Rural-Urban Comparisons of Age and Health at the Time of Nursing Home Admission

This study re-examines the contention that rural elders admitted to nursing homes are younger and healthier than their counterparts who enter urban facilities. The analysis uses interview data gathered in both urban and rural nursing homes. Residents were interviewed at or near the time of admission regarding their health and circumstances immediately prior to entering the nursing home. The findings indicate few and modest differences between urban and rural residents. In those instances where differences are observed, there is ambiguity--some measures indicate lower health status in the case of rural residents, while others suggest that urban residents are more likely to report health impairments. The divergence of these findings from earlier research may be due to differences in the study populations, measurement differences, or, more likely, that policies and processes have changed over time.     

Urban/Rural Differences in Decision Making and the Use of Advance Directives Among Nursing Home Residents at Admission

CONTEXT: Advance directives promote patient autonomy and encourage greater awareness of final care options while reducing physician and family uncertainty regarding patient preferences. PURPOSE: To investigate differences in decision making authority and the use of advance directives among nursing home residents admitted from urban and rural areas. METHODS: A total of 551,208 admission assessments in the Minimum Data Set were analyzed for all residents admitted to a nursing facility in 2001. Using the Rural Urban Commuting Areas (RUCA) methodology and ZIP code of primary residence before admission, these residents were classified into 4 urban/rural areas. FINDINGS: Residents from rural areas were significantly more likely to have executed a durable power of attorney for health care or for financial decisions than residents admitted from the other areas, with the largest differences observed between residents admitted from urban and rural areas. Almost 6 residents in 10 from urban areas had no advance directives in place at admission compared with only 4 residents in 10 admitted from rural areas. CONCLUSIONS: Health providers and social workers in both rural and urban areas should advise patients about the value of advance directives.     

Rural-Urban Comparisons of Nursing Home Residents With Multiple Sclerosis

CONTEXT: Multiple sclerosis (MS) is the most common neurologic disease that disables younger adults, affecting as many as 350,000 Americans. PURPOSE: The objectives of this study are to develop profiles of nursing home residents with MS from rural areas and compare them to residents with MS who lived in urban areas, suburban areas, and large towns. METHODS: We analyzed all admission assessments for residents with MS (13,357 assessments) in the Minimum Data Set between June 23, 1998, and December 31, 2000, that also had the resident's ZIP code of primary residence before admission. FINDINGS: Urban and rural comparisons of residents with MS demonstrate a range of significant demographic differences. Significantly greater proportions of MS residents from rural areas exhibited a sense of initiative or involvement in activities of the nursing facility compared with residents with MS from urban and suburban areas. The differences in the utilization of physical and occupational therapies were striking, with MS residents from rural areas averaging significantly fewer minutes of these therapies. We also found that MS residents from rural areas averaged fewer minutes of psychological therapy in the nursing facility and also were less likely to have seen a licensed mental health specialist than MS residents from urban areas. CONCLUSIONS: Nursing home residents with MS from rural areas receive fewer therapies and less mental health care than residents with MS from other areas.     

Variations in Nursing Home Discharge Rates for Urban and Rural Nursing Facility Residents With Hip Fracture

CONTEXT: The more limited availability and use of community-based long-term care services in rural areas may be a factor in higher rates of nursing home use among rural residents. PURPOSE: This study examined differences in the rates of nursing home discharge for older adults receiving posthospital care in a nursing facility. METHODS: The study sample was comprised of a cohort of rural and urban residents newly admitted to nursing home care in Maine following surgery for hip fracture. FINDINGS: The results indicated that rural residents who were hospitalized for hip fracture and subsequently admitted to a nursing facility for rehabilitation were significantly less likely than urban residents to be discharged within the first 30 days of their admission. Rural residents who stayed in the nursing facility beyond 30 days were also less likely to be discharged in the first 6 months. These geographic differences were not explained by service use and resident characteristics such as age, health, or functional status. CONCLUSIONS: The finding of lower discharge rates among rural nursing facility residents appears to be consistent with previous studies demonstrating higher rates of nursing home use among rural residents. There continues to be a need for a better understanding of the role that service supply and accessibility and other factors play in the patterns and outcomes of rural long-term care.     

