Despite the efforts of state and federal policymakers trying to encourage the use of home- and community-based services (HCBS) over the past several decades, patients in rural areas still face more challenges gaining access to those kinds of supports compared to their urban counterparts.

That’s according to a new study published this month in the Journal of Post-Acute and Long-Term Care and Medicine.

Overall, the study suggests home- and community-based care is potentially cost-saving for state Medicaid agencies, but that there are a number of barriers that prevent rural patients from benefitting from these services.

“Though this is just one study, it points to the need for system-level efforts to reduce rural HCBS disparities,” Daniel Siconolfi, lead author and associate behavioral scientist at Rand Corporation, told Home Health Care News. “The factors we identified have implications across the HCBS care continuum, ranging from general awareness of the availability of waivers and services, through the continuity of care for persons who have already initiated services.”

Santa Monica, California-based Rand Corporation is a public policy research organization.

As part of the study, Rand Corporation researchers conducted interviews with 40 participants, including Medicaid administrators, service agency staff and patient advocates from 14 states, specifically asking about the implementation of the Balancing Incentive Program and its impact on home- and community-based services access.

The interviews also focused on perceptions of home health care services and long-term supports and services in their states more broadly.

Participants interviewed for the study highlighted a number of factors that contribute to the HCBS and home health care access disparities in rural areas. Those factors included caregiving workforce retention, limited access to the internet and limited availability of long-term supports and services providers, as well as limited cell and landline connectivity.

Poor business viability and a lack of transportation options were also cited as factors.

“The role of transportation challenges is particularly notable because of its indirect effects,” Siconolfi said. “Directly, it means that beneficiaries may not be able to access the resources and services that would allow them to stay in community settings. Indirectly, it also decreases the visibility of patients and their care needs, which can contribute to a perceived lack of demand.”

To help solve for transportation challenges, several home care providers have launched partnerships with ride-hailing giants Lyft and Uber. One of the first was 24 Hour Home Care, which now provides roughly 2,000 rides per month through its RideWith24 transportation program.

Additionally, advances such as telehealth might seem promising, but stakeholders reported in the study that internet access and technology literacy is still limited among rural populations.

“And telehealth addresses only one aspect of this spatial isolation, the need for medical care and advice,” Siconolfi said. “It may not address the other important aspects of community living, such as social participation.”

Instead of turning to professional home care and home health providers, patients in rural areas frequently rely on informal caregiving, meaning care provided by their families and neighbors, due to cultural preferences, according to the study.

Researchers suggest that the keys to addressing these challenges are comprehensive policy approaches with the collaboration of Medicaid administrators, service agency staff and patient advocates.

“Rural populations tend to be older, so these gaps are critical to address,” Siconolfi said. “There is work to be done to link the actual experiences of providers and patients in rural areas with that of administrators, who are responsible for ensuring adequate coverage across geographic areas.”

“Rebalancing initiatives are critical to help consumers access care in the settings they desire,” he added. “However, rebalancing may have unintended consequences in rural environments if these initiatives end up directly or indirectly limiting access to institutional settings as a safety net.”

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