Assessing Racial‐, Ethnic‐, and Socioeconomic‐Disparities in Access to High‐Quality Home Health Agencies
Authors: Fashaw S. , Thomas K. 
Published: August 2020

Research ObjectivePrior research indicates that neighborhoods with predominantly minority and low‐income individuals have decreased access to high‐quality hospitals, primary care physicians, and nursing homes. Research in the home health (HH) setting reports that blacks and Medicare/Medicaid dually eligible beneficiaries are less likely to receive care from 4‐ and 5‐star rated HH Agencies (HHAs) and more likely to receive care from lower‐ and unrated HHAs. We know very little about why this is. One possible explanation could be that the available choices for minorities and low‐income older adults are only lower quality HHAs. The objective of this study is to document the availability of high‐quality HHAs across neighborhoods. We hypothesize that neighborhoods that have a larger proportion of racial and ethnic minorities, and low‐income individuals, will have fewer high‐quality (4‐ and 5‐star) HHAs available.Study DesignA national descriptive study using 2017 Census data linked with HHCompare Star Rating and Agency Service Area. We characterize neighborhoods (defined by ZIP Code Tabulation Areas) by racial and ethnic composition and the proportion of residents below the federal poverty line (FPL). Neighborhoods with greater than 60% of one race were coded as predominately black, Hispanic, minority, or white; otherwise, the neighborhood was listed as integrated. Poor neighborhoods were those with 20% of their population below 200% of the FPL.Population StudiedAll neighborhoods (n = 31 620) served by Medicare‐certified HHAs.Principal FindingsOn average, there are more HHAs per one thousand older adults available in predominantly minority communities than in white and communities. Black neighborhoods have an average of 57 HHAs, 45 HHAs in Hispanic neighborhoods, and 31 HHAs in white neighborhoods per one thousand older adults. Predominately minority neighborhoods are served by the highest proportion of unrated HHAs. 11% of the HHAs in black neighborhoods are unrated, as compared to 8% in Hispanic neighborhoods and 5% in predominately white neighborhoods. 29% of HHAs in black neighborhoods and 35% in Hispanic neighborhoods are low quality (1‐2.5 stars) as compared to 22% in white neighborhoods. Over 33% of the HHAs serving white neighborhoods are high quality, as compared to 26% in predominantly black neighborhoods and 28% in Hispanic neighborhoods. 33% of the HHAs in poor neighborhoods are unrated or low quality, as compared to 31% of HHAs in non‐poor neighborhoods being unrated or low quality.ConclusionsDespite a greater number of HHAs serving minority areas, there are racial/ethnic disparities in access to high‐quality HH care. Socioeconomic disparities also exist, but at a smaller magnitude. This study provides a signal and potential explanation for why minorities and duals receive care from lower quality HHAs.Implications for Policy or PracticeFuture research to understand HHA practices may help to policies and practices aimed at reducing disparities in access to high‐quality HH. For example, policy makers can potentially implement incentive practices that will encourage HHAs to serve historically underserved areas. This is important and timely work because HH is a large and growing form of care, and the greatest geographic variation in overall Medicare spending results from HH.Primary Funding SourceAgency for Healthcare Research and Quality.