Bridging The Divide: Addressing The Unique Challenges Of Rural Home Health Care Access

Living in an urban area typically offers greater access to a wider range of home care services than living in a rural area. Urban residents generally have more choices regarding providers and facilities, while those in rural areas face challenges such as longer travel distances, limited provider availability and potential concerns about the quality of care.

Research from the South Carolina Rural Health Research & Policy Center indicates that rural home health patients are more likely to be severely ill or in fragile condition. They also have more risk factors for hospitalization, often need respiratory therapies and may require treatment for surgical wounds.

Delivering person-centered care requires addressing a wide range of needs, from primary and preventive services to the management of chronic conditions, acute episodes of care, and social and behavioral health needs, as noted by the Centers for Medicare & Medicaid Services (CMS). Meeting these comprehensive needs can be especially challenging in rural areas.

“One of CMS’ priorities is to expand access to high-quality, affordable health care and to address the unique challenges faced by rural communities,” a CMS spokesperson told Home Health Care News. “Individuals in rural areas encounter several health care challenges that can vary significantly among different types of rural environments across the country. Rural residents tend to be older and in poorer health compared to their urban counterparts, and rural communities often struggle with access to care, financial viability, and the important connection between health care and economic development.”

An estimated 67 million Americans live in areas designated as rural, tribal, frontier or geographically isolated, according to CMS. Those issues are exacerbated by payment structures that depend on volume, regulatory hurdles and limited coverage options.

“Access to health care professionals at all levels can be challenging,” Care Advantage CEO Tim Hanold told HHCN. “Matching supply and demand is a more complex equation in rural settings due to limited financial resources, geographic spread, low population density and potentially more complex patient needs.”

Care Advantage provides both home care and home health services in Virginia, Maryland, Washington, D.C. and Delaware.

This limited access impacts health outcomes, and many patients turn to the emergency room as their first line of support.

Rural home health agencies encounter various challenges, including staffing shortages and resource limitations. Providers spend a significant amount of time traveling to and from patient homes, which can result in less efficient care delivery and negatively impact patient outcomes. These travel demands contribute to higher overhead costs for agencies due to increased fuel and travel expenses, which can also financially affect home health workers.

Fuel and travel reimbursements vary among rural home health agencies, decreasing clinicians’ take-home pay. This disparity can further impact staffing levels at agencies offering lower reimbursements.

Despite these challenges, a study from New York University found that rural agencies often initiate care more quickly, even though the quality of home health care can vary by location. In contrast, urban agencies are better at preventing hospitalizations.

However, the availability of home health care agencies in rural communities is a concern.

While specific statistics for rural agencies are limited, the Research Institute for Home Care reports that the number of active home health agencies has declined since 2014. In 2022, there were only 11,353 active agencies in the U.S.

These closures often stem from unique challenges, including difficulties in complying with Medicare regulations and reimbursement policies. The prospective payment model does not adequately support low-volume agencies, and issues like high caregiver turnover, equipment procurement regulations, high poverty rates and population decline complicate the situation.

A call for government assistance

Medicare is the largest payer for home health services; however, many home health agency administrators report that current reimbursement rates do not cover the costs of delivering care to some rural beneficiaries. They also warn that further cuts in reimbursement rates or the elimination of rural add-ons could reduce service availability in these areas.

“With ongoing reimbursement cuts, we anticipate accelerated closure rates, particularly among small agencies in rural areas – agencies that are often the backbone of health care delivery in their communities,” LTM Group CEO David Kerns told HHCN. “At the LTM Group, we’re actively seeking to partner with high-quality, five-star providers and local or hospital-owned home care agencies that may be struggling. By bringing our operational expertise, improving quality and centralizing functions to reduce costs, we aim to help these agencies continue serving rural health care needs. Our goal is to preserve access to care in underserved areas while supporting agencies through these challenging times.”

The LTM Group consists of several home health, personal care, hospice and rehab companies with more than 500 employees in Indiana, Ohio and Michigan.

In 2023, the Biden-Harris Administration took significant steps to improve the health of rural communities and to support rural health providers.

These actions included upfront payments to specific accountable care organizations (ACOs) to help them expand care to rural areas and serve historically underserved populations. The funds were meant to allow ACOs to invest in staffing, such as hiring community health workers, enhancing health care infrastructure, and addressing the health-related social needs of Medicare beneficiaries – issues like food insecurity, housing instability and transportation challenges.

Additionally, the Department of Health and Human Services (HHS) offered various grant opportunities to support rural communities, including $28 million for direct health services and infrastructure improvement.

Despite these efforts, financial support from external sources has become essential for home health agencies to remain solvent. This funding may come from county health general funds or local foundation grants. Agencies that are affiliated with or owned by hospitals may receive direct funding from those institutions.

Home health agencies can also seek resources from community non-profit organizations, local agencies on aging, state-level elder affairs or aging departments, and the Veterans Health Administration for veterans who are at least 50% disabled due to a service-related condition.

“Unfortunately, we are seeing many agencies being purchased by publicly traded companies or insurer-owned home care organizations that often reduce service areas – especially in rural communities – and compromise quality,” Kerns said. “This trend highlights the need to support independent providers who remain committed to delivering exceptional care where it is most needed.”

What can patients do if there are no providers in their area?

Rural health clinics (RHCs) and federally qualified health centers can obtain certification to provide home health services in areas without functioning home health agencies. In locations where CMS has identified a shortage of home health agencies, RHCs can offer visiting nurse services to homebound patients. Rural hospitals sometimes operate home health agencies to meet community needs, even when it’s not financially advantageous.

Telemedicine offers the opportunity to deliver health care services over vast distances to underserved urban and rural areas. It can give individuals in rural regions access to teleconsultations with health care providers and specialists who may otherwise be unavailable. Telemedicine may also help attract and retain health care providers in rural areas by facilitating ongoing training and interaction with other professionals.

However, despite its potential, telehealth use in some rural regions is hampered by poor internet access and speeds, significant gaps in home broadband availability, and low adoption rates, according to CMS.

“When agencies close, it increases reliance on health care providers with telemedicine capabilities, which can be challenging for regions with limited high-speed internet and lower comfort levels with technology,” Hanold said. “As a result, many rural patients who typically age in place may need to transition to a facility or nursing home.”

The CMS Innovation Center recently held a hackathon to explore new rural health strategies. Participants highlighted the importance of using the existing workforce within rural communities, including non-hospital-based providers such as paramedics, emergency medical technicians, pharmacists and community health workers. They stressed the need for a structure that formally integrates these professionals into care teams through flexible role definitions and requirements.

Part of this flexibility includes broader role definitions that relax professional licensing requirements, allowing rural providers to maximize their existing workforce. For instance, care navigators do not need to be licensed social workers. The roles of non-physician care providers, such as nurse practitioners, physician assistants and social workers, could be expanded to include home visits.

Hackathon participants also proposed flexibilities for integrating emergency medical services, enabling paramedics to supplement or expand home-based care visits. These include treating patients on-site during emergency calls, sharing data with primary care providers and receiving payment outside transport.

“CMS seeks to ensure the perspectives of members from rural, tribal and geographically isolated communities – and those serving those communities – are reflected in discussions and policy considerations as we work to improve health care quality, outcomes and access,” a CMS spokesperson said. “CMS has released a Framework for Advancing Health Care in Rural, Tribal, and Geographically Isolated Communities. This framework outlines priority areas for continuously focusing these efforts.”

To create this framework, which builds on the 2018 CMS Rural Health Strategy, the agency engaged with individuals, organizations and government entities who have experienced receiving health care or have supported health care service delivery in these communities.