Rural Older Adults' Access Barriers to In-Home and Community-Based Services

This study identified specific access barriers to seven commonly used in-home and community-based services (HCBS) and examined factors that were related to barriers to these services. The data used in this study were extracted from the 1999 National Long Term Care Survey and included 283 dyads of rural older adults and their caregivers. The HCBS to which caregivers most frequently reported access barriers were respite care, transportation, and homemaker services. Although access barriers varied depending on individual services, the main access barriers were unavailability, unawareness, and affordability of HCBS. Findings showed that predisposing, enabling, and need factors had differential influence on access barriers to individual services. The older adult's race, educational attainment, and Medicaid enrollment were significant predictors of access barriers to homemaker services. The older adult's educational attainment and annual household income were significant predictors of access barriers to home modification services. Implications of these findings for social work practice are discussed. KEY WORDS: access barriers; in-home and community-based services; rural older adults ********** Rural in-home and community-based services (HCBS) have improved greatly over the past decade. However, increasing access to HCBS remains a challenge for many rural service providers. Lack of coordination among service providers, limited funding sources, shortages of qualified professionals, and a sparsely populated clientele are major structural obstacles to the delivery of HCBS in rural communities (Coburn, 2002). Personal factors such as a preference for family caregiving, a tradition of self-reliance, and a general mistrust of government services hamper an older adult's use of needed HCBS (Coward, Netzer, & Peek, 1996; Krout, 1998; Rowles, Beaulieu, & Myers, 1996). Knowledge of these structural and personal access barriers has improved our understanding of the challenge in the development and delivery of rural HCBS. However, information linking access barriers to specific services is limited. When older adults attempt to gain access to different HCBS, we do not know whether they will encounter the same or different barriers. There is limited information on what risk factors identify rural older adults as vulnerable to access barriers (Coburn, 2002; Coward et al., 1996). This information is important to social work practice because social workers play a critical role in helping rural older adults and their caregivers overcome access barriers to needed services. Using data from the 1999 National Long Term Care Survey (NLTCS), this study examined the prevalence of access barriers to seven commonly used HCBS in rural communities and identified risk factors that were related to these access barriers. LITERATURE REVIEW Rural older adults are in particular need of HCBS (Coward, McLaughlin, Duncan, & Bull, 1994; Coward, Vogel, Duncan, & Uttaro, 1995; Rogers, 1999). Compared with their urban counterparts, rural older adults are less educated, have fewer financial resources, and experience more health problems (Coward, McLaughlin, et al., 1994; Rogers). According to a report by the U.S. Department of Agriculture, nearly two-thirds of rural older adults assessed their health as "fair" or "poor" in 1997 (Rogers). Using data from the National Health Interview Survey (NHIS) (1990-1994), Coburn and Bolda (1999) estimated that between 37.6% and 40.5% of rural older adults reported functional impairment. Most rural older adults with functional impairment have relied on their families to help them with household, financial, and other needs (Stoller, 1998). In addition, a relatively small proportion of rural older adults have used HCBS. Data from the 1984 NHIS, for example, showed that about 17.5% of rural older adults with disabilities used formal services (Coward, Cutler, & Mullens, 1990). …