Rural-Urban Disparities in Access to Home- and Community-Based Services and Supports: Stakeholder Perspectives From 14 States

Abstract

Objectives: Trends over time in the United States show success in rebalancing long-term services and supports (LTSS) towards increased home and community-based services (HCBS) relative to institutionalized care. However, the diffusion and utilization of HCBS may be inequitable across rural and urban residents. We sought to identify potential disparities in rural HCBS access and utilization, and to elucidate factors associated with these disparities. Design:We used qualitative interviews with key informants to explore and identify potential disparities and their associated supply-side factors. Setting and participants:We interviewed three groups of healthcare stakeholders (Medicaid administrators, service agency managers and staff, and patient advocates) from 14 states (n = 40).Measures: Interviews were conducted using a semi-structured interview guide, and data were thematically coded using a standardized codebook.Results: Stakeholders identified supply-side factors inhibiting rural HCBS access, including limited availability of LTSS providers, inadequate transportation services, telecommunications barriers, threats to business viability, and challenges to caregiving workforce recruitment and retention. Stakeholders perceived that rural persons have a greater reliance on informal caregiving supports, either as a cultural preference or as compensation for the dearth of HCBS.

At-a-glance - Living arrangements and health status of seniors in the 2018 Canadian Community Health Survey

“…11 Seniors with low income 17,18 or low education 16 have been reported in other studies to be more likely to live alone, which may be a consequence of their inability to afford the high cost of assisted living facilities. 19 Moreover, seniors living in urban areas were more likely to live alone, which may be due to the disparity in supports and services available to seniors in rural areas 20 ; in fact, the most-used services for seniors are senior centres, homemaker services and transportation services, 21 all of which are more likely to be available in urban areas.…”

Research Recommendations to Address Dementia Workforce Development Needs

“…Disparities continue in accessing home-based-care-and-services in urban versus rural communities. Infrastructure needs to be addressed in order to develop an adequate caregiver workforce in rural areas [8].…”

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“…Availability, awareness, and affordability are persistent barriers to receiving HCBS, which contribute to subsequent adverse health experience (Li, 2006; Siconolfi et al, 2019). In addition, there are persistent systemic barriers that inhibit access to services in rural areas, including limited providers, inadequate transportation services, and workforce recruitment and retention challenges (Siconolfi et al, 2019). A shortage of geographically proximate care options contributes to low (Jonk et al, 2015; VanderWielen, et al, 2015) or more costly service use.…”