Diagnosed Mental and Physical Health Conditions in the united States Nursing Home Population: Differences Between Urban and Rural Facilities

CONTEXT: There has been limited examination of the differences in health characteristics of the rural long-term care population. Recognizing these differences will allow policymakers to improve access to long-term care services in rural communities. PURPOSE: To determine whether differences in likelihood of diagnosis exist between urban and rural nursing home residents for 8 common medical conditions: 4 mental health conditions (depression, anxiety, Alzheimer's, and non-Alzheimer's dementia) and 4 physical health conditions (cancer, emphysema/chronic obstructive pulmonary disease, heart disease, and stroke/transient ischemic attack). METHODS: We used multivariate logistic regression to examine data derived from the 1996 Nursing Home Component of the Medical Expenditure Panel Survey, a multistage stratified probability sample of 815 nursing homes and 5899 residents, representing 3.1 million individuals in the United States who spent 1 or more nights in nursing homes during 1996. FINDINGS: Residents in rural homes were less likely to be diagnosed with depression compared to those in homes in large metropolitan areas, and residents in homes in small metropolitan areas were less likely to have cancer than those in large metropolitan areas. Diagnostic status between urban and rural residents was comparable for the other 6 conditions. CONCLUSIONS: Further research is necessary to determine whether and why depression is inadequately diagnosed in rural nursing homes and to ascertain which types of cancer are responsible for the observed differential. Such research is particularly important for elderly nursing home residents who are more likely to suffer from chronic conditions that require significant medical supervision.     

Racial/Ethnic Disparities in Nursing Home End-of-Life Care: A Systematic Review

ObjectiveHealth disparities are pervasive in nursing homes (NHs), but disparities in NH end-of-life (EOL) care (ie, hospital transfers, place of death, hospice use, palliative care, advance care planning) have not been comprehensively synthesized. We aim to identify differences in NH EOL care for racial/ethnic minority residents.DesignA systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and registered in PROSPERO (CRD42020181792).Setting and ParticipantsOlder NH residents who were terminally ill or approaching the EOL, including racial/ethnic minority NH residents.MethodsThree electronic databases were searched from 2010 to May 2020. Quality was assessed using the Newcastle-Ottawa Scale.ResultsEighteen articles were included, most (n = 16) were good quality and most (n = 15) used data through 2010. Studies varied in definitions and grouping of racial/ethnic minority residents. Four outcomes were identified: advance care planning (n = 10), hospice (n = 8), EOL hospitalizations (n = 6), and pain management (n = 1). Differences in EOL care were most apparent among NHs with higher proportions of Black residents. Racial/ethnic minority residents were less likely to complete advance directives. Although hospice use was mixed, Black residents were consistently less likely to use hospice before death. Hispanic and Black residents were more likely to experience an EOL hospitalization compared with non-Hispanic White residents. Racial/ethnic minority residents experienced worse pain and symptom management at the EOL; however, no articles studied specifics of palliative care (eg, spiritual care).Conclusions and ImplicationsThis review identified NH health disparities in advance care planning, EOL hospitalizations, and pain management for racial/ethnic minority residents. Research is needed that uses recent data, reflective of current NH demographic trends. To help reduce EOL disparities, language services and cultural competency training for staff should be available in NHs with higher proportions of racial/ethnic minorities.     

Understanding the Landscape: Promoting Health for Rural Individuals After Tertiary Level Cardiac Revascularization

Purpose: The purpose of this pilot study was to describe the needs and experiences of rural individuals commuting to an urban center for percutaneous coronary intervention (PCI). Methods: Data were analyzed from a “Patient Adherence and Satisfaction Survey” conducted by telephone as part of a quality improvement focus, and supplemented with in‐depth semi‐structured interviews with rural patients following PCI. Findings: Both urban and rural patients after PCI experienced few complications, had made some attempts to reduce tobacco usage, and were highly satisfied with explanations of their treatment and their overall treatment experience. Patients in rural settings were more likely to experience chest pain at least rarely following their surgery than people in urban settings (P < .05). Data on participation in cardiac rehabilitation (CR) showed no significant differences between urban and rural dwellers. Four themes emerged from the interviews: standards of care during treatment; transportation; local resources and community support; and lifestyle changes. Although patients were highly satisfied with standards of care during acute treatment, there were unmet needs in relation to transportation and lifestyle changes. Conclusion: Transitions between rural communities and urban centers and rural adaptations of secondary prevention programs require more attention in health service delivery. Further research is required to better understand potential variations in chest pain patterns between urban and rural residents.     

