Home health care agency staffing patterns before and after the Balanced Budget Act of 1997, by rural and urban location.

CONTEXT: The Balanced Budget Act (BBA) of 1997 and other recent policies have led to reduced Medicare funding for home health agencies (HHAs) and visits per beneficiary. PURPOSE: We examine the staffing characteristics of stable Medicare-certified HHAs across rural and urban counties from 1996 to 2002, a period encompassing the changes associated with the BBA and related policies. METHODS: Data were drawn from Medicare Provider of Service files and the Area Resource File. The unit of analysis was the 3,126 counties in the United States, grouped into 5 categories: metropolitan, nonmetropolitan adjacent, and 3 nonmetropolitan nonadjacent groups identified by largest town size. Only relatively stable HHAs were included. We generated summary HHA staff statistics for each county group and year. FINDINGS: All staff categories, other than therapists, declined from 1997 to 2002 across the metropolitan and nonmetropolitan county groupings. There were substantial population-adjusted decreases in stable HHA-based home health aides in all counties, including remote counties. CONCLUSIONS: The limited presence of stable HHA staff in certain nonmetropolitan county types has been exacerbated since implementation of the BBA, especially in the most rural counties. The loss of aides in more rural counties may limit the availability of home-based long-term care in these locations, where the need for long-term care is considerable. Future research should examine the degree to which the presence of HHA staff influences actual access and whether other paid and unpaid sources of care substitute for Medicare home health care in counties with limited supplies of HHA staff.

Impact of a health promotion nurse intervention on disability and health care costs among elderly adults with heart conditions.

CONTEXT: Patients with heart conditions in rural areas may have different responses to health promotion-disease Self-management interventions compared to their urban counterparts. PURPOSE: To estimate the impact of a multi-component health promotion nurse intervention on physical function and total health care expenditures among elderly adults with heart conditions and to examine the impact of rural residence on the intervention effect. METHODS: We analyzed data on 281 community-living Medicare beneficiaries with heart conditions from the Medicare Primary and Consumer-Directed Care Demonstration (a randomized controlled trial). We estimated ordinary least squares (OLS) models to determine the effect of the intervention on the change in functional status and log-linear models to determine the impact of the intervention on total health care expenditures over a 2-year period. RESULTS: The OLS models showed that the nurse intervention resulted in fewer impairments in Activities of Daily Living (ADL) (-0.307 on 0-6 scale, P = .055) at the end of 2 years. The effect of the intervention on ADL appeared to be stronger for rural than for urban participants (-0.490 vs -0.162, respectively). However, the difference was not statistically significant (P = .150). The effect of the intervention on Instrumental Activities of Daily Living (IADL) was not significant (P = .321). Average total health care expenditures were 6.5% ($1,981, 95% CI: -$8,048, $4,087) lower in the nurse group. CONCLUSIONS: The nurse intervention led to better physical functioning and has potential to reduce total health care expenditures among high-risk Medicare beneficiaries with heart conditions.

The influence of rural location on utilization of formal home care: the role of Medicaid.

PURPOSE: This research examines the impact of rural-urban residence on formal home-care utilization among older people and determines whether and how Medicaid coverage influences the association between rural-urban location and risk of formal home-care use. DESIGN AND METHODS: We combined data from the 1998 consolidated file of the Medical Expenditure Panel Survey Household Component with data from the Area Resource File to generate the analytical data set. We established two measures of formal home-care utilization: home care reimbursed through any source, and Medicare-reimbursed home health care. Our measures of rural-urban residence included metropolitan counties, nonmetropolitan counties having towns of at least 10,000 people, and nonmetropolitan counties with no towns of 10,000 people. We used logistic regression analyses to examine main effects and interaction effects of Medicaid coverage and residence on the two types of formal home care under controls for person-level characteristics and state fixed effects. RESULTS: The unadjusted logistic analyses demonstrate that older people who reside in the most rural counties (nonmetropolitan counties having no town of 10,000) are significantly more likely than metropolitan residents to use any formal home care and Medicare home health care. The fully adjusted logistic analysis results point to an interplay between residential status and Medicaid coverage with regard to formal home-care use. In comparison with metropolitan residents covered by Medicaid, the adjusted relative risk of any formal home-care use is significantly higher for Medicaid enrollees residing in nonmetropolitan counties having no town of 10,000 people. Use of Medicare home health care is significantly greater for residents of the most rural counties, irrespective of their Medicaid coverage, as well as Medicaid-covered residents of nonmetropolitan counties having a town of at least 10,000 people. IMPLICATIONS: In nonmetropolitan areas, Medicaid may be an important mechanism for linking older individuals with formal home care, especially Medicare home health care, and with the services that generate formal home care. Formal home care, including Medicare home health care, may substitute for less available forms of care in the most rural of nonmetropolitan areas. Therefore, policies that limit access to formal home care could lead to increased service-related vulnerabilities among older rural residents.

Access to bereavement services in hospice.

