Publication Date: January 8th, 2025
Publication Type: Policy Brief
Topic(s): Aging, Disabilities, Health Services, Healthcare Access, Long-term Care, Social Determinants of Health
Author(s): Henning-Smith C, Tuttle M, Jacobson I, Pick M, and Interrante JD
The Program of All-Inclusive Care for the Elderly (PACE) operates in the majority of states and numerous rural areas. Despite well-documented differences in population socio-demographic characteristics between rural and urban areas, as well as unique challenges and strengths related to providing long-term services and supports in rural areas, little is known about how PACE enrollee characteristics vary between rural and urban areas. This brief addresses that gap.
Year(s) Funded: 2024-2025
Topic(s): Aging, Disabilities, Health Disparities and Health Equity, Healthcare Access, Quality, Social Determinants of Health
Project Lead(s): Carrie Henning-Smith
There is abundant evidence that rural residents face unique barriers to accessing high-quality care; it is also well documented that individuals with disabilities face reduced access to high-quality care. Despite these largely known realities, and some evidence that rural people with disabilities have higher out-of-pocket costs than their urban counterparts, very little research exists that specifically examines rural-urban differences in access to or quality of care for individuals with disabilities. The purpose of this project is to address these gaps, identifying rural-urban differences in access to and use of health care services for people with disabilities.
To do this, we will primarily rely on quantitative analyses using data from the National Health Interview Survey, a nationally representative study of the U.S. population. We will also use data from the American Community Survey (ACS) to map rates of disability and their socio-demographic correlates across rural and urban areas of the U.S., overlaying data from County Health Rankings on health care access (e.g., provider-to-population ratios) and quality (e.g., use of preventive services) to better understand regional patterns. Coupled with the quantitative analyses, we will conduct a series of key informant interviews with subject matter experts in rural disability and health care access and quality. Results from this project will help inform policy to improve access to and quality of care for this growing population in rural areas.
Year(s) Funded: 2024-2025
Topic(s): Aging, Disabilities, Health Disparities and Health Equity, Home Health, Rural Statistics and Demographics, Social Determinants of Health
Project Lead(s): Carrie Henning-Smith
The U.S. population is aging, especially in rural areas, and most older adults would prefer to age at home rather than move to a new home, community, or institutional setting. However, age is sometimes accompanied by changes in mobility and physical and mental functioning, which can make it challenging for older adults to leave their homes and engage in their communities. In some cases, such functional limitations cause an older adult to be classified as “homebound”; that is, not able to leave their home without help, or at all. Without access to adequate institutional or home and community-based care, older adults may become homebound, a state that is associated with poorer health outcomes, higher rates of hospitalization and emergency department use, and greater risk of social isolation, functional decline, and mortality. Despite the growing population of homebound older adults and the associated costs and health inequities, little is known about how geographic and social context contributes to one’s risk of being homebound. The purpose of this project is to address the current gap in understanding of how social and geographic context contributes to older adults’ risk of being homebound in rural and urban areas.
Publication Date: September 25th, 2024
Publication Type: Policy Brief
Topic(s): Aging, Disabilities, Health Disparities and Health Equity, Health Services, Healthcare Access, Long-term Care, Quality
Author(s): Interrante JD, Jacobson I, Pick M, Tuttle M, and Henning-Smith C
The purpose of this policy brief is to measure sociodemographic differences in areas with and without a PACE organization headquarters among rural communities and by state-level PACE availability and headquarters location.
Year(s) Funded: 2023-2024
Topic(s): Aging, Disabilities, Health Disparities and Health Equity, Social Determinants of Health, Violence and abuse
Project Lead(s): Carrie Henning-Smith
Elder abuse, including financial, physical, and emotional abuse, as well as self-neglect, is too common and has serious implications for the health and well-being of older adults. Rural residents are older, on average, than urban residents, and rural older adults are in poorer health and have higher rates of disabilities than urban older adults. This may make rural older adults a more common target of elder abuse; however, little is known about rural/urban differences in the extent of elder abuse. Even less is known about within-rural differences in elder abuse by socio-demographic and geographic factors (e.g., differences by race, ethnicity, gender, socio-economic status, and region). This project will address those important gaps using two national data sources combined with qualitative data from a series of key informant interviews.
