urban location. The sample included 37,395 veterans receiving VHA-paid home- and community-based long-term care services in FY17. Our primary outcomes were changes in monthly incidence of VHA or VHA-paid community acute care admissions, nursing home admissions, and emergency department (ED) visits. We used fixed effects logistic regression models on unmatched and coarsened exact matched cohorts, stratified by rural/urban location.

RESULTS

Both urban and rural VDC recipients were significantly less likely to be admitted to VHA-paid nursing homes, compared to those receiving other VHA-paid personal care services (rural: incremental effect = -0.22, [-0.30, -0.14]; urban: incremental effect = -0.14, [-0.20, -0.07]). Rural, but not urban, VDC enrollees had significantly fewer VHA-paid acute care admissions and ED visits, relative to recipients of other VHA-paid personal care services (acute care, rural: incremental effect = -0.07, 95% CI = [-0.14, -0.01], urban: incremental effect = -0.01, [-0.06, 0.03]; ED, rural: incremental effect = -0.08, [-0.14, -0.02], urban: incremental effect = 0.01, [-0.03, 0.05]).

CONCLUSIONS

VDC recipients had fewer incidents of potentially avoidable VHA-paid health care use, compared to similar veterans receiving other VHA-paid personal care services. These differences were more pronounced among rural VDC recipients than urban VDC recipients.

Rural and urban disparities in quality of home health care: A longitudinal cohort study (2014-2018)

PURPOSE

Home health care is one of the fastest growing health care sectors in the United States. However, little is known of differences in trends in quality performance between rural and urban home health agencies over time. This study aimed to examine disparities in quality performance between rural and urban home health agencies between 2014 and 2018.

METHODS

This is a cohort study using 2014-2018 national Home Health Compare data and Providers of Service Profile data, including 7,908 home health agencies, of which 1,537 were rural agencies. Quality performance measures included timely initiation of care, hospitalization, and emergency department (ED) visits. Two-level hierarchical regression models were used to identify rural-urban differences in these quality indicators over time when controlling organizational characteristics.

FINDINGS

Rural agencies were less likely to be for-profit and accredited, and more likely to be hospital-based, serve both Medicare and Medicaid beneficiaries, and have hospice programs. Rural agencies consistently outperformed on timely initiation of care over time, and urban agencies consistently outperformed on hospitalization and ED visits over time. These gaps between rural and urban agencies were steady over time except the gap in hospitalization, which slightly narrowed over time (Coef. = 0.11, P = .001 for urban and year interaction term).

CONCLUSIONS

Significant differences exist in quality of care between rural and urban home health agencies and such differences have not been significantly narrowed over time. To reduce rural-urban disparities, policy makers should take into account unique challenges faced by urban and rural agencies when making policy decisions.

Acuity Differences Among Newly Admitted Older Residents in Rural and Urban Nursing Homes

BACKGROUND AND OBJECTIVES

Our primary objective was to assess rural-urban acuity differences among newly admitted older nursing home residents.

RESEARCH DESIGN AND METHODS

Data included the 2015 Minimum Data Set v3.0, the Area Health Resources File, the Provider of Services File, and Rural-Urban Commuting Area codes. Activities of daily living, the Cognitive Function Scale, and aggression/wandering indicators were used to assess functional, cognitive, and behavioral status, respectively. Excluding assessments for short stays (less than 90 days), assessments for 209,719 newly admitted long-stay residents aged 65 and older across 14,834 facilities in 47 states were evaluated. Difference in differences (DID) generalized linear models with state-fixed effects and clustering by facilities were used to assess the interaction effect of older age (75 plus) on rural-urban acuity differences, controlling for socioeconomic factors, admission source, and market characteristics.

RESULTS

Residents admitted to rural facilities were less functionally impaired (incidence rate ratio: 0.973-0.898) but had more cognitive (odds ratio [OR]: 1.03-1.22) and problem behaviors (OR: 1.19-1.48) than urban. Although older age was predictive of higher acuity, in DID models, the expected decline in functional status was comparable in rural and urban facilities, while the cognitive and behavioral status for older admissions was 8.0% and 8.5% lower in rural versus urban facilities, respectively.

DISCUSSION AND IMPLICATIONS

Although the higher prevalence of cognitive impairment and problem behaviors among rural admissions was attributable in part to older age, rural facilities admitted less complex individuals among older age residents than urban facilities. Findings may reflect less capacity to manage older, complex individuals in rural facilities.

"They're not leaving their home; this is where they were born, this is where they will die.": Key Informant Perspectives From the U.S. Counties With the Greatest Concentration of the Oldest Old

The "oldest old," age 85 and older, constitute one of the fastest growing segments of the U.S. population. Yet, surprisingly little is known about the characteristics of U.S. counties with the highest percentage of the oldest old, nearly all of which are rural. We used qualitative analysis of key informant interviews (n = 50) with county commissioners and other county-level representatives from rural counties with the highest prevalence of the oldest old, targeting the 54 rural counties with ≥5% of the population age 85+. We found that the rural counties with the highest proportion of residents age 85+ face unique challenges to supporting successful aging among the oldest old, including resource constraints, limited services, isolated locations, and widespread service areas. Still, interviewees identified particular reasons why the oldest old remain in their counties, with many highlighting positive aspects of rural environments and community.

Perceived impacts of a Medicaid rebalancing initiative to increase home- and community-based services

OBJECTIVE

To assess governmental and nongovernmental stakeholders' perceived impacts of a Medicaid home- and community-based services (HCBS) rebalancing initiative, the Balancing Incentive Program (BIP).

DATA SOURCES

Governmental stakeholders (Medicaid administrators) and nongovernmental stakeholders (service providers and consumer advocates) (n = 30) from eight states that participated in BIP.