Functional Disability at Nursing Home Admission: A Comparison of Urban and Rural Admission Cohorts

This study's objective was to examine the relationships between rural residence and availability of nursing home and home health care to functional disability at the time of nursing home admission. Secondary data were obtained from the Minimum Data Set (MDS) 2.0 for Nebraska for 3,443 rural and 1,296 urban older people admitted to nursing facilities. Data from the MDS were merged with county-level data on home health agencies and nursing homes in Nebraska. The relationship of rurality of nursing home residents' prior residence and availability of nursing home and home health care to functional status at admission, controlling for demographic and health characteristics of older people, was estimated using multiple linear regression with robust variance estimates. After taking account of demographic and health status characteristics, rural residence and availability of home health and nursing home care had nonsignificant effects on functional status at admission. The findings indicate that functional disability at admission is associated with specific diseases and medical conditions, cognitive status, gender, living arrangements and marital arrangements. Rural older people are not at higher risk of admission at lower levels of functional disability compared to their urban counterparts.     

Socio-spatial patterns of home care use in Ontario, Canada: A case study

Home care is the fastest growing segment of Canada's health care system. Since the mid-1990s, the management and delivery of home care has changed dramatically in the province of Ontario. The objective of this paper is to examine the socio-spatial characteristics of home care use (both formal and informal) in Ontario among residents aged 20 and over. Data are drawn from two cycles of the Canadian Community Health Survey (CCHS Cycle 3.1 2005 and Cycle 4.1 2007) and are analyzed at a number of geographical scales and across the urban to rural continuum. The study found that rural residents were more likely than their urban counterparts to receive government-funded home care, particularly nursing care services. However, rural residents were less likely to receive nursing care that was self-financed through for-profit agencies and were more reliant on informal care provided by a family member. The study also revealed that women and seniors were far more dependent on services that they paid for as compared to informal services. People with lower incomes and poorer health status, as well as rural residents, were also more likely to use informal services. The paper postulates that the introduction of managed competition in Ontario's home care sector may be effective in more populated parts of the province, including large cities, but at the same time may have left a void in access to for-profit formal services in rural and remote regions.     

Rural/Urban Differences in Barriers to and Burden of Care for Children With Special Health Care Needs

PURPOSE: To examine the barriers and difficulties experienced by rural families of children with special health care needs (CSHCN) in caring for their children. METHODS: The National Survey of Children with Special Health Care Needs was used to examine rural-urban differences in types of providers used, reasons CSHCN had unmet health care needs, insurance and financial difficulties encountered, and the family burden of providing the child's medical care. We present both unadjusted and adjusted results to allow consideration of the causes of rural-urban differences. FINDINGS: Rural CSHCN are less likely to be seen by a pediatrician than urban children. They are more likely to have unmet health care needs due to transportation difficulties or because care was not available in the area; there were minimal other differences in barriers to care. Families of rural CSHCN are more likely to report financial difficulties associated with their children's medical needs and more likely to provide care at home for their children. CONCLUSIONS: Examining results from both unadjusted and adjusted odds ratios shows that the burden of care for families of rural CSHCN stems both from socioeconomic differences and health system differences. Policies aimed at achieving equity for rural children will require focusing on both individual factors and the health care infrastructure, including increasing insurance coverage to lessen financial difficulties and addressing the availability of providers in rural areas.     

