ORIGINAL ARTICLE

The Impact of Rurality on 30-Day Preventable Readmission,

Illness Severity, and Risk of Mortality for Heart Failure Medicare
Home Health Beneficiaries
Hsueh-Fen Chen, PhD;1 Erin Carlson, Dr Ph;1 Taiye Popoola, MBBS, MPH;2 & Sumihiro Suzuki, PhD3
1 Department of Health Management and Policy, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas
2 Department of Health Policy and Management, School of Medicine, University of Kansas Medical Center, Kansas City, Kansas
3 Department of Biostatistics and Epidemiology, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas

Disclosures: The study was approved by the
IRB at the University of North Texas Health
Science Center. No potential conflicts of
interest are reported. The findings from this
study were presented at the annual meeting of
the AcademyHealth, Minneapolis, Minnesota,
June 14, 2015.
Funding: This study was supported by the
Junior Faculty Seed Fund at the University of
North Texas Health Science Center (UNTHSC).
The authors thank the 3M Company, which
provided the 3M All Patient Refined Diagnosis
Related Groups (APR-DRGs) software and
technical support. The views expressed in this
publication are the views of the authors and do
not necessarily reflect the views of the 3M
Company or the UNTHSC.
For further information, contact: Hsueh-Fen
Chen, PhD, Department of Health Management
and Policy, School of Public Health, University of
North Texas Health Science Center, 3500 Camp
Bowie Blvd. EAD 601S, Fort Worth, TX 76107;
e-mail: Hsueh-Fen.Chen@unthsc.edu.
doi: 10.1111/jrh.12142
Abstract
Purpose: To examine the impact of rurality on 30-day preventable readmis-
sion, and the illness severity and risk of mortality for 30-day preventable read-
missions.
Methods: We analyzed heart failure Medicare beneficiaries who received
home health services for postacute care after hospital discharge in 2009. The
study was a cross-sectional design with the unit of analysis as the home health
episode for postacute care. Data sources included the following: Medicare Ben-
eficiary Summary File, Medicare Provider Analysis Review, Outcome Assess-
ment Information Set, Home Health Agency Research Identifiable File, and
Area Health Resources File. The dependent variables were 30-day preventable
readmission, and the extreme/major level of illness severity and of risk of mor-
tality for a 30-day preventable readmission. The key independent variable was
rurality defined as remote rural, adjacent rural, and micropolitan areas, with
urban areas in the reference group.
Findings: Home health beneficiaries in remote rural areas had 27% lower
30-day preventable readmission than those in urban areas. Home health ben-
eficiaries in adjacent rural areas were 33% less likely to have high illness sever-
ity at readmission due to a preventable condition than those in urban areas.
Conclusions: Geographical location affects preventable readmission and ill-
ness severity of preventable readmission. Patients’ geographic location along
with patients’ risk factors should be taken into consideration in the risk adjust-
ment model for the financial incentive program that penalizes home health
agencies with high preventable readmissions.
Key words home health, illness severity, preventable readmission, risk of
mortality, rural.

The home health industry is uniquely positioned to pro-
vide professional assistance to help patients transition
from facilities, such as a hospital, to their homes. To qual-
ify for the Medicare home health benefit, Medicare bene-
ficiaries must be homebound, require intermittent skilled
care, and receive physician referral; thus, Medicare home
health beneficiaries should be distinguished from general
Medicare beneficiaries.1 The role of home health on pro-
viding postacute care is critical given the priority under
the Affordable Care Act (ACA) to reduce readmissions.
Additionally, the number of home health episodes (an
episode is defined as 60 days of home health care) pre-
ceded by being in a health care facility increased from
1.9 million in 2001 to 2.3 million in 2011.1 It is expected
that home health services would help patients safely stay
in the community and reduce the utilization of acute care
hospitals; however, 29% of Medicare beneficiaries who
received home health services for postacute care were

