July 2022 FUsYO [ | RURAL POLICY RESEARCH INSTITUTE NURSING HOMES IN RURAL AMERICA: A CHARTBOOK KEY FACTS ABOUT NURSING HOME AVAILABILITY IN RURAL AMERICA RUPRI CENTER FOR RURAL HEALTH POLICY ANALYSIS Table of Contents Infroduction Executive Summary Section 1: Nursing Home Availability e Figure 1 Percent of Counties with Nursing Homes ] ¢ Figure 1.1 Counties without Dually or Medicare Certified Nursing Homes ¢ Figure 1.2 Counties without Dually or Medicaid Certified Nursing Homes 2 e Figure 2 Percent of Counties with Swing-bed Hospitals e Figure 3 Percent of Counties with Nursing Homes by Swing-bed Hospital 3 Availability e Figure 4 Percent of Counties with Access to Post-acute Care and Long-term Care Service ¢ Figure 4.1 Counties without Dually or Medicare Certified Nursing Homes 4 and without Hospitals with SNF-type Swing Beds ¢ Figure 4.2 Counties without Dually or Medicaid Certified Nursing homes 5 and without Hospitals with NF-type Swing Beds Section 2: Supply of Nursing Home Beds e Figure 5 Number of Nursing Homes Beds per 1,000 Population Aged 65 and 6 Older e Figure 6 Number of Nursing Homes Beds per 1,000 Population Aged 65 and Older by Swing-bed Hospital Availability e Figure 7 Dually or Medicare Certified Nursing Home Beds per 1,000 Population 7 Aged 65 and older at the County Level e Figure 8 Dually or Medicaid Certified Nursing Home Beds per 1,000 Population Aged 65 and Older at the County Level Section 3: Nursing Home and Resident Characteristics e Figure 2 Nursing Home Certification Status 8 e Figure 10 Number of Nursing Home Beds e Figure 11 Nursing Home Occupancy Rates 9 e Figure 12 Nursing Home Ownership Status e Figure 13 Nursing Home Payer Mix 10 e Figure 14 Overall 5-star Rating of Nursing Homes in 2019 RURAL NURSING HOMES CHARTBO OK ] Table of Contents ¢ Figure 14.1 Survey Rating of Nursing Homes in 2019 11 ¢ Figure 14.2 Quality Rating of Nursing Homes in 2019 + Figure 14.3 Staffing Rating of Nursing Homes in 2019 12 e Figure 15 Nursing Home Resident Demographics 13 e Figure 16 Percent of Nursing Home Residents with Activities of Daily Living 14 Dependency e Figure 17 Percent of Nursing Home Residents with Behavioral/Mental Health 15 Needs . 16 Conclusions References 17 Appendix 18 Data & Methods Prepared by Hari Sharma Lili Xu Fred Ullrich Clint MacKinney Keith J. Mueller of the RUPRI Center for Rural Health Policy Analysis G L Rural He_alth Research RURAL POLICY RESEARCH INSTITUTE & Policy Centers Funded by the Federal Office of Rural Health Palicy RUPRI Center for Rural Health Policy Analysis www.ruralhealthresearch.org University of lowa College of Public Health Department of Health Management and Policy This project was supported by the Federal Office of Rural Health Policy (FORHP), 145 Riverside Dr., lowa City, IA 52242-2007 Health Resources and Services Administration (HRSA), U.S. Department of Health (319) 384-3830 and Human Services (HHS) under cooperative agreement/grant #U1CRH20419. The information, conclusions and opinions expressed in this http://www.public-health.uiowa.edu/rupri policy brief are those of the authors and no endorsement by FORHP, HRSA, HHS E-mail: coh- e iries@ui d isintended or should be inferred. mail: ephrruprHnquiriessuiowa.edu RURAL NURSING HOMES CHARTBO OK Infroduction Policymakers are increasingly concerned about the availability of post-acute care and long-term care services in rural areas. A recent study found that a higher proportion of nursing homes in rural areas have closed compared to urban areas between 2008 and 2018 (Sharma et al., 2021). Many rural residents rely on rural hospitals with swing beds for both post-acute care and long-term care services but the