by
Linnae Hutchison, Catherine Hawes, and Lisa Williams
·
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
The goal of Healthy People 2010’s Access to
Quality Health Services focus area is to improve access to comprehensive, high-quality
health care services. Included in this focus area is improving access to
long-term care (LTC). In a national study, this focus area was the top-ranked
rural health priority among state and local rural health leaders.1 This review
addresses the following objective and focuses specifically on 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.
·
1-15. Increase the proportion of persons
with long-term care needs who have access to the continuum of long-term care
services.7
Prevalence
This discussion first provides a brief profile
of the American elderly; it then examines the long-term care continuum outside
the acute hospital setting and includes two main categories of services
classified as residential and non-residential, as well as the roles of the
informal care provider.8
An Aging Society
The United States is poised for what has been
described in the literature as a “gerontological explosion” as a confluence of
factors will significantly increase the ranks of the elderly population over
the next 50 years.9 In 2000,
persons over age 65 totaled 35 million; by the year 2030, this age group is
expected to double to 70 million (an increase from 12.4 percent to 20 percent
of the total population).2 Of particular
note is the growth in the oldest old population (those over 85), which is
expected to increase five fold between 2000 and 2050.10 Overall, this
“graying of America” is attributed to advances in medicine, improvements in
health, and aging of the baby boom generation (defined as those born between
1946 and 1964).11,
12
Profile of the Rural Elderly
Long-term care is a particularly important
concern for rural areas given the proportionately larger number of elderly in
rural areas than in urban areas. According to the 2000 census, 12.3 percent of
the urban population was 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 Moreover,
rural elderly are older than urban elderly, with the age increasing as one
moves along the continuum from urbanized to rural areas.13, 14 Rural areas
are also home to a greater proportion of the oldest old population segment,
comprising 7.8 percent of the population over age 60 in nonmetro areas compared
to 7.5 percent in metro areas.15
The key predictors of institutionalization are
health status, sociodemographic factors, and the role of social support
networks.16, 17,
18
The indicators used in assessing health status and the need for and degree of
long-term care services include perception of health, number of medical
conditions, cognitive status, functional status, and the number and severity of
impairments in activities of daily living (ADLs) and instrumental activities of
daily living (IADL). Several national studies have found rural-urban
differences for some measures of health among elderly populations.
Rural and urban elders differ in their perception
of health, number of medical conditions, utilization of preventive services,
and response to functional limitations. A number of studies found that rural
elderly are more likely to report a lower or worse perception of health than
their urban counterparts.19-21, 22, 23 Rural elderly are
also more likely to have chronic conditions such as arthritis, hypertension,
diabetes, and heart disease.24-26 The research is mixed
on rural-urban differences in functional status, with some studies finding a
higher number of functional limitations among nonmetro, nonfarm rural areas
when compared across four locales.19, 25, 27 Other studies found
rural and urban elderly have similar functional status.21,
23
The reasons for the mixed results may be attributed to variations in rural-urban
classification schemes employed or possibly rural culture itself. One study
suggests rural elderly may view aging differently than urban dwellers,
discounting functional limitations as a normal part of aging and reporting
fewer limitations.28
Understanding the socioeconomic status (e.g.,
education and income levels) of the rural elderly is also important in
predicting utilization of services; higher education and incomes are associated
with more positive health self-assessments.29 Rural elderly
are less educated and poorer than their urban counterparts, with 21 percent of
rural elderly classified as poor compared to 10.1 percent of the general
population 65 and older.30, 31 Nearly half of rural
elders live below 200 percent of the federal poverty level compared to roughly
one-third of urban residents.32
Residential Providers
Assisted Living
Assisted living has emerged as one of the
fastest-growing segments of the long-term care market, providing care for those
seniors who are unable to remain in their homes but do not require the depth of
care found in nursing homes. Despite the growth of assisted living services,
understanding the availability and utilization of these services is complicated
by the lack of a national definition of assisted living facilities (ALFs), the
lack of national licensing standards, and limited research on the breadth,
scope, and quality of this industry in rural versus urban areas.33,
34
A national study of assisted living in rural areas found that assisted living
is predominantly an “urban industry,” with roughly 76 percent of ALFs located
in metro areas.33 Rural ALFs
tend to differ significantly in the mix of privacy and services, with rural
facilities more likely to offer a combination of low privacy and limited services
compared to urban facilities.33 While assisted
living is suggested as a less expensive alternative to nursing home care, the
cost may be prohibitive for many low-income rural seniors.33, 35
Nursing Homes
Nursing homes serve as an important provider of
long-term care services to the chronically ill and disabled, especially in
rural areas where other service options are limited. While many services are
lacking in rural areas, nursing homes remain the notable exception, with 40
percent of all nursing homes in rural areas.36 Rural areas
have the highest rate of nursing home use, with 12 percent of the population
over age 75 in nursing homes in 2000 compared to 8.2 percent in urban areas.13 Rural nursing
home residents and facilities differ from their urban counterparts along a
number of dimensions. Rural nursing homes have fewer beds, have a larger
percentage of homes below the Centers for Medicare and Medicaid Services (CMS)
suggested nurse-staffing thresholds, and offer fewer specialized services such
as Alzheimer’s units.13 Compared to
their urban counterparts, rural nursing home residents are older, have fewer
functional limitations, similar cognitive impairment, and are more likely to be
dependent on Medicaid.13
While quality of care in nursing homes is a
national issue, few studies have investigated how quality differs across the
rural-urban continuum. In a recent national study, 10 of 19 indicators of
potential quality problems were higher in nursing homes located in rural areas,
denoting potentially more quality-of-care problems in nonurban areas.36
Non-residential Care Providers
Home Health
Home health (HH) fosters and promotes
independence while providing necessary medical care in patients’ homes for
those with chronic disease or those recovering from an acute incident. Overall,
rural home health agencies (HHAs) differ substantially from urban HHAs in
organizational structure and provision of services.37 When compared
to urban HHAs, rural HHAs are smaller, more sparsely located, more likely to
use health aides, and less likely to offer a wide range of ancillary services
(e.g., physical and occupational therapy, as well as social services).37,
38
Rural and urban home health patients differ in a
number of ways, with rural patients more likely to have long-term care needs
versus urban beneficiaries who are more likely to need post-acute care.39 One study
found that rural home health patients tended to have more ADL and IADL
disabilities, significantly more intractable pain, more
neuro/emotional/behavioral status problems, terminal conditions, and slightly
more chronic conditions (1.98 versus 1.77), although the difference was not
statistically significant. At discharge, rural residents were less likely to
have their goals met and more likely to have a poor prognosis.25
Home and Community-based Services
(HCBS)
Coburn observed that the “landscape of long-term
care is changing, forcing increased reliance on private funding for services, expansion
of nonresidential care alternatives, increasing in-home care options, and
attempts to integrate care across the acute and LTC system.”34 The 1915c
waiver program allows states to offer a wide range of services including homemaker/home health aide services,
personal care services, adult day health, habilitation, case management, respite
care, and “other” services (such as home-delivered meals or transportation
services).8, 40 All 50 states
offer some form of HCBS; however, there is variation in the programs offered.8
While it is generally agreed that rural elderly have access to a narrower range of and fewer alternatives to HCBS and confront greater barriers in accessing care, the degree to which these constraints affect utilization is complex.5, 6, 41 Rabiner et al. found that residents in the northeast and those living in moderately densely populated areas were more predisposed to using some HCBS than those living in remote areas.