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Rural Health Care: Challenges & Opportunities

Long-term Care


Elise J. Bolda, Ph.D., Assistant Professor, Health Policy Institute, Edmund S. Muskie School of Public Service, University of Southern Maine, Portland, ME.

Joyce Bohn Allen, M.S.W., Assistant to the Director, Office of Strategic Finance, Department of Health and Family Services, Madison, WI.

Consumers of long-term care (LTC) include frail older adults and adults of all ages with physical disabilities, chronic diseases (including mental illness), and/or developmental disabilities. Presently, older adults comprise about 11 percent of the population. By 2050, the number is expected to increase to approximately 20 percent.

Older rural LTC consumers differ from urban LTC consumers in that older adults in rural areas represent a greater percentage of the local population and are more likely to be Medicaid beneficiaries. They are more likely to own their own homes, mortgage-free, yet their homes are likely to be of lower value and in poorer condition.

LTC includes residential and home-based care services. Residential care includes nursing facilities, such as skilled and intermediate care facilities for persons with mental retardation; and nonmedical residential care, such as assisted living, residential care, adult foster care, and supportive living. Home-based care includes home health care, personal care—assisting with activities of daily living (ADLs) such as bathing, transferring, eating—housekeeping, adult day services, and respite services.

Assisted living is the fastest growing area of LTC services, in large part because of changes in Federal and State policy, moving away from a reliance on nursing facilities and toward more home-like environments and less resource-intensive service settings. A major challenge in rural areas is how to keep assisted living affordable because not all State programs under Medicaid will cover services in assisted living, and many rural older adults have low incomes yet are ineligible for Medicaid if they sell their homes or relocate.

Compared with urban residents, older rural residents have:

  • Lower use of home health services overall.
  • Higher numbers of home health visits per user.
  • More nurse and aide visits, fewer therapy and medical social service visits.
  • Higher nursing facility use.
  • Longer nursing facility stay.
  • Lower case mix.

Public financing for LTC is challenging because acute and LTC services are often covered by different payers. Medicare covers acute care for all eligible seniors, while Medicaid covers LTC services for the 40-50 percent of persons with disabilities and income-eligible seniors. Integrating the delivery of acute and LTC services is challenging, especially for LTC users who are dually eligible for Medicare and Medicaid. Currently, the fragmentation of the financing system creates perverse incentives to shift costs between programs rather than promoting integration of the delivery system.

Rural opportunities in LTC. Dr. Bolda identified the following key areas in which policymakers can help strengthen rural LTC systems.

  • Home-based care development through Medicaid eligibility expansions and buy-in options for non-Medicaid eligible individuals.
  • Innovative housing with services for persons with low incomes and higher assets and encouraging varying levels of supportive services.
  • Rural hospitals playing a leadership role for rural integration models and through development/sponsorship of rural LTC services.
  • Integration in rural areas may become more feasible given providers' negotiating strengths, telemedicine applications, and co-location of services.

In 1998 Wisconsin began a plan for redesigning its LTC system. A consensus emerged that the existing system was undependable and unresponsive, too complicated and costly, and not meeting needs. System barriers such as fiscal incentives aligned toward institutional care, multiple entry points, and poor outcome orientation also played a role in initiating reform.

Wisconsin's new proposed LTC system is called Family Care. The goals of the reform proposal include:

  • Increased consumer choice.
  • Improved access and quality through a focus on health and social outcomes.
  • Creation of a cost-effective, comprehensive, and flexible service system for the future.

Strategies to support goals include:

  • Prevention and early intervention.
  • Better informed private pay market.
  • Reduced reliance on institutional care incentives in payment system and rate structure.
  • A managed care model that combines medical service providers with the State-funded services system in one care management organization contract.

The Family Care system includes:

  • Eligibility, aging, and disability resource centers.
  • Care management organizations and comprehensive LTC benefit options.
  • Quality improvement.

The $224 million budget for fiscal year 2000-2001 is funded through a variety of sources, including Federal funds (approximately half), State revenue, and a small amount from revenue from clients.

Family Care was implemented as a pilot program in five counties in early 2000. Three of the pilot counties are rural. Rural issues that arose with regard to LTC reform include:

  • Can small rural counties be successful and remain solvent?
  • Is there an adequate choice of service providers?
  • Can rural areas develop needed affordable housing options?
  • Is there an adequate health care labor force?

Although the program is still in its early implementation phase, lessons learned in Wisconsin thus far include:

  • Create a common vision.
  • Keep stakeholders at the table.
  • Develop common data sets across systems/services.
  • Use data to inform decisionmaking.
  • Start talking early with the Federal Government.
  • Build the future while respecting the past.


Coburn AF. Rural long-term care: what do we need to know to improve policy and programs? Prepared for the Rural Health Agenda Setting Conference. 2000 Jan. Washington, DC.

Family Care: Redesigning the Long-term Care System. Wisconsin Department of Health and Family Services.

Ricketts TC, ed. Rural health in the United States. New York: Oxford University Press; 1999.

Rogers CC. Growth of the oldest old population and future implications for rural areas. Rural Development Perspectives 14(3):22-6.

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