Analyses of nursing home residents with diabetes at admission

OBJECTIVE: The objective of this study was to profile nursing home residents with diabetes at admission to the nursing facility. METHODS: We used all admission assessments in the Minimum Data Set recorded throughout the United States during 2002 to identify 144,969 residents with diabetes, or 26.4% of all admissions. RESULTS: Only approximately one fourth of residents with diabetes were projected to have stays in the facility of 90 days or less when admitted. Heart and circulatory comorbidities were common among residents with diabetes at admission, as was depression. More than half of residents with diabetes were in pain at admission. A majority of residents with diabetes were either totally dependent or required extensive assistance in the self-performance of many activities of daily living and more than one third were at least moderately impaired in cognitive performance. CONCLUSIONS: Residents with diabetes could be one of the most "heavy care" groups in nursing facilities, as demonstrated by their levels of functional disability and prevalence of serious comorbid conditions. The care provided to residents with diabetes should address depression, pain, and low rates of advance care planning.     

Rurality and nursing home quality: results from a national sample of nursing home admissions

OBJECTIVES: We examined differences in quality of care among nursing homes in locales of varying degrees of rurality. METHODS: We classified locales into 4 classes according to rurality. We analyzed a 10% sample of nursing home admissions in the United States in 2000 (n=198613) to estimate survival models for 9 quality indicators. RESULTS: For postacute admissions, we observed significant differences in rates of decline for residents in facilities in large towns compared with urban areas, but differences in quality were both negative and positive. Among admissions for long-term or chronic care, rates of decline in 2 of 9 quality areas were lower for residents in isolated areas. CONCLUSIONS: We observed significant differences in a number of quality indicators among different classes of nursing home locations, but differences varied dramatically according to type of admission. These differences did not exhibit the monotonicity that we would have expected had they derived solely from rurality. Also, quality indicators exhibited more similarities than differences across the 4 classes of locales. The results underscore the importance, in some instances, of emphasizing the effects of specific settings rather than some continuum of rurality and of moving beyond the assumption that nursing home residents constitute a homogeneous population.     

Investigating the educational needs of licensed nursing staff and certified nursing assistants in nursing homes regarding end-of-life care

Nursing homes care for people at the end of life (EOL). There is evidence to suggest, however, that nursing staff in these settings is often unprepared to provide a high level of EOL care. This article reports the findings from three preliminary studies that investigated the needs of licensed staff and certified nursing assistants in nursing homes regarding EOL care. The studies involved needs assessment surveys, focus group interviews with staff members, and telephone interviews with nursing home administrators. Data show that the major needs included a lack of knowledge and skills in symptom management; communication difficulties; conflicts with families and physicians; and emotional distress in dealing with time constraints and attachment to residents. Implications for nursing home staff education are described.     

Rural Residence and Poor Birth Outcome in Washington State

It is often assumed that poor birth outcomes are more common among rural women than urban women, but there is little substantive evidence to that effect. While the effectiveness of rural providers and hospitals has been evaluated in previous studies, this study focuses on poor birth outcomes in a population of rural residents, including those who leave rural areas for obstetrical care. Rural and urban differences in rates of inadequate prenatal care, neonatal death, and low birth weight were examined in the general population and in subpopulations stratified by risk and race using data from five years (1984-88) of birth and infant death certificates from Washington state. Also examined were care and outcome differences between rural women delivering in rural hospitals and those delivering in urban facilities. Bivariate analyses were confirmed with logistic regression. Results indicate that rural residents in the general population and in various subpopulations had similar or lower rates of poor outcome than did urban residents but experienced higher rates of inadequate prenatal care than did urban residents. Rural residents delivering in urban hospitals had higher rates of poor outcomes than those delivering in rural hospitals. We conclude that rural residence is not associated with greater risk of poor birth outcome. White and nonwhite differences appear to exceed any rural and urban resident differences in rates of poor birth outcome.     

Discharge planning in nursing homes.

