Cover: Rural-Urban Disparities in Access to Home- and Community-Based Services and Supports

Rural-Urban Disparities in Access to Home- and Community-Based Services and Supports

Stakeholder Perspectives From 14 States

Published in: Journal of the American Medical Directors Association, Volume 20, Issue 4, pages 503-508.e1 (April 2019). doi:

Posted on Jun 26, 2019

by Daniel Siconolfi, Regina A. Shih, Esther M. Friedman, Virginia Kotzias, Sangeeta C. Ahluwalia, Jessica Phillips, Debra Saliba


Trends over time in the United States show success in rebalancing long-term services and supports (LTSS) toward increased home- and community-based services (HCBS) relative to institutionalized care. However, the diffusion and utilization of HCBS may be inequitable across rural and urban residents. We sought to identify potential disparities in rural HCBS access and utilization, and to elucidate factors associated with these disparities.


We used qualitative interviews with key informants to explore and identify potential disparities and their associated supply-side factors.

Setting and participants

We interviewed 3 groups of health care stakeholders (Medicaid administrators, service agency managers and staff, and patient advocates) from 14 states (n = 40).


Interviews were conducted using a semistructured interview guide, and data were thematically coded using a standardized codebook.


Stakeholders identified supply-side factors inhibiting rural HCBS access, including limited availability of LTSS providers, inadequate transportation services, telecommunications barriers, threats to business viability, and challenges to caregiving workforce recruitment and retention. Stakeholders perceived that rural persons have a greater reliance on informal caregiving supports, either as a cultural preference or as compensation for the dearth of HCBS.


LTSS rebalancing efforts that limit the institutional LTSS safety net may have unintended consequences in rural contexts if they do not account for supply-side barriers to HCBS. We identified supply-side factors that (1) inhibit beneficiaries' access to HCBS, (2) affect the adequacy and continuity of HCBS, and (3) potentially impact long-term business viability for HCBS providers. Spatial isolation of beneficiaries may contribute to a perceived lack of demand and reduce chances of funding for new services. Addressing these problems requires stakeholder collaboration and comprehensive policy approaches with attention to rural infrastructure.

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