176 The Journal of Rural Health 32 (2016) 176–187 

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Chen et al.
readmitted to hospital.1 To achieve the ACA’s goal in re-
ducing readmissions and improve quality of home health
care, the Medicare Payment Advisory Commission (Med-
PAC) has recommended a home health financial incen-
tive program to penalize home health agencies (HHAs)
with high preventable readmission rates.1
Evidence has shown that rural populations have a
higher risk of preventable hospitalization than urban
populations because of the lack of health care infrastruc-
ture in rural areas.2-4 Approximately 18% of 6.1 mil-
lion home health episodes were provided in rural areas
in 2011.1 Given long driving distances and shortages of
health care resources in rural areas,5-8 the reduction in
preventable readmission for the rural elderly can be chal-
lenging. Home health professionals may face difficulty in
arranging health care resources to meet patients’ posta-
cute care needs. Previous studies indicated that rural ben-
eficiaries are less likely to access home health services
than urban beneficiaries, and rural home health bene-
ficiaries have poorer outcomes than urban home health
elderly.9,10 As 88% of HHAs are for-profit organizations
which thereby pursue profit maximization,1 the home
health financial incentive program may discourage HHAs
from providing postacute care for the rural elderly if they
are at high risk of preventable readmission. Thus, inves-
tigating the association between rurality and preventable
readmission is imperative under the home health finan-
cial incentive program proposed by MedPAC.
Previous studies showed that greater distance or
delayed treatment increases the severity of illness and
mortality.11-13 If the rural elderly experience treatment
delays due to difficulty accessing primary care physicians
(PCPs) or referrals to specialists for follow-up after
hospital discharge, an elevated severity of illness and risk
of mortality can be expected upon hospital readmission.
Despite MedPAC’s national focus to reduce preventable
readmission for Medicare home health beneficiaries,
there is a paucity of research examining the impact of
rurality on quality of postacute care for Medicare home
health beneficiaries.
The purpose of this study was to address 2 research
questions: (1) Is there an association between rurality
and the likelihood of 30-day preventable readmission for
heart failure Medicare home health beneficiaries, and (2)
What is the impact of rurality on the severity of illness
and risk of mortality for 30-day preventable readmission
for heart failure Medicare home health beneficiaries?
We focused on heart failure and 30-day preventable
readmissions for the following reasons: heart failure has
the highest 30-day readmission rate among all diseases
for Medicare beneficiaries14 and is one of the diseases
that the Medicare program uses to calculate 30-day
readmission rates to penalize hospitals under the Hospital
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Rurality and Postacute Care for Home Health
Readmission Reduction Program (HRRP).15 We chose
preventable readmissions rather than all-cause readmis-
sions because, as discussed previously, HHAs with high
preventable readmission rates will face financial penalty
under the home health financial incentive program.1
Methods
Study Design and Data Sources
The study was a cross-sectional study using data from
2009. The unit of analysis was the home health episode
for postacute care. The data sources included several files
that have patient- and community-level data. Patient-
level data included the Master Beneficiary Summary File
to identify Medicare beneficiaries who were enrolled in
the fee-for-service (FFS) program; the Medicare Provider
Analysis Review (MedPAR) file to provide patients’
demographics and clinical conditions, such as age and
diagnoses, during the hospitalizations; the Outcome As-
sessment Information Set (OASIS) B1 version to provide
patients’ social, clinical, and functional conditions at
the time when patients were admitted to home health
care; and the Home Health Agency Research Identifiable
File (HHA RIF) to provide the number of home health
visits that patients received during the home health
episode. The data at the community-level included the
Area Health Resources File (AHRF). It provides county
characteristics, such as the number of PCPs, for the
counties where patients resided.
Study Sample
There were 2 study samples in the study. The first study
sample was heart failure Medicare beneficiaries who re-
ceived home health services for postacute care within
14 days of hospital discharge, which was used to ex-
amine the association between rurality and 30-day pre-
ventable readmission. These beneficiaries can be directly
referred by physicians in the hospital or referred by pa-
tients’ PCPs anytime within 14 days of hospital discharge.
The HRRP identifies the International Classification of
Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
codes for heart failure admissions.16 Following the HRRP,
we used these ICD-9-CM codes from the primary diag-
nosis to identify heart failure admission at the index ad-
mission from MedPAR. The 14-day criterion to define
home health beneficiaries for postacute care is commonly
used in OASIS assessment and previous studies.1,17,18 We
used the date of hospital discharge from MedPAR and the
date of start of home health care from OASIS to ver-
ify home health services after hospital discharge, sug-
gested by Wolff et al.18 Beneficiaries who experienced