closure of many hospitals in rural areas (Holmes et al., 2017) may potentially leave residents with few to no options for care. Despite recent efforts to promote home- and community-based services over institutional care (Kaye & Harrington, 2015), residents living in rural areas have limited access to alternatives to nursing home care such as assisted living facilities and adult day care centers (Siconolfi et al., 2019; Tyler & Fennell, 2017). As a result, nursing homes continue to be the primary providers of post-acute and long -term care services in rural areas (Coburn et al., 2016). Yet, we do not have a good understanding of the availability of nursing homes in rural areas. In this chartbook, we define nursing homes as Medicare and/or Medicaid certified facilities providing post-acute care (skilled nursing facilities) and/or long-term care (nursing facilities) services. We document nursing home availability at the county level and identify counties without nursing homes. We also evaluate the supply of nursing home beds per 1,000 population aged 65 and older. We examine availability and beds by certification type because the type of services provided depends on certification. Facilities that are dually certified by Medicare and Medicaid tend to provide both post-acute care and long-term care services. On the other hand, facilities certified only by Medicare tend to focus on post-acute care services whereas facilities certified only by Medicaid tend to focus on long-term care services. We assume! that counties with a dually certified facility or Medicare only facility have access to post-acute care services and counties with a dually certified facility or Medicaid only facility have access to long-term care services. In addition, we identify county- level nursing home availability for counties with and without hospitals with swing beds. Finally, we describe the resident and nursing home characteristics including occupancy levels, payer mix, demographics, and health care needs. Our analyses incorporate the certification status of nursing homes, and we summarize data for the urban (meftropolitan), and rural (micropolitan, and noncore) counties. Additional information on data and methods is available in the appendix to this document. 1 Actual access to services may depend on resident needs as well as facility policies and beds availability that are beyond the scope of this study. RURAL NURSING HOMES CHARTBO OK Executive Summary Availability of Medicare and/or Medicaid certified nursing homes and hospitals with swing beds e Overall, 92% of counties in the United States have Medicare and/or Medicaid certified nursing homes but fewer noncore counties have nursing homes. e About 96% of metropolitan and 95% of micropolitan counties have dually/Medicare certified or dually/Medicaid certified nursing homes. e About 87% of noncore counties have dually/Medicaid certified nursing homes but only 82% of noncore counties have dually/Medicare-certified nursing homes. e Average number of Medicare and/or Medicaid certified nursing home beds per 1000 individuals who are 65 or older are higher in noncore counties (50.2) than in metropolitan (35.6) or micropolitan (44) counties but there is considerable variation in the number of nursing home beds across rurality, states, and regions. ¢ A high proportion of noncore counties have hospitals with skilled nursing facility (SNF) swing beds (61%) or nursing facility (NF) swing beds (52%). But among noncore counties without hospitals with SNF or NF swing beds, 25% have no Medicare and/or Medicaid certified nursing homes. Characteristics of Medicare and/or Medicaid certified nursing homes and residents