Number 30 n November 9, 2010

Comparison of Home Health and Hospice Care 

Agencies by Organizational Characteristics and 

Services Provided: United States, 2007 by Eunice Y. Park-Lee, Ph.D., and Frederic H. Decker, Ph.D.,

Division of Health Care Statistics

Abstract

Objective—This report presents national estimates of the organizational

characteristics of home health and hospice care agencies in 2007. Comparisons

of organizational characteristics and provision of selected services are made by

agency type. A comparison of selected characteristics between 1996 and 2007 is

also provided to highlight changes that have occurred leading to the current

composition of the home health and hospice care sector.

Methods—Estimates are based on data collected on agencies from the 1996,

2000, and 2007 National Home and Hospice Care Survey, conducted by the

Centers for Disease Control and Prevention’s National Center for Health

Statistics. Estimates are derived from data collected during interviews with

administrators and staff designated by the administrators.

Results—In 2007, there were 14,500 home health and hospice care agencies

in the United States, an increase from 11,400 in 2000. Three-quarters of these

agencies provided home health care only, 15% provided hospice care only, and

10% provided both home health and hospice care (mixed). The percentage of

proprietary home health care only and hospice care only agencies increased

during 1996–2007, whereas the percentage of proprietary mixed agencies

remained relatively stable. The average number of home health care patients that

home health care only and mixed agencies served decreased, while the average

number of hospice care patients that hospice care only agencies served increased

across years. Among mixed agencies, no significant changes were observed in

the average number of hospice care patients being served. The percentage of

home health care only agencies offering certain therapeutic and nonmedical

services declined over the years. There was an increase in the proportion of

hospice care only agencies’ providing many core and noncore hospice care

services during 1996–2007. Also during this time, the proportion of mixed

agencies providing selected nonmedical services decreased.

Keywords: National Home and Hospice Care Survey • home health care •

hospice care • organizational characteristics

Introduction

Home health and hospice care has

grown over recent years (1–4). This

growth may be due to a combination of

factors. Patients and families may have

become more aware of home health care

services as an alternative, in some cases,

to traditional inpatient care (5,6).

Patients’ preferences for spending their

last days at home (7), and bereaved

family members’ high satisfaction with

hospice care (8) may have been another

contributing factor to the increase in

hospice use (3,9). At the same time,

changes in the Medicare payment

system may underlie some of the recent

growth in home health and hospice care

agencies. Medicare is the single largest

payer for both home health and hospice

care (9,10) and, hence, changes in the

Medicare payment system associated

with the Balanced Budget Act of 1997

(BBA) had a major impact according to

most observers (11–13). Initially BBA

implementation seemed to have resulted

in a considerable number of home

health care agencies’ exits from the

market (11). But adjustment to changes

in the Medicare payment system and

regained financial stability of agencies

under the prospective payment system

(PPS) may have led to renewed growth

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Center for Health Statistics 
Page 2	 National Health Statistics Reports n Number 30 n November 9, 2010

in the home health care industry since

2000 (2,4,11). Expansion of Medicare

payment and covered hospice care

services may also have increased the

supply of hospices (3,9).

Much of the information on the

present-day characteristics of home

health and hospice care agencies, as

well as the trends in the home health

and hospice care industry, deals with

only Medicare-certified agencies, with

data available from the Centers for

Medicare & Medicaid Services (3,4).

Previous reports have also been limited

because they did not distinguish among

agencies that provide only one set of

services (i.e., home health care only or

hospice care only) and those mixed

agencies that provide both home and

hospice care services. To provide a more

complete picture of home health and

hospice care agencies in the United

States, this report focuses on differences

among these three agency types. Little is

known about the present-day

characteristics of these three agency

types or changes in their number and

the services they provide. Data from the

National Home and Hospice Care

Survey (NHHCS) enable these

comparisons and provide a unique

opportunity to examine if, for example,

the growth in home health and hospice

care sectors has been tied mainly to

home health care only and hospice care

only agencies, or to mixed agencies, and

if there have been changes in the

services that different agency types

provided over the years.

In this report, we used the 2007

NHHCS to compare the organizational

characteristics and services provided by

home health care only and mixed

agencies, and by hospice care only and

mixed agencies. Organizational

characteristics compared include

ownership status, chain affiliation,

Medicare and Medicaid certification,

patient volumes, primary patient referral

sources, use of electronic medical

records (EMRs), and patient care

revenue by payer, among others. We

also describe changes in agency number,

organizational characteristics, and

service provision within each agency

type over time using data from NHHCS,

conducted in 1996, 2000, and 2007.

Through this comparison, we highlight

changes within each agency type leading

to the current composition of agencies

in the home health and hospice care

sector.

Methods

Data source

Data are from the NHHCS. The

NHHCS was first conducted in 1992

and was repeated in 1993, 1994, 1996,

1998, and 2000, and most recently in

2007. The statistics in this report are

based on information collected in the

agency components of the 1996, 2000,

and 2007 NHHCS (14–19). Agencies

that provided home health or hospice

care services at the time of the survey

were eligible to participate in NHHCS.

The 2007 NHHCS, while similar in

structure to previous NHHCS years,

included many new data items and

collected data using a computer-assisted

personal interviewing (CAPI) system.

Core data items include selected

organizational characteristics and the

provision of selected services. For

further information on the sampling,

survey design, and other survey

methodology, see the ‘‘Technical Notes’’

in this report and the documentation for

each survey year provided on: http://

www.cdc.gov/nchs/nhhcs.htm.

Variables

Agency type

Agencies were classified as home

health care only agencies, hospice care

only agencies, or agencies that provide

both types of care (mixed). In 2007,

respondents reported whether the agency

provided either or both home health and

hospice care services, and agency type

was coded accordingly. In previous

survey years, however, agency type was

determined based on the numbers of

current home health and hospice care

patients the agency served. For instance,

if the agency reported serving one or

more home health care patients and no

hospice care patients at the time of the

interview, it was classified as a home

health care only agency.

Ownership type and chain

affiliation

Ownership type refers to the type of

organization that controls and operates

the home health or hospice care agency,

and has three categories:

1.	 Proprietary

2.	 Voluntary nonprofit

3.	 Government and other ownership

Proprietary or for-profit means operated

under private commercial ownership,

including individual or private

ownership, partnerships, or corporations.

Voluntary nonprofit means operated

under voluntary or nonprofit auspices,

including church-related and nonprofit

corporations. Government and other

means operated under federal, state, or

local government and other auspices not

specified.

Chain affiliation has two categories:

1.	 Part of a chain of agencies

2.	 Not part of a chain of agencies

A chain agency is defined as an agency

that is part of a group of agencies

operating under one corporate authority

or corporate ownership.

Medicare and Medicaid

certification status

There are four certification statuses:

1.	 Certified as a Medicare home health

care agency

2.	 Medicare-certified hospice care

agency

3.	 Certified in the Medicaid program as

a home health care agency

4.	 Medicaid-certified hospice care

agency

A mixed agency could have all four

statuses. If a certification status was

pending, the agency was coded as not

certified for the analyses in this report.

Geographic location

Geographic region has four

categories corresponding to the U.S.

Census Bureau’s four geographic

regions:
National Health Statistics Reports n Number 30 n November 9, 2010 Page 3

1. Northeast

2. Midwest

3. South

4. West

Another variable in the 2007 NHHCS is

related to the metropolitan statistical

area (MSA) status of the agency

location:

1. MSA

2. Micropolitan statistical area

3. Neither

Definition and titles of MSAs are

established by the U.S. Office of

Management and Budget (OMB).

Generally, a MSA consists of a county

or group of contiguous counties that

contains at least one urbanized area of

50,000 or more population. It may also

contain other counties that are

economically and socially integrated

with the central county as measured by

commuting. In contrast, a micropolitan

statistical area refers to a

nonmetropolitan county or group of

contiguous nonmetropolitan counties

that contains an urban cluster of 10,000

to 49,999 persons. It may include

surrounding counties if there are strong

economic ties between the counties,

based on commuting patterns.

In NHHCS data collection years

prior to 2007, two categories were used:

MSA and non-MSA. In the analysis of

NHHCS across years, the categories of a

micropolitan statistical area and neither

in the 2007 survey were combined and

recoded as non-MSA.

Number of current patients

In all NHHCS years, a respondent

was asked to provide the number of

home health and hospice care patients

that the agency was serving at the time

of the interview.

Primary referral source

Questions on primary patient

referral sources were newly added to the

2007 NHHCS. Response categories for

referral sources were hospital, nursing

home, physician’s office, outpatient

medical or surgical center, rehabilitation

facility, and the patient or family, among

others. In this report, because of small

sample sizes, estimates for categories

other than hospital and physician’s

office are not reported.

Electronic medical records

(EMRs)

A number of questions on EMRs

were included in the 2007 NHHCS. The

definition of EMRs was designed to

include only ‘‘a computerized version of

the patient’s medical information used in

the management of the patient’s health

care,’’ and to exclude ‘‘electronic

records used only for billing purposes

and required documentation, such as

OASIS (Outcome and Assessment

Information Set) files.’’ Questions on the

availability and use of different

components of EMRs were also added

in the 2007 survey. In the 2000

NHHCS, although one question was

included asking respondents if the

agency had computerized medical

records, the definition of ‘‘computerized

medical records’’ was not provided and

did not articulate the exclusion of

systems used only for billing or OASIS.

Findings on EMRs described in this

report are based on the 2007 NHHCS

data only.

Patient care revenue

In the 2007 NHHCS, the agency

was asked to indicate approximately

what percentage of the agency’s patient

revenue falls into the following five

categories:

1. Medicare

2. Medicaid

3. Private health insurance program

4. Patient out-of-pocket payments

5. Other

The question wording noted that

percentages provided should add to

100%.

Services provided

In the 2007 and previous NHHCS

years, respondents were asked whether

the agency provided a variety of

services. Questions on the following

services were worded in the same

manner: bereavement counseling,

continuous home care, dietary and

nutritional services, durable medical

equipment and supplies, (medical) social

services, occupational therapy, personal

care (i.e., assistance with activities of

daily living), physical therapy, physician

services, referral services, respite care,

skilled nursing services, speech therapy

or audiology, transportation services,

and volunteer services. See the

‘‘Technical Notes’’ for definitions of the

different services used in this report.

In 2007, respondents were asked if

the agency provided pastoral or spiritual

care. In NHHCS years prior to 2007, the

provision of pastoral care and spiritual

care was asked in two separate

questions. Responses to pastoral care

and spiritual care questions in 1996 and

2000 surveys were recoded to indicate if

the agency offered either of the services

in a given year. In the 1996 NHHCS,

respondents were asked if the agency

provided either companion services or

homemaker services. For 2000 and

2007, the provision of companion

services was asked separately from the

provision of homemaker services.

Responses to companion services and

homemaker services for these 2 years

were recoded to indicate whether the

agency provided either of the services in

a given survey year.