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Rurality and Postacute Care for Home Health
30-day readmission without a preventable condition
were excluded. In addition to the criteria discussed above,
additional inclusion criteria were being 65 years or older,
enrolling in the FFS program, and being discharged from
hospitals before December 1, 2009. Patients whose dates
of admission and discharge were the same were excluded.
The second study sample was extracted from the first
study sample but restricted to only those who experi-
enced a 30-day preventable readmission. This study sam-
ple was used to examine the impact of rurality on the
severity of illness and risk of mortality for a 30-day pre-
ventable readmission.
Dependent Variables
There were 3 outcome variables of interest: (1) a 30-day
preventable readmission; (2) the extreme/major level of
illness severity for a 30-day preventable readmission; and
(3) the extreme/major level of risk of mortality for a 30-
day preventable readmission. Preventable readmissions
within 30 days of hospital discharge were extracted from
MedPAR by applying the Prevention Quality Indicator
Software Version 4.5 from the Agency for Healthcare
Research and Quality.19 These conditions were diabetes
with short-term complications, diabetes with long-term
complications, chronic obstructive pulmonary disease or
asthma in older adults, hypertension, heart failure, de-
hydration, bacterial pneumonia, urinary tract infection,
angina without procedure, uncontrolled diabetes, lower-
extremity amputation among patients with diabetes,
and perforated appendix. After identifying the pre-
ventable conditions, we coded and analyzed the 30-day
preventable readmission as a dichotomous variable.
The severity of illness and the risk of mortality for
30-day preventable readmissions were extracted from
MedPAR by applying 3M All Patient Refined Diagnosis
Related Groups (APR-DRGs) software. The 3M APR-
DRGs defined the severity of illness as “the extent of
physiological decompensation or organ system loss of
function” and the risk of mortality as “the likelihood of
dying.”20 The severity of illness and risk of mortality were
categorized into 4 subclasses—extreme, major, moderate,
and minor levels—based on patients’ clinical condi-
tions that take several factors into account, including
patients’ age, principle diagnosis, secondary diagnoses,
the presence of procedures, and the interaction of these
factors.20 Given the definition and the categories for the
severity of illness and risk of mortality, a disease may
have extreme/major level of illness severity but have
moderate/minor level of risk of mortality. The example
provided by Averill et al20 is that patients with acute
cholecystitis but without any comorbid conditions are
categorized into the extreme level of severity of illness
178
Chen et al.
because patients with this condition significantly lose
functioning of their gallbladder; however, the level of
risk of mortality for these patients is low because they
are less likely to die. Although all study samples had
heart failure, their risk of mortality varied. For example,
the risk of mortality for patients with heart failure is
lower than that for those with heart failure and having
respiratory failure as the secondary diagnosis. Because
the percentage of patients whose severity of illness
and risk of mortality at the extreme or minor level is
relatively small, we created a dichotomous variable to
represent patients with extreme or major illness severity,
and categorized patients with moderate or minor illness
severity as the reference group. A similar procedure was
applied to create a dichotomous variable to represent
patients with the extreme or major level of risk of
mortality, with patients whose risk of mortality was at
the moderate or minor level as the reference group.
Key Independent Variables
The key independent variable of interest was the degrees
of rurality. The US Department of Agriculture and Eco-
nomic Research Service developed the urban influence
codes (UIC) distinguishing metropolitan counties by pop-
ulation size (codes 1 and 2) and nonmetropolitan coun-
ties by population size of their town or city and proximity
to macro and micropolitan areas (codes ranging from 3 to
12).21 Following a previous study,22 we categorized ru-
rality into 3 categories to represent the various degrees
of rurality based on the counties where patients resided:
(1) micropolitan areas defined as a micropolitan area ad-
jacent or not adjacent to a large or small metropolitan
area (UIC codes 3, 5, and 8); (2) adjacent rural areas de-
fined as noncore counties adjacent to a large or small
metropolitan area (UIC codes 4, 6, and 7); and (3) remote
rural areas defined as noncore counties not adjacent to
metropolitan/micropolitan areas or noncore counties ad-
jacent to a micropolitan area that does not contain a town
of at least 2,500 or more residents (UIC codes 9, 10, 11,
and 12), with urban counties defined as a large or small
metropolitan areas (UIC codes 1 and 2) in the reference
group.
Control Variables
In addition to rurality, we controlled for several covari-
ates at the patient and community level in the analytical
models.17,23-25 At the patient level, patient demographics
included age, race/ethnicity, and gender. Beneficiaries’
social conditions included 2 variables: whether patients
were dual-eligible and whether patients lived alone.
Patients’ clinical conditions included: (1) beneficiaries’
The Journal of Rural Health 32 (2016) 176–187 
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Chen et al.