e Nursing homes in noncore counties have fewer beds {78.6) and lower occupancy (75.1%) compared to metropolitan (beds: 117.4; occupancy: 80.1%) and micropolitan (beds: 96.7; occupancy: 76.4%) counties. ¢ A higher proportion of nursing homes in noncore counties are government- owned (13.7%) compared to micropolitan {(10.0%) and metropolitan (4.4%) counties. ¢ Nursing homes in noncore counties had better survey ratings but worse quality ratingsin 2019. e About 40% of nursing homes in noncore counties have a 4- or 5-star survey rating compared to 32.8% in metropolitan and 33% in micropolitan counties. « A higher percentage of nursing homes in noncore counties have a 1- or 2-star quality rating (33.2%) compared to metropolitan (17.7%) and micropolitan (28.5%) counties. e Residents in nursing homes in noncore counties are more likely to be female, older, and white than those in metropolitan counties. e Compared to metropolitan counties, a higher proportion of residents in nursing homes in noncore counties have depression (41.1% vs. 34.5%), dementia or Alzheimer's disease (48.2% vs. 42.9%), psychiatric diagnosis (35.6% vs. 32.0%), and other mental/behavioral needs (25.0% vs. 19.8%). RURAL NURSING HOMES CHARTBO OK Section 1: Nursing Home Availability A higher percentage of noncore counties have no nursing homes and only 82% of noncore counties have a dually- or Medicare-certified nursing home. Figure 1 Percent of Counties with Nursing Homes Any Nursing Home Dually- or Medicare- certified Nursing Home Dually- or Medicaid- certified Nursing Home OOverall _ | 92% 7] 96% 95% 87% | 90% | 96% 95% 82% | 92% 96% 95% 87% Metro @EMicropolitan B Noncore Most of the counties without dually or Medicare certified nursing homes are in the West (123). the South (109), and the Midwest (82). Only 4 counties in the Northeast have no dually certified or Medicare certified nursing homes. Figure 1.1 Counties without Dually or Medicare Certified Nursing Homes SR L ==¢a$§;'-'%3¢'igm=.§:§$a-'é o 43 b | [ 1 Metro., Dually/Medicaid certified NH % | 1 Mic/Non., Dually/Medicaid certified NH F! e PR S e N, ".:' [ AL T gl o ~ [ Metro.., no Dually/Medicaid certified NH I icro.. no Dually/Medicaid certified NH N Moncore, no Dually/Medicaid certified NH RURAL NURSING HOMES CHARTBO OK PAGE 1 Section 1: Nursing Home Availability Most of the counties without dually or Medicaid certified nursing homes are in the West (113), the South (89), and the Midwest (53). Only 4 counties in the Northeast have no dually certified or Medicaid certified nursing homes. Figure 1.2 Counties without Dually or Medicaid Certified Nursing Homes 0 ] ' L] | " " O' fii ; 2 [ [ g (o Lty ¥ e i =g S oy b | [ 1 Metro., Dually/Medicare certified NH % | [ Mic/Non.. Dually/Medicare centified NH [ Metro., no Dually/Medicare certified NH N Micro., no Dually/Medicare certified NH N tioncore, no Dually/Medicare certified NH A higher percentage of noncore counties have access to hospitals with SNF-type swing beds (61% vs. 22%) and NF-type swing beds (52% vs. 17%) when compared to metropolitan counties. Figure 2 Percent of Counties with Swing-bed Hospitals 42% : . 