Rural Home-Based Care Remains Both Necessary and Extraordinarily Challenging

Aging in place is difficult for many Americans, but it’s even more difficult for those living in rural areas. Things are additionally hard on in-home care providers in such parts of the country.

To ensure access to home health services, the Medicare program has historically provided a rural add-on payment to agencies, giving them slightly more resources to deliver care and compensate staff.

But that add-on payment is being phased out, jeopardizing patient access and exacerbating operational difficulty for providers.

It’s not just a home health issue, either. Aging in place is frequently out of reach for rural Americans because of other factors, such as the physical structure of their homes and complications with transportation.

Home health care in rural America

As more and more seniors wish to age at home, home-based care providers are grappling with how to satisfy their wishes.

Ken Albert, president and CEO of the Maine-based Androscoggin Home Healthcare + Hospice, said it’s an evolving challenge, with serious consequences if solutions aren’t found.

“People do not want to leave their homes. They want to be cared for in the comfort of their home,” Albert told Home Health Care News. “And so, they will go unattended, absent those providers who are willing to serve rural America. These individuals will go without service and their medical conditions will go untreated for longer periods of time.”

One of the biggest challenges for both providers and patients is cost. Rural home-based care means more driving for caregivers, something Albert calls “windshield time.” That time adds up quickly.

“When I have to put a nurse or a therapist in a car to drive an hour to see a patient, my costs go up exponentially,” he said. “The productivity of that individual clinician goes down. Then on the palliative medicine side, when you’re sending a physician or a nurse practitioner, the cost of the person behind the windshield is even higher.”

Despite the financial complications, providing home-based care to these areas provides tremendous value – not only to these smaller communities – but to the overall health care network.

“We’re helping that patient navigate advancing illness, keeping them out of the hospitals, keeping them out of the emergency departments,” Albert said. “And that is adding value to the health care network and to Medicaid and Medicare.”

However, that value is not recognized through any reimbursement mechanism, short of Part B Medicare. With the rural add-on payment to agencies being phased out, that adds another hurdle to jump over for agencies.

The future of rural add-on payments

Over the past several years, home health providers operating in rural areas have received on-and-off payment bumps to help them overcome the inherent obstacles of operating in remote and sparsely populated areas.

While relatively small, those payment bumps – officially known as rural add-on payments – have played an important, cost-effective role in allowing America’s non-city-dwelling seniors age in place, experts say.

However, the bulk of rural providers have lost or are losing these payments.

Unless Congress decides to bring these payments back, home health providers will have to find an alternative solution, National Association for Home Care & Hospice (NAHC) President William A. Dombi told HHCN.

“The challenge has been that the data demonstrates that not all agencies serving rural patients would really need the add-on,” Dombi said. “Some agencies have higher margins than non-rural agencies. We think that the rural add-on is still needed, but not by everybody. The difficulty is determining who should get it and who should not.”

So far, NAHC hasn’t been able to come up with a solution.

Albert believes one way to help assist agencies in rural areas is to change the wage index formula.

“In rural America, there’s this assumption that workforce wages are lower,” Albert said. “In addition to the whole increased cost of providing care in rural areas, our reimbursement is lower because our wage indices are lower.”

Because of that, Albert and Androscoggin have one the lowest wage indices in New England. He regularly has to compete with the Boston market, which is often not feasible for the company.

“I think the wage index formula was effective once upon a time,” Albert said. “But given the workforce shortages we have in America, given the wage inflation and given the transient nature of our workforce, the federal government really needs to take a look at the whole wage index formula and how it applies not only in rural areas, but across the whole reimbursement structure.”

A focus on home modification

When considering the difficulties of aging in place in a rural setting, the quality of the home and environment takes priority over nearly every other factor.

That’s why companies like TruBlue Total House Care have focused on helping seniors by making the home a safer and more accessible place to live.

“We pick up where the home care agency stops,” Sean Fitzgerald, president of TruBlue, told HHCN. “They take care of the individual and light housekeeping and things like that, but caregivers aren’t going to change light bulbs in the ceiling, change batteries in a smoke detector, move furniture or anything like that. That’s where we come in.”

The Cincinnati, Ohio-based TruBlue is a senior-focused home repair company that operates under a franchising business model. TruBlue specializes in house care, home maintenance and safety modifications.

Fitzgerald said TruBlue likes to say it is “the missing puzzle to aging in place.” In rural areas, that puzzle piece is even more crucial.

Transportation is the No. 1 factor in Fitzgerald’s mind when it comes to challenges facing rural Americans and their health care. Even though proper home-based care should lessen the need for transportation, he believes organizations like TruBlue can help fill another big gap in service.

“In rural markets, you tend to have [fewer] senior communities where there’s an HOA that takes care of the lawn and those sorts of things,” he said. “That’s where a program like TruBlue comes in. You’re going to need more programs like TruBlue that can actually help with the routine maintenance of the property and the home itself.”

Roughly 77% of people 50 and older would like to stay in their current home as long as possible. Despite this, less than 1% of U.S. homes have particular features needed to support aging in the home, according to AARP.

The problem of homes not being set up for aging in place is often underscored when falls occur. It’s estimated that falls cost over $50 billion a year in medical expenses, and individuals over 65 have a 10% annual probability of suffering a serious fall costing an average of $11,500 in related expenses.

“If they try to do these things themselves, they put themselves in situations where they could fall,” Fitzgerald said.

When considering solutions to the complicated rural home-based care issue, Fitzgerald believes collaboration between agencies and specialized companies is where a true difference can be made.

“Aging in place is like a stool,” he said. “One leg is going to be the environment, one leg is going to be medical — where the home care agencies come in — and the other piece of it is going to be the monitoring security side of things. Having agencies partner with companies with these core competencies and aligning with them will help solve these challenges.”

Gas prices, the implementation of telehealth and access to broadband are three of the biggest issues facing rural home-based care, Dombi said.

“Rural health care continues to be one of those difficult nuts to crack in all spheres of health care,” Dombi said. “Not just home health care. That’s [still] where we’re at with it at this point in time.”