severity of illness or risk of mortality during the index ad-
mission. The methods used to create an indicator variable
for patients’ severity of illness and risk of mortality for
preventable 30-day readmissions, discussed previously,
were applied to create the indicator variables for patients’
severity of illness and risk of mortality during the in-
dex admission; (2) whether beneficiaries felt depressed
or hopeless; (3) the frequency of anxiety; (4) patients’
cognitive functions; (5) conditions when beneficiaries felt
dyspnea or shortness of breath; (6) beneficiaries’ activities
of daily living (ADL) functioning; (7) whether beneficia-
ries had pressure or stasis ulcer; (8) whether beneficiaries
required assistance in medication management; and (9)
the intensity of home health visits per week.
At the community level, we included the number of
PCPs per 1,000 population, the number of acute care hos-
pital beds per 1,000 population, and per capita income at
the county level. The operational definition of variables
and the data sources are presented in Table 1.
Statistical Analysis
We applied multivariable logistic regression to examine
the impact of rurality on each of 3 outcome variables: (1)
30-day preventable readmissions, (2) the extreme/major
level of illness severity for 30-day preventable readmis-
sions, and (3) and the extreme/major level of risk of
mortality for 30-day preventable readmissions. For the
model estimating 30-day preventable readmission, we in-
cluded the extreme/major level of illness severity during
the index admission. In a sensitivity analysis, we replaced
the extreme/major level of illness severity with the ex-
treme/major level of risk of mortality during the index
admission. Estimated odds ratio (OR) and 95% confi-
dence intervals (CI) are reported.
Results
We identified 51,667 postacute home health care
episodes as our first study sample, and 4,862 posta-
cute home health care episodes that had 30-day pre-
ventable readmission were our second study sample.
Table 2 presents descriptive statistics for the study vari-
ables for the 2 study samples. For our first study sample,
approximately 83% was from urban areas, with about
2%, 4%, and 11% of heart failure home health benefi-
ciaries from remote rural areas, adjacent rural areas, and
micropolitan areas, respectively. Approximately 51% and
49% of the index admissions were at the extreme/major
level of illness severity and extreme/major level of risk of
mortality, respectively. Approximately 43% of the study
sample was aged 85 and older. The majority (83%) of
The Journal of Rural Health 32 (2016) 176–187 
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Rurality and Postacute Care for Home Health
heart failure Medicare beneficiaries who received home
health services for postacute care were Caucasian. More
than 90% of our study sample required assistance in
medication management or ADL. Finally, approximately
93% of the study sample had shortness of breath.
For the second study sample, 79% were readmitted to
the same hospital. Approximately 64% of the preventable
readmissions were at the extreme/major level of illness
severity, while 55% of the index admission presented at
the extreme/major level of illness severity. Similar con-
ditions were observed for the risk of mortality as 54% of
the index admissions were at the extreme/major level of
risk of mortality, while 58% of readmissions were at the
extreme/major level of risk of mortality.
Table 3 presents the OR and 95% CI from the mul-
tivariable logistic regression for a 30-day preventable
readmission. Regardless of including the extreme/major
level of illness severity or the extreme/major level of risk
of mortality in the regression, the likelihood of 30-day
preventable readmission for patients in remote rural
areas was 27% lower than that in urban areas (OR:
0.73; 95CI: 0.57-0.94). However, we did not observe a
statistically significant difference among adjacent rural
areas, micropolitan areas, and urban areas. Among all
covariates, several were significantly associated with 30-
day preventable readmission (P< .05), including African
American race; the extreme/major level of severity and
the extreme/major level of mortality during the index
admission; patients who experienced anxiety daily or all
of the time; patients who felt shortness of breath when
they walked less than 20 feet, with minor effort, or at
rest; patients who reported depression or hopelessness;
and patients who had a pressure or stasis ulcer. Few
variables were negatively associated with 30-day pre-
ventable readmission: gender (being a female), requiring
assistance in 1 to 3 ADLs (compared to those who did
not have any ADL assistance), requiring assistance in
medication management (compared to those who did
not have any assistance in medication management),
and increases in intensity of home health visits per
week.
Table 4 presents the results for the impact of rural-
ity on the likelihood of being at the extreme/major
level of illness severity or the extreme/major level of
risk of mortality at readmission due to a preventable
condition. We did not observe significant difference
in the extreme/major level of illness severity and the
extreme/major level of risk of mortality for a preventable
readmission across various degrees of rurality, with one
exception indicating that beneficiaries living in adjacent
rural areas were 33% less likely to have extreme/major
level of illness severity than those in urban areas
(OR: 0.67; 95% CI: 0.46-0.98). It is expected that the
179
Rurality and Postacute Care for Home Health Chen et al.