22% Any Swing-bed Hospital 40% 61% 42% Hospitals with SNF-type Swing Beds 40% 61% | 35% Hospitals with NF-type [ 17% Swing Beds 31% 52% OOverall OMetro BEMicropolitan MBNoncore RURAL NURSING HOMES CHARTBO OK PAGE 2 Section 1: Nursing Home Availability Noncore counties without swing-bed hospitals are also less likely to have nursing homes. Approximately, 27% of noncore counties without swing-bed hospitals do not have dually certified or Medicare certified nursing homes. Figure 3 Percent of Counties with Nursing Homes by Swing-bed Hospital Availability = o & o N PN & 0 & 3 Metro Metro Micropolitan Micropolitan Noncore Noncore Counties Counties Counties Counties Counties Counties with Swing- without with Swing- without with Swing- without bed Swing-bed bed Swing-bed bed Swing-bed Hospitals Hospitals Hospitals Hospitals Hospitals Hospitals OAny Hursing Home B Dually- or Medicare-certified Nursing Home m Dually- or Medicaid-certified Nursing Home Even after we account for the presence of nursing homes and/or swing-bed hospitals at the county level to assess the availability of post-acute care services or long-term care services', a higher percentage of noncore counties have no access to post-acute care or long-term care services compared to metropolitan and micropolitan counties. About 10% of noncore counties do not have access to post-acute services and/or long- term care services. Figure 4 Percent of | 939 . . Q Counties with Access to Have Access to Post-acute | | 96% Post-acute Care and Long- Care Service 96 term Care Services ° 'Our assumption is that counties have access to post-acute care service if | 94% they have any dually- or Medicare- Have Access to Long-term | 96% certified nursing homes or hospitals Care Service 96Y% Q with SNF-type swing beds. Similarly, we assume that counties have access to long-term care service if they have any dually- or Medicaid-cerdified nursing homes or hospitals with NF- OOverall @Metro ®EMicropolitan ®mNoncore type swing beds. RURAL NURSING HOMES CHARTBO OK [ (€7 =] 90% Section 1: Nursing Home Availability Many counties in the South (82), the West (74), and the Midwest (50) do not have dually certified or Medicare certified nursing homes and do not have hospitals with SNF-type swing beds either. There are only 3 counties in the Northeast without dually or Medicare certified nursing homes and without hospitals with SNF-type swing beds. Of the 1.52 million individuals who live in counties without SNF services, 660,888 individuals live in noncore counties with 131,483 of them being 65 and older. Figure 4.1 Counties without Dually or Medicare Certified Nursing Homes and without Hospitals with SNF-type Swing Beds L i h Y LN AN A BSARONALLL LR S riaate) 1 o P T -i' '-l!l"li!'f-' =W |¢&I}f§.==fir¢$|§!fld . -y e X vt ¥ b | [ Metro., Hosp/NH Skilled nursing sves .'4 1 MiefMon., Hosp/NH Skilled nursing swes [ Metro., ne Hosp/NH Skilled nursing sves I Micro., no Hosp/MH Skilled nursing sves I roncore, no Hosp/MH Skilled nursing sves RURAL NURSING HOMES CHARTBO OK PAGE 4 Section 1: Nursing Home Availability Many counties in the South (79), the West (76), and the Midwest (45) do not have dually certified or Medicaid certified nursing homes and do not have hospitals with NF-type swing beds either. There are only 3 counties in the Northeast without dually or Medicaid certified nursing homes and without hospitals with NF-type swing beds. Of the 1.52 million individuals who live in counties without NF services, 655,247 individuals live in noncore counties with 132,849 aged 65 and older. Figure 4.2 Counties without Dually or Medicaid Certified Nursing Homes and without Hospitals with NF-type Swing Beds A SAETRNE ARy e T ""'?fia'«\ [ ORI L [ Metro.. Hosp/NH LTC services 1 Mic/Non., Hosp/NH LTC services [ Metro, no HospdNH LTC services B Micro., no Hosp/NH LTC services I Noncore, no Hosp/NH LTC services RURAL NURSING HOMES CHARTBO OK PAGEDS Section 2: Supply of Nursing Home Beds Micropolitan and noncore counties have more nursing home beds per 1,000 population aged 65 and older, overall and by certification status, than metropolitan counties. Figure 5 Number of Nursing Homes Beds per 1000 Population Aged 65 and older | 435 Total Nursing Home