Hospice bereavement services, though often overlooked in hospice research, are an important area of study due not only to the potential value of bereavement support but also the emphasis placed on such services by the Centers for Medicare and Medicaid Services. Moreover, access to these services is seldom understood or researched. Therefore, using the patient public use file of the 2007 National Home and Hospice Care Survey, we explored the relationships between patient, informal caregiver, and agency characteristics as well as discharges from hospice to gain perspective into bereavement service access to informal caregivers. Findings suggested that death at discharge from hospice may be an important moderator variable between access to hospice bereavement support and many other factors. However, even under controls for death at discharge, two agency characteristics remain significantly associated with access. Bereavement access tends to be more likely in agencies that provide only hospice care as opposed to other services, and in micropolitan agencies. Furthermore, death at discharge is less likely among African Americans, suggesting the value of enhanced culturally-appropriate and more targeted hospice care and hospice bereavement support for this population. Future research should explore the strategies used to effectively deliver bereavement services and how these strategies may benefit from targeted and culturally sensitive approaches.

Organizational factors associated with the use of telehospice.

We investigated organizational factors associated with the use of telehospice (defined as the use of video technology by hospices). The investigation was based on the 2007 National Home and Hospice Care Survey. There were 695 hospice agencies, of which 6% used telehospice. Logistic regression was used to examine the relation between use of hospice and a number of organizational factors. The dependent variable was the use/non-use of video technology in patient monitoring or consultations with professionals. Most of the variables that were significantly associated with the use of telehospice were related to characteristics of the agency director. If the director had at least a Masters degree or had a longer tenure as director of the agency, there was a higher likelihood that the agency used telehospice. If the director was a nurse, the likelihood that telehospice was used was considerably lower. Organizations with inter-agency contracts were less likely to use telehospice. Providing financial, training and organizational support to agencies that recognize the potential benefits of telehospice would probably assist in its future introduction.

Choice of personal assistance services providers by medicare beneficiaries using a consumer-directed benefit: rural-urban differences.

PURPOSE: To examine the impact of an experimental consumer-choice voucher benefit on the selection of independent and agency personal assistance services (PAS) providers among rural and urban Medicare beneficiaries with disabilities. METHODS: The Medicare Primary and Consumer-Directed Care Demonstration enrolled 1,605 Medicare beneficiaries in 19 counties in New York State, West Virginia, and Ohio. A total of 839 participants were randomly assigned to receive a voucher benefit (up to $250 per month with a 20% copayment) that could be used toward PAS provided by either independent or agency workers. A bivariate probit model was used to estimate the probabilities of choosing either type of PAS provider while controlling for potential confounders. FINDINGS: The voucher was associated with a 32.4% (P < .01) increase in the probability of choosing agency providers and a 12.5% (P= .03) increase in the likelihood of choosing independent workers. When the analysis was stratified by rural/urban status, rural voucher recipients had 36.8% higher probability of using independent workers compared to rural controls. Urban voucher recipients had 37.1% higher probability of using agency providers compared to urban controls. CONCLUSIONS: This study provided evidence that rural and urban Medicare beneficiaries with disabilities may have very different responses to a consumer-choice PAS voucher program. Offering a consumer-choice voucher option to rural populations holds the potential to significantly improve their access to PAS.

Formal home care utilization patterns by rural-urban community residence.

BACKGROUND: We examined formal home care utilization among civilian adults across metro and nonmetro residential categories before and after adjustment for predisposing, enabling, and need variables. METHODS: Two years of the Medical Expenditure Panel Survey (MEPS) were combined to produce a nationally representative sample of adults who resided in the community for a calendar year. We established 6 rural-urban categories based upon Urban Influence Codes and examined 2 dependent variables: (a) likelihood of using any formal home care and (b) number of provider days received by users. The Area Resource File provided county-level information. Logistic and negative binomial regression analyses were employed, with adjustments for the MEPS complex sampling design and the combined years. RESULTS: Under controls for predisposing, enabling, and need variables, differences in likelihood of any formal home care use disappear, but differences in number of provider days received by users emerged, with fewer provider days in remote areas than in metro and several other nonmetro types. CONCLUSIONS: It is important to fully account for predisposing, enabling, and need factors when assessing rural and urban home care utilization patterns. The limited provider days in remote counties under controls suggest a possible access problem for adults in these areas.

Urban-rural differences in the effect of a Medicare health promotion and disease self-management program on physical function and health care expenditures.

PURPOSE: To evaluate the impact of a multicomponent health promotion and disease self-management intervention on physical function and health care expenditures among Medicare beneficiaries. To determine if these outcomes vary by urban or rural residence. DESIGN AND METHODS: We analyzed data from a 22-month randomized controlled trial of a health promotion/disease self-management program that included 766 elderly Medicare beneficiaries from western New York, West Virginia, and Ohio. Physical function was measured by changes in self-reported dependencies in activities of daily living over the study period. Total health care expenditures were measured by aggregating expenditures from major sources (acute, postacute, and long-term care). We used ordinary least squares models to examine the effects of the intervention on both physical function and cost outcomes during the 22-month period. RESULTS: The results indicated that the intervention reduced physical functional decline by 54% (p = .03) in the study sample. Stratified analyses showed that the intervention effect was much stronger in the rural sample. Mean total health care expenditures were 11% ($3,100, p = .30) lower in the intervention group. The effects of the intervention on average health care expenditures were similar among urban and rural participants. IMPLICATIONS: The intervention offered a promising strategy for reducing decline in physical function and potentially lowering total health care expenditures for high-risk Medicare beneficiaries, especially for those in rural areas. Future studies need to investigate whether the findings can be replicated in other types of rural areas through a refined intervention and better targeting of the study population.