Lower quality of Medicare-certified home health care in areas with high levels of Native American/Alaska Native residents

Compared to most other groups, Native Americans/Alaska Natives (NA/AN) individuals have higher levels of chronic disease and morbidity. Many are concentrated in rural areas, which may have lower and poorer levels of service, including home health care (HHC). This study examined whether quality indicators reported to CMS by Medicare-certified HHC agencies are equal in areas with higher levels of NA/AN residents. We conducted a cross-sectional analysis using Medicare's Home Health Compare files (2008) and RTI International's Spatial Impact Factor Data (v3, 2010). The unit of analysis was the ZCTA (n=32,239). The independent variable was NA/AN concentration in the ZCTA, dichotomized into high (at or above the 95th percentile) versus all other. The dependent variables were risk-adjusted patient self-care quality measures. Adjusted analyses controlled for rurality, income, Medicare eligibles and proportion white. Unadjusted means for patients who improved while receiving HHC were: ambulation, 45.1% (high NA/AN=43.3%, other=45.2%, p<.0001); transferring, 52.7% (high NA/AN=49.6%; other=52.8%, p<.0001), incontinence, 45.4% (high NA/AN=42.1%, other=45.5%, p<.0001); pain management, 61.6% (high NA/AN=57.7%, other=61.8%, p<.0001); bathing, 62.7% (high NA/AN=62.1% other=62.8%, p=.0001); taking oral medications, 40.8% (high NA/AN=40.0%, other=40.9%, p<.0001); and breathing at 58.6% (high NA/AN=55.7% other=58.8%, p<.0001). Improvements with wound healing, were uniformly high 81.3% (high NA/AN=81.6%, other=81.3%, p=.08). In multivariable analysis quality differences in ambulation, transferring, incontinence, pain management, bathing, taking oral medication and breathing remained significant. Vulnerable individuals receiving HHC in these areas are facing several gaps with regard to quality of care. Further research is needed to identify sources of these disparities and design corrective actions.