Beds 35.6 Per 1000 Elderly Population 440 50.2 | 40.0 Medicare- or Dually-certified Beds 33.9 Per 1000 Elderly Population 41.3 448 | 412 Medicaid- or Dually-certified Beds 33.0 Per 1000 Elderly Population 41.5 481 OOverall OMetro @ Micropolitan BNoncore Micropolitan and noncore counties have more nursing home beds per 1000 population aged 65 and older, overall and by certification status, than metropolitan counties even after stratifying by the presence of swing-bed hospitals at the county level. Figure 6 Number of Nursing Homes Beds per 1000 Population Aged 65 and Older by Swing-bed Hospital Availability M) 1 Metro Metro Micropolitan Micropolitan Noncore Noncore Countieswith Counties Countieswith Counties Countieswith Counties Swing-bed without Swing-bed without Swing-bed without Hospitals Swing-bed Hospitals Swing-bed Hospitals Swing-bed Hospitals Hospitals Hospitals 412 453 422 34.0 ONursing homes beds per 1000 elderly population B Dually or Medicare certified beds per 1000 elderly population m Dually or Medicaid certified beds per 1000 elderly population RURAL NURSING HOMES CHARTBO OK Section 2: Supply of Nursing Home Beds Although many noncore counties have nursing homes with 30+ beds, there is considerable variation across states and regions. In noncore counties with at least one nursing home, the number of nursing home beds per 1000 individuals who are 65 or older ranges from 3.3 to 329.7. Figure 7 Dually or Medicare Certified Nursing Home Beds per 1000Population Aged 65 and Older edl ] 1T ) Tk o e 7 (] L [ ey A Y A i IS SR o S R el .'ih i !it' !-fi;:, 5 L) b | 1 Metio., Dually/Medicare cert. 30+ bed | 1 Metio., Dually/Medicare cert. <30 bed [ Mic/Mon., Dually/Medicare cert, 30+ bed [ Mic/Mon., Dually/Medicare cert, <30 bed I vetio., no Dually/Medicare certified NH [ vic/Non., no Dually/Medicare certified NH Figure 8 Dually or Medicaid Cerlified Nursing Home Beds per 1000Population Aged 65 and Older at the County Level [ e LA } " ::.'_quhjfnnf P P e : SRS 7 - lIr. [ Metro., Dually/Medicaid cert. 30+ bed | 1 Metro.. Dually/Medicaid cert. <30 bed [ Mie/Non., Dually/Medicaid cert. 30+ bed [ Mie/Nen., Dually/Medicaid cert. <30 bed I vetro., no Dually/Medicaid certified NH I ic/Nen., no Dually/Medicaid certified NH RURAL NURSING HOMES CHARTBO OK PAGE7 Section 3: Nursing Home and Resident Characteristics Overall, 94% of nursing homes are dually certified by Medicare and Medicaid. A lower percentage (0.3%) of nursing homes in noncore counties are certified for only Medicare and a higher percentage (3.7%) of nursing homes in noncore counties are certified for only Medicaid. Figure 92 Nursing Home Certification Status 4.3% . 56% Med I edicare only = - 0.3% | 1.4% G 1.0% Medicaid onl edicaid only § <0 3.7% | 94.3% o : : 93.4% Dually-certified Medicare and Medicaid 97 5%, 96.0% OOverall OMetro M@EMicropolitan BENoncore On average, nursing homes have 109 beds certified by Medicare and/or Medicaid. Nursing homes in noncore counties are smaller than those in metropolitan counties. Figure 10 Number of Nursing Home Beds 1091 Nn7.4 Total certified beds OOverall @Metro @EMicropolitan mNoncore RURAL NURSING HOMES CHARTBO OK Section 3: Nursing Home and Resident Characteristics The average occupancy rate in nursing homes is 79%. Nursing homes in noncore counties have lower occupancy rates than those in metropolitan counties. Figure 11 Nursing Home Occupancy Rates 78.9% 80.1% Occupancy 76.4% 75.1% ? OOverall @Metro mMicropolitan B Noncore Overall, 70% of nursing homes are for-profit. A higher percentage of nursing homes in noncore counties are non-profit or government-owned. Figure 12 Nursing Home Ownership Status 70.1% i 72.5% For Profit 66.7% 61.1% 23.5% 23.2% Non Profit 23.4% 252% 6.4% 4.4% 10.0% 13.7% Government-owned K OOverall O Metro @EMicropolitan MmNoncore RURAL NURSING HOMES CHARTBO OK Section 3: Nursing Home and Resident Characteristics Figure 13 Nursing Home Payer Mix On average, Medicaid Medicaid pays for about 59% of nursing home residents, | 59.4% 57.7% 63.1% 64.5% 13.2% 13% are paid for b . % ) P Y Medicare 14.4% Medicare, and 27% are 11.9% private pay. A higher 8.4% percentage of nursing 27 4% home residents in Private 27.9% noncore counties are on 25.0% . 