Year(s) Funded: 2023-2024
Topic(s): Aging, Disabilities, Health Disparities and Health Equity, Home Health, Social Determinants of Health
Project Lead(s): Carrie Henning-Smith
The Program of All-Inclusive Care for the Elderly (PACE) is an innovative model supporting functionally and medically vulnerable older adults (55 and older) living in the community, rather than in institutional settings. Funded through Medicaid and Medicare, PACE provides comprehensive services (e.g., medical care, transportation, home care, respite care, social services, nutrition) to support people to remain in their home and community. PACE can be found in all regions across the country, with 150 PACE organizations currently operating in 32 states and Washington, D.C. In 2005, the Rural PACE Pilot Act was passed, which resulted in the growth of PACE in rural areas, funding 15 programs across the rural U.S.; the majority of those still operate today. More information is needed, however, to understand how effectively PACE is being used in rural areas and where there is room for growth.
Using U.S. Census data on income and disability, this project will estimate how many rural older adults are potentially PACE-eligible, but are not currently being served by a PACE program or in a PACE state. This project will also use data from PACE to examine what proportion of rural PACE eligible people are in a PACE service area, and how that compares with the proportion of urban PACE eligible people in urban PACE areas. We will work collaboratively with the National PACE Association in this work, building on our prior work in rural aging in place.
Publication Date: August 17th, 2023
Publication Type: Peer-reviewed Journal Publications
Topic(s): Aging, Disabilities, Health Services
Author(s): Henning-Smith C, Swendener A, MacDougall H, and Lahr M
In this paper, our research team examines the lessons rural areas present for supporting aging, including the role that aging and social services, public health systems, and health care have to play.
Published in: Public Policy and Aging Report
Publication Date: August 2nd, 2023
Publication Type: Policy Brief
Topic(s): Disabilities, Health Disparities and Health Equity, Rural Statistics and Demographics, Social Determinants of Health
Author(s): Henning-Smith C, Tuttle M, Swendener A, Lahr M, and Yam H
Living in the same home and community for a prolonged period of time is associated with increased social cohesion and better health outcomes. However, it may also be indicative of limited opportunities for mobility, especially for individuals with fewer financial resources and in communities with limited housing supply. This policy brief identifies rural/urban differences in residential stability and examines rural/urban differences in regional, socio-demographic, and health characteristics associated with living in the same home for more than 20 years.
Publication Date: July 31st, 2023
Publication Type: Policy Brief
Topic(s): Disabilities, Health Disparities and Health Equity, Rural Statistics and Demographics, Social Determinants of Health
Author(s): Swendener A, Pick M, Lahr M, Yam H, and Henning-Smith C
Housing quality is associated with health and well-being; however, little research examines these factors by location. In this policy brief, we examine rates of two key housing quality indicators (having incomplete plumbing and incomplete kitchen facilities) by rural-urban location, as well as at the intersections of racial/ethnic identity and disability status.
Publication Date: March 16th, 2023
Publication Type: Policy Brief
Topic(s): Disabilities, Health Disparities and Health Equity, Rural Statistics and Demographics, Social Determinants of Health
Author(s): Swendener A, Rydberg K, Tuttle M, Yam H, and Henning-Smith C
Housing is well documented as an important social determinant of health. Inadequate housing quality can lead to negative health outcomes. Two such housing quality factors that impact health include the financial burdens of housing (e.g., housing affordability) and the internal conditions of a home, such as overcrowding. Although housing has been linked to health equity, what is less understood is how these housing characteristics vary by geography, particularly by rural or urban location. Differences in housing characteristics among various demographics of rural and urban adults is one mechanism that can be used to better understand population-level health inequalities, especially among marginalized populations.
