Patterns and predictors of noninstitutional health care utilization by older adults in rural and urban America

Older adults' home- and community-based care service use and residential transitions: a longitudinal study

Background

As Home-and Community-Based Services (HCBS), such as skilled nursing services or personal care services, have become increasingly available, it has become clear that older adults transit through different residential statuses over time. Older adults may transit through different residential statuses as the various services meet their needs. The purpose of this exploratory study was to better understand the interplay between community-dwelling older adults’ use of home- and community-based services and their residential transitions.

Methods

The study compared HCBS service-use patterns and residential transitions of 3,085 older adults from the Second Longitudinal Study of Aging. Based on older adults’ residential status at the three follow-up interviews, four residential transitions were tracked: (1) Community-Community-Community (CCC: Resided in community during the entire study period); (2) Community-Institution-Community (CIC: Resided in community at T1, had lived in an institution at some time between T1 and T2, then had returned to community by T3); (3) Community-Community-Institution (CCI: Resided in community between at T1, and betweenT1 and T2, including at T2, but had used institutional services between T2 and T3); (4) Community-Institution-Institution (CII: Resided in community at T1 but in an institution at some time between T1 and T2, and at some time between T2 and T3.).

Results

Older adults’ use of nondiscretionary and discretionary services differed significantly among the four groups, and the patterns of HCBS use among these groups were also different. Older adults’ use of nondiscretionary services, such as skilled nursing care, may help them to return to communities from institutions. Personal care services (PCS) and senior center services may be the key to either support elders to stay in communities longer or help elders to return to their communities from institutions. Different combinations of PCS with other services, such as senior center services or meal services, were associated with different directions in residential transition, such as CIC and CII respectively.

Conclusions

Older adults’ differing HCBS use patterns may be the key to explaining older adults’ transitions. Attention to older adults’ HCBS use patterns is recommended for future practice. However, this was an exploratory study and the analyses cannot establish causal relationships.

Does the universal health insurance program affect urban-rural differences in health service utilization among the elderly? Evidence from a longitudinal study in taiwan

PURPOSE

To assess the impact of the introduction of Taiwan's National Health Insurance (NHI) on urban-rural inequality in health service utilization among the elderly.

METHODS

A longitudinal data set of 1,504 individuals aged 65 and older was constructed from the Survey of Health and Living Status of the Elderly. A difference-in-differences model was employed and estimated by the random-effect probit method.

FINDING

The introduction of universal NHI in Taiwan heterogeneously affected outpatient and inpatient health service utilization among the elderly in urban and rural areas. The introduction of NHI reduced the disparity of outpatient (inpatient) utilization between the previously uninsured and insured older urban residents by 12.9 (22.0) percentage points. However, there was no significant reduction in the utilization disparity between the previously uninsured and insured elderly among rural residents.

CONCLUSIONS

Our study on Taiwan's experience should provide a valuable lesson to countries that are in an initial stage of proposing a universal health insurance system. Although NHI is designed to ensure the equitable right to access health care, it may result in differential impacts on health service utilization among the elderly across areas. The rural elderly tend to confront more challenges in accessing health care associated with spatial distance, transportation, social isolation, poverty, and a lack of health care providers, especially medical specialists.

Unmet Needs for Home and Community-Based Services Among Frail Older Americans and Their Caregivers

Objective: This study examined unmet needs for home- and community-based services (HCBS) among frail older Americans. Method: Using population-based sample from the National Long-Term Care Survey, a hierarchical logistic regression analysis was conducted to examine the predictors of unmet needs for seven types of HCBS. Results: Lack of awareness, reluctance, unavailability, and affordability of services were the main reasons for unmet needs for HCBS. Factors that were associated with unmet needs included Black race/ethnicity, greater care needs (functional limitations and behavioral problems), and less informal support (substitute help and family agreement). Discussion: It is important to identify risk factors that may lead to older adults’ unmet needs for HCBS. The findings of this study charge researchers to look beyond service utilization and give more attention to service needs among those who did or could not access the services.

Perceived barriers to health care access among rural older adults: a qualitative study

CONTEXT

Many rural elders experience limited access to health care. The majority of what we know about this issue has been based upon quantitative studies, yet qualitative studies might offer additional insight into individual perceptions of health care access.

PURPOSE

To examine what barriers rural elders report when accessing needed health care, including how they cope with the high cost of prescription medication.

