An increasing body of evidence highlights the importance of an individual’s place of residence on their health and functional outcomes. This study is based on Outcome and Assessment Information Set data to assess the differences in emergency department visits among Medicare home health care patients by patients' residence location (rural/urban status and neighborhood socioeconomic status). Compared to urban patients, a disproportionately higher proportion of rural patients lived in more or most disadvantaged neighborhoods (83.9% vs. 41.3%). Using linear probability regression models, patients in rural areas (coefficient = .02, p < .001) and disadvantaged neighborhoods (less disadvantaged: coefficient = .02, p < .001; more disadvantaged: coefficient = .034, p < .001; most disadvantaged: coefficient = .042, p < .001) were more likely to experience emergency department visits. Policymakers should consider utilizing area-based target interventions to mitigate gaps in home health care. Also, given that the majority of rural patients reside in disadvantaged neighborhoods, neighborhood characteristics should be considered in addressing rural–urban disparities and improving home health care.
AgarwalP.BiasT. K.MadhavanS.SambamoorthiN.FrisbeeS.SambamoorthiU. (2016). Factors associated with emergency department visits: A multistate analysis of adult fee-for-service Medicaid beneficiaries. Health Services Research and Managerial Epidemiology, 3(3), 2333392816648549. https://doi.org/10.1177/2333392816648549
2.
AndersenR. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter?Journal of Health and Social Behavior, 36(1), 1–10. https://doi.org/10.2307/2137284
3.
BarrenetxeaJ.TanK. B.TongR.ChuaK.FengQ.KohW. P.ChenC. (2021). Emergency hospital admissions among older adults living alone in the community. BMC Health Services Research, 21(1), 1192. https://doi.org/10.1186/S12913-021-07216-3
4.
BastaN. E.MatthewsF. E.ChatfieldM. D.BrayneC.MRC-CFAS (2008). Community-level socio-economic status and cognitive and functional impairment in the older population. The European Journal of Public Health, 18(1), 48–54. https://doi.org/10.1093/eurpub/ckm076
5.
BosmaH.Van De MheenH. D.BorsboomG. J. J. M.MackenbachJ. P. (2001). Neighborhood socioeconomic status and all-cause mortality. American Journal of Epidemiology, 153(4), 363–371. https://doi.org/10.1093/AJE/153.4.363
6.
CarlsonL. C.KimJ.Samuels-KalowM. E.YunB. J.TerryD. F.WeilburgJ. B.LeeJ. (2021). Comparing neighborhood-based indices of socioeconomic risk factors and potentially preventable emergency department utilization. The American Journal of Emergency Medicine, 44, 213–219. https://doi.org/10.1016/J.AJEM.2020.03.035
ChenH. F.LandesR. D.SchuldtR. F.TilfordJ. M. (2020). Quality performance of rural and urban home health agencies: Implications for rural add-on payment policies. The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association, 36(3), 423–432. https://doi.org/10.1111/JRH.12415
12.
CohenS. A.CookS. K.KelleyL.FoutzJ. D.SandoT. A. (2017). A closer look at rural-urban health disparities: Associations between obesity and rurality vary by geospatial and sociodemographic factors. The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association, 33(2), 167–179. https://doi.org/10.1111/jrh.12207
13.
CutronaC. E.WallaceG.WesnerK. A. (2006). Neighborhood characteristics and depression: An examination of stress processes. Current Directions in Psychological Science, 15(4), 188–192. https://doi.org/10.1111/J.1467-8721.2006.00433.X
14.
DickA. W.MurrayM. T.ChastainA. M.MadiganE. A.SorberoM.StoneP. W.ShangJ. (2019). Measuring quality in home healthcare. Journal of the American Geriatrics Society, 67(9), 1859–1865. https://doi.org/10.1111/JGS.15963
15.
DobisE. A.ToddJ. E. (2022). Health care access among self-employed workers in nonmetropolitan counties. USDA
16.
DreyerK.SteventonA.FisherR.DeenyS. R. (2018). The association between living alone and health care utilisation in older adults: A retrospective cohort study of electronic health records from a London general practice. BMC Geriatrics, 18(1), 269–275. https://doi.org/10.1186/s12877-018-0939-4.
17.
FahrenbachJ.ChinM. H.HuangE. S.SpringmanM. K.WeberS. G.TungE. L. (2020). Neighborhood disadvantage and hospital quality ratings in the medicare hospital compare program. Medical Care, 58(4), 376–383. https://doi.org/10.1097/MLR.0000000000001283
18.
