Home Health Agencies Face Added Hardships in Rural Markets

For many of its clients, Sangre de Cristo Hospice & Palliative Care provides their only access to home health care services. The company has cemented its position within the industry by engaging underserved rural and frontier communities.

Founded in 1985, nonprofit Sangre de Cristo Hospice & Palliative Care is based in Pueblo, Colorado. The company serves 22,000 square miles of southeastern Colorado with offices in La Junta, Trinidad, Cañon City and Walsenburg.

Originally, Sangre de Cristo Hospice & Palliative Care opened its doors as a hospice provider. The company eventually expanded its coverage area to include advanced-care planning and grief support.


Last year, the company entered the home health arena as well. In some ways, the strategic move runs counter to industry trends, as many post-acute businesses start with home health and then branch off into end-of-life care.

“There are opportunities with some health systems and payers for palliative care under a home health license,” Tarrah Lowry-Schreiner, president and CEO of Sangre de Cristo Hospice & Palliative Care, told Home Health Care News. “While this was the main reason we decided to venture into home health, we also saw a need for services in some of our rural communities.”

Sangre de Cristo Hospice & Palliative Care entered the home health space to fill a void that was created when another local agency shut its doors, leaving the surrounding rural and frontier communities without care.


“If we had not started serving some areas of southern Colorado when another agency stopped services, there would be no home-based care options outside of hospice available to those communities,” Lowry-Schreiner said. “When having to choose between going to a skilled facility for rehab or being able to return to their home in their rural community, most choose their home. We want to make sure home is always a choice for them.”

In general, seniors in rural areas have more barriers to gaining access to home and community-based care, especially in comparison to urban counterparts.

Specifically, caregiving workforce retention, limited access to the internet and limited availability of long-term supports and services providers all play a role in the home health care access disparities in rural areas.

Limited cell and landline connectivity and a lack of transportation options are also factors, according to research from Rand Corporation.

The clinicians at Sangre de Cristo Hospice & Palliative Care know firsthand that providing care for these underserved areas has its own set of unique challenges.

“Finding clinicians in rural areas is tough, and there are other challenges like travel time to and from patients’ homes. Bad weather and dirt roads never are a good combination,” Lowry-Schreiner said. “Clinicians in rural communities have to have excellent assessment skills, reliable transportation and a big trunk.”

Along with logistical challenges, Sangre de Cristo Hospice & Palliative Care often has to navigate clinical ones as well, according to Lowry-Schreiner.

“Many times, the needs of the patient are greater than what our team expected when we got the referral. And extra equipment, medications or services may need to be added for the best patient outcomes,” she said. “Usually, this means another trip out to a home that could be 80 miles from our office.”

Furthermore, Sangre de Cristo Hospice & Palliative Care isn’t immune to recruitment challenges.

It’s not uncommon to have an RN position that has been open for several months in its rural offices, according to Lowry-Schreiner.

“Our organization has a great reputation, which greatly helps us with retention, but it’s hard to fill positions like therapists. And clinical leadership with hospice or home health experience is hard to find,” she said. “Finding leaders or therapists willing to relocate to our rural communities is extremely hard.”

In order to find quality leadership, the company reaches back into the very same community it serves, according to Lowry-Schreiner.

“We grow our own in many cases,” she said. “For example, our administrator in one of our rural offices was raised in the community and came to us as a nurse with just a couple of years of experience. Several years later, she’s a great administrator who truly understands the community she serves.”

Additionally, Sangre de Cristo Hospice & Palliative Care offers its staff benefits that include flexible and part-time schedules.

Looking ahead, the company is making sure it is prepared for the upcoming Patient-Driven Groupings Model (PDGM), which industry experts say will be tough on small and mid-size agencies.

Sangre de Cristo Hospice & Palliative Care will also have to face the phasing out of home health pre-payments, or Requests for Anticipated Payment (RAPs). A reduction of rural add-on payments is also a challenge for all rural providers.

“We’ve had to do a lot of work in the last few months, just to get everybody ready,” Lowry-Schreiner said. “We’ve had to get staff ready and figure out how to do business.”