For the 1996, 2000, and 2007 data,

if the respondent reported that the

agency provided a given service, it was

coded as ‘‘yes, the agency provides the

service.’’ In the 1996 NHHCS, no

distinction was made between ‘‘no, the

agency does not provide the service,’’

and nonresponses (e.g., ‘‘don’t know,’’

‘‘refused’’). Responses of ‘‘no’’ in 1996,

thus, include both actual ‘‘no’’ responses

and nonresponses. In 2000 and 2007,

distinctions were made between ‘‘no’’

responses and nonresponses.

Data analysis

All analyses were performed in

SAS-callable SUDAAN (20) to account

for sampling weights and the complex

sampling design. Chi-square tests and

t-tests were used to test for significance

at the p<0.05 level. No adjustments

were made for multiple comparisons.

The difference between any two

estimates is mentioned in the text only
Page 4 National Health Statistics Reports n Number 30 n November 9, 2010

if it is statistically significant. However,

if a comparison is not made or

mentioned, it does not mean it is not

significant. Otherwise, terms such as

‘‘similar’’ or ‘‘no significant

differences’’ are used to denote that the

estimates being compared are not

statistically significantly different. A

weighted least squares technique was

used (21) to test linear trends across 3

survey years. A downward or upward

trend is mentioned if it is statistically

significant.

There were cases in 1996 and 2000,

but not in 2007, in which agency type

was missing due to missing data on

either current home health or hospice

care patient numbers; 0.2% of cases in

1996 and 6.3% of cases in 2000. Cases

missing agency type were not included

in the analyses by agency type.

Numbers of agencies by agency type do

not sum to the total number of home

health and hospice care agencies

because of rounding.

Nonresponses (e.g., ‘‘don’t know,’’

‘‘refused’’) were excluded when

calculating estimates for continuous

variables (e.g., number of home health

care patients or percentage of agency’s

patient care revenue from Medicare).

The percentage of cases with

nonresponses for continuous variables

ranged from 0.02% for the number of

current home health patients in 2007 to

9.2% for the percentage of agency’s

patient care revenue from private health

insurance program in 2007. For

categorical variables, nonresponses were

recoded as unknown and included in the

analyses. The percentage of cases with

nonresponses for categorical variables

ranged from 0.1% for service provision

variables (e.g., the provision of skilled

nursing services) in 2000 to

approximately 4.4% for agency’s

Medicare certification status as a

hospice care agency in 2007.

Results

Home health and hospice

care agencies in 2007

In 2007, there were 12,300 home

health care agencies, that is, home

health care only and mixed agencies

combined. There were 3,700 hospice

care agencies, including both hospice

care only and mixed agencies, in 2007

in the United States (Table 1). More

than two-thirds of all agencies providing

home health care were proprietary

(69.7%), not part of a chain of agencies

(69.5%), and were certified under

Medicare (81.6%) or Medicaid (80.7%).

Approximately one-half of agencies

providing home health care were located

in the South (50.3%) and 73.6% were in

a MSA. About one-third (34.0%) of all

agencies providing hospice care were

proprietary. The rest were owned by

either voluntary nonprofit organizations

(55.5%) or government and other

entities (10.6%). Over three-quarters

(76.3%) of agencies providing hospice

care were not part of a chain. A majority

were certified as a hospice care agency

under Medicare (93.4%) or Medicaid

(86.4%). About 44.5% of hospice care

agencies were located in the South and

66.8% in a MSA.

Home health and hospice

care agencies in 2007, by

agency type

Number of agencies by agency

type

In 2007, there were 14,500 home

health and hospice care agencies in the

United States (Table 2); 74.8% of these

agencies provided home health care

services only, 15.3% provided hospice

care services only, and 9.9% were

mixed agencies that provided both home

health and hospice care services.

Organizational characteristics

Ownership type and chain

affiliation

A little over three-quarters (75.5%)

of home health care only agencies were

proprietary, while 25.6% of mixed

agencies were proprietary. More than

three-fifths (62.9%) of mixed agencies

were owned by voluntary nonprofit

organizations. In 2007, 32.2% of home

health care only agencies were part of a

chain while only 17.6% of mixed

agencies were part of a chain of

agencies.

When hospice care only and mixed

agencies were compared, no significant

differences were found in ownership

type and chain affiliation.

Medicare and Medicaid

certification

Nearly all mixed agencies were

certified as a home health care agency

by Medicare (97.6%) and Medicaid

(96.6%), whereas close to four-fifths of

home health care only agencies were

certified as a home health care agency

under Medicare (79.5%) and Medicaid

(78.6%).

When hospice care only and mixed

agencies were compared on certification

status as a hospice care agency, no

significant differences were found in the

Medicare (90.9% compared with 97.2%)

or Medicaid (82.8% compared with

91.9%) certification status.

Geographic location

More than one-half of home health

care only agencies (53.9%) were located

in the South and in a MSA (75.7%). In

contrast, mixed agencies were more

likely to be about evenly distributed

across the four geographic regions and

more likely to be located in non-MSAs

than home health care only agencies

(42.0% compared with 24.3%).

Similarly, hospice care only

agencies were more likely than mixed

agencies to be located in the South

(58.1% compared with 23.4%) and in a

MSA (72.5% compared with 58.0%)

Number of current patients

Home health care only agencies had

109.0 current home health care patients

on average at the time of the interview

while mixed agencies provided home

health care services to 177.7 current

patients (Table 3). Hospice care only

agencies, on the other hand, reported

serving nearly twice as many current

hospice care patients as mixed agencies;

hospice care only agencies were serving

78.1 patients on average at the time of

the interview, while mixed agencies

were serving 39.1 hospice care patients.

The number of current patients was

broken into five categories (i.e., 0–25,

26–50, 51–100, 101–150, 151 or more)
Home health and hospice 

care (mixed) 

Home health care only 

Percent 

67.0 

89.5 

74.1 

89.8 

63.1 

93.3 

37.8 

56.6 56.0 

1

13.6 

100 

80 

60 

40 

20 

0 

Speech therapy Occupational Medical Homemaker Durable medical 

or audiology therapy social services or companion equipment and 

services supplies 

1

Estimate does not meet standards of reliability or precision because the sample size is between 30 and 59, or the sample 

size is greater than 59 but has a relative standard error of 30 percent or more. 

NOTES: All differences between home health care only and mixed agencies are significant at p<0.05. Percentages are 

based on the unrounded numbers. Denominator includes unknowns. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007. 

National Health Statistics Reports n Number 30 n November 9, 2010 Page 5

and compared by agency type. More

mixed agencies (37.4%) provided

services to 151 or more current home

health care patients on average than did

home health care only agencies (23.0%).

Compared with 51.6% of hospice care

only agencies, the overwhelming

majority of mixed agencies (82.1%)

were serving on average 50 or fewer

hospice care patients at the time of the

interview.

Services provided

Home health care agencies provide

a range of medical and therapeutic

services (e.g., skilled nursing services,

physical therapy, occupational therapy,

medical social services, or home health

aide services) as well as other

nonmedical services (e.g., homemaker or

companion services) delivered at a

patient’s home or in a residential setting

such as assisted living on an intermittent

or part-time basis.

Home health care only agencies in

2007 were less likely than mixed

agencies to provide speech therapy or

audiology (67.0% compared with

89.5%), occupational therapy (74.1%

compared with 89.8%), medical social

services (63.1% compared with 93.3%),

homemaker or companion services

(37.8% compared with 56.6%), and

durable medical equipment and supplies

(13.6% compared with 56.0%)

(Figure 1). No significant differences

were found between home health only

and mixed agencies relative to the

provision of skilled nursing services,

physical therapy, personal care,

transportation services, and referral

services.

Hospice care services are often

categorized as core and noncore services

based on federal regulations (22). Core

services include skilled nursing services,

physician services, volunteer services,

dietary and nutritional services, spiritual

care, counseling (including bereavement

care), and medical social services.

Noncore services are therapeutic

services (e.g., physical therapy,

occupational therapy, and speech

therapy), continuous home care, respite

care, personal care, homemaker services,

Figure 1. Selected services offered by agencies providing home health care only and

agencies providing home health and hospice care (mixed): United States, 2007

and durable medical equipment and

supplies.

In 2007, hospice care only agencies

were more likely to provide both

selected core and noncore services

compared with mixed agencies:

physician services (91.7% compared

with 48.3%), pastoral or spiritual care

(94.3% compared with 88.9%),

volunteer services (93.6% compared

with 87.9%), bereavement counseling

(94.1% compared with 90.7%),

continuous home care (78.3% compared

with 56.5%), respite care (92.9%

compared with 84.3%), homemaker or

companion services (74.3% compared

with 56.6%), and durable medical

equipment and supplies (92.8%

compared with 56.0%) (Figure 2). There

were no significant differences between

hospice care only and mixed agencies

providing skilled nursing services,

dietary and nutritional services, medical

social services, physical therapy, speech

therapy or audiology, occupational

therapy, and personal care.

Primary referral source

Hospital was the primary referral

source of home health care patients for

74.3% of mixed agencies, while only

40.1% of home health care only

agencies reported hospital as their

primary patient referral source

(Figure 3).

For more than three-quarters of

hospice care only and mixed agencies,

hospital (33.3% and 40.4%) and

physician’s office (44.4% and 48.2%)

were primary referral sources of hospice

care patients; the difference between

hospice care only and mixed agencies

was not statistically significant.

Electronic medical records

Less than one-half (41.0%) of home

health and hospice care agencies

reported having EMRs at the time of the

interview (Figure 4). Compared with

36.6% among home health care only,

62.6% of mixed agencies had EMRs.

Among agencies with current

EMRs, a substantial majority used

EMRs to manage patient demographics
Physician services 

Pastoral or 

spiritual care 

Volunteer services 

Bereavement counseling 

Continuous 

home care 

Respite care 

Homemaker or 

companion services 

Durable medical 

equipment and supplies 

0 20 40 60 80 100 

91.7 

48.3 

94.3 

88.9 

87.9 

94.1 

90.7 

78.3 

56.5 

92.9 

84.3 

74.3 

56.6 

92.8 

56.0 

93.6 

Hospice care only 

Home health and hospice 

care (mixed) 

Percent 

NOTES: All differences between hospice care only and mixed agencies are significant at p<0.05. Percentages are based on the unrounded numbers. Denominator includes unknowns. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007. 

Page 6 National Health Statistics Reports n Number 30 n November 9, 2010

Figure 2. Selected services offered by agencies providing hospice care only and agencies providing home health and hospice care Percent 

Hospital Physician's office 

0 

20 

40 

60 

80 

100 

Home health care only Home health and hospice care (mixed)

1

40.1 

31.7 

74.3 

23.1 

1

Significantly different from mixed agencies (p<0.05). 

NOTES: Percentages are based on the unrounded numbers. Denominator includes unknowns. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007. 

Figure 3. Selected primary referral sources of home health care patients, by agency type:

United States, 2007

(mixed): United States, 2007

(98.5%) and for clinical notes (82.7%).

