Study finds disparities in functional improvement of home health care patients based on race, ethnicity and income

Reliance on home health care services is increasing in the U.S. A new study from the University of Minnesota School of Public Health (SPH) quantifies the degree to which home health care patients' race, ethnicity and income level is linked to disparities in their functional improvement. This can include clinically significant improvement in activities of daily living and a reduction in dependency on continued medical treatment.

SPH researchers analyzed overall functional improvement outcomes for a sample of home health patients that included Black, Hispanic, Asian-American/Pacific Islander (AAPI), American Indian/Alaska Native (AIAN) and white Medicare-enrolled people aged 65 years and older. By measuring the functional improvement of patients both within specific home health agencies and between different home health agencies, the researchers developed a more complete analysis of what causes disparities in functional improvement.

The researchers measured functional improvement using a five-category outcome: any functional improvement, no functional improvement, death while a patient, transfer to an in-patient setting, and continuing to use home health services.

"When inequities exist within an agency, there are differences in treatment (i.e., discrimination)," says SPH Assistant Professor and lead researcher Shekinah Fashaw-Walters. "When inequities exist between agencies, it suggests there are differences in access. These within-agency and between-agencies differences also speak to various levels and types of racism—within-agency differences may more readily reflect interpersonal racism, whereas between-agency differences are more likely to be the result of structural or institutional racism."

The study, which appears in Health Services Research, found disparities within and across different home health agencies, including:

• The percentage of patients with functional improvement was 79% for white and higher-income patients, 76% for AAPI patients, 72% for Black and AIAN patients, 71% for low-income patients and 70% for Hispanic patients.
• Adjusting for individual-level characteristics, Black, Hispanic, AIAN and low-income home health patients were all more likely to be discharged from home health care without functional improvement compared to white and higher-income patients.
• Functional improvement inequities for Black, Hispanic and AIAN patients are mostly attributable to the quality of the home health agencies to which they have access in their communities.
• Low-income patients had less functional improvement than their higher-income counterparts within the same home health agencies.

"Understanding how inequities are created and maintained is important for understanding how we can advance equity in the home health care setting," Fashaw-Walters says.

"As one of the first studies to look at racial, ethnic and income-based disparities in home health functional improvement for older adults, this research speaks to the various ways in which functional improvement inequities are created and maintained."

"Inequities are not created equally—to create change for most racial and ethnically minoritized home health patients we have to focus on improving access to higher quality agencies; but for lower-income home health patients we have to focus on making sure they are receiving equitable treatment within each agency."

The researchers also provide recommendations for mitigating both within and between home health agency inequities, including improving the quality of home health agencies that serve more marginalized patients, incentivizing improved equity within home health agencies and encouraging home health agencies to develop socially-conscious caregiver training programs.