271% Medicaid. OOverall @OMetro BEMicropolitan MBNoncore Figure 14 Overall 5-star Ratings of Nursing Homes in 2019' | 18.1% 18.3% A lower percentage (33.4%) 1-star 18.9% of nursing homes in 16.2% noncore counties have 1-2 1 19.29% stars (1 being the lowest 19.4% 2-star 19.79% quality and 5 being the 720 ? highest quality) than nursing homes in |1;72-§A,% . . 3-star : metropolitan (37.7%) 20.5% counties. | 22.1% 21.3% 4-star 53.6% 1Nursing Home 5-Star Quality Rating System 251% gives each nursing home a rating of between 1 and 5 stars. 4-5 star rated nursing homes are | 22 9% considered to have much better quality than - OO those rated 1-2 stars. Each nursing home S_star 235.8% receives a separate rating on three categories 19.6% (i.e.. health inspection surveys, staffing, and 21.1% quality) and an overall 5-star rating {(https:// www.cm§:goylMedic_qre/l?rovider-EnroII.men'r- and-Certification/CertificationandComplianc/ OOverall BMetro mEMicropolitan mNoncore FSQRS). RURAL NURSING HOMES CHARTBO OK PAGE 10 Section 3: Nursing Home and Resident Characteristics Figure 14.1 Survey Ratings of ] 19.3% Nursing Homes in 2019" Lt 20.7% -star : 17.9% 14.0% A higher percentage (40%) . . | 24.0% of nursing homes in 4 4% 5 stars in Survey Rating 22.1% than nursing homes in | 22.9% Micropolitan {33.0%) and I-star Metropolitan (32.7%) counties. | 23.5% 4-star - 2222%}/:' 103% 27.8% B 9.9% 5-star 10.3% 12.2% OOverall OMetro mMicropolitan BNoncore Figure 14.2 Quality Ratings of Nursing Homes in 20192 6.4% 4.8% T-star 9.0% 1.6% A higher percentage (33%) of nursing homes in noncore o éSQ;O% B Q counties have 1-2 stars in 2-star 19.5% quality rating than nursing 21.6% homes in micropolitan (28.5%) | 21.0% and metropolitan (17.7%) 20.1% . 3-star counties. 23.5% 23.7% | 25.6% 'Survey ratings are based on information 4-star 2 4%35% obtained by frained health inspectors. All =170 Medicare/Medicaid certified nursing homes 227% are inspected approximately once a year for compliance with federal and state regulations | 32.0% and facilities that fail to adhere to regulations 35.89% are cited. 5-star 23 9 ) 2Quality ratings are based on different A physical and clinical measures of quality and 20.4% are meant to capture the extent to which nursing homes are caring for resident's clinical and physical needs. OOverall @Metro EMicropolitan B Noncore RURAL NURSING HOMES CHARTBO OK PAGE 11 Section 3: Nursing Home and Resident Characteristics Figure 14.3 Staffing Ratings of Nursing Homes in 2019 15.1% 14.5% T-star 151% A higher percentage 18.0% (35.2%) of nurS|.ng homes in | 24.5% noncore counties have a 4- 25.2% . . 2-star or 5-star Staffing rating 24.7% . . 21.1% than nursing homes in Micropolitan (31.1%) and | 27.8% Metropolitan (32.4%) 3-star 272993/8/ counties. A higher a0 percentage (18.0%) of nursing homes in noncore | %}Efi Staffing rating. 22.9% 1% . 