ACCESS TO QUALITY HEALTH SERVICES IN RURAL AREAS

ACCESS TO Quality Health Services IN RURAL AREAS — LONG-TERM CARE

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

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.