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Rural Elderly - Health And Home- And Community-based Service Use Among Rural Older Adults

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National Health Interview Survey data point to a tendency for nonmetropolitan elders aged sixty-five to sixty-nine, adjacent to a metropolitan area, to visit physicians less frequently than same-aged people living in other locations. Rural elderly residents aged seventy-five and over, however, were as likely or more likely to visit a physician as their urban counterparts (Coburn and Bolda). It seems that rural elders who are financially able manage to get to physicians when there is a need, regardless of distance. In their study of health and community-based service use among rural southeastern community-dwelling older adults, Mitchell, Mathews, and Griffin (1997) found that rural and small town (under twenty-five hundred) residence had no effect on visits to primary care or specialty physicians when poverty status, transportation needs, and the availability of informal care were considered. This suggests that the poverty status, transportation problems, and lack of informal assistance coinciding with rural residence may be more important predictors of visits to primary care and specialty physicians than residence.

Services that help older persons stay in their homes as long as possible include those available through the Older Americans Act (OAA), the Social Services Block Grant (SSBG) program, Medicaid waivers, and largely for-profit in-home care. Initially assisting all older persons, OAA services now target socially impaired and economically disadvantaged people age sixty-five and over. OAA services include senior centers, transportation, in-home services, legal assistance, congregate meals, home delivered meals, and in-home services for the frail. Allocated to states through Title XX of the Social Security Act based upon the size of the needy population, SSBG assistance includes homemaker, chore service, home health care, protective services, and nutrition for older people. Medicaid funds home- and community-based long-term, skilled nursing care for eligible older adults as an alternative to institutional care. With Medicare restrictions in hospital care reimbursement in the 1980s, the private sector began to offer home health care following hospital discharge. Many agencies have expanded their services to include other types of in-home assistance, including chore service. This array of services is so complex that some have tried to categorize them in a more meaningful way. For example, Cox (1993) groups them as preventive for those less impaired, supportive for the moderately impaired, and protective for the severely impaired.

Assessment of the extent to which rural residence compromises access to home- and community-based services among older adults has been frustrated by inconsistent definitions of rural residence and because of different service designations across studies. Federal service delivery requirement (e.g., only volunteers can deliver meals), transportation costs, and the lack of larger numbers of service personnel found in urban areas, certainly limits innovation and the penetration of specialized services into rural communities (e.g., Salmon, Nelson, and Rouse). Consequently, Rowles concludes that relocation away from the rural community becomes the only option when rural elderly people lose capacity to accommodate declining physical capability, and when the support from kin, neighbors, or aging peers is no longer viable. Since the supply of nursing homes and nursing home beds is nearly 43 percent greater in nonmetropolitan than metropolitan areas (Coburn and Bolda) and complex in-home services that replace or delay institutionalization are generally less available in rural compared to urban areas (Nelson), this rural relocation is more likely to be to a skilled nursing facility than would be an urban relocation.

Regional studies with samples sufficiently large to uncover variability among older rural residents are needed to unmask findings of ‘‘little if any residential variability’’ resulting from simplistic dichotomous residential definitions. For example, virtually all of the contributors to Coward and Krout’s (1998) edited volume called for research to better understand the implications of the variety of rural locations across America. The culture of rural Kansas is certainly different than the culture of rural Vermont, and such cultural difference impacts all aspects of rural aging, from the propensity towards self-care to the availability of residential alternatives.

JIM MITCHELL

BIBLIOGRAPHY

BEALE, C. ‘‘Nonmetro Population Growth Rebound of the 1990’s Continues, but at a Slower Rate.’’ Rural Conditions and Trends 8 (1997): 46–50.

COBURN, A. F., and BOLDA, E. J. ‘‘The Rural Elderly and Long-Term Care.’’ In Rural Health in the United States. Edited by T. C. Ricketts, III. New York: Oxford University Press, 1999. Pages 179–189.

COWARD, R. T., and CUTLER, S. J. ‘‘Informal and Formal Health Care Systems for the Rural Elderly.’’ Health Services Research 23 (1989): 785–806.