More than one-half of agencies with

EMRs utilized EMR components such

as a Clinical Decision Support System

(CDSS) for contraindications, allergies,

and guidelines (56.6%), and

Computerized Physicians Order Entry

(CPOE) (52.1%) (Figure 5). Less than

one-quarter of agencies with current

EMRs reported using components for

test reminders (22.6%), viewing test

results (20.1%), or sharing medical

records electronically with other

agencies (8.9%). Comparison by agency

type in usage of the different EMR

components was not done due to small

sample sizes.

Patient care revenue

In 2007, at least 90% of the U.S.

home health and hospice care agencies’

patient care revenues, regardless of

agency type, were from Medicare,

Medicaid, and private health insurance

programs (Figure 6). On average, more

than one-half of home health care only

agencies’ (55.7%) and mixed agencies’

(65.7%) patient care revenues were from

Medicare; this difference was not

statistically significant. A higher

percentage of home health care only

agencies’ (22.4%) patient care revenues

were from Medicaid compared with

mixed agencies (10.3%).

On average, 81.0% of hospice care

only agencies’ patient care revenues

were from Medicare, while a much

lower percentage was reported for

mixed agencies (65.7%). Compared with

hospice care only agencies (6.7%), a

higher percentage of mixed agencies’

(10.3%) patient care revenues were from

Medicaid. Payments with private health

insurance accounted for 17.1% of mixed

agencies’ total patient care revenues,

while only 5.1% of hospice care only
National Health Statistics Reports n Number 30 n November 9, 2010 Page 7 Percent 

Currently having EMRs 

0 

20 

40 

60 

80 

100 

Home health and 

hospice care (mixed) 

Hospice 

care only 

Home health 

care only 

All agencies 

1

Significantly different from mixed agencies (p<0.05). 

NOTES: Electronic medical records (EMRs) include only “a computerized version of the patient’s medical information used 

in the management of the patient’s health care,” and exclude “electronic records used only for billing purposes and required 

documentation, such as (Outcome and Assessment Information Set) OASIS files.” Percentages are based on the 

unrounded numbers. Denominator includes unknowns. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007. 

41.0 

48.6 

62.6 

1

36.6 

Figure 4. Prevalence of agencies currently having electronic medical records, by agency

type: United States, 2007

NOTES: EMR is an electronic medical record. Percentages in this figure are calculated using only respondents with EMRs 

who responded they used the EMR capability. Percentages are based on the unrounded numbers. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007. 

98.5 

82.7 

56.6 

52.1 

22.6 

20.1 

8.9 

0 20 40 60 80 100 

Sharing medical records 

electronically with other agencies 

Test results 

Electronic reminders for tests 

Computerized Physicians 

Order Entry (CPOE) 

Clinical Decision Support 

System (CDSS) 

Clinical notes 

Patient demographics 

Percent 

EMR components 

Figure 5. Usage of different electronic medical record components among home health

and hospice care agencies with current electronic medical records: United States, 2007

agencies’ revenues were from private average percentage of revenues from

health insurance. patient out-of-pocket payments and

No significant differences were other sources.

found between different agency types in

Home health care only,

hospice care only, and

mixed agencies from 1996 to

2007

Number of agencies

The number of home health and

hospice care agencies in the United

States has fluctuated over the years. It

declined from 13,500 in 1996 to 11,400

in 2000 but since 2000, the number has

increased and, by 2007, there were as

many as 14,500 home health and

hospice care agencies in the United

States.

Number of agencies by agency

type

The number of home health care

only agencies followed a similar pattern

(Figure 7), decreasing between 1996 and

2000 and experiencing sizeable growth

between 2000 and 2007 as an

overwhelming majority of agencies in

the home health and hospice care sector

in the United States were those that

provided home health care only.

The number of hospice care only

agencies stayed relatively unchanged

between 1996 and 2000. However,

between 2000 and 2007, it grew as did

home health care only agencies.

Between 1996 and 2007, there was close

to a 70% increase in the number of

hospice care only agencies. Mixed

agencies did not experience significant

changes in numbers during 1996–2007.

Hospice care only and mixed agencies

accounted for less than 20%,

respectively, of all home health and

hospice care agencies in 1996, 2000,

and 2007.

Changes in organizational

characteristics of home health

care only agencies

Ownership type and chain

affiliation

In 2007, 75.5% of home health care

only agencies were proprietary. This was

a significant increase from 1996 and

2000 (Table 4). Between 2000 (53.3%)

and 2007 (75.5%), the percentage of

proprietary home health care only
0 

20 

40 

60 

100 

Page 8 National Health Statistics Reports n Number 30 n November 9, 2010

There was a downward trend in the

percentage of Medicaid-certified home

health care only agencies during

1996–2007. Compared with 84.6% in

1996, 78.6% of home health care only

agencies were Medicaid-certified in

2007.

Geographic location

No significant changes were noted

during 1996–2007 relative to the

percentage of home health care only

agencies located in the Northeast and

the West. There was an increasing trend

in the percentage of home health care

only agencies located in the South and

in a MSA. By 2007, 53.9% of home

health care only agencies were located

in the South and 75.7% were located in

a MSA. A decreasing trend, on the other

hand, was observed in the percentage of

home health care only agencies located

in the Midwest.

Number of current home health

care patients

Compared with 1996, home health

care only agencies in 2000 and 2007

were serving fewer patients on average

at the time of the interview (Table 5).

Home health care only agencies were

serving about 53 fewer patients on

average at the time of the interview in

2007 than in 1996.

Changes in organizational

characteristics of hospice care

only agencies

Ownership type and chain

affiliation

Close to two-fifths (39.4%) of

hospice care only agencies were

proprietary in 2007, which was a

significant increase from 21.5% in 2000

(Table 6). In contrast, the percentage of

voluntary nonprofit hospice care only

agencies declined by approximately 30%

between 2000 and 2007 (from 71.5% to

50.7%).

Between 1996 and 2000, no

significant changes were observed

relative to the percentage of chainaffiliated hospice care only agencies. In

2007, however, a smaller proportion of

Other sources 

Out-of-pocket 

payments 

80 

Percent 

55.7 

1

22.4 

12.3 1

6.7 

5.8 

3.0 

1

81.0 

65.7 

10.3 

3.6 5.4 3.4

17.1 

1

5.1 1.3 

Private health 

insurance 

Medicaid 

Medicare 

Home health Hospice Home health and 

care only care only hospice care (mixed) 

1

Significantly different from mixed agencies (p<0.05). 

NOTE: Percentages in this figure are calculated using only respondents who reported the percentage of agency's patient 

care revenue by different payment source. Percentages may not add to totals because of rounding. Percentages are based 

on the unrounded numbers. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007. 

Figure 6. Patient care revenue, by revenue source and agency type: United States, 2007 Percent 

0 

3,000 

6,000 

9,000 

12,000 

15,000 

1996 2000 2007

Total 

Home health care only 

Home health and hospice care (mixed) 

Hospice care only 

NOTES: Total includes agencies with unknown agency type in 1996 and 2000. There was no unknown agency type in 2007. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 1996, 2000, and 2007. 

Figure 7. Number of home health and hospice care agencies, by year and agency type:

United States, 1996–2007

agencies grew by approximately 42%,

while the proportion of home health

care only agencies owned by voluntary

nonprofit organizations, and government

and other entities fell by 46% (from

33.6% to 18.3%) and 51% (from 12.8%

to 6.3%), respectively (Figure 8).

During 1996–2007, there was a

downward trend in the percentage of

home health care only agencies

affiliated with a chain of agencies.

About 32.2% of home health care only

agencies were part of a chain in 2007,

which was significantly lower than the

percentage reported in 1996 (50.9%) and

2000 (46.6%).

Medicare and Medicaid

certification

The percentage of Medicarecertified home health care only agencies

declined from 87.4% in 1996 to 78.3%

in 2000, and remained relatively stable

thereafter.
National Health Statistics Reports n Number 30 n November 9, 2010 Page 9

Percent 

Proprietary 

Government and other 

Voluntary nonprofit 

1

Estimate does not meet standards of reliability or precision because the sample size is between 30 and 59, or the sample size is greater than 59 but has a relative standard error of 

30 percent or more. 

NOTES: Percentages may not add to totals because of rounding, and because percent distribution includes a category of unknowns not reported in the figure. Percentages are based 

on the unrounded numbers. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 1996, 2000, and 2007. Year 

0 20 40 60 80 100 

1996 

2000 

2007 75.5 

53.3 

18.3 1

6.3 

12.8 

1

11.4 

33.6 

61.7 26.9

Figure 8. Ownership type of agencies providing home health care only, by year: United States, 1996–2007

hospice care only agencies was part of a

chain of agencies (27.6%) compared

with 2000 (43.2%).

Medicare and Medicaid

certification

In 1996, of hospice care only

agencies, 60.7% were Medicare-certified

and 50.9% were Medicaid-certified. In 4

years, the percentage of Medicarecertified hospice care only agencies rose

by 58%, and was stable at

approximately 93% between 2000 and

2007. The percentage of Medicaidcertified hospice care only agencies

followed a similar trend, growing

considerably between 1996 and 2000

and remaining relatively unchanged

between 2000 (89.1%) and 2007

(82.8%).

Geographic location

With the exception of the Midwest,

during 1996–2007, changes were

observed in the percentage of hospice

care only agencies located in all other

regions. The percentage of hospice care

only agencies located in the Northeast

decreased from 29.7% in 1996 to 12.3%

in 2007. In contrast, there was a rising

trend in the percentage of hospice care

only agencies located in the South; close

to three-fifths (58.1%) of hospice care

only agencies were located in the South

in 2007, which was a significant

increase from 38.1% in 1996 and 39.3%

in 2000. Compared with 1996, the

percentage of hospice care only agencies

located in the West also increased by

approximately 92% in 2000 (from 9.2%

to 17.7%).

During 1996–2007, no significant

changes were observed in the percentage

of hospice care only agencies located in

a MSA; about 7 out of 10 hospice care

only agencies were located in a MSA

during this time period.

Number of current hospice care

patients

During 1996–2007, there was an

upward trend in the average number of

patients that hospice care only agencies

were serving at the time of the interview

(Table 5). In 1996, hospice care only

agencies were serving fewer than 30

patients on average at the time of the

interview. Compared with 1996, the

average number of patients that hospice

care only agencies were serving at the

time of the interview doubled (53.7

patients) by 2000 and almost tripled

(78.1 patients) by 2007.

Changes in organizational

characteristics of mixed

agencies

Ownership type and chain

 affiliation

During 1996–2007, the ownership

status of mixed agencies was relatively

stable (Table 7); less than 30% of mixed

agencies were proprietary, while more

than 60% were owned by voluntary

nonprofit organizations, and government

and other entities.

In 2007, 17.6% of mixed agencies

were chain-affiliated. This was a

significant decrease from 1996 (32.8%)

and 2000 (41.4%). Conversely, the

proportion of mixed agencies that were

not affiliated with a chain grew by 41%

between 2000 and 2007.