METHODS

During Spring 2001, thirteen 90-minute focus groups were conducted in 6 rural West Virginia communities. A total of 101 participants, aged 60 years and older, were asked several culminating questions about their perceptions of health care access.

FINDINGS

Five categories of barriers to health care emerged from the discussions: transportation difficulties, limited health care supply, lack of quality health care, social isolation, and financial constraints. In addition, 6 diverse coping strategies for dealing with the cost of prescription medication were discussed. They included: reducing dosage or doing without, limiting other expenses, relying on family assistance, supplementing with alternative medicine, shopping around for cheapest prices, and using the Veteran's Administration.

CONCLUSIONS

Overall, rural older adults encounter various barriers to accessing needed health care. Qualitative methodology allows rural elders to have a voice to expound on their experiences. Research can contribute valuable information to shape policy by providing a forum where older adults can express their concerns about the current health care delivery system.

Awareness and use of home- and community-based long-term care by rural American Indian and white elderly with co-morbid diabetes

The purposes of this study were to determine if there are any differences in awareness and utilization of available home- and community-based long-term care (HCBLTC) between rural American Indian and white elderly with co-morbid diabetes, and to examine how they learned about HCBLTC programs. Survey data were analyzed from 62 American Indians and 64 whites aged 65 years or older living in the community. The American Indian respondents were more likely to be aware of and to have used HCBLTC programs compared to their white counterparts. The most common way that the American Indian participants learned about HCBLTC programs was through health care referrals, while the most common way for whites was through friends.

Exploring the dimensions of access to health services: implications for nursing research and practice

Access to health services is a major concern across North America and abroad, with particular salience for the residents of rural and remote areas and the health professionals committed to providing services to them. Intrinsic to this discussion is clarification of the phenomenon of access to health services, a concept that remains nebulous and obscure to consumers, health care providers, and policymakers alike. Multiple understandings of access to health services impedes progress in the development of policy, the creation of programs, and the transformation of health services. Considerable discussion of theory concerning access to health services is articulated in public or community health literature and that of other disciplines; however, limited attention to this topic is apparent in nursing literature. This report articulates definitions, dimensions, and frameworks of access to health services from available literature and existing theory. Further, key points are identified and discussed for consideration in nursing research on the term access and implications for practice.

Determinants of Medicare home healthcare service use among Medicare recipients

BACKGROUND

Medicare reimbursement for home healthcare (HHC) services has changed dramatically in recent years. A clear understanding of the determinants of Medicare HHC services use is needed so that HHC agencies can meet the demand for services from an aging population while remaining financially sound.

OBJECTIVES

The purpose of the study was to identify the determinants of Medicare HHC service within the framework of the Andersen Behavioral Model.

METHODS

This cross-sectional secondary analysis used data from the 1996 Medical Expenditures Panel Survey to examine characteristics of 239 subjects who had received Medicare reimbursed HHC services. Predisposing characteristics, enabling resources, and need characteristics were examined to explain Medicare HHC service use. Two criterion measures, annual Medicare expenditures and days of care, were employed in hierarchical regression analyses.

RESULTS

Variance in annual Medicare expenditures was explained by both the predisposing (R(2) =.16, <.001) and need characteristics (R(2) =.09, <.001). Variance in days of care was explained by predisposing characteristics (R(2) =.12, <.001) and need characteristics (R(2) =.15, <.001). The adjusted for the total model was.21 for annual Medicare expenditures and.25 for days of care.

CONCLUSIONS

While Andersen's Behavioral Model is useful in explaining Medicare HHC service use, it may be important to use multiple measures as criterion variables since the amount and proportion of variance explained differs with the variable used.

Rural long-term care: what do we need to know to improve policy and programs?

This article examines what is known and what we need to know about rural long-term care populations and the formal and informal service systems that support their long-term care needs. The article provides a framework for identifying some of the critical policy and research questions concerning the financing and delivery of rural long-term care that merit the attention of health services researchers and policymakers. It documents differences in the demographic and health characteristics of the rural and urban elderly and in the availability, organization, and use of health and long-term care services in rural areas that have significant implications for long-term care policy and programs. With this background in mind, the author discusses specific topics and questions relevant to long-term care policy and program improvements for rural communities and people: (a) the changing role of the rural nursing home; (b) residential care alternatives in rural areas; (c) health personnel and rural long-term care; (d) the quality of rural long-term care; (e) innovations in long-term care financing and service delivery; (f) use of technology in rural long-term care; and (g) the effects of Medicaid and Medicare policy changes on the rural long-term care system.

