Health Services Research
Volume 59, Issue 2 e14194
RESEARCH ARTICLE

Getting to the root: Examining within and between home health agency inequities in functional improvement

Shekinah A. Fashaw-Walters PhD, 

Corresponding Author

Shekinah A. Fashaw-Walters PhD

Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA

Correspondence

Shekinah A. Fashaw-Walters, PhD, Division of Health Policy and Management, University of Minnesota, School of Public Health, 420 Delaware St. SE, Minneapolis, MN 55455, USA.

Email: safw@umn.edu

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Momotazur Rahman PhD, 

Momotazur Rahman PhD

Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA

Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA

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Olga F. Jarrín PhD, 

Olga F. Jarrín PhD

Division of Nursing Science, School of Nursing, Rutgers, The State University of New Jersey, New Brunswick, New Hampshire, USA

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Gilbert Gee PhD, 

Gilbert Gee PhD

Department of Community Health Sciences, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, California, USA

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Vincent Mor PhD, 

Vincent Mor PhD

Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA

Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA

Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA

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Manka Nkimbeng PhD, 

Manka Nkimbeng PhD

Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA

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Kali S. Thomas PhD, 

Kali S. Thomas PhD

Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA

Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA

Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA

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First published: 25 June 2023
https://doi.org/10.1111/1475-6773.14194
Citations: 1

Abstract

Objective

To quantify racial, ethnic, and income-based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs).

Data Sources

2016–2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data.

Data Collection/Extraction Methods

Not Applicable.

Study Design

We use multinomial-logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five-category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins.

Principal Findings

Of the 3+ million Medicare beneficiaries with a HH start-of-care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual-level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low-income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% CI:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income-based disparities persisted within HHAs. Black-White, Hispanic-White, and AIAN-White disparities were largely driven by between-HHA differences, whereas income-based disparities were mostly due to within-HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities.

Conclusions

Both within- and between-HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes.

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