Quality of home healthcare differs in rural vs. urban settings

Rural home healthcare agencies perform better on process measures, urban agencies on outcome measures

The quality of home healthcare varies by location, with rural home healthcare agencies initiating care more quickly while urban agencies excel in preventing hospitalizations, according to a new study by researchers at NYU Rory Meyers College of Nursing. The findings are published in the Journal of Rural Health.

Home healthcare—in which healthcare providers, primarily nurses, visit patients’ homes to deliver care—is one of the fastest growing healthcare sectors in the United States. In 2018, more than 5 million Medicare beneficiaries received home healthcare; 9 percent of patients lived in rural areas.

As the use of home healthcare increases across the country, researchers are working to better understand how quality varies and whether there are disparities in care based on location. To understand differences between quality in urban and rural home healthcare, the researchers analyzed national data on home health quality performance measures from the Centers for Medicare and Medicaid Services over five years (2014 to 2018). Their data included 7,908 home health agencies, of which nearly 20 percent (1,537) were in rural areas. Quality performance measures included timely initiation of care (a measure of care process), and hospitalization and emergency department visits (two measures of care outcomes).

The researchers measured numerous differences between urban and rural agencies, both at individual time points and over time, with rural agencies performing better on the care process measure and urban agencies performing better on the outcome measures. Rural agencies consistently initiated care in a timely fashion, meaning that they quickly started home care upon a doctor’s orders or within two days of hospital discharge or referral to home care.  

“Providing early, intensive visits to patients during a home health episode has been shown to be effective in reducing hospitalization and improving functional status, so timely initiation of care is a critical component of quality home care for patients,” said Chenjuan Ma, PhD, MSN, an assistant professor at NYU Meyers and the study’s lead author. “Strong relationships between rural home health agencies and local hospitals, as evidenced in previous research, may be facilitating the timely initiation of home healthcare to rural patients.”

In contrast, urban agencies consistently performed better on preventing hospitalization and emergency room visits during home care over time—although, notably, emergency department visits increased over the five years studied for both urban and rural home health agencies. These gaps between rural and urban agencies were steady over time except the gap in hospitalization, which narrowed slightly over time.  

“Our study highlights the persistence of disparities in quality of home healthcare. Limited improvements have been made in the quality of home healthcare over time, and the gaps in quality of care did not significantly shrink between rural and urban agencies,” added Ma.

The researchers stress the importance of reducing rural-urban disparities by taking into account the unique geographic, staffing, and health challenges facing agencies. For instance, in addition to staffing and resource challenges, providers from rural home health agencies often spend a significant amount of time traveling to and from patient homes, which could result in less efficient care delivery and could ultimately influence outcomes. In addition, reports on rural and urban recipients of home healthcare suggest that rural patients are in poorer overall health status than their urban counterparts.

Additional study authors include Andrea Devoti of the National Association for Home Care & Hospice and Melissa O’Connor of the Villanova University M. Louise Fitzpatrick College of Nursing.