1.0% 5-star 10.3% 12.3% OOverall @Metro @Micropolitan BNoncore 'Staffing ratings capture the average number of hours of care provided to each resident each day by nursing staff. Ratings are adjusted for the differences in the needs of residents. RURAL NURSING HOMES CHARTBO OK PAGE 12 Section 3: Nursing Home and Resident Characteristics Residents of nursing homes in Noncore counties are older, and more likely to be White compared to residents of nursing homes in metropolitan or micropolitan counties. Figure 15 Nursing Home Resident Demographics | 789 Averge Age in Years 78.6 79.4 80.4 | 651 Percent Female 64.4 66.8 66.6 | 79.7 Percent White 76.0 88.1 89.6 16.74 Percent Black 20.9 9.15 6.97 443 Percent Hispanic SHE 0.99 0.53 OOverall @OMetro @Micropolitan B Noncore RURAL NURSING HOMES CHARTBO OK PAGE 13 Section 3: Nursing Home and Resident Characteristics A lower percentage of nursing home residents in noncore counties have Activities of Daily Living (ADL) dependencies. About 31% of residents of nursing homes in noncore counties need help with bathing, 17% need help with toilet, and 17% need help with transfer. Figure 16 Percent of Nursing Home Residents with Activities of Daily Living Dependency | 34.0% . 34.9% th Bathing 21.9% 31.4% [ 14.3% Dressin 151% 9 11.9% 12.3% | 18.7% Toilet 19:4% 16.4% 17.3% 9.3% 0, Eating 9.9% 7.7% 7.9% 18.5% 0, Transfer s 17.2% 16.8% OOverall @OMetro @EMicropolitan mBNoncore RURAL NURSING HOMES CHARTBO OK PAGE 14 Section 3: Nursing Home and Resident Characteristics A higher percentage of nursing home residents in noncore counties have mental health needs. About 41% of nursing home residents in noncore counties have depression, 36% have a psychiatric diagnosis, 25% have mental/behavioral needs, and 48% have dementia or Alzheimer's disease. Figure 17 Percent of Nursing Home Residents with Behavioral/Mental Health Needs 36.3% 34.5% Depression 411% 41.1% - 33.0% 32.0% 45:5% 35.6% Psychiatric diagnosis I 21.0% 19.8% 23.6% 25.0% Mental behaviroal needs | 44.0% 42.9% 45.5% 48.2% Dementia or Alzheimers OOverall @OMetro BEMicropolitan MBENoncore RURAL NURSING HOMES CHARTBO OK PAGE 15 Conclusions e A lower proportion of noncore counties have nursing home post-acute care and long-term care services. Even the inclusion of hospitals with swing beds does not eliminate the differences in access to post-acute care and long-term care services between noncore counties and metro/micropolitan counties. A little over 131,000 individuals aged 65 and older live in noncore counties without nursing homes or hospitals that provide post-acute care or long-term care services. ¢ Many noncore counties have a higher number of nursing home beds per 1000 population aged 65 and older, particularly in the Midwest. However, differences in the beds per 1000 population aged 65 and older between noncore counties and metropolitan counties vary by states/regions. e Residents of nursing homes in noncore counties are less likely to have functional limitations but are more likely to have behavioral/mental health needs. e Ourfindings are based on data from 2019. We need further research to understand the impact of COVID-19 on two key issues in rural areas: a) availability of post-acute care and long-term care services and, b) functional limitations as well as behavioral/mental health needs of residents. RURAL NURSING HOMES CHARTBO OK [ N(E T References Coburn, A., Griffin, E., Thayer, D. A., Croll, Z., & Ziller, E. C. (2016). Are rural older adults benefiting from increased state spending on Medicaid home and community-based services? (PB-65). Portland, ME: University of Southern Maine, Muskie School of Public Service, Maine Rural Health Research Center. Holmes, G. M., Kaufman, B. G., & Pink, G. H. (2017). Predicting Financial Distress and Closure in Rural Hospitals: Predicting Financial Distress and Closure. The Journal of Rural Health, 33(3). 