Promoting Aging in Place By Promoting Equity in Home Health Care

Background and Purpose: Prior research has documented racial and ethnic disparities in health outcomes for home health care recipients. However, there is a critical lack of understanding regarding the contributing factors to such disparities, in particular the role that practice factors play in home health disparities. Understanding racial/ethnic disparities in home health is essential from an ethical position and for advancing the overall health of the Medicare population, thereby reducing costs from morbidity and mortality. Equitable distribution of home health services are is also essential to enabling frail older adults of color to age in place in their homes and communities.

Methods: A mixed methods study was conducted to understand the contributing factors to home care outcome disparities. Utilizing existing Medicare data from the Outcome ASsessment Information Set (OASIS), and Provider of Services file for all home health assessments conducted in 2006, we tested the hypothesis that minority home care patients would have lower functional status at discharge compared to white patients. Multivariate regression procedures with Rasch modeling were used on composite measures of activities and instrumental activities of daily living. We also conducted focus group interviews with 23 home health agency staff recruited from a list of all agencies in a tri-state metropolitan region. We obtained a convenience sample of staff from a variety of home health agencies, representing a mix of disciplines (e.g., social work, nursing, therapy), races/ethnicities, gender, and professional and paraprofessional positions. Focus groups were facilitated by a racially diverse team in a convenient and anonymous site. The focus group interviews explored agency staff’s unique and intimate perspectives on caring for the elderly in their homes and the complex practice factors that may contribute to disparate health outcomes. The interviews were digitally recorded and professionally transcribed. Data analysis was conducted using Nvivo software with a grounded theory framework.

Results: Quantitative analyses demonstrated that minority home health recipients experienced greater deterioration in functional status during their home health episode relative to white patients. These results were significant for multiple minority groups. In focus groups, staff reported multiple levels of influence in the home health setting, including patient (e.g. health literacy, income), staff (e.g. staff discretion, staff bias), agency (e.g. lack of staff diversity, cost control practices), and system factors (e.g. insurance coverage, reimbursement cuts,) which influence the relationship between race/ethnicity and outcomes.

Conclusions and Implications: Disparities in home health care can erode support for aging in place in community for frail older adults of color. Results highlight the relationship between access to care, quality care and outcomes. Staff discretion, bias and institutional forms of racism may contribute to disparities in functional status for minority home health care recipients. Research and practice implications, including quality assurance recommendations focused on vulnerable groups, will be discussed.