Fashaw-WaltersS. A.RahmanM.GeeG.MorV.WhiteM.ThomasK. S. (2022). Out of reach: Inequities in the use of high-quality home health agencies. Health Affairs, 41(2), 247–255. https://doi.org/10.1377/hlthaff.2021.01408
19.
GengF.MansouriS.StevensonD. G.GrabowskiD. C. (2020). Evolution of the home health care market: The expansion and quality performance of multi-agency chains. Health Services Research, 55(Suppl 3), 1073–1084. https://doi.org/10.1111/1475-6773.13597
20.
GentiliS.Emberti GialloretiL.RiccardiF.ScarcellaP.LiottaG. (2021). Predictors of emergency Room access and not urgent emergency Room access by the frail older adults. Frontiers in Public Health, 9, 721634. https://doi.org/10.3389/fpubh.2021.721634
21.
Greenwood-EricksenM. B.KocherK. (2019). Trends in emergency department use by rural and urban populations in the United States. JAMA Network Open, 2(4), Article e191919. https://doi.org/10.1001/JAMANETWORKOPEN.2019.1919
22.
GregoryP.EdwardsL.FaurotK.WilliamsS. W.FelixA. C. G. (2010). Patient preferences for stroke rehabilitation. Topics in Stroke Rehabilitation, 17(5), 394–400. https://doi.org/10.1310/tsr1705-394
23.
GriffithsP.Recio-SaucedoA.Dall’OraC.BriggsJ.MaruottiA.MeredithP.SmithG. B.BallJ.Missed Care Study Group (2018). The association between nurse staffing and omissions in nursing care: A systematic review. Journal of Advanced Nursing, 74(7), 1474–1487. https://doi.org/10.1111/JAN.13564
24.
GunnarsdottirO. S.RafnssonV. (2006). Mortality of the users of a hospital emergency department. Emergency Medicine Journal: Engineering Management Journal, 23(4), 269–273. https://doi.org/10.1136/emj.2005.026690
25.
HanchateA. D.DyerK. S.Paasche-OrlowM. K.BanerjeeS.BakerW. E.LinM.XueW. D.FeldmanJ. (2019). Disparities in emergency department visits among collocated racial/ethnic medicare enrollees. Annals of Emergency Medicine, 73(3), 225–235. https://doi.org/10.1016/J.ANNEMERGMED.2018.09.007
26.
HannawaA. F.WuA. W.KolyadaA.PotemkinaA.DonaldsonL. J. (2022). The aspects of healthcare quality that are important to health professionals and patients: A qualitative study. Patient Education and Counseling, 105(6), 1561–1570. https://doi.org/10.1016/J.PEC.2021.10.016
27.
JacksonT.BarrM.WelberryH.KabirA.Harris-RoxasB.LloydJ.BlundenL.-A.DonnellyD.GoodgerB.HarrisM. (2021). Impact of social isolation and living alone on health service use, morbidity and mortality over time in Central and Eastern Sydney, Australia. International Journal of Integrated Care, 20(3), 23. https://doi.org/10.5334/ijic.s4023
28.
JohnstonK. J.WenH.KotwalA.Joynt MaddoxK. E. (2021). Comparing preventable acute care use of rural versus urban Americans: An observational study of national rates during 2008-2017. Journal of General Internal Medicine, 36(12), 3728–3736. https://doi.org/10.1007/s11606-020-06532-4
29.
JungD.KindA.RobertS.BuckinghamW.DuGoffE. (2018). Linking neighborhood context and health in community-dwelling older adults in the medicare advantage program. Journal of the American Geriatrics Society, 66(6), 1158–1164. https://doi.org/10.1111/JGS.15366
30.
KindA. J. H.BuckinghamW. R. (2018). Making neighborhood-disadvantage metrics accessible — the neighborhood atlas. New England Journal of Medicine, 378(26), 2456–2458. https://doi.org/10.1056/NEJMP1802313
31.
KindA. J. H.JencksS.BrockJ.YuM.BartelsC.EhlenbachW.GreenbergC.SmithM. (2014). Neighborhood socioeconomic disadvantage and 30-day rehospitalization: A retrospective cohort study. Annals of Internal Medicine, 161(11), 765–774. https://doi.org/10.7326/M13-2946
32.
