Health disparities, which have been exacerbated by the COVID-19 pandemic, have become a growing public health concern nationwide. There are also growing concerns about disparity in home health care, one of the fastest growing health care sectors in the United States.
The number of homebound people in need of home care is expected to grow rapidly in size, complexity and diversity in rural and urban areas. This is expected for several reasons: a rapidly aging U.S. population, the strong preference of older adults and their families to age in place, health policies that encourage the use of home and community services, and the changing profile demographic of the American population. population, with a substantial increase in racial and ethnic minorities.
As the role of home care in the health system grows, researchers are working to better understand how quality varies and whether there are disparities in care based on location, with the aim of optimize the quality of home care and reduce health disparities.
In 2018, more than 5 million Medicare beneficiaries received home care. Of those recipients, about 9% were rural residents who were served by about 1,690 home care agencies located in rural areas, according to published home care sector statistics.
We recently published a longitudinal study analyzing nationwide Centers for Medicare & Medicaid Services Home Health Quality Performance Measures data over five years (2014 to 2018) to understand differences in quality of care across agencies. urban and rural home health care. Full results are published in the Journal of Rural Health.
Data from this study covered 7,908 home health agencies nationwide, nearly 20% of which were in rural areas. The study measured the quality and performance of home health agencies by looking at timely initiation of care (a process of care measure) and inpatient and emergency department visits (two outcome measures of care) . We discovered a number of differences between urban and rural organisms both at specific times and over the five-year period we studied.
As shown in Chart 1, rural organizations were less likely than those in urban areas to be for-profit and accredited organizations. They were also more likely to be in a hospital setting, enrolled in both Medicare and Medicaid programs, and offering palliative care programs.
Compared to urban agencies, rural agencies consistently performed better on timely initiation of care, meaning they began home health care quickly when prescribed by a physician or in within two days of discharge from hospital or referral to home health care (Figure 1). On average, rural agencies had a 1.05% higher annual rate of timely care initiation, ranging from 0.88% higher in 2015 to 1.20% higher in 2017.
Figure 1. Trends in Timely Care Initiation Rate: Urban vs. Rural
2014: 91.89±6.74, range: 20.80-100.00 2014: 90.79±8.38, range: 20.00-100.00
2018: 94.78±6.79, range: 44.10-100.00 2018: 93.65±8.15, range: 17.20-100.00
Urban agencies consistently performed better in preventing hospitalizations and emergency department visits during overtime home care (Figure 2). Over the five years studied, urban agencies had on average a 0.90% lower hospitalization rate, ranging from 0.62% lower in 2017 to 1.27% lower in 2014. Urban agencies also had a lower hospitalization rate. average emergency room hospitalization lower by 2.6%. visits, ranging from 2.48% fewer in 2016 to 2.65% fewer in 2014 (Figure 3).
Figure 2. Trends in hospitalization rate: urban vs. rural
2014: 16.52±3.99, range: 3.90-37.20 2014: 15.33±3.62, range: 0.90-40.20
2016: 17.05±3.99, range: 1.40-35.50 2016: 15.99±3.68, range: 0.00-41.10
2018: 15.79±3.82, range: 2.40-36.00 2018: 15.11±3.57, range: 0.00-38.40
Figure 3. Trends in emergency department (ED) visit rate: urban vs. rural
2014: 14.30±4.17, range: 2.00-45.70 2014: 11.71±3.70, range: 0.00-31.70
2018: 14.90±4.15, range: 0.60-38.90 2018: 12.28±3.82, range: 0.00-33.00
Importantly, the differences between rural and urban agencies remained stable over time, with the exception of the hospitalization rate gap, which narrowed slightly from a difference of 1 .19% in 2014 to 0.68% in 2018. It should also be noted that the rate of urgency visits increased over the five-year study period in both settings.
This study highlights the persistence of quality disparities within home health care, related to both care processes and outcomes. Differences in rural and urban disparities in care processes and outcomes also indicate that organizations may choose different strategies given the resources available to them and the care or client populations.
This study underscores the importance of considering the unique geographic, workforce, and health challenges organizations face when investing to reduce rural-urban disparities. For example, while rural agencies are more likely to have a better relationship with referral care facilities for faster initiation of care, they are often more constrained by staffing and the long journeys providers have to make to reach each other. visit patients’ homes. In addition, rural residents are generally in poorer health than their urban counterparts.
It is critically important that policy makers consider these distinctive challenges for rural and urban organizations when developing policies to improve the quality of home health care. Rural and urban organizations need more opportunities to share strengths and learn from each other to determine what really works.