ACCESS TO Quality Health Services in Rural Areas—LONG-TERM CARE: A LITERaTURE REVIEW

by Linnae Hutchison, Catherine Hawes, and Lisa Williams

Scope of Problem

· Access to quality health services was identified as the top ranking rural health priority in a national survey of state and local rural health leaders and stakeholders.¹

· By the year 2030, the elderly population will double. One-fifth of the U.S. population will be over age 65.²

· Approximately 75 percent of those over 65 suffer from at least one chronic illness.³

· Nearly 22 percent of the nation’s elderly reside in rural areas.⁴

· Rural elderly represent a larger proportion of the rural population than the urban population.⁴

· The elderly in rural areas have access to fewer and a narrower range of long-term care services.^{5, 6}

Goals and Objectives

Improving access to comprehensive, high-quality health care services is the goal of the first Healthy People 2010 focus area—Access to Quality Health Services. Included in this focus area are objectives relating to improving access to primary care providers and emergency services, increasing the number of individuals with health insurance, and improving access to the long-term care continuum and rehabilitative services.⁷ This literature review focuses on long-term care and the unique challenges faced by the rural elderly in accessing these services including access to nursing homes, assisted living, home health, hospice, and home and community-based services.

The following Healthy People 2010 objective drives this discussion:

· 1-15. Increase the proportion of persons with long-term care needs who have access to the continuum of long-term care services.⁷

Identified by People Living in Rural Areas as a high priority health issue for them

Improving access to long-term care and rehabilitation is one of the goals under the Healthy People 2010 Access to Quality Health Services focus area. This area was the top-ranked rural health priority among state and local rural health leaders in a national survey.¹ Approximately two-thirds of the leaders of state agencies and associations, rural hospitals, rural health centers/clinics, and local public health agencies identified access to quality health services as one of the five top priorities among the 28 Healthy People 2010 focus areas.¹

Prevalence and disparities in rural areas

Access to long-term care (LTC) and rehabilitation services includes improving access to those providers, services, and facilities that play a vital role in the long-term care continuum. While hospitals often serve as the entry point for elderly into the long-term care system, for the purpose of this discussion, the long-term care continuum includes those services outside the acute hospital setting. These services may be classified as residential (e.g., assisted living, nursing homes) and non-residential (e.g., home health, hospice, and home and community-based services).⁸ In addition, the role of informal care providers (e.g., spouses, children, and friends), who are invaluable in meeting the needs of the elderly, will be included in this discussion.

An Aging Society

The United States is poised for what has been described in the literature as a “gerontological explosion”⁹ as a confluence of factors will significantly increase the ranks of the elderly population over the next 50 years. Since 1900, the U.S. population has experienced a 10-fold increase in the number of those over 65—from three million (4 percent of the total population) at the turn of the last century to 35 million (12.4 percent of the total population) in 2000.^{2, 4} By the year 2030, the population over age 65 will double to 70 million, and one in five individuals will be 65 and older.²

Overall, Americans are older. The average age of U.S. citizens is 35.3 years, while the average life expectancy is 77 years—a significant increase from 1900 when the average life expectancy was 43 years.^{71, 72} This “graying of America” is attributed to simultaneous advances in medicine prolonging life, improvements in health, decreasing fertility rates, and aging of the baby boom generation.^{11, 12} Baby boomers, identified as those born between 1946 and 1964, currently comprise nearly one-third of the United States population and will begin to reach retirement age beginning in 2011.¹¹ Between 1990 and 2020, the population age 65–74 is expected to increase 74 percent compared to only 24 percent for those under 65.¹¹

Given the increases in life expectancy, it is important to recognize that the 65 plus age bracket is comprised of smaller subgroups (65–74, 75–85, 85 plus, and centenarians), each with unique characteristics that influence long-term care demands. One trend of particular relevance to long-term care and aging services is the growth in the population termed the “oldest old,” those over age 85. In 2000, there were 4.26 million people over age 85, representing the most rapidly growing segment of the elderly population and growing 38 percent in the last decade.^{10, 74} This age group is anticipated to increase five-fold between 2000 and 2050—growing to 20.8 million, with the largest growth between 2030 and 2050 coinciding with the baby boom generation turning 85 and over.¹⁰ This trend portends future increased demands on formal and informal providers as persons over 85 are the most likely to need and use long-term care services.⁵⁶

Other demographic information is relevant to understanding the long-term care demands. One observation is the inverse relationship between heterogenity and advancing age. Those over 65 are disproportionately women, widowed, and predominantly white—comprising 87 percent of those 65 and older.^{2, 74} Regional differences also exist. The western and southern regions of the U.S. exhibit the fastest growth in total population and also the most rapid growth in the elderly population—growing 20 percent and 16 percent, respectively, between 1990 and 2000.⁷⁴ Such regional differences may reflect overall population growth as well as choices of elderly regarding geographic location for retirement living.