Medicare and Medicaid

certification

During 1996–2007, there was an

upward trend in the percentage of mixed

agencies certified by Medicare as a

home health care agency; by 2007,

97.6% of mixed agencies were

Medicare-certified. In contrast, no

significant changes were observed in the

percentage of mixed agencies certified

by Medicaid as home health care
Page 10 National Health Statistics Reports n Number 30 n November 9, 2010

agencies; 94.2% in 1996, 93.4% in

2000, and 96.6% in 2007.

The percentage of mixed agencies

that were Medicare- or Medicaidcertified as hospice care agencies also

experienced considerable growth over

the years. Although there was no

significant change between 1996 and

2000, the percentage of mixed agencies

that were certified by Medicare to

provide hospice care increased from

86.0% in 2000 to 97.2% in 2007. An

increasing trend was observed in the

percentage of mixed agencies certified

by Medicaid as hospice care agencies

during 1996–2007; compared with 1996,

the percentage of mixed agencies that

were certified as hospice care agencies

grew by approximately 20% in 2007

(from 76.5% to 91.9%).

Geographic location

There was a decreasing trend in the

percentage of mixed agencies located in

the South, while an increasing trend was

observed in the percentage of mixed

agencies located in the West. No

significant changes were observed in the

percentages of mixed agencies located

in other geographic regions. About

69.5% of mixed agencies were located

in a MSA in 1996. In 4 years, the

proportion of mixed agencies in a MSA

declined by more than 25% (to 51.1%),

and remained fairly stable between 2000

and 2007.

Number of current patients

The number of home health care

patients that mixed agencies were

serving on average at the time of the

interview declined from 290.2 patients

in 1996 to 149.0 patients in 2000

(Table 5). Although no significant

changes were observed between 2000

and 2007, compared with 1996, mixed

agencies were serving approximately

113 fewer home health care patients in

2007.

During 1996–2007, no significant

changes were observed in the number of

hospice care patients that mixed

agencies were serving; on average at the

time of the interview mixed agencies

were serving fewer than 40 hospice care

patients.

Changes in services provided

by home health care only

agencies

During 1996–2007, no significant

changes were observed in the

percentages of home health care only

agencies providing skilled nursing

services and occupational therapy

(Table 8). In any given survey year, for

example, at least 9 out of 10 home

health care only agencies provided

skilled nursing services, and more than

three-fifths offered occupational therapy.

Declines, on the other hand, were

noted in the percentage of home health

care only agencies providing physical

therapy, speech therapy or audiology,

medical social services, personal care,

homemaker or companion services,

transportation services, referral services,

and the provision of durable medical

equipment and supplies.

The percentage of home health care

only agencies providing physical therapy

decreased by approximately 10%

between 1996 and 2000 and remained

fairly stable between 2000 and 2007—

84.6% in 1996, 76.2% in 2000, and

77.4% in 2007.

The percentage of home health care

only agencies providing speech therapy

or audiology followed a similar pattern,

declining from 78.5% in 1996 to 68.4%

in 2000 with no significant change

between 2000 and 2007.

There was a decreasing trend in the

percentage of home health care only

agencies providing medical social

services during 1996–2007.

The percentage of home health care

only agencies providing personal care

also experienced a downward trend

between 1996 and 2007; it declined

continuously from 92.0% in 1996 to

82.5% in 2007.

Almost two-fifths (37.8%) of home

health care only agencies provided

either homemaker or companion

services in 2007. This was the lowest

percentage reported during 1996–2007,

and a significant decline from 50.6% in

1996 and 56.8% in 2000.

During 1996–2007, a downward

trend was observed in the percentage of

home health care only agencies

providing transportation services. There

was a decreasing trend in the percentage

of home health care only agencies that

provided referral services over the years;

it declined from 83.5% in 1996 to

62.5% in 2000 and to 44.8% in 2007.

Overall there was a decline of about

46% between 1996 and 2007.

The percentage of home health care

only agencies that offered durable

medical equipment and supplies also

experienced a downward trend during

1996–2007. Compared with 1996, the

proportion of home health care only

agencies providing durable medical

equipment and supplies fell by close to

60% in 2007 (from 33.9% to 13.6%).

Changes in services provided

by hospice care only agencies

Core hospice care services

The percentage of hospice care only

agencies providing skilled nursing

services declined from 93.5% in 1996 to

88.0% in 2000 and remained steady

thereafter (Table 9).

For all other core services, the

proportion of hospice care only agencies

that reported providing these services

increased between 1996 and 2000; the

proportion of agencies providing these

core services remained fairly stable

between 2000 and 2007. In 2000 and

2007, over 90% of hospice care only

agencies offered pastoral or spiritual

care, volunteer services, bereavement

counseling, and medical social services.

The percentage of hospice care only

agencies that offered physician services

increased during 1996–2007. The largest

increase occurred between 1996 (49.9%)

and 2000 (86.4%) and, by 2007, close to

92% of hospice care only agencies

provided physician services.

The percentage of hospice care only

agencies providing dietary and

nutritional services rose by

approximately 20% between 1996 and

2000 (from 73.1% to 87.8%). The

percentage of hospice care only agencies

that provided pastoral or spiritual care

increased between 1996 (65.8%) and

2000 (99.4%).

The percentage of hospice care only

agencies providing volunteer services

and bereavement counseling also
National Health Statistics Reports n Number 30 n November 9, 2010 Page 11

experienced growth over the years;

between 1996 and 2000, there was an

increase of about 42% and 21%,

respectively—from 69.6% to 99.1% for

volunteer services, and from 82.3% to

99.5% for bereavement counseling. By

2000, almost all hospice care only

agencies provided medical social

services, representing a significant

increase from 85.0% in 1996.

Noncore hospice care services

There were no significant changes

in the percentage of hospice care only

agencies providing physical therapy,

continuous home care, and homemaker

or companion services during 1996–

2007. For instance, at least 6 out of 10

hospice care only agencies offered

continuous home care and homemaker

or companion services, respectively, in

any given survey year. Significant

changes were noted in the provision of

all other noncore services among

hospice care only agencies during

1996–2007.

During 1996–2007, there was an

increasing trend in the percentage of

hospice care only agencies providing

speech therapy or audiology, and

occupational therapy. By 2007, 8 out of

10 hospice care only agencies offered

speech therapy or audiology, and

occupational therapy, respectively.

In 1996, 6 out of 10 hospice care

only agencies provided respite care. By

2000 and 2007, 95.3% and 92.9% of

hospice care only agencies, respectively,

provided respite care.

The percentage of hospice care only

agencies offering durable medical

equipment and supplies increased

between 1996 (59.1%) and 2000

(89.2%). Compared with 1996, there

was an increase of about 57% in 2007.

By 2007, close to 92.8% of hospice care

only agencies offered this service.

Relative to personal care, on the

other hand, a decreasing trend was

observed in the percentage of hospice

care only agencies offering these

services; there was about a 2.3%

decrease between 1996 and 2007 (from

92.4% to 90.3%).

Changes in services provided

by mixed agencies

Mixed agencies provide services

both to home health and hospice care

patients. Hence, Table 10 contains the

services listed in Table 8 for home

health care only agencies and in Table 9

for hospice care only agencies.

During 1996–2007, there were no

significant changes in the percentage of

mixed agencies providing skilled

nursing services, physical therapy,

speech therapy or audiology, medical

social services, physician services,

pastoral or spiritual care, bereavement

counseling, and homemaker or

companion services (Table 10). In any

given survey year, more than 80% of

mixed agencies provided skilled nursing

services, physical therapy, speech

therapy or audiology, medical social

services, pastoral or spiritual care, and

bereavement counseling.

Although the percentage of mixed

agencies offering physician services

increased from 37.8% in 1996 to 50.3%

in 2000, this increase was not

statistically significant. With no

significant changes, about one-half or

more of mixed agencies provided

homemaker or companion services in

any given survey year during 1996–

2007.

During 1996–2007, an upward trend

was observed in the percentage of

mixed agencies offering occupational

therapy, dietary and nutritional services,

volunteer services, and durable medical

equipment and supplies. By 2007, over

four-fifths of mixed agencies offered

occupational therapy (89.8%) and

dietary and nutritional services (87.7%).

The percentage of mixed agencies

providing volunteer services increased

by about 9% between 1996 and 2007

(from 81.0% to 87.9%). The percentage

of mixed agencies that provided durable

medical equipment and supplies

increased from 49.9% in 1996 to 56.0%

in 2007. The percentage of mixed

agencies that offered respite care also

rose from 73.7% in 1996 to 87.4% in

2000.

At the same time, there were

reductions in the percentage of mixed

agencies providing continuous home

care, personal care, transportation

services, and referral services.

Compared with 1996, the percentage of

mixed agencies providing continuous

home care fell by approximately 26% in

2007 (from 76.6% to 56.5%). The

percentage of mixed agencies providing

personal care fell from 97.2% in 2000 to

82.7% in 2007. The percentage of

mixed agencies that provided

transportation services experienced a

52% decrease between 1996 and 2007

(from 29.1% to 14.0%). In 1996, almost

9 out of 10 mixed agencies provided

referral services. In about 10 years, less

than 60% of the agencies offered

referral services.

Discussion

Of 14,500 home health and hospice

care agencies in 2007, 74.8% were

home health care only agencies while

9.9% were mixed agencies. Significant

differences by agency types relative to

selected organizational characteristics

and the provision of selected services

were found. Home health care only

agencies, compared with mixed

agencies, were more likely to be

proprietary, and were less likely to be

certified by Medicare or Medicaid, and

less likely to have current EMRs. Home

health care only agencies (109.0

patients) were serving fewer home

health care patients than mixed agencies

(177.7 patients) on average at the time

of the interview. Compared with mixed

agencies, a higher percentage of home

health care only agencies’ patient care

revenues was from Medicaid. In

addition, home health care only agencies

were less likely than mixed agencies to

provide certain therapeutic and

nonmedical services.

In 2007, there were 2,200 hospice

care only agencies, accounting for

15.3% of all home health and hospice

care agencies in the United States. No

significant differences were observed

between hospice care only and mixed

agencies relative to ownership type,

chain affiliation, and certification status.

On the other hand, hospice care only

agencies (78.1 patients) were serving

nearly twice as many hospice care

patients as mixed agencies (39.1
Page 12 National Health Statistics Reports n Number 30 n November 9, 2010

patients) on average at the time of the

interview. Hospice care only agencies

compared with mixed agencies reported,

on average, a higher percentage of their

total patient care revenues from

Medicare, and lower percentages from

Medicaid and private health insurance

programs. Consistent with previous

findings (23), hospice care only agencies

were more likely than mixed agencies to

provide many core and noncore services.

Although over three-quarters

(75.5%) of home health care only

agencies in 2007 were for-profit or

proprietary establishments, this has not

always been the case. According to data

from the 1996, 2000, and 2007 NHHCS,

the number of home health care only

agencies was the lowest in 2000, of

which only a little over one-half were

proprietary. The growth in proprietary

establishments is, however, not limited

to home health care only agencies.

