An older rural widow's transition from home care to assisted living.

Designed to foster appreciation of comprehensive evaluation of home care outcomes, this case study of an older rural widow is part of a longitudinal phenomenological study of home care. Over 14 months, while her home care agency reacted to the Balanced Budget Act, nine interviews were done with a 95-yearold woman who lived alone until she moved to an assisted living facility. Data analysis yielded structures of her changing experience of home care. Although primarily supportive services may have been inconsistent with Medicare regulations, such services may have influenced the favorable outcomes of sustaining elders at home and undergirding the rural economy. The impact of the Balanced Budget Act of 1997 (BBA) has been felt acutely in some rural areas (U.S. Senate, 1988a). As a result of the Balanced Budget Act, Medicare home health services were reduced and a major transition in home care service provision ensued (Hiebert-White, 1997; Komisar & Feder, 1998). The subject of considerable feedback to the United States Congress from home health agencies and individual constituents (U.S. Senate, 1988a), this dialogue is ongoing and is fundamental to consideration of further policy changes for Medicare home health care (Hiebert- White, 1997; Komisar & Feder, 1998; Moon, 1996; Stewart, 1998). In this article, I consider the impact of BBA upon the services provided to individual recipients by means of qualitative research and public policy analysis and report an older woman's perceptions, intentions, and actions concerning her Medicare home nursing care before the enactment of the BBA, as well as after her rural home health agency began implementing changes wrought by that legislation. I explore changes in her experiences throughout the transition from home care to assisted living, a transition that she attributed primarily to the fact that she was considered ineligible for home care. This woman's perceptions of values are revealed to enable others to appreciate those facts and values (Vickers, 1968) and to relate her experience to potential outcomes of home health care policy. By bringing to light the experiences of elders who have witnessed changes in services concurrent with the BBA, qualitative researchers can enable decision makers to appreciate the differential impacts of public policies upon individuals. REVIEW OF THE LITERATURE Prior to the adoption of the BBA, the United States Senate Special Committee on Aging (U.S. Senate, 1988b) noted that rural elders had less opportunity to utilize their Medicare home health benefits due to limited availability of home care services. In a later study, Kenney and Dubay (1992) confirmed that rural elders were less likely to use Medicare home health benefits. Other studies noted the association of a low utilization rate and limited access to formal home care services. For instance, from the 1982-1984 National Long-Term Care Survey, Coward and Dwyer (1991) compared urban and rural sub-samples of impaired older adults on the types of helpers used over a two-year period. They found that compared to a small group of rural elders, urban elders were twice as likely to have received services from a formal home care provider. Similarly, in a review of the literature comparing rural and urban elders' use of Medicare services, Nelson (1994) concluded that compared to urban elders, rural elders had less access to such services. Kenney (1991), on the other hand, found that urban and rural agencies were comparable in skilled nursing and home health aide services, but that urban agencies were twice as likely to have specialized services, such as speech therapy. During the 1980s, changes in the regulations governing Medicare billing for home health care led to the development of more home health care agencies in both urban and rural areas (Estes, Swan, Bergthold, & Spohn, 1992). In some rural communities, the initiation of a home health agency was a community-based endeavor, and its success was a matter of community pride, meaning that in effect: "We can take care of our own. …