Long-term Care Spending

Long-term care spending is expected to continue increasing as a result of the growth in the older population. The Congressional Budget Office projects total long-term care spending to reach 160.7 billion dollars by 2010 and 207.3 billion dollars by 2020. Assisted living and adult day care are not included in this projection.⁷⁵ It is estimated that half of all elderly over age 65 will require some care in a nursing home, and approximately 75 percent will require home care.⁵⁶

Approximately 64 percent of long-term care spending for institutional care and home care (e.g., home and community-based services, personal assistance, and home health) is from public sources, with Medicaid being the primary funder (27 percent) followed by Medicare (17 percent).^{77, 78} The remaining expenses are covered out-of-pocket (21 percent), by private insurance (10 percent), and by other private and public sources (5 percent).⁷⁹ Approximately one quarter of Medicare and Medicaid expenditures occur in the last year of life.^{80, 81} In 2003, two-thirds of LTC spending was directed toward institutional care versus one-third spent on home-care services, including home and community-based services, personal care, and home health.⁷⁹ Medicaid, the largest payer of LTC, is available only after other sources of private funding are exhausted. This spend-down requirement is a significant concern for those in need of long-term care services, as well as their families.

Elderly in Rural and Urban Areas

Long-term care and aging is an important concern for rural areas given the proportionately larger number of elderly in rural areas than in urban areas combined with less access to health resources. According to the 2000 census, 12.3 percent of the urban population is over age 65 compared to 12.8 percent of the rural population.⁴ Of the nearly 35 million elderly over age 65, 21.6 percent of this group resides in rural areas.⁴ Rural elderly are older than urban elderly. Studies have found age increases as one moves along the continuum from urbanized to rural areas, with a greater proportion of those over age 65 and those over 75 residing in isolated areas compared to more urban areas.^{13, 14} Rural areas are also home to a greater proportion of the oldest old population segment (those over age 85), which is an age group more likely to need long-term care and aging services, comprising 7.8 percent of the population over age 60 in the nonmetro areas compared to 7.5 percent in metro areas.^{15, 75} An estimated 50 percent of those over age 85 need personal assistance with everyday activities (e.g., bathing, meal preparation, and mobility within the home).⁷⁴

Profile of the Rural Elderly

The key predictors of institutionalization are health status, sociodemographic factors, and the role of social support networks.^16-18 Among the indicators used in assessing overall health status, as well as determining the need for and degree of long-term care services, are the perception of health, number of medical conditions, cognitive status, functional status, and the number and severity of activities of daily living (ADLs) and instrumental activities of daily living (IADL) impairment. Assessing the degree to which rural and urban elderly differ in health status is complex; studies comparing the health status of the elderly across different locales vary not only in the health indicators utilized but also in the definitions of rural and urban employed. Despite these limitations, a series of national reports conclude that rural and urban differences exist for some measures of health, functional, and cognitive status among elderly populations.

Foremost among these differences is self-reported perception of health. These assessments, which are tied to objective indicators of health status such as number of physician visits, illness presence, and lifestyle choices (e.g., exercise, smoking, etc.), provide insight into the health of a population group.⁸² A number of studies have found rural elderly report a lower or worse perception of health than their urban counterparts.^{19- 21} Mueller and colleagues found that Medicare beneficiaries residing in nonmetro areas were more likely to rate their health as fair or poor and less likely to rate their health as good or excellent than their metro counterparts.²² Coward and Cutler found the lowest perceived health status among nonmetro nonfarm elderly (the largest population of rural elderly); however, the reported perception of health did not decrease with increasing rurality. Instead, elderly residing in the most rural locales had a slightly higher perceived health status than the nonmetro nonfarm elderly, although the perception was still lower than that of metro residents.¹⁹ Eggenbeen and Lichter found that rural elders were—in addition to reporting a lower perceived health status—more likely to report greater unhappiness.²³

Rural and urban elders also differ in the number of medical conditions and utilization of preventive services. Data from the Behavior Risk Factor Surveillance Survey (BRFSS) from 1993–1997 found rural elders had a higher incidence of obesity and physical inactivity, and they were more likely to never have smoked; however, if they did smoke, they were more likely to be a current smoker (i.e., smoked in the last 30 days).⁸³ The same source found rural older women less likely to have received a mammogram or pap smear, and rural males and females were less likely to have received a cholesterol check in the last six months.⁸³ Overall, rural elderly are more likely to have chronic conditions such as arthritis, hypertension, diabetes, and heart disease.^24-26

Physical and cognitive functioning are essential measures in assessing an individual’s need for long-term care services. Cutler and Coward found that elderly in nonmetro-nonfarm rural areas had the highest number of medical conditions and functional limitations of the four groups (central city, noncentral city, non metropolitan statistical area [nonMSA] nonfarm, and nonMSA farm).