Although less than one-half of hospice

care only agencies were for-profit in

2007, the percentage of 39.4%

represents a notable increase from

21.5% in 2000. In contrast, the

percentage of for-profit mixed agencies

has remained at about one-quarter or

less between 1996 and 2007.

Many observers attribute the growth

in for-profit home health care agencies

to the changes in the payment

environment associated with the

implementation of the BBA (2,11–

13,24–28). In particular, studies on

Medicare-certified home health care

agencies suggest that the decreases in

the number of agencies and the number

of patients served while undergoing the

two BBA-mandated payment system

changes (i.e., interim payment system in

1997, PPS in 2000) occurred primarily

among for-profit establishments (11,13).

Other sources have shown that

for-profit establishments in both home

health and hospice care sectors have

entered the market in greater numbers

since 2000 (3,11). Our analysis of

NHHCS shows a similar fluctuation

across the years. It also shows that the

fluctuation appears mainly among home

health care only agencies and not among

mixed agencies. The number of mixed

agencies and their ownership status have

remained relatively constant. Among

hospice care only agencies, in addition

to the increasing demand for hospice

care services in recent years, changes in

the Medicare hospice payment system

may have made the hospice market a

more viable enterprise, hence the growth

in the number of hospice care agencies

and the proportion of for-profit agencies

in particular (3,29,30).

The average number of patients

served per home health care only

agency decreased considerably between

1996 and 2000, and stayed fairly

unchanged even when the number of

home health care only agencies

increased between 2000 and 2007. But

this trend is not isolated to home health

care only agencies. The average number

of home health care patients served by

mixed agencies, although it has always

been greater than the average among

home health care only agencies during

1996–2007, also declined between 1996

and 2000. It remained relatively

unchanged thereafter as did home health

care only agencies.

In contrast, the average number of

current hospice care patients served by a

hospice care only agency continuously

increased during 1996–2007. The

number of hospice care patients served

by hospice care only agencies and

mixed agencies was basically similar in

1996. The number of hospice care

patients that mixed agencies served on

average remained fairly constant

between 1996 and 2007, whereas the

typical hospice care only agency had

nearly twice as many current hospice

care patients as the typical mixed

agency by 2007.

Conceivably, the growth in the

number of home health care agencies

over the years could be associated with

a change toward smaller home health

care only agencies whereas the growth

in hospice care agencies, predominately

in hospice care only agencies, could be

related to a change toward larger

agencies. This study cannot depict the

market dynamics that may underlie this

differential change in agency size

between the home health and hospice

care sectors. Additional research could

provide further insights into the

dynamics underlying the changes in the

organizational characteristics of agencies

within the home health care sector and

within the hospice care sector.

The analysis in this report does

suggest, however, that changes in

agency size—as measured by the

average number of patients served at the

time of the interview—may be

associated with changes in services

offered. As the number of home health

care patients served by a home health

care only agency dropped, so did the

proportion of home health care only

agencies offering services such as

personal care, homemaker or companion

services, and durable medical equipment

and supplies. On the other hand, as the

number of patients served by a hospice

care only agency increased, so did the

proportion of hospice care only agencies

providing services such as physician

services, bereavement counseling,

respite care, and durable medical

equipment and supplies among others.

In contrast, among mixed agencies,

agencies for which there was no

significant change in the average

number of hospice care patients served,

there were no changes in the proportion

of agencies offering many services.

Among mixed agencies there were

decreases only in the percentage

offering continuous home care, personal

care, transportation services, and referral

services.

Estimates presented in this report

are based on a large, nationally

representative sample of home health

and hospice care agencies in the United

States. Using data from 1996, 2000, and

2007 NHHCS, changes were examined

in the number of agencies,

organizational characteristics, and

service provision over time. In addition,

this analysis included both Medicarecertified and non-Medicare-certified

agencies, and differentiated agencies that

provided a single type of service (i.e.,

home health care only, hospice care

only) from those that provided both

home health and hospice care, providing

a more complete picture of the U.S.

home health and hospice care sectors.

Despite these strengths, however, there

are several important limitations. First,

the cross-sectional nature of the data

collected in NHHCS precludes

establishing causal links between agency
National Health Statistics Reports n Number 30 n November 9, 2010	 Page 13

characteristics and service provision.

The analysis in this report does not, by

itself, demonstrate direct links among,

for instance, changes in ownership

composition, agency size, and services

provided. Second, for some content,

analyses by agency type were not

conducted due to small sample sizes.

Lastly, this study did not evaluate

changes in case-mix and its association

with changes in organizational

characteristics or service provision,

although service provision would be tied

to the type of patients that the agency

served. As a result, findings in this

report cannot indicate whether the

changes that were found over time in

the organizational characteristics and

services of home health and hospice

care agencies were associated with any

notable changes in the patient

populations served. The findings of this

analysis, therefore, should be considered

as preliminary, suggesting a number of

questions that could be explored in

future research including:

1.	 Does the growth in hospice care

agencies, and the size of hospice

care only agencies, mean an

expansion in the types of patients

served?

2.	 To what extent does the growth in

hospice care simply mean a greater

acceptance and desire to use hospice

care among the terminally ill and

their family members?

3.	 Does the reduction in the size of

home health care only agencies

represent more specialization across

agencies in the types of patients

cared for?

4.	 To what extent does the reduced

patient volume in home health care

only agencies signify a change in the

business model of agencies moving

toward smaller agencies concomitant

with the alteration of the financial

environment associated with the

BBA?

The home health and hospice care

market is not stagnant and, as the

findings in this report reveal, has

undergone noticeable changes over the

past decade. More research is needed to

gain a better understanding of the causes

of variations in organizational

characteristics and service delivery and

their impacts on patient outcomes.

References

1.	 Ogle KS, Mavis B, Wyatt GK.

Physicians and hospice care:

Attitudes, knowledge, and referrals. J

Palliat Med 5:85–92. 2000.

2.	 Murkofsky RL, Alston K. The past,

present, and future of skilled home

health agency care. Clin Geriatr Med

25:1–17. 2009.

3.	 MedPac. Chapter 12. Other services:

Dialysis, hospice, clinical laboratory.

Available from: http://

www.medpac.gov/chapters/

Jun09DataBookSec12.pdf. Accessed

October 12, 2009.

4.	 MedPac. Chapter 9. Post-acute care.

Available from: http://www.medpac.

gov/Chapters/Jun09DataBook

Sec9.pdf. Accessed October 7, 2009.

5.	 Levine SA, Boal J, Boling PA. Home

care. J Am Med Assoc 290:1203–07.

2003.

6.	 Kane RA. Long-term care and

quality of life: Bringing them closer

together. The Gerontologist 41:293–

304. 2001.

7.	 Barnato A, Herndon MB, Anthony D,

Gallgher PM, Skinner JS, Bynum

JPW, et al. Are regional variations in

end-of-life care intensity explained

by patient preferences? Med Care

45(5):386–93. 2007.

8.	 Teno JM, Clarridge BR, Casey V,

Welch LC, Wetle T, Shield R, et al.

Family perspectives on end-of-life

care at the last place of care. J Am

Med Assoc 291(1):88–93. 2004.

9.	 The Hospice Association of America.

Hospice facts and statistics. March

2008. Available from: http://

www.nahc.org/facts/Hospice

Stats08.pdf. Accessed July 17, 2009.

10. The National Association for Home

Care and Hospice. Basic statistics

about home care: Updated 2008.

Available from: http://www.nahc.org/

facts/08HC_Stats.pdf. Accessed July

17, 2009.

11. Choi S, Davitt JK. Changes in the

Medicare home health care market:

The impact of reimbursement policy.

Med Care 47(3):302–9. 2009.

12. Spector WD, Cohen JW, Pesis-Katz

I. Home care before and after the

Balanced Budget Act of 1997: Shifts

in financing and services. The

Gerontologist 44(1):39–47. 2004.

13. McCall N, Peterson A, Moore S,

Korb J. Utilization of home health

services before and after the

Balanced Budget Act of 1997: What

were the initial effects? Health

Services Research 38(1):85–106.

2003.

14. Dwyer LL, Harris-Kojetin LD,

Branden L, Shimizu IM. Redesign

and Operation of the National Home

and Hospice Care Survey, 2007.

National Center for Health Statistics.

Vital Health Stat 1(53). 2010.

15. Haupt BJ, Jones A. National Home

and Hospice Care Survey: Annual

summary, 1996. National Center for

Health Statistics. Vital Health Stat

13(141). 1999.

16. 1996 National Home Health and

Hospice Care Survey. Scope of

survey. Available from: http://

www.cdc.gov/nchs/nhhcs/

nhhcs_scope.htm#96scope.

17. 1998 National Home Health and

Hospice Care Survey. Scope of

survey. Available from: http://

www.cdc.gov/nchs/nhhcs/

nhhcs_scope.htm#98scope.

18. 2000 National Home Health and

Hospice Care Survey. Scope of

survey. Available from: http://

www.cdc.gov/nchs/nhhcs/

nhhcs_scope.htm#00scope.

19. 2007 National Home Health and

Hospice Care Survey. Survey

documentation. Available from:

http://www.cdc.gov/nchs/data/nhhcsd/

NHHCS_NHHAS_web_documentation.pdf.

20. Research Triangle Institute.

SUDANN (Release 9.0.1). Research

Triangle Park, NC. 2005.

21. Sirken MG, Shimizu BI, French DK,

et al. Manual on standards and

procedures for reviewing statistical

reports. Hyattsville, MD: National

Center for Health Statistics. 1992.

22. Social Security Act—Sec. 1861. [42

U.S.C. 1395x]. Definitions of 

services, institutions, etc.; Hospice 

Care; Hospice Program. Available 

from: http://www.socialsecurity.gov/ 

OP_Home/ssact/title18/1861.htm. 

Accessed July 17, 2009. 

23. Rich SE, Gruber-Baldini AL.

Differences in services provided by

hospices based on home health

agency certification status. Med Care

47:9–14. 2009.
Page 14 National Health Statistics Reports n Number 30 n November 9, 2010

24. Grabowski DC, Stevenson DG,

Huskamp HA, Keating NL. The

influence of Medicare home health

payment incentives: Does payer

source matter? Inquiry 43:135–49.

2006.

25. Murtaugh CM, McCall N, Moore S,

Meadow A. Trends in Medicare

home health care use: 1997–2001.

Health Aff 22(5):146–56. 2003.

26. U.S. General Accounting Office.

Medicare home health agencies:

Closures continue, with little

evidence beneficiary access is

impaired. Washington, DC: General

Accounting Office. 1999.

27. U.S. General Accounting Office.

Medicare home health benefit:

Impact of Interim Payment System

and agency closures on access to

services. Washington, DC: General

Accounting Office. 1998.

28. U.S. General Accounting Office.

Medicare home health care:

Prospective Payment System could

reverse recent declines in spending.