239-249. https://doi.org/10.1111/jrh.12187 Kaye, H. S., & Harrington, C. (2015). Long-term services and supports in the community: Toward a research agenda. Disability and Health Journal, 8(1), 3-8. https://doi.org/10.1016/ j-dhjo.2014.09.003 Sharma, H., Baten, R. B. A., Ullrich, F., MacKinney, A. C., & Mueller, K. J. (2021). Trends in Nursing Home Closures in Nonmetropolitan and Metropolitan Counties in the United States, 2008- 2018. Brief No. 2021-1. RUPRI Center for Rural Health Policy Analysis Rural Policy Brief. Siconolfi, D., Shih, R. A., Friedman, E. M., Kotzias, V. |., Ahluwaliq, S. C., Phillips, J. L., & Saliba, D. {2019). Rural-Urban Disparities in Access to Home- and Community-Based Services and Supports: Stakeholder Perspectives From 14 States. Journal of the American Medical Directors Association, 20(4), 503-508.e1. https://doi.org/10.1016/j.jamda.2019.01.120 Tyler, D. A., & Fennell, M. L. (2017). Rebalance Without the Balance: A Research Note on the Availability of Community-Based Services in Areas Where Nursing Homes Have Closed. Research on Aging. 39(5), 597-611. https://doi.org/10.1177/0164027515622244 RURAL NURSING HOMES CHARTBO OK PAGE 17 Appendix Data and Methods We use the 2019 Medicare Provider of Services (POS) file to obtain all Medicare and/or Medicaid certified nursing homes that were openin 2019. We use 2019 Medicare Cost Report data to identify swing-bed hospitals and the type of swing beds available. We include both CAH and non-CAH hospitals with swing beds. Depending on the swing-bed agreement with CMS, hospitals may use swing beds for acute care, skilled nursing services (SNF) or nursing facility services (NF). Medicare pays for SNF services while the state Medicaid agency may pay for NF services. Medicare uses the SNF Prospective Payment System (PPS) to pay for SNF swing-bed services in non-CAH hospitals but CAHs are paid using cost-basis. We use the 2019 Certification and Survey Provider Enhanced Reporting (CASPER) data to obtain nursing home level information on provider certification for Medicaid/Medicare, number of Medicare residents, number of Medicaid residents, and percent of residents with functional limitations and mental health needs. We use Nursing Home Compare to obtain other nursing home characteristics in 2019 including ownership status and Five-star ratings. We use Long-Term Care: Facts on Care in the US (LTCFocus.org) to obtain resident characteristics in 2019 including gender, age, and race/ethnicity. We use theUrban Influence Codes (UIC) to classify nursing homes into urban (metropolitan), and rural (micropolitan, and noncore) counties. UICs divide US counties into 12 groups but we create three distinct groups for our analytical purposes: metropolitan (UIC codes 1 & 2), micropolitan (UIC codes 3, 5, & 8), and noncore counties (UIC codes 4, 6, 7, 92, 10, 11, 12). Further information on UICs can be found in the USDA website (https://www.ers.usda.gov/data-products/urban- influence-codes/documentation.aspx ). First, we document the availability of nursing homes in the metropolitan, micropolitan, and noncore counties. Second, we examine the availability of nursing homes by presence of hospitals with swing beds in counties by rurality. Third, we assess the supply of nursing home beds per 1000 population aged 65 and older in metropolitan, micropolitan, and noncore counties. Finally, we examine the resident and nursing home characteristics in metropolitan, micropolitan, and noncore counties. We present the findings using charts and/or maps. Terms and abbreviations SNF-Skilled Nursing Facility NF-Nursing Facility LTC-Long-term care services ADL-Activities of Daily Living Metro-Metropolitan Micro-Micropolitan RURAL NURSING HOMES CHARTBO OK PAGE 18