Posthospital home care for frail older adults in rural locations

After discharge from the hospital, older patients often require continued home care, including both professional and nonprofessional services. These needs can be exacerbated by health status (i.e., frailty) and geographic residence (i.e., rurality). It was the purpose of this study to examine patterns of postdischarge home care and outcomes for frail elders from rural locations. Seventy frail older adults being discharged from an acute urban-based hospital to home in a rural setting were recruited. Baseline data were collected before discharge from the hospital, and then calls were made at 48 hr and 2 and 4 weeks after discharge to evaluate use of resources and out-of-pocket expenses. Nonprofessional services were used most frequently, and the most intense time of use was at the 2-week postdischarge period. These findings suggest that discharge planning should include obtaining information about availability of both professional and nonprofessional services in the home community and arranging for appropriate delivery of both.

Distribution and utilization of home- and community-based long-term care services for the elderly in North Carolina

Provision of home- and community-based long-term care is a growing concern at the national, state, and local levels. As more persons grow old, the need for these services is expected to rise. This analysis examines the distribution and utilization of three home- and community-based long-term care programs in North Carolina for each of the state's 100 counties. Maps were generated to examine how counties differed in respect to service utilization among the elderly. Great variability was found in number of elderly utilizing the services across the state as well as the percent of Medicaid- and/or age-eligible persons who utilized the programs. Multivariate modeling for associations to service utilization was only possible for one of the long-term care programs. Results indicated that living alone, being non-white, and having a mobility and self-care limitation were all positively related to utilization. Percent of persons 85 years or older and the ratio of institutionalized long-term care beds were negatively associated with utilization. It was concluded that states must engage in concerted efforts to ensure equity in access to home- and community-based long-term care.

Identification of needs of and utilization of resources by rural and urban elders after hospital discharge to the home

The recent reductions in lengths of hospital stays may particularly affect the elderly in rural communities where resources may be scarce. The purpose of this descriptive, comparative study was to assess and evaluate the match of formal and informal resources with individual functional, behavioral, knowledge, and skilled care needs of rural and urban elderly during a 21-day transition period following hospital discharge to the home. Eighty-one elderly patients discharged to one urban and two frontier rural counties were selected. There were no significant differences in demographic variables between rural and urban participants. The Comprehensive Health Care Needs Assessment (CHCNA) questionnaire was used to assess needs and utilization of resources at 3 days and 3 weeks after discharge. Using repeated measure analyses of variance, there were significantly fewer needs identified at 3 weeks than at 3 days after discharge. Rural dwellers identified significantly more skilled care needs than their urban counterparts; however, none were highly technical in nature. Unexpectedly, at 3 weeks after discharge, considerably more functional needs were met by families in the urban setting than in the rural setting. Although only a small number of participants reported unmet needs in multiple domains, the complexity of the unmet needs requires further exploration.

The perceived availability, quality, and cost of long-term care services in America

This study gathered primary data on the patterns and predictors of home-based, community-based, and institutional long-term care services for older adults residing in the United States. A stratified random sample of policymakers and agency representatives (n = 153; response rate 67.1%) completed a comprehensive mail survey to provide detailed information on the perceived availability, quality, and costs of long-term care services in their community settings. Descriptive analyses revealed that there are significant differences in perceived access, use, quality, and costs of care by service type and agency affiliation. The results present an interesting dilemma for policymakers as many of the services found to be most widely available and of the highest quality were considered too costly. Implications for public policy and suggestions for further research are highlighted.

Attitudes toward and use of subsequent nursing home services among a national sample of older adults

This study was designed to examine the relationship between attitudes toward nursing homes and subsequent nursing home utilization, and assess the impact of prior nursing home utilization on subsequent attitudes among a national sample of older Americans. Multivariate estimation procedures for complex survey designs were performed on the National Long-Term Care Survey data set. Although prior nursing home use did not directly affect subsequent attitudes toward nursing homes, having favorable attitudes about nursing homes increased the odds of using subsequent nursing home services by 1.5 and increased the total nursing home length of stay by 17%. Implications of this research for public policy and long-term care treatment planning are discussed.