STUDY DESIGN

We conducted key informant interviews.

DATA COLLECTION

Interviews followed a semi-structured guide and were professionally transcribed. We thematically coded transcripts using an iterative codebook with a priori and emergent codes.

PRINCIPAL FINDINGS

Stakeholders reported that BIP participation had a range of impacts on the HCBS ecosystem, often beyond the mandated structural reforms. BIP activities were believed to have changed the culture of HCBS in some states, for example, at the level of state administration or in the provision of HCBS to consumers. Stakeholders also described significant improvements in cross-stakeholder relationships and communication, for example, in the context of troubleshooting consumers' unmet needs or improvements in the states' responsiveness to providers' inquiries. Stakeholders believed that within-state data harmonization undertaken through Core Standardized Assessment (CSA) was a positive impact of BIP, particularly with regard to its utility for administrative data, care planning, and patient-centeredness. Two stakeholders also voiced concerns regarding the validity of spending-based rebalancing metrics. The impacts that stakeholders attributed to BIP may help create a more sustained rebalancing environment through their changes to the ecosystem, including infrastructure upgrades, data harmonization, collaboration across stakeholders and agencies, more patient-centeredness, and greater recognition of HCBS.

CONCLUSIONS

Our findings highlight additional BIP impacts to monitor over the longer term and to consider in evaluations of future rebalancing efforts. Some potential impacts of BIP are more readily quantified (e.g., HCBS spending), while others are less likely to be formally assessed (e.g., improved stakeholder cooperation). These latter impacts are likely instrumental to future rebalancing efforts.

Prevalence and Correlates of Gray Market Use for Aging and Dementia Long-Term Care in the U.S

OBJECTIVES

To estimate the national prevalence and sociodemographic correlates of gray market utilization, consisting of paid providers who are unrelated to the recipient, not working for a regulated agency, and potentially unscreened and untrained, for aging and dementia-related long-term care.

METHODS

We surveyed a nationally representative sample of 1,037 American Life Panel respondents aged 18 years and older.

RESULTS

Nearly a third of Americans who arranged paid care sought gray market care for persons with dementia, and most (65%) combined it with unpaid care. Respondents who arranged gray market care had 66% lower odds of currently working, and those living in rural areas had an almost 5-times higher odds of arranging dementia gray market care.

DISCUSSION

Gray market care represents a substantial proportion of paid, long-term care for older adults and may fill gaps in access to care.

Rural/urban differences in discharge from rehabilitation in older adults with traumatic brain injury

BACKGROUND/OBJECTIVES

Rates of traumatic brain injury (TBI) among older adults and treatment of this population in nursing homes are increasing. The objective of this study is to examine differences in the quality of care and outcomes of older adults with TBI in rural and urban settings by (1) comparing the rates of successful community discharge; and (2) reasons for not achieving successful discharge among patients in rural and urban environments.

DESIGN

Retrospective national cohort study of skilled nursing facility (SNF) patients using Medicare inpatient claims linked with Minimum Data Set assessments. Demographic, health, and facility characteristics were compared between rural and urban settings using descriptive statistics. Logistic regression with state random effects was used to identify characteristics that predicted successful discharge.

SETTING

U.S. skilled nursing facilities (n = 11,771).

PARTICIPANTS

Medicare beneficiaries aged 66 and older discharged to a SNF following hospitalization for TBI between 2011 and 2015 (n = 61,021).

MEASUREMENTS

Successful community discharge defined as discharge from SNF within 100 days of admission and remaining in the community for ≥30 days without dying or admission to an inpatient healthcare facility.

RESULTS

Unadjusted rates of successful discharge were significantly lower for patients in rural settings compared with patients in urban settings (52.1% vs 58.5%, p < 0.01). Patients in rural settings had lower adjusted odds (odds ratio 0.84, 95% confidence interval = 0.80-0.89) of successful discharge. Reasons for not discharging successfully differed between rural and urban settings with rural patients less likely to discharge from SNF within 100 days though also less likely to be rehospitalized within 30 days of SNF discharge.

CONCLUSION

Given the low overall rate of successful community discharge and worse outcomes among rural patients, further research to explore interventions to improve SNF care and discharge planning in this population is warranted.

At-a-glance - Living arrangements and health status of seniors in the 2018 Canadian Community Health Survey

Currently, 1 in 3 Canadian seniors meet the criteria for successful aging, which include low probability of disease and disability, high cognitive and physical ability and active engagement in life. The sociodemographic characteristic of living alone can identify high-risk seniors, due to its association with lower social support and interactions, thus increasing susceptibility to negative health outcomes in older age. However, limited data exists on the living arrangements of Canadian seniors. In this analysis, we present sociodemographic characteristics and measures of health and social well-being of seniors by living arrangement. This information should be used to identify and support vulnerable seniors and increase the prevalence of healthy aging among Canadians.

Location Matters: Disparities in the Likelihood of Receiving Services in Late Life

Moving beyond typical dichotomous rural-urban categorizations, this study examines older adults' likelihood of receiving home- and community-based services. Data from 1608 individuals aged 60+ who requested assistance from Area Agencies on Aging in Virginia in 2014-2015 were analyzed; 88% of individuals received at least one service. Receiving services was associated with geographic-based factors. Individuals living in completely rural areas were significantly less likely to receive any service compared to individuals in mostly rural (OR = 2.46, p = .003) and mostly urban (OR = 1.97, p = .024) areas. There were subtle but significant geographic-based differences in the likelihood of receiving specific services including food/meal, fresh food, information and referral, in-home care, utilities support, and transportation. Findings provide nuanced insights about geographic-based disparities in the receipt of services and suggest the need for new and modified service delivery strategies that maximize older adults' ability to live.