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Rural LTC in the US: policies to “re-balance” without the balance

2012 Conference Presentation

Policy United States

6 September 2012

Rural LTC in the US: policies to “re-balance” without the balance

Mary L. Fennell, Brown University, United States
Denise A. Tyler, Brown University, United States
Zhanlian Feng, Brown University, United States


Objective: Local long term care (LTC) market structures throughout the US are undergoing profound transformation. Federal policies to “re-balance” funding away from nursing homes (NHs) and toward support of home and communitybased (HCBS) options (including home health agencies, adult day care (ADC), chore service organizations, and assisted living facilities (ALF)) have encouraged national trends of NH closure and the proliferation of HCBS. These changes are unfolding without a clear understanding of what LTC services are available at the local level as NHs have closed. The purpose of this study was twofold: (1) to describe the current distributions of HCBS, focusing on ALFs and ADCs (i.e. community-based rather than home-based providers), at the level of local community markets where NHs have closed; and (2) to examine differences between urban and rural area’s HCBS access, using local market characteristics and state policy differences as regressors in a multinomial logistic model.

Data & Methods: Through internet searches and telephone calls to state agencies, we collected data on all ALFs and ADCs licensed or certified in the 48 contiguous states. We used the addresses gathered to geo-code these facilities, which were merged with data developed during a previous study of NH closures. We then used ArcGIS to define a 5- mile radius around all NHs that closed between the years 2006 and 2010. Our goal was to identify two types of local markets where NHs closed: local markets where there are ALFs and ADCs, and those where there are not such facilities. We then compared these local market areas in terms of local population characteristics (% below poverty, % minority, rural location, year of NH closure, etc), based on census and NH administrative data for the zip code in which the closed NH was located. We also examined state-level differences in Medicaid spending for HCBS from 2000-2008.

Results: We identified and geo-coded 11,277 ALFs and 4556 ADCs. A total of 714 NHs closed from 2006 to 2010; 57% of these were independent (not part of another facility) and 65% were located in urban areas. Of the 714 local LTC markets with NH closures, 27% did not have ALFs and 60% did not have ADCs. The association between urban/rural location and availability of ALFs or ADCs is strong: 84% of rural radii have no ADCs, and 58% have no ALFs; proportions of urban areas without these facilities were 46% and 11%, respectively. Multinominal logistic regression results will also be presented.

Policy Implications: Both ADCs and ALFs are primarily an urban phenomenon: very few are available in rural communities that have lost NHs. Because of these locational differences, the availability of HCBS alternatives is less strongly related to either the per cent minority or the per cent in poverty. Although 35% of NH closures occurred in rural areas, availability of HCBS does not appear to compensate. Clearly, federal policy favoring HCBS is outpacing availability of these services, especially in rural areas of the US.