Rural Elderly

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.