LEBANON, N.H. – Older adults living in rural communities are less likely to receive hospice care, and when they do, are less likely to receive the most intensive hospice services for severe symptoms, according to a new study led by a Dartmouth Health researcher and published in the Journal of the American Medical Association (JAMA). The study found that 52.4% of older adults who died in urban ZIP codes received hospice care, compared with 44.8% of those in the most rural ZIP codes.
Among people who received hospice care, rural and urban patients were similarly likely to receive routine visits from hospice nurses, social workers, and aides, despite the longer distances rural hospice teams often travel to reach patients.
“Rural hospice teams are doing a remarkable job of providing routine care to patients despite the challenges of distance and geography,” said Dr. Claire Ankuda, lead author of the study, palliative medicine physician at Dartmouth Health, and associate professor of medicine and of health policy and clinical practice at Dartmouth’s Geisel School of Medicine. “What we found is that the biggest differences emerge when patients need more intensive, round-the-clock support – and that’s the gap we need to understand better.”
The study found significant differences in access to two types of intensive hospice care. General inpatient hospice care, which provides around-the-clock care for patients with severe symptoms that cannot be managed at home, was provided to 21.7% of hospice patients in urban ZIP codes compared with 12.7% of patients in the most rural ZIP codes.
Continuous home care, which provides at least eight hours of nursing care in a patient’s home, was provided to 2.5% of hospice patients in urban ZIP codes compared with just 0.5% of patients in the most rural ZIP{ codes.
The findings highlight challenges facing rural hospice providers, where greater travel distances, workforce shortages, and lower population density can make it more difficult to provide intensive services. The researchers point to one possible fix: a rural payment adjuster that would let Medicare pay rural hospice agencies more for delivering general inpatient and continuous home care, helping offset the added cost of providing intensive services in low-density areas.
“Rural patients should have the same opportunity to receive the level of hospice care they need, regardless of where they live,” said Ankuda. “Understanding what is driving these differences is an important next step so we can identify ways to improve access to high-intensity hospice care in rural communities.”
The study was conducted by researchers from Dartmouth Health/Geisel School of Medicine; the Icahn School of Medicine at Mount Sinai; the University of California, San Francisco; and Dana-Farber Cancer Institute.
The full study, “Rural-Urban Disparities in the Delivery and Intensity of the Medicare Hospice Benefit,” is published in JAMA.