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Healthcare Perspective: Home Health: Urban vs. Rural

A five-year study looking at 7,900 home health agencies revealed interesting disparities.

The Journal of Rural Health published a recent article by the New York University (NYU) college of nursing that is catching some buzz regarding the health disparities between urban and rural settings.  The study looked at process and outcome measures over a five-year period, from 2014 to 2018. They compared the two geographic regions across approximately 7,900 home health agencies, looking at the timeliness of initiation of home health services, from the referral to the utilization of ED and hospitalizations. 

The results were telling, in the rural settings: home health agencies were better at starting new patients for services, either from the PCP office or the hospital discharge referral. Urban settings showed better outcomes and lower ED visits and hospitalizations for enrolled patients. However, the concern is that despite referrals for home health, both rural and urban locations showed an increase in utilization on ED and hospitalizations. So I ask: what is going on, and what can we do about this? Granted, this study ended before COVID began. However, the results highlight the continued concept that not one single service can always prevent a patient from returning to the ED or the hospital. 

So, here’s the concern: rural home health may be able to start working with patients in timely fashion, but they may be limited in their ability to navigate and coordinate resources to prevent the failsafe return for hospital services. Completing a home visit in a rural area means significant travel, with limited resources and staffing capabilities. There is less availability to providers and late-night services, and access to testing could take months and require traveling a long distance.

The ED and hospital, as we know, could offer immediate resolution. I am not even compounding the COVID factor of limited staff, delayed appointments, and overwhelmed EDs and hospitals.

Regardless of your geographic setting, urban or rural, the care of the patient is a public health concern that requires a community approach with multiple disciplines. Although there are best practices on how to reduce hospital utilization, the greatest outcomes arise when organizations collaborate openly – and creatively. 

The referral to home health is still a positive option, with continued support and care for the patient with eyes on their living environment, such as checking to ensure that there is food in the refrigerator, that old medications have been discarded, and that fall hazards have been removed. The referral also provides nursing and physical therapy services in the home, and support with infusions that could not otherwise be possible, along with many other things.

So, my key question goes back to that COVID issue: how many of you are seeing delays in discharge at your hospital because patients are waiting for post-acute placement or services?

Programming Note: Listen to Tiffany Ferguson’s live reports on SDoH Mondays on Monitor Mondays, 10 Eastern.

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Tiffany Ferguson, LMSW, CMAC, ACM

Tiffany Ferguson is CEO of Phoenix Medical Management, Inc., the care management company. Tiffany serves on the ACPA Observation Subcommittee. Tiffany is a contributor to RACmonitor, Case Management Monthly, and commentator for Finally Friday. After practicing as a hospital social worker, she went on to serve as Director of Case Management and quickly assumed responsibilities in system level leadership roles for Health and Care Management and c-level responsibility for a large employed medical group. Tiffany received her MSW at UCLA. She is a licensed social worker, ACM, and CMAC certified.

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