Because of its adaptability and diversity, home health care bears strong potential for solving problems in our rural health care delivery system. At a time when rural hospitals are closing, medical care continues to be in short supply, and solutions to rural health care problems are costly, improved and expanded home health care may represent a practical solution to several such problems. However, little is known about the effectiveness of home health care provided in rural America. Fragmented evidence in the literature, as well as pilot data from previous studies of home health care, imply that the quality of home health care is inferior in rural areas relative to urban areas. The purpose of the proposed study is to test this hypothesis. Differences in home health care patient outcomes in rural and urban communities will be assessed. Factors that explain such differences or, more generally, factors that explain variation in patient outcomes, will also be studied. Such factors will include measures of the quality and quantity of home health services (process quality and resource consumption measures). All measures were developed and refined through a series of national, multi-site, longitudinal studies that have incorporated extensive clinical review and evaluation of relevant work conducted by other researchers. Agency and patient-level samples are designed to permit outcome comparisons (1) between a representative (random) sample of 3000 rural patients and a representative sample of 3000 urban patients, (2) between the representative sample of 3000 rural patients and a sample of 3000 urban patients from the same state, and (3) among three strata of at least 800 rural patients, each from different types of rural communities defined in terms of population, (non)adjacency to metropolitan areas, and population density. Rural and urban outcomes will be compared statistically, adjusting for patient-level case mix and socioeconomic factors, as well as covariates at the agency, community, and state levels using logistic regression, multiple regression, and proportional hazards survival analysis with covariates. The primary aim of the project is to empirically investigate whether home health care patient outcome differences exist between urban and rural communities. Based on these findings, in conjunction with the process quality and resource consumption comparisons, the second aim is to suggest ways to solve quality problems that may exist in the expanding field of home health care.