KusS.MüllerM.StroblR.GrillE. (2011). Patient goals in post-acute geriatric rehabilitation--goal attainment is an indicator for improved functioning. Journal of Rehabilitation Medicine, 43(2), 156–161. https://doi.org/10.2340/16501977-0636
33.
LakeE. T.RimanK. A.SloaneD. M. (2020). Improved work environments and staffing lead to less missed nursing care: A panel study. Journal of Nursing Management, 28(8), 2157–2165. https://doi.org/10.1111/JONM.12970
34.
LloydT.CrellinE.BrineR. J.ShenJ. Y.WoltersA. T. (2022). Association between household context and emergency hospital use in older people: A retrospective cohort study on indicators for people living alone or living with somebody with frailty, developed from routine healthcare data in england. BMJ Open, 12(5), Article e059371. https://doi.org/10.1136/bmjopen-2021-059371
35.
LowthianJ.StraneyL. D.BrandC. A.BarkerA. L.SmitP. d. V.NewnhamH.HunterP.SmithC.CameronP. A. (2016). Unplanned early return to the emergency department by older patients: The safe elderly emergency department discharge (SEED) project. Age and Ageing, 45(2), 255–261. https://doi.org/10.1093/ageing/afv198
36.
MaC.DevotiA.O’ConnorM. (2022). Rural and urban disparities in quality of home health care: A longitudinal cohort study (2014-2018). The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association, 38(4), 705–712. https://doi.org/10.1111/jrh.12642
MrozT. M.PattersonD. G.FrognerB. K. (2020). The impact of medicare’s rural add-on payments on supply of home health agencies serving rural counties. Health Affairs, 39(6), 949–957. https://doi.org/10.1377/hlthaff.2019.00952
40.
NelsonJ. A.Stover GingerichB. (2010). Rural health: Access to care and services. Home Health Care Management & Practice, 22(5), 339–343. https://doi.org/10.1177/1084822309353552
41.
NiedzwieckiM. J.SharmaP. J.KanzariaH. K.McConvilleS.HsiaR. Y. (2018). Factors associated with emergency department use by patients with and without mental health diagnoses. JAMA Network Open, 1(6), Article e183528. https://doi.org/10.1001/JAMANETWORKOPEN.2018.3528
42.
NielsenM.D’AgostinoD.GregoryP. (2017). Addressing rural health challenges head on. Missouri Medicine, 114(5), 363–366.
O’ConnorA.WelleniusG. (2012). Rural-urban disparities in the prevalence of diabetes and coronary heart disease. Public Health, 126(10), 813–820. https://doi.org/10.1016/J.PUHE.2012.05.029
45.
O’ConnorM.DavittJ. K. (2012). The outcome and assessment information set (OASIS): A review of validity and reliability. Home Health Care Services Quarterly, 31(4), 267–301. https://doi.org/10.1080/01621424.2012.703908
46.
OhlsenT. J. D.DoodyD. R.MuellerB. A.DesaiA. D.ChowE. J. (2023). Population-based impact of rurality and neighborhood-level socioeconomic disadvantage on pediatric cancer mortality in Washington State. Cancer Epidemiology, Biomarkers & Prevention, 32(1), 141. https://doi.org/10.1158/1055-9965.EPI-22-0897
PinesJ. M.LotrecchianoG. R.ZocchiM. S.LazarD.LeedekerkenJ. B.MargolisG. S.CarrB. G. (2016). A conceptual model for episodes of acute, unscheduled care. Annals of Emergency Medicine, 68(4), 484–491.e3. https://doi.org/10.1016/J.ANNEMERGMED.2016.05.029
49.
PozniakA.TurenneM.LammersE.MukhopadhyayP.SlanchevV.GreenL.SchurC.TomaiL.ArbitM.CoganC.DingZ.GoyatR.HanslitsK.JiN.MandellR.MilkovichK.RepeckK.RochotteS.SchragerJ.BottD. (2022). Evaluation of the home health value-based purchasing (HHVBP) model - fifth annual report. https://innovation.cms.gov/data-and-reports/2022/hhvbp-fifthann-rpt
R Core Team. (2023). R: A language and environment for statistical computing (4.1.2). R Foundation for Statistical Computing.
53.
RichmanL.PearsonJ.BeasleyC.StaniferJ. (2019). Addressing health inequalities in diverse, rural communities: An unmet need. SSM - population health, 7, 100398. https://doi.org/10.1016/j.ssmph.2019.100398
54.