Washington, DC: General Accounting

Office. 2000.

29. Carlson MD, Gallow WT, Bradley

EH. Ownership status and patterns of

care in hospice: Results from the

National Home and Hospice Care

Survey. Med Care 42(5):432–8.

2004.

30. MedPac. Chapter 6. Reforming

Medicare’s hospice benefit. Available

from: http://www.medpac.gov/

documents/Mar09_EntireReport.pdf.

Accessed July 17, 2009.

31. Pearson WS, Bercovitz AR. Use of

computerized medical records in

home health and hospice agencies:

United States, 2000: National Center

for Health Statistics. Vital Health Stat

13(161). 2006.

Table 1. Selected organizational characteristics of home health and hospice care agencies: United States, 2007

Home Hospice

Characteristic health care1 care1

Number (standard error)

All agencies2 ............................................. 12,300 (746) 3,700 (250)

Percent distributions (standard error)

All agencies2 ............................................. 100.0 . . . 100.0 . . .

Ownership

Proprietary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69.7 (3.2) 34.0 (3.9)

Voluntary nonprofit ......................................... 23.5 (2.9) 55.5 (4.0)

Government and other ....................................... 6.9 (1.2) 10.6 (2.9)

Chain affiliation

Part of a chain............................................ 30.5 (3.8) 23.7 (3.3)

Not part of a chain ......................................... 69.5 (3.8) 76.3 (3.3)

Medicare certification status

Certified as home health care agency ............................. 81.6 (4.0) ... ...

Certified as hospice care agency ................................ ... ... 93.4 (2.9)

Medicaid certification status

Certified as home health care agency ............................. 80.7 (3.9) ... ...

Certified as hospice care agency ................................ ... ... 86.4 (3.4)

Geographic region 

Northeast ............................................... 13.5 (3.3) 14.8 (2.5) 

Midwest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.1 (3.2) 22.6 (2.5) 

South ................................................. 50.3 (4.2) 44.5 (4.0) 

West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.1 (2.6) 18.2 (3.3) 

Location

Metropolitan statistical area (MSA)3 ............................... 73.6 (1.9) 66.8 (2.5)

Micropolitan statistical area4 ................................... 13.8 (1.2) 19.5 (1.7)

Neither ................................................ 12.6 (1.2) 13.7 (1.2)

. . . Category not applicable. 1

Include agencies that provide both home health and hospice care services (mixed). 2

Include agencies that provide home health care services, hospice care services, or both types of services, and currently or recently served home health and/or hospice care patients. Agencies 

that provided only homemaker services or housekeeping services, assistance with instrumental activities of daily living (IADLs), or durable medical equipment and supplies were excluded from the 

survey. 3

A metropolitan statistical area is a county or group of contiguous counties that contains at least one urbanized area of 50,000 or more population. May also contain other counties that are 

economically and socially integrated with the central county as measured by commuting. 4

A micropolitan statistical area is a nonmetropolitan county or group of contiguous nonmetropolitan counties that contains an urban cluster of 10,000 to 49,999 persons. May include surrounding 

counties if there are strong economic ties between the counties,based on commuting patterns. 

NOTE: Numbers may not add to totals because of rounding, and/or because estimates and percent distributions include a category of unknowns not reported in the table. Percentages are based 

on the unrounded numbers. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007. 
National Health Statistics Reports n Number 30 n November 9, 2010 Page 15

Table 2. Selected organizational characteristics of home health and hospice care agencies, by agency type: United States, 2007

Home health

Home health Hospice and hospice

Characteristic Total care only care only care (mixed)

Number (standard error)

All agencies1 .............................. 14,500 (769) 10,800 (753) 2,200 (210) 1,400 (145)

Percent distributions (standard error)

All agencies1 .............................. 100.0 . . . 100.0 . . . 100.0 . . . 100.0 . . .

Ownership

Proprietary................................ 65.0 (2.9) 75.5 (3.3) 39.4 (5.6) †25.6 (4.5)

Voluntary nonprofit ........................... 27.6 (2.7) 18.3 (3.0) 50.7 (5.6) 62.9 (4.9)

Government and other ........................ 7.4 (1.3) †6.3 (1.4) * (*) †11.5 (2.1)

Chain affiliation

Part of a chain ............................. 70.0 (3.3) 32.2 (4.3) 27.6 (4.7) †17.6 (4.1)

Not part of a chain ........................... 30.0 (3.3) 67.8 (4.3) 72.4 (4.7) 82.4 (4.1)

Medicare certification status

Certified as home health care agency ............... . . . . . . 79.5 (4.5) . . . . . . 97.6 (1.6)

Certified as hospice care agency .................. . . . . . . . . . . . . 90.9 (4.5) 97.2 (1.7)

Medicaid certification status

Certified as home health care agency ............... . . . . . . 78.6 (4.3) . . . . . . 96.6 (1.6)

Certified as hospice care agency .................. . . . . . . . . . . . . 82.8 (5.3) 91.9 (2.3)

Geographic region

Northeast ................................ 13.4 (2.8) †12.9 (3.7) †12.3 (3.4) 18.8 (3.4)

Midwest ................................. 21.5 (2.8) 21.1 (3.6) 18.2 (3.1) 29.3 (4.1)

South ................................... 51.5 (3.6) 53.9 (4.7) 58.1 (5.2) 23.4 (4.0)

West ................................... 13.7 (2.2) †12.1 (2.8) †11.5 (3.1) 28.6 (6.2)

Location

Metropolitan statistical area (MSA)2 ................ 73.5 (1.7) 75.7 (2.1) 72.5 (2.8) 58.0 (4.5)

Micropolitan statistical area3 ..................... 14.2 (1.1) 12.5 (1.4) 16.9 (1.9) 23.6 (3.3)

Neither .................................. 12.3 (1.0) 11.8 (1.3) 10.7 (1.2) 18.4 (2.5)

. . . Category not applicable.

† Estimate does not meet standards of reliability or precision because the sample size is between 30 and 59, or the sample size is greater than 59 but has a relative standard error of 30 percent or 

more. 

* Estimate does not meet standards of reliability or precision because the sample size is fewer than 30. 1

Include agencies that provide home health care services, hospice care services, or both types of services, and currently or recently served home health and/or hospice care patients. Agencies 

that provided only homemaker services or housekeeping services, assistance with instrumental activities of daily living (IADLs), or durable medical equipment and supplies were excluded from the

survey.

2

A metropolitan statistical area is a county or group of contiguous counties that contains at least one urbanized area of 50,000 or more population. May also contain other counties that are

economically and socially integrated with the central county as measured by commuting. 3

A micropolitan statistical area is a nonmetropolitan county or group of contiguous nonmetropolitan counties that contains an urban cluster of 10,000 to 49,999 persons. May include surrounding 

counties if there are strong economic ties between the counties, based on commuting patterns. 

NOTE: Numbers may not add to totals because of rounding, and/or because estimates and percent distributions include a category of unknowns not reported in the table. Percentages are based

on the unrounded numbers.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007.
Page 16 National Health Statistics Reports n Number 30 n November 9, 2010

Table 3. Home health and hospice care patients served at the time of the interview, by agency type and number of patients:

United States, 2007

Home health Home health and

Number of patients care only hospice care (mixed)

Mean (standard error)

Number of home health care patients .................................. 109.0 (9.2) 177.7 (17.7)

Percent distributions (standard error)

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 . . . 100.0 . . . 

0–25 ..................................................... †16.0 (4.3) †9.8 (2.4) 

26–50 .................................................... †21.3 (4.2) †25.1 (6.4) 

51–100.................................................... 29.0 (4.0) 18.4 (3.1) 

101–150 .................................................... †10.8 (2.3) †9.4 (1.9) 

151 or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.0 (3.5) 37.4 (4.8) 

Home health and

Number of patients Hospice care only hospice care (mixed)

Mean (standard error)

Number of hospice care patients ..................................... 78.1 (6.4) 39.1 (5.7)

Percent distributions (standard error)

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 . . . 100.0 . . . 

0–25....................................................... 29.5 (5.4) 57.6 (5.6) 

26–50 ...................................................... 22.1 (4.9) 24.5 (5.9) 

51–100 ..................................................... 21.2 (4.0) †6.3 (1.4) 

101–150 .................................................... †9.9 (2.5) * (*) 

151 or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . †11.6 (2.3) * (*) 

. . . Category not applicable.

†Estimate does not meet standards of reliability or precision because the sample size is between 30 and 59, or the sample size is greater than 59 but has a relative standard error of 30 percent or 

more. 

* Estimate does not meet standards of reliability or precision because the sample size is fewer than 30. 

NOTE: Unknowns are excluded when calculating estimates. There was 1 (unweighted) case with unknown number of home health care patients, while 19 (unweighted) cases with unknown 

number of hospice care patients. Percentages are based on the unrounded numbers. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007. 
National Health Statistics Reports n Number 30 n November 9, 2010 Page 17

Table 4. Selected organizational characteristics of agencies providing home health care only: United States, 1996, 2000, and 2007

Characteristic 1996 2000 2007

Number (standard error)

Total .................................................. 10,600 (460) 7,600 (324) 10,800 (753)

Percent distributions (standard error)

Total .................................................. 100.0 . . . 100.0 . . . 100.0 . . .

Ownership

Proprietary .............................................. 61.7 (2.8) 53.3 (2.8) 75.5 (3.3)

Voluntary nonrpofit ......................................... 26.9 (2.6) 33.6 (2.7) 18.3 (3.0)

Government and other ....................................... †11.4 (1.9) 12.8 (1.7) †6.3 (1.4)

Chain affiliation

Part of a chain ........................................... 50.9 (2.9) 46.6 (2.8) 32.2 (4.3)

Not part of a chain ......................................... 45.0 (2.9) 52.4 (2.8) 67.8 (4.3)

Medicare certification status

Certified as home health care agency ............................. 87.4 (1.9) 78.3 (2.5) 79.5 (4.5)

Medicaid certification status

Certified as home health care agency ............................. 84.6 (2.2) 80.9 (2.3) 78.6 (4.3)

Geographic region

Northeast ............................................... 13.0 (1.9) 14.4 (1.9) †12.9 (3.7)

Midwest ................................................ 26.8 (2.7) 24.9 (2.2) 21.1 (3.6)

South ................................................. 41.6 (2.9) 46.9 (2.8) 53.9 (4.7)

West .................................................. 18.7 (2.3) 13.7 (1.6) †12.1 (2.8)

Location1

MSA .................................................. 66.8 (2.0) 65.9 (2.1) 75.7 (2.1)

Non-MSA ............................................... 33.2 (2.0) 34.1 (2.1) 24.3 (2.1)

. . . Category not applicable.

† Estimate does not meet standards of reliability or precision because the sample size is between 30 and 59, or the sample size is greater than 59 but has a relative standard error of 30 percent or

more. 1

A metropolitan statistical area (MSA) is a county or group of contiguous counties that contains at least one urbanized area of 50,000 or more population. May also contain other counties that are 

economically and socially integrated with the central county as measured by commuting. 

