Although the Centers for Medicare and Medicaid Services (CMS) spends over $18 billion annually to care for approximately 3.4 million home health (HH) beneficiaries, little is known about access to HH for vulnerable populations (i.e., racial/ethnic minorities, low-income older adults, and older adults living in high minority and/or high poverty neighborhoods.) Prior research shows that lower quality home health agencies (HHAs) have higher proportions of minorities, low-income older adults, and beneficiaries from low-income neighborhoods. Reasons for these findings are not well understood, but they may be associated with disparate availability of high-quality HH for underserved populations. Additionally, there is limited information about whether or not current public reporting strategies (i.e., HHCompare Five-Star Ratings) have impacted access to HH or exacerbated disparities in access to HH. The long-term goal of this research is to ensure access to high-quality long-term services and supports for older adults in order to improve older adults' quality of life and care, regardless of individual- and neighborhood-level attributes. The first step towards this goal, and the overall objective of this application is to use national administrative datasets (e.g., standardized HH patient assessment data) to analyze differences in access to high-quality HH care for vulnerable older adults and to understand if and how public reporting influences patients' access to high-quality services. The central hypotheses are that low-income and racial/ethnic minority older adults, as well as beneficiaries living in vulnerable neighborhoods, are more likely to have lower access to high-quality HHAs as compared to their white, more affluent counterparts; and that HHCompare Five- Star ratings will negatively impact access for these underserved populations. To evaluate these hypotheses, the following specific aims are proposed: 1) Assess the impact of individual- and neighborhood-level factors on the utilization of high-quality HHAs among older racial/ethnic minorities and low-income older adults; and 2) Evaluate the differential impact of the HHCompare Five-Star ratings on the utilization of high-quality HHAs for vulnerable populations. To achieve these objectives, this study examines the national population of Medicare beneficiaries receiving HH care between 2012 and 2017 using enrollment, HH Outcome and Assessment Information Set (OASIS), HHCompare, and Census data. The proposed work is innovative because 1) few studies examine HH disparities, 2) this is the first study to examine HHA and patient response to public reporting of quality summary measures, 3) it will link several national data sources, and 4) it will utilize models that jointly consider the relative influence of individual- and neighborhood-level effects. This work is significant because understanding within- (individual-level) and across-neighborhood disparities in access to high-quality HH, over time, can guide interventions and policy-making aimed at decreasing these disparities. This work is time sensitive and significant as it will generate critical evidence on how recent public reporting combined with individual attributes and neighborhood characteristics impact access to high-quality HH for vulnerable populations.
The proposed research is relevant to public health because it examines the extent to which Medicare beneficiaries have access to high-quality home health, as well as if and how that access varies by race, ethnicity, socioeconomic position, and neighborhood. Ultimately, reducing health disparities and improving the health status of older adults in diverse populations begins with equitable access to high-quality care for all aging populations. This work is relevant to the mission of the National Institute on Aging (NIA) because assessing health disparities in access to quality care is critical to understanding health disparities among older adults and developing strategies to improve the health status of older adults in diverse populations, a goal established within the NIA's strategic plan.