Publication Date: January 13th, 2023
Topic(s): Aging, Disabilities, Health Disparities and Health Equity, Health Services, Healthcare Access, Long-term Care
Author(s): Henning-Smith C, Lahr M, Mulcahy J, and MacDougall H
Year(s) Funded: 2022-2023
Topic(s): Disabilities, Environmental and Agricultural Health, Health Disparities and Health Equity, Poverty, Public Health, Rural Statistics and Demographics, Social Determinants of Health
Project Lead(s): Carrie Henning-Smith
Housing is a well-recognized social determinant of health, with direct impacts on health outcomes (e.g., mortality, disability, falls, and asthma), especially for lower-income individuals with fewer resources to afford safe, accessible, and high-quality housing. Housing is directly related to environmental exposures, including lead paint, mold, mildew, pests, air quality, access to cooking equipment and refrigeration, and water and sewage quality, all of which can have deleterious short and long-term health impacts. Housing is also directly related to financial stability, in that it constitutes both one of the largest regular household expenses that people have and that it can be a way to build financial stability, wealth, and equity for those who own property. In turn, the financial risks and rewards associated with housing can impact health and racial equity. Housing also takes on particular relevance for people with disabilities, for whom the home environment may inhibit or promote functional independence depending on its physical characteristics.
While housing has long been a focus of population health research, such research has rarely included or focused on rural populations. This is problematic on multiple levels. Rural areas have, on average, older and poorer quality housing stock, which may be perpetuating rural/urban health disparities via the direct and indirect mechanisms described above. Many rural areas also struggle to either provide adequate affordable housing for new residents and/or to manage vacant homes and properties in rural communities where the population is decreasing. Further, housing is deeply intertwined with structural racism, including racist zoning policies like redlining and the relocation of Indigenous populations onto reservation lands. Yet, while the most egregious racial and ethnic health inequities are found among rural residents, very little research focuses on racial differences in the connection between housing and health in rural areas.
The purpose of this project is to identify rural/urban and within-rural differences in housing quality and its relationship to health and disability status, especially for individuals living in poverty. We will also identify rural-specific housing issues and innovative policy solutions to address housing challenges in order to improve rural health.
Year(s) Funded: 2021-2022
Topic(s): Aging, Disabilities, Health Disparities and Health Equity, Healthcare Access, Quality, Rural Statistics and Demographics, Social Determinants of Health
Project Lead(s): Carrie Henning-Smith
The purpose of this project is to identify rural/urban differences in health and health care access for lesbian, gay, bisexual, and transgender (LGBT) adults. We will also identify within-rural differences among LGBT adults by race, ethnicity, age, disability status, and socio-economic , as well as examples of best practices supporting LGBT health and wellness in rural areas.
Year(s) Funded: 2021-2022
Topic(s): Aging, Disabilities, Health Disparities and Health Equity, Healthcare Access, Home Health, Long-term Care, Workforce
Project Lead(s): Janette Dill
The purpose of this project is to assess the supply of the long-term care services and supports (LTSS) direct care workforce to care for older adults (ages 65+ and 85+) in rural and urban areas of the US. We will also explore how compensation – including wages and employer-based health insurance – is related to and predicts worker turnover in the LTSS direct care workforce in rural and urban areas.
Publication Date: May 20th, 2021
Publication Type: Policy Brief
Topic(s): Aging, Disabilities, Health Disparities and Health Equity, Health Services, Home Health, Long-term Care, Social Determinants of Health
Author(s): Henning-Smith C, Mulcahy J, Lahr M, Tanem J
As the population ages, information is urgently needed about how best to provide long-term care for older adults who develop functional limitations. Such information should incorporate the preferences of older adults themselves for care setting. This study describes care preferences by rural and urban location, and by demographic characteristics among rural residents.