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Health Care for the Elderly

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Elderly people in rural areas receive fewer home health care services and have worse outcomes than those in urban areas

Elderly men and women who live in rural areas receive fewer services per home health care episode, and they have poorer outcomes than their city-dwelling counterparts, according to a recent study supported by the Agency for Healthcare Research and Quality (HS08031). Robert E. Schlenker, Ph.D., of the University of Colorado Health Sciences Center, and his colleagues used Medicare data, home health care agency records, and health status assessments by agency nurses to compare home health care use and patient outcomes for a national random sample of 3,869 rural and urban elderly home health care patients in 1995 and 1996. They followed the patients for 120 days or until discharge from home care, whichever occurred first.

After adjustment for differences in rural-urban case mix and agency differences, elderly people living in rural areas received fewer mean total visits per home health episode than their urban counterparts (33.7 vs. 35.6), and they received less costly care due to use of fewer high-cost professionals such as physical or occupational therapists ($2,317 vs. $2,527). The rural elderly were more likely to receive visits involving less costly resources such as home health aides.

Rural elderly patients also had less favorable outcomes than the urban elderly. Fewer of them were discharged from home health care meeting health goals (38.6 vs. 52.7 percent), and more were hospitalized (30.3 vs. 24.9 percent) or not discharged (18.5 vs. 10 percent), that is, still needed more home care. Also, average length of stay in home health care was longer for rural patients (54.1 vs. 46.7 days).

These findings may represent adaptation of rural home health providers to rural realities such as lower availability of certain health care personnel (such as physical therapists) and longer travel distances or to the greater amount of informal outside support for rural patients. Rural agencies will likely find it even more challenging to serve the elderly since implementation of prospective payment under which Medicare pays the same amount for a home health care episode (case-mix adjusted) regardless of the services provided, an incentive to limit services.

More details are in "Rural-urban home health care differences before the Balanced Budget Act of 1997," by Dr. Schlenker, Martha C. Powell, Ph.D., and Glenn K. Goodrich, M.S., in the Spring 2002 Journal of Rural Health 18(2), pp. 359-372.

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