OBJECTIVE. The purpose of this study is to identify nursing home residents who vary in their discharge planning needs. DATA SOURCES AND STUDY SETTING. Administrative records from a database maintained by the National Health Corporation were the primary data source. The 3,883 persons studied were admitted in 1982 to one of 48 nursing homes located in Tennessee, other southern states, and Missouri. STUDY DESIGN. Residents were followed until discharge or for one year, whichever occurred first. A multinomial logistic regression model was used to identify the characteristics at the time of admission of persons likely to go home and the characteristics of those who may be able to be discharged to other residential care facilities. DATA EXTRACTION METHODS. A data tape with resident information was supplied by the National Health Corporation, which also provided data on the 48 nursing homes. Market data were obtained from the Area Resource File. PRINCIPAL FINDINGS. Health status measures are important predictors of discharge status. Financial status (i.e., primary payer) also had a large effect on discharge status; a measure of potential informal care in the community did not. CONCLUSIONS. It is possible to identify at admission nursing home residents likely to have very different discharge planning needs. Nursing home staff can use the results to focus their discharge planning efforts. Regulators can use them to assess how well nursing homes are meeting the discharge planning needs of their residents.     

Access to and Use of Eye Care Services in Rural Arkansas

Context: Rural residents are more likely to be uninsured and have low income.
Purpose: To determine if rural residents in Arkansas have decreased access to eye care services and use them less frequently than urban residents.
Methods: Data from the 2006 Visual Impairment and Access to Eye Care Module from the Arkansas Behavioral Risk Factor Surveillance System (BRFSS) were used in the analysis. Adults age 40 years and older were included (n = 4,289). Results were weighted to reflect the age, race, and gender distribution of the population of Arkansas. Multiple logistic regression was used to adjust for demographic differences between rural and urban populations.
Findings: Significantly fewer rural residents (45%) reported having insurance coverage for eye care services compared with residents living in urban areas (55%). Rural residents were less likely (45%) than urban residents (49%) to have had a dilated eye exam within the past year. Among residents aged 40-64, those from rural areas were more likely than their urban counterparts to report cost/lack of insurance as the main reason for not having a recent eye care visit.
Conclusions: In 2006, rates of eye care insurance coverage were significantly lower for rural residents while use of eye care services differed slightly between rural and urban residents. Rural residents in Arkansas age 40-64 would benefit from having increased access to eye care insurance and/or low cost eye care services.     

Rural-Urban Differences in Stigma and the Use of Care for Depressive Disorders

Stigma may be a particularly important barrier to mental health care in rural communities where lack of anonymity increases the probability that someone who seeks care will be labeled "crazy." This study examined rural-urban differences in the stigma associated with depressive symptoms and the stigma associated with seeking treatment for depressive disorders. In addition, the study compared how the stigma associated with seeking treatment predicted use of care in rural and urban residents with a history of depressive symptoms. Two hundred subjects from metropolitan and adjacent non-metropolitan counties rated one of four randomly selected vignettes using 14-point semantic differential scales. The findings indicated that rural residents with a history of depressive symptoms labeled people who sought professional help for the disorder somewhat more negatively than their urban counterparts. Logistic models controlling for sociodemographic characteristics demonstrated that the more negative the labeling, the less likely depressed rural residents were to have sought professional help. Labeling was not associated with use of care among urban people with depressive symptoms. We concluded that prospective studies are warranted to inform the development of interventions to decrease the stigma associated with seeking treatment for depressive disorders in rural communities.     

Urban and Rural Differences in Health Insurance and Access to Care

This study considers differences in access to health care and insurance characteristics between residents of urban and rural areas. Data were collected from a telephone survey of 10,310 randomly selected households in Minnesota. Sub-samples of 400 group-insured, individually insured, intermittently insured, and uninsured people, were asked about access to health care. Those with group or individual insurance were also asked about the costs and characteristics of their insurance policies.
Rural areas had a higher proportion of uninsured and individually insured respondents than urban areas. Among those who purchased insurance through an employer, rural residents had fewer covered benefits than urban residents (5.1 vs 5.7, P < 0.01) and were more likely to have a deductible (80% versus 40%, P < 0.01). In spite of this, rural uninsured residents were more likely to have a regular source of care than urban residents (69% versus 51%, P < 0.01), and were less likely to have delayed care when they thought it was necessary (21% versus 32%, P<0.01). These differences were confirmed by multivariate analysis.
Rural residents with group insurance have higher out-of-pocket costs and fewer benefits. Uninsured rural residents may have better access to health care than their urban counterparts. Attempts to expand access to health care need to consider how the current structure of employment-based insurance creates inequities for individuals in rural areas as well as the burdens this structure may place on rural providers.