NOTE: Numbers may not add to totals because of rounding, and/or because estimates and percent distributions include a category of unknowns not reported in the table. Percentages are based

on the unrounded numbers.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 1996, 2000, 2007.
Page 18 National Health Statistics Reports n Number 30 n November 9, 2010

Table 5. Home health and hospice care patients served at the time of the interview, by agency type: United States, 1996, 2000, and 2007

Patients served at the time of interview 1996 2000 2007

Home health care patients Mean (standard error)

Home health care only ....................................... 161.8 (10.8) 114.9 (8.8) 109.0 (9.2)

Home health and hospice care (mixed) ............................ 290.2 (30.2) 149.0 (16.8) 177.7 (17.7)

Hospice care patients

Mean (standard error)

Hospice care only.......................................... 27.5 (3.4) 53.7 (4.6) 78.1 (6.4)

Home health and hospice care (mixed) ............................ 34.9 (12.2) 27.6 (2.5) 39.1 (5.7)

NOTE: Unknowns are excluded when calculating estimates. The (unweighted) number of cases with unknown number of home health care patients ranges from 1 to 28. There were no unknowns

for the number of hospice care patients in 1996 and 2000, respecitvely. There were 19 (unweighted) cases with unknown number of hospice care patients in 2007.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 1996, 2000, 2007.

Table 6. Selected organizational characteristics of agencies providing hospice care only: United States, 1996, 2000, and 2007

Characteristics 1996 2000 2007

Number (standard error)

Total .................................................. 1,300 (145) 1,300 (96) 2,200 (210)

Percent distributions (standard error)

Total .................................................. 100.0 . . . 100.0 . . . 100.0 . . .

Ownership

Proprietary .............................................. †28.0 (5.6) 21.5 (2.9) 39.4 (5.6)

Voluntary nonprofit ......................................... 59.5 (6.3) 71.5 (3.2) 50.7 (5.6)

Government and other ....................................... * (*) * (*) * (*)

Chain affiliation

Part of a chain ........................................... 38.5 (5.2) 43.2 (4.1) 27.6 (4.7)

Not part of a chain ......................................... 59.7 (5.3) 56.0 (4.1) 72.4 (4.7)

Medicare certification status

Certified as hospice care agency ................................ 60.7 (5.9) 95.6 (0.9) 90.9 (4.5)

Medicaid certification status

Certified as hospice care agency ................................ 50.9 (5.7) 89.1 (1.5) 82.8 (5.3)

Geographic region

Northeast ............................................... †29.7 (6.8) †18.8 (4.6) †12.3 (3.4)

Midwest ................................................ 23.0 (4.1) 24.3 (2.9) 18.2 (3.1)

South ................................................. 38.1 (5.0) 39.3 (3.6) 58.1 (5.2)

West .................................................. †9.2 (1.7) 17.7 (2.8) †11.5 (3.1)

Location of agency1

MSA .................................................. 71.5 (3.9) 69.8 (2.7) 72.5 (2.8)

Non-MSA ............................................... 28.5 (3.9) 30.2 (2.7) 27.6 (2.8)

. . . Category not applicable.

† Estimate does not meet standards of reliability or precision because the sample size is between 30 and 59, or the sample size is greater than 59 but has a relative standard error of 30 percent

or more.

* Estimate does not meet standards of reliability or precision because the sample size is fewer than 30. 1

A metropolitan statistical area (MSA) is a county or group of contiguous counties that contains at least one urbanized area of 50,000 or more population. May also contain other counties that are

economically and socially integrated with the central county as measured by commuting.

NOTE: Numbers may not add to totals because of rounding, and/or because estimates and percent distributions include a category of unknowns not reported in the table. Percentages are based

on the unrounded numbers.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 1996, 2000, 2007.
National Health Statistics Reports n Number 30 n November 9, 2010 Page 19

Table 7. Selected organizational characteristics of agencies providing home health and hospice care (mixed): United States, 1996, 2000,

and 2007

Characteristics 1996 2000 2007

Number (standard error)

Total .................................................. 1,600 (188) 1,800 (151) 1,400 (145)

Percent distributions (standard error)

Total .................................................. 100.0 . . . 100.0 . . . 100.0 . . .

Ownership

Proprietary .............................................. †26.9 (5.4) †17.7 (3.5) †25.6 (4.5)

Voluntary nonprofit ......................................... 63.5 (6.3) 66.6 (4.3) 62.9 (4.9)

Government and other ....................................... * (*) * (*) †11.5 (2.1)

Chain affiliation

Part of a chain ........................................... 32.8 (5.3) 41.4 (4.6) †17.6 (4.1)

Not part of a chain ......................................... 65.3 (5.4) 58.3 (4.6) 82.4 (4.1)

Medicare certification status

Certified as home health care agency ............................. 92.0 (2.9) 92.6 (1.8) 97.6 (1.6)

Certified as hospice care agency ................................ 86.2 (4.2) 86.0 (4.3) 97.2 (1.7)

Medicaid certification status

Certified as home health care agency ............................. 94.2 (2.6) 93.4 (1.4) 96.6 (1.6)

Certified as hospice care agency ................................ 76.5 (5.0) 83.3 (4.2) 91.9 (2.3)

Geographic region

Northeast ............................................... †16.3 (3.6) 15.1 (2.8) 18.8 (3.4)

Midwest ................................................ 31.4 (5.7) 32.9 (4.1) 29.3 (4.1)

South ................................................. †32.7 (6.1) 30.6 (4.7) 23.4 (4.0)

West .................................................. †19.7 (4.7) 21.4 (3.6) 28.6 (6.2)

Location of agency1

MSA .................................................. 69.5 (4.4) 51.1 (4.3) 58.0 (4.5)

Non-MSA ............................................... 30.5 (4.4) 48.9 (4.3) 42.0 (4.5)

. . . Category not applicable.

† Estimate does not meet standards of reliability or precision because the sample size is between 30 and 59, or the sample size is greater than 59 but has a relative standard error of 30 percent

or more.

* Estimate does not meet standards of reliability or precision because the sample size is fewer than 30. 1

A metropolitan statistical area (MSA) is a county or group of contiguous counties that contains at least one urbanized area of 50,000 or more population. May also contain other counties that are

economically and socially integrated with the central county as measured by commuting.

NOTE: Numbers may not add to totals because of rounding, and/or because estimates and percent distributions include a category of unknowns not reported in the table. Percentages are based

on the unrounded numbers.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 1996, 2000, 2007.
Page 20 National Health Statistics Reports n Number 30 n November 9, 2010

Table 8. Selected services offered by agencies providing home health care only: United States, 1996, 2000, and 2007

Services provided 1996 2000 2007

Number (standard error)

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,600 (460) 7,600 (324) 10,800 (753)

Percent (standard error)

Skilled nursing services ......................................

Physical therapy...........................................

Speech therapy or audiology ...................................

Occupational therapy........................................

Medical social services ......................................

Personal care ............................................

Homemaker or companion services...............................

Transportation services ......................................

Referral services ..........................................

Durable medical equipment and supplies ...........................

93.6

84.6

78.5

73.2

75.2

92.0

50.6

12.8

83.5

33.9

(1.4)

(2.2)

(2.5)

(2.6)

(2.7)

(1.7)

(3.0)

(1.9)

(2.1)

(2.8)

90.8

76.2

68.4

68.2

67.6

87.7

56.8

12.5

62.5

21.2

(2.2)

(2.7)

(2.8)

(2.8)

(2.7)

(1.9)

(2.8)

(1.9)

(2.7)

(2.3)

95.2

77.4

67.0

74.1

63.1

82.5

37.8

†9.4

44.8

†13.6

(1.8)

(4.4)

(4.6)

(4.4)

(4.8)

(3.5)

(4.5)

(2.1)

(4.6)

(2.9)

† Estimate does not meet standards of reliability or precision because the sample size is between 30 and 59, or the sample size is greater than 59 but has a relative standard error of 30 percent

or more.

NOTE: Percentages are based on the unrounded numbers. Denominator includes unknowns.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 1996, 2000, 2007.

Table 9. Selected services offered by agencies providing hospice care only: United States, 1996, 2000, and 2007

Services provided 1996 2000 2007

Number (standard error)

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,300 (145) 1,300 (96) 2,200 (210)

Core services Percent (standard error)

Skilled nursing services ......................................

Physician services .........................................

Dietary and nutritional services..................................

Pastoral or spiritual care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Volunteer services .........................................

Bereavement counseling .....................................

Medical social services ......................................

93.5

49.9

73.1

65.8

69.6

82.3

85.0

(1.5)

(5.6)

(5.1)

(6.9)

(6.0)

(5.4)

(4.7)

88.0 (2.3)

86.4 (2.5)

87.8 (1.7)

99.4 (0.4)

99.1 (0.3)

99.5 (0.2)

97.8 (0.6)

89.6

91.7

83.4

94.3

93.6

94.1

92.5

(4.2)

(3.8)

(5.9)

(3.9)

(4.1)

(3.9)

(3.9)

Noncore services

Physical therapy...........................................

Speech therapy or audiology ...................................

Occupational therapy........................................

Continuous home care.......................................

Respite care .............................................

Personal care ............................................

Homemaker or companion services...............................

Durable medical equipment and supplies ...........................

81.4

75.4

76.2

64.3

64.2

92.4

65.8

59.1

(4.6)

(5.1)

(5.0)

(6.4)

(6.6)

(1.9)

(5.7)

(6.4)

89.2 (1.6)

80.9 (2.4)

81.0 (2.5)

77.7 (3.1)

95.3 (1.3)

92.4 (4.1)

75.3 (3.3)

89.2 (2.1)

90.9

83.8

87.4

78.3

92.9

90.3

74.3

92.8

(3.9)

(4.1)

(4.0)

(5.2)

(3.9)

(4.1)

(5.4)

(3.9)

NOTE: Percentages are based on the unrounded numbers. Denominator includes unknowns.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 1996, 2000, 2007.
National Health Statistics Reports n Number 30 n November 9, 2010 Page 21

Table 10. Selected services offered by agencies providing home health and hospice care (mixed): United States, 1996, 2000, and 2007

Services provided 1996 2000 2007

Number (standard error)

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,600 (188) 1,800 (151) 1,400 (145)

Percent (standard error)

Skilled nursing services ...................................... 95.9 (3.1) 97.7 (0.6) 95.8 (1.9)

Physical therapy........................................... 93.4 (3.8) 95.4 (1.5) 88.2 (4.1)

Speech therapy or audiology ................................... 93.0 (3.7) 90.4 (2.6) 89.5 (3.1)

Occupational therapy........................................ 86.3 (6.1) 87.0 (4.1) 89.8 (3.0)

Medical social services ...................................... 87.8 (5.9) 93.6 (2.4) 93.3 (2.6)

Physician services ......................................... 37.8 (5.6) 50.3 (4.5) 48.3 (5.3)

Dietary and nutritional services.................................. 71.8 (6.9) 72.0 (4.0) 87.7 (3.0)

Pastoral or spiritual care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84.7 (6.1) 88.9 (2.9) 88.9 (3.2)

Volunteer services ......................................... 81.0 (6.2) 82.0 (3.8) 87.9 (3.1)

Bereavement counseling ..................................... 90.9 (4.0) 90.1 (2.9) 90.7 (3.0)

Continuous home care....................................... 76.6 (6.1) 67.6 (3.9) 56.5 (5.5)

Respite care ............................................. 73.7 (6.2) 87.4 (2.6) 84.3 (3.8)

Personal care ............................................ 95.3 (3.1) 97.2 (1.0) 82.7 (6.0)

Homemaker or companion services............................... 57.5 (6.4) 69.8 (3.8) 56.6 (5.6)

Transportation services ...................................... 29.1 (4.8) †19.6 (4.3) 14.0 (2.8)

Referral services .......................................... 89.6 (3.6) 85.9 (2.8) 57.4 (5.7)

Durable medical equipment and supplies ........................... 49.9 (6.1) 53.4 (4.5) 56.0 (5.1)

† Estimate does not meet standards of reliability or precision because the sample size is between 30 and 59, or the sample size is greater than 59 but has a relative standard error of 30 percent

or more.