COWARD, R. T., and KROUT, J. A. Aging in Rural Settings: Life Circumstances and Distinctive Features. New York: Springer, 1998.

COWARD, R. T.; MCLAUGHLIN, D. K.; DUNCAN, R. P.; and BULL, C. N. ‘‘An Overview of Health and Aging in Rural America.’’ In Health Services for Rural Elders. Edited by R. T. Coward, C. N. Bull, G. Kukulka, and J. M. Galliher. New York: Springer Publishing Company, 1994. Pages 1–32.

COX, C. The Frail Elderly: Needs and Community Responses. Westport, Conn.: Auburn House, 1993.

GLASGOW, N. L., and REEDER, R. J. ‘‘Economic and Fiscal Implications of Nonmetropolitan Retirement Migration.’’ Journal of Applied Gerontology 9 (1990): 433–451.

JOHNSON, K. M. ‘‘Demographic Change in Nonmetropolitan America.’’ Rural Sociology 58 (1993): 347–365.

LEE, G. R.; DWYER, J. D.; and COWARD, R. D. ‘‘Residential Location and Proximity to Children among Impaired Elderly Parents.’’ Rural Sociology 55 (1990): 579–589.

LONGINO, C. F., and SMITH, M. H. ‘‘The Impact of Elderly Migration on Rural Communities.’’ In Aging in Rural Settings. Edited by R. T. Coward and J. A. Krout. New York: Springer Publishing Company, 1990. Pages 209–226.

MANSFIELD, C. J.; WILSON, J. L.; KOBRINSKI, E. J.; and MITCHELL, J. ‘‘Premature Mortality in the United States: The Roles of Geographic Areas, Socioeconomic Status, Household Type, and Availability of Medical Care.’’ American Journal of Public Health 89 (1999): 893–898.

MITCHELL, J.; MATHEWS, H. F.; and GRIFFIN, L. W. ‘‘Health and Community-Based Service Use: Differences between Elderly African-Americans and Whites.’’ Research on Aging 19 (1997): 199–222.

MCLAUGHLIN, D. K., and JENSEN, L. ‘‘The Rural Elderly: A Demographic Portrait.’’ In Aging in Rural Settings. Edited by R. T. Coward and J. A. Krout New York: Springer Publishing Company, 1998. Pages 15–43.

NELSON, G. M. ‘‘In-Home Care for Rural Elders.’’ In Health Services for Rural Elders. Edited by R. T. Coward, C. Neil Bull, G. Kukalka, and J. M. Galliher. New York: Springer, 1994. Pages 65–83.

REEDER, R. J., and GLASGOW, N. L. ‘‘Nonmetro Retirement Counties: Strengths and Weaknesses.’’ Rural Development Perspectives 6 (1990): 12–17.

RICKETTS, T. C.; JOHNSON-WEBB, K. D.; and RANDOLPH, R. K. ‘‘Populations and Places in Rural America.’’ In Rural Health in the United States. Edited by T. C. Ricketts, III. New York: Oxford University Press, 1999. Pages 7–24.

ROWLES, G. D. ‘‘Community and the Local Environment.’’ In Aging in Rural Settings. Edited by R. T. Coward and J. A. Krout. New York: Springer Publishing Company, 1998. Pages 105–125.

SALMON, M. A. P.; NELSON, G. M.; and ROUSE, S. G. ‘‘The Continuum of Care Revisited: A Rural Perspective.’’ The Gerontologist 33 (1993): 658–666.

SEROW, W. J. ‘‘Economic Implications of Retirement Migration.’’ Journal of Applied Gerontology 9 (1990): 452–462.

STOLLER, E. P. ‘‘Families of Elderly Rural Americans.’’ In Aging in Rural Settings. Edited by R. T. Coward and J. A. Krout. New York: Springer Publishing Company, 1998. Pages 127–146.

WEINBERG, D. H. ‘‘Rural Pockets of Poverty.’’ Rural Sociology 52 (1987): 398–408.

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