Poorer utilization outcomes 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) service. We 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, 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 admitted to the hospital were 29.9% (high NA/AN=31.9%; other=29.8%, p<.0001); 23.7% (high NA/AN=24.8%; other=23.7%, p<.0001) for patients needing emergent care; 1.3% (high NA/AN=1.4%; other=1.3%, p=.0002) for those needing emergent care due to a wound getting worse; and 66.2% (high NA/AN=63.5%; other=66.3%, p<.0001) for staying home after an episode of care. In multivariable analysis, areas with high levels of NA/AN residents had higher rates of being admitted to the hospital and needing emergent care; while rates of staying home after an episode of care were lower. 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.