NOTE: Percentages are based on the unrounded numbers. Denominator includes unknowns.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 1996, 2000, 2007.
Page 22	 National Health Statistics Reports n Number 30 n November 9, 2010

Technical Notes

Findings presented in this report

were based on data from the agency

component of the 1996, 2000, and 2007

National Home and Hospice Care

Survey (NHHCS). NHHCS is a

continuing series of cross-sectional,

nationally representative sample surveys

of home health and hospice care

agencies in the United States. The

survey includes agencies that are

certified by Medicare or Medicaid, or

licensed by a state. Data from NHHCS

have been used to track changes in

home health and hospice care provided

to individuals and their family members

since 1992.

Sample design

The sampling design for NHHCS

was a stratified, two-stage probability

design. The first stage consisted of the

selection of a stratified sample of

agencies. The primary sampling strata of

agencies were defined by agency type,

metropolitan statistical area (MSA)

status, and Census region in 1996 and

2000 surveys. In contrast, agency type

and MSA status were used to define the

primary sampling strata in 2007. The

second stage of sample selection was

done using a sample selection table (in

1996, 2000) or a computer algorithm (in

2007) to obtain systematic probability

samples of current patients and

discharges.

Data collection

Data for NHHCS were collected

through personal interviews with agency

directors and staff who used

administrative records to answer

questions about the agencies, staffs,

services, and programs, and medical

records to answer questions about

current patients and discharges. The

agency component of NHHCS

interviews was completed for 1,053

agencies in 1996, 1,425 in 2000, and

1,036 in 2007. The first-stage agency

unweighted response rates were 96% in

1996, 96% in 2000, and 71% in 2007.

Starting with the 2007 NHHCS, the

weighted response rate was calculated.

The first-stage agency response rate

weighted by the inverse of the

probability of selection was 59%.

A detailed description of the

sampling design, data collection, and

procedures, including data collection

forms for each survey year, is provided

in other reports (15,31) as well as at the

following website: (http://www.cdc.gov/

nchs/nhhcs/nhhcs_questionnaires.htm).

Estimation

Because of the complex multistage

design of the NHHCS, NCHS computed

a weight that took all sampling stages

into account. This weight was used to

inflate the sample numbers to national

estimates, and included three basic

components: inflation by reciprocals of

selection probabilities, adjustment for

nonresponse, and population ratio

adjustment. Further information on the

NHHCS estimation procedures is

available at: http://www.cdc.gov/nchs/

data/nhhcsd/NHHCS_NHHAS_web_

documentation.pdf.

Standard errors

Because the statistics presented in

this report are based on a sample, they

will differ somewhat from statistics that

would have been obtained if a complete

census had been taken using the same

schedules, instructions, and procedures.

The standard errors (SEs) of statistics

presented in this report are included in

each of the tables. The SEs used in this

report were approximated using

SUDAAN software, which computes

SEs by using a first-order Taylor

approximation of the deviation of

estimates from their expected values. A

description of the software has been

published (20). Estimates are considered

reliable if they are based on 60 or more

sample cases and the RSE is less than

30 percent. Estimates based on 30–59

cases, or based on more than 59 cases

but with an RSE exceeding 30%, are

displayed with a dagger (†) and cannot

be assumed to be reliable. Estimates

based on fewer than 30 cases (indicated

with an asterisk) are not reported

because they do not meet standards of

reliability or precision. Standard errors

can be calculated for agency estimates

using any statistical software package,

including SUDAAN, so long as

clustering within agencies and other

aspects of the complex sample design

are taken into account. Software

products such as SAS, STATA, and

SPSS all have these capabilities.

Definition of terms used in

this report

Terms relating to organizational

characteristics

Home health care—Home health

care refers to a range of medical and

therapeutic services as well as other

services delivered at a patient’s home or

in a residential setting for the purpose of

promoting, maintaining, or restoring

health, or maximizing the level of

independence, while minimizing the

effects of disability and illness,

including terminal illness.

Hospice care—Hospice care focuses

on relieving pain and uncomfortable

symptoms of individuals with terminal

illness and providing emotional and

spiritual support to both the terminally

ill and their family members.

Geographic region—Geographic

region refers to a region created by

grouping the conterminous states into

geographic areas corresponding to

groups used by the U.S. Census Bureau,

as follows:

Region States included

Northeast	 Maine, Vermont, New

Hampshire, Massachusetts,

Connecticut, Rhode Island,

New York, New Jersey, and

Pennsylvania;

Midwest	 Ohio, Illinois, Indiana,

Michigan, Wisconsin,

Minnesota, Iowa, Missouri,

North Dakota, South Dakota,

Kansas, and Nebraska;

South	 Delaware, Maryland, District

of Columbia, West Virginia,

Virginia, Kentucky,

Tennessee, North Carolina,

South Carolina, Georgia,

Florida, Alabama,

Mississippi, Louisiana,
National Health Statistics Reports n Number 30 n November 9, 2010 Page 23

Oklahoma, Arkansas, and information about, and referrals to Also included is case management and

Texas; available community resources such as coordination of a care plan.

West Washington, Oregon,

California, Nevada, New

Mexico, Arizona, Idaho,

Utah, Colorado, Montana,

Wyoming, Alaska, and

Hawaii.

Terms relating to services

Bereavement counseling—

Bereavement counseling refers to

services provided either or both

one-on-one and group support in coping

with grief and sadness upon the loss of

a loved one.

Companion services—Companion

services refer to the provision of

companionship, support, and comfort to

individuals who may not be left alone.

These services are usually limited to the

provision of sitter or escort services.

Continuous home care—Continuous

home care refers to providing care to

patients who need 24-hour monitoring

of either or both equipment and

conditions.

Dietary and nutritional

services—Dietary and nutritional

services refer to direct counseling by a

trained nutritionist to individuals who

need professional dietary assessment and

guidance to properly manage an illness

or disability, and do not include

supervision of special diets.

Durable medical equipment and

supplies—Durable medical equipment

and supplies refers to nondisposable

equipment such as respirators,

intravenous infusion therapy equipment,

total parenteral nutrition, and home

dialysis machines that has equipment

life expectancy of more than 1 year.

Homemaker services—Homemaker

services include services that are

necessary for maintaining a safe and

healthy home environment for the

patient such as housecleaning, personal

laundry, and preparing meals. These

services help to maintain a patient’s

household rather than providing

hands-on personal care to patients.

Medical social services—Medical

social services refer to the provision of

counseling, advocacy coordination,

legal aid, job, and housing assistance.

Occupational therapy—

Occupational therapy is obtained from a

registered or licensed occupational

therapist. This therapeutic service is

provided to restore or maintain

independence in performing activities of

daily living (ADLs) and basic functional

skills.

Pastoral care—Pastoral care refers

to care from a minister, priest, rabbi, or

other clergy.

Personal care—Personal care refers

to assistance with ADLs such as

bathing, dressing, using the toilet,

getting in and out of bed, eating,

walking, shaving, combing or

shampooing hair, care of dentures and

teeth.

Physical therapy—Physical therapy

is obtained from a certified or licensed

physical therapist. This therapeutic

service is provided to restore the

mobility and strength and to relieve pain

experienced by patients through the use

of exercise, massage, and other methods.

Physician services—Physician

services refer to evaluation and

treatment provided by a licensed

physician including M.D., Doctor of

Osteopathic Medicine (D.O.), and

physician associate (not including

psychiatrist).

Referral services—Referral services

refer to the provision of information on

services available from public and

private providers. Agencies may also

order or arrange services but they do not

provide the service directly.

Respite care—Respite care refers to

care provided to the patient to relieve

the stress of a family or primary

caregiver due to family psychological

problems, caregiver fatigue, or required

short-term absence of the caregiver.

Skilled nursing services—Skilled

nursing services are services essential to

the maintenance or restoration of health

provided to sick or disabled persons by

a registered nurse (RN) or a licensed

practical nurse (LPN). Examples of

services provided are injections, wound

care, education or disease treatment and

prevention, and patient assessments.

Speech therapy or audiology—

Speech therapy or audiology is obtained

from a certified or licensed speech

language pathologist or audiologist. It

includes evaluation, treatment, and

monitoring of specific communication

disorders.

Spiritual care—Spiritual care refers

to care provided either or both one-onone and group support in coping with

grief, fear, anxiety, and social problems

for the patient, caregiver, and family.

Transportation services—

Transportation services refer to the

provision of a driver and vehicle by the

agency.

Volunteer services—Volunteer

services refer to services provided to

patients by individuals in an unpaid

capacity.
Page 24 National Health Statistics Reports n Number 30 n November 9, 2010

Suggested citation

Park-Lee EY, Decker FH. Comparison of

home and hospice care agencies by

organizational characteristics and services

provided: United States, 2007. National health

statistics reports; no 30. Hyattsville, MD:

National Center for Health Statistics. 2010.

Copyright information

All material appearing in this report is in the

public domain and may be reproduced or

copied without permission; citation as to

source, however, is appreciated.

National Center for Health Statistics

Edward J. Sondik, Ph.D., Director 

Jennifer H. Madans, Ph.D., Associate Director 

for Science 

Division of Health Care Statistics

Jane E. Sisk, Ph.D, Director

U.S. DEPARTMENT OF

HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road

Hyattsville, MD 20782

FIRST CLASS 

POSTAGE & FEES PAID 

CDC/NCHS 

PERMIT NO. G-284 

OFFICIAL BUSINESS

PENALTY FOR PRIVATE USE, $300

To receive this publication regularly, contact

the National Center for Health Statistics by

calling 1–800–232–4636

E-mail: cdcinfo@cdc.gov

Internet: http://www.cdc.gov/nchs

DHHS Publication No. (PHS) 2011–1250

CS216011

T37990 (11/2009)