RobertS. A. (1998). Community-level socioeconomic status effects on adult health. Journal of Health and Social Behavior, 39(1), 18–37. https://doi.org/10.2307/2676387
55.
RossC. E.MirowskyJ. (2001). Neighborhood disadvantage, disorder, and health. Journal of Health and Social Behavior, 42(3), 258–276. https://doi.org/10.2307/3090214
56.
SabbatiniA. K.KocherK. E.BasuA.HsiaR. Y. (2016). In-hospital outcomes and costs among patients hospitalized during a return visit to the emergency department. JAMA, 315(7), 663–671. https://doi.org/10.1001/JAMA.2016.0649
57.
SchiemanS. (2005). Residential stability and the social impact of neighborhood disadvantage: A study of gender- and race-contingent effects. Social Forces, 83(3), 1031–1064. https://doi.org/10.1353/sof.2005.0045
58.
ShaughnessyP. W.SchlenkerR. E.CrislerK. S.ArnoldA. G.PowellM. C.BeaudryJ. M. (1996). Home care: Moving forward with continuous quality improvement. Journal of Aging & Social Policy, 7(3–4), 149–167. https://doi.org/10.1300/J031V07N03_09
SmithD. B.FengZ.FennellM. L.ZinnJ.MorV. (2008). Racial disparities in access to long-term care: The illusive pursuit of equity. Journal of Health Politics, Policy and Law, 33(5), 861–881. https://doi.org/10.1215/03616878-2008-022
61.
SolteroE. G.HernandezD. C.O’ConnorD. P.LeeR. E. (2015). Does social support mediate the relationship among neighborhood disadvantage, incivilities, crime and physical activity?Preventive Medicine, 72, 44–49. https://doi.org/10.1016/J.YPMED.2014.12.030
62.
SpilsburyK.HewittC.StirkL.BowmanC. (2011). The relationship between nurse staffing and quality of care in nursing homes: A systematic review. International Journal of Nursing Studies, 48(6), 732–750. https://doi.org/10.1016/J.IJNURSTU.2011.02.014
TothM.HolmesM.Van HoutvenC.TolesM.WeinbergerM.SilbermanP. (2015). Rural medicare beneficiaries have fewer follow-up visits and greater emergency department use postdischarge. Medical Care, 53(9), 800–808. https://doi.org/10.1097/MLR.0000000000000401
65.
TurneyK.HarknettK. (2010). Neighborhood disadvantage, residential stability, and perceptions of instrumental support among new mothers. Journal of Family Issues, 31(4), 499–524. https://doi.org/10.1177/0192513X09347992
66.
UddinJ.MallaG.LongD. L.ZhuS.BlackN.CherringtonA.DuttonG. R.SaffordM. M.CummingsD. M.JuddS. E.LevitanE. B.CarsonA. P. (2022). The association between neighborhood social and economic environment and prevalent diabetes in urban and rural communities: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. SSM - Population Health, 17, 101050. https://doi.org/10.1016/J.SSMPH.2022.101050
van SebenR.SmorenburgS. M.BuurmanB. M. (2019). A qualitative study of patient-centered goal-setting in geriatric rehabilitation: Patient and professional perspectives. Clinical Rehabilitation, 33(1), 128–140. https://doi.org/10.1177/0269215518791663
69.
WangC.-L.DingS.-T.HsiehM.-J.ShuC.-C.HsuN.-C.LinY.-F.ChenJ.-S. (2016). Factors associated with emergency department visit within 30 days after discharge. BMC Health Services Research, 16(1), 190. https://doi.org/10.1186/s12913-016-1439-x
70.
WernerR. M.CoeN. B.QiM.KonetzkaR. T. (2019). Patient outcomes after hospital discharge to home with home health care vs to a skilled nursing facility. JAMA Internal Medicine, 179(5), 617–623. https://doi.org/10.1001/JAMAINTERNMED.2018.7998
71.
ZhangY.AnckerJ. S.HallJ.KhullarD.WuY.KaushalR. (2020). Association between residential neighborhood social conditions and health care utilization and costs. Medical Care, 58(7), 586–593. https://doi.org/10.1097/MLR.0000000000001337
72.
ZhouR. A.BaickerK.TaubmanS.FinkelsteinA. N. (2017). The uninsured do not use the emergency department more- they use other care less. Health Affairs, 36(12), 2115–2122. https://doi.org/10.1377/hlthaff.2017.0218
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