Table 1 Operational Definition of Study Variables

Variables Operational Definition Data Source(s)

Outcome Variables
30-day preventable readmission 1 if patients readmitted to hospital due to a preventable condition within 30 days of MedPAR
hospital discharge; 0 otherwise
The extreme/major level of 1 if severity of illness is at the extreme or major level at the preventable readmission; 0 if
illness severity severity of illness is at the moderate or minor level at the preventable readmission
The extreme/major level of risk 1 if risk of mortality is at the extreme or major level at the preventable readmission; 0 if
of mortality risk of mortality is at the moderate or minor level at the preventable readmission
Key Independent Variables
Remote rural areas 1 if the county’s UIC is from 9 to 12; 0 otherwise AHRF
Adjacent rural areas 1 if the county’s UIC is 4, 6, and 7; 0 otherwise
Micropolitan areas 1 if the county’s UIC is 3, 5, and 8; 0 otherwise
Urban areas 1 if the county’s UIC is 1 and 2; 0 otherwise (reference group)
Covariates
The extreme/major level of 1 if severity of illness is at the extreme or major level at the index admission; 0 if severity MedPAR
illness severity of illness is at the moderate or minor level at the index admission
The extreme/major level of risk 1 if risk of mortality is at the extreme or major level at the index admission; 0 if risk of
of mortality mortality is at the moderate or minor level at the index admission
Age Two indicator variables identifying patients 75-84 years and 85+ years, with patients
65-74 years as the reference group
Race/ethnicity Two indicator variables identifying patients as African American, and Hispanic and other
races, with white as the reference group
Female 1 if gender is female, with male in the reference group.
Live alone 1 if patients live alone; 0 otherwise. OASIS
Dual eligible 1 if patients are Medicare/Medicaid dual eligible; 0 otherwise
Depression and/or hopeless 1 if patients feel depressed and/or hopeless; 0 otherwise
Anxiety Two indicator variables identifying patients with anxiety less often than daily, and with
anxiety daily or all of the time. Patients without anxiety all of the time are in the
reference group
Cognitive function Two indicator variables identifying patients with: (1) requiring assistance under
stress/unfamiliar conditions or in specific conditions and (2) requiring substantial help
in routine situations or total dependence on others. Patients being alert or oriented
were in the reference group.
Dyspnea Four indicator variables identifying patients with dyspnea at different levels of activities.
These activities are: (1) when walking more than 20 feet or climbing stairs; (2) when
walking less than 20 feet or dressing; (3) when under minor efforts, such as eating or
talking; and (4) when at rest during day or night. Patients who never felt dyspnea or
shortness of breath are in the reference group.
Pressure or stasis ulcer 1 if patients have pressure and/or stasis ulcer; 0 otherwise.
Requirement of assistance in 1 if patients required assistance in managing their oral, inhalant, or injectable
medication management medications; 0 otherwise
ADL ADL functions include grooming, toileting, bathing, dressing upper body, dressing lower
body, transferring, ambulating, and eating.
Three dummy variables represent patients with different levels of ADL functions: (1)
patients required assistance in 1 to 3 ADL functions; (2) patients required assistance in
4 to 6 ADL functions; and (3) patients required assistance in at least 7 ADL functions or
were completely dependent on someone to perform ADL functions. The reference
group is the patients who could independently perform all ADL functions.
Intensity of home health visits (Number of visits divided by the length of home health care) multiplied by 7. The number HHA RIF
per week of visits include the visits from 6 home health care professionals: nurses, physical
therapists, occupational therapists, speech therapists, home health aides, and
medical social workers.
Primary care resources Number of PCPs/1,000 population AHRF
Acute care hospital bed Number of acute care hospital beds/1,000 population
Income Per capita income

MedPAR, Medicare Provider Analysis Review; AHRF, Area Health Resources File; OASIS, Outcome Assessment Information Set; HHA RIF, Home Health
Agency Research Identifiable Research File.

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Chen et al. Rurality and Postacute Care for Home Health

Table 2 Descriptive Analysis for Study Variables

Percentage or Meana Percentage or Meanb

Variables (SD; N = 51,667) (SD; N = 4,862)

Dependent Variables
Preventable readmission 9.41 (29.20) NA
The extreme/major level of illness severity at the preventable readmission NA 63.70 (48.09)
The extreme/major level of risk of mortality at the preventable readmission NA 57.90 (49.38)
Key Independent Variables
Remote rural areas 2.26 (14.87) 2.08 (14.29)
Adjacent rural areas 4.02 (19.63) 4.02 (19.66)
Micropolitan areas 10.78 (31.01) 10.86 (31.11)
Covariates
Patients’ Clinical and Functional Conditions
The extreme/major level of illness severity at the index readmission 51.48 (49.98) 55.35 (49.72)
The extreme/major level of risk of mortality at the index readmission 48.88 (49.99) 53.60 (49.88)
Patients aged 65 and 74 20.02 (40.74) 22.83 (41.98)
Patients aged 75 and 84 37.49 (48.41) 37.39 (48.39)
African American 12.36 (32.91) 14.38 (35.09)
Other race 4.49 (20.72) 4.50 (20.73)
Female 58.26 (49.31) 55.02 (49.75)
Live alone 30.05 (45.85) 28.30 (45.05)
Dual eligible for the Medicare and Medicaid 3.97 (19.52) 4.20 (20.05)
Depression or hopeless 17.77 (38.22) 20.51 (40.38)
Levels of anxiety:
Not anxious all of the time Reference
Less often than daily 25.81 (43.76) 25.89 (43.81)
Daily or all of the time 17.17 (37.71) 20.05 (40.04)
Level of cognitive functions:
Being alert or oriented and able to focus and shift attention independently Reference
Required assistance under stress/unfamiliar conditions or in specific conditions 38.41 (48.64) 40.43 (49.08)
Required substantial help in routine situations or totally dependent 2.21 (14.70) 2.49 (15.58)
Level of dyspnea or shortness of breath:
Never felt dyspnea or shortness of breath Reference
When walking more than 20 feet or climbing stairs 26.31 (44.03) 20.71 (40.53)
When walking less than 20 feet or dressing 38.43 (48.64) 36.46 (48.14)
When under minor efforts, such as eating or talking 22.98 (42.07) 28.94 (45.35)
When at rest during day or night 5.84 (23.46) 9.40 (29.18)
Pressure or stasis ulcer 7.36 (26.12) 9.26 (28.99)
Required assistance in medication management 94.66 (22.48) 92.34 (26.60)
Level of ADL assistance:
Without any assistance in ADL Reference
Required assistance in 1 to 3 ADL 28.78 (45.27) 24.68 (43.12)
Required assistance in 4 to 6 ADL 28.41 (45.10) 28.75 (45.27)
Required assistance in at least 7 ADL or complete dependence on ADL 34.31 (47.47) 37.80 (48.49)
Number of home health visits per week (log-transformed) 2.83 (1.94) 2.19 (1.77)
Community Factors
Number of PCPs per 1,000 population 0.75 (0.30) 0.75 (0.30)
Number of acute hospital beds per 1,000 population 3.10 (2.23) 3.14 (2.18)
Income per capita ($1,000) 40.07 (11.65) 39.72 (11.58)

a
The percentage or mean was based on the study sample from heart failure Medicare beneficiaries who received home health services for postacute
care within 14 days of hospital discharge.
b
The percentage or mean was based on the study sample who both appeared in the index admission and experienced 30-day preventable readmission.

extreme/major level of illness severity and of risk of mor- 2.26; 95% CI: 1.95-2.63 and OR: 2.51; 95% CI: 2.17-2.90
tality at the index admission is strongly associated with for the extreme/major level of illness severity and the
the extreme/major level of illness severity and of risk of extreme/major level of risk of mortality, respectively).
mortality at readmission for a preventable condition (OR: Additionally, beneficiaries who felt depressed or hopeless

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Rurality and Postacute Care for Home Health Chen et al.

Table 3 Multivariate Regression Models for the Likelihood of 30-Day Preventable Readmission

Variables Odds Ratio (95% CI) Odds Ratio (95% CI)

Remote rural areas 0.73∗ (0.57-0.94) 0.73∗ (0.56-0.94)

Adjacent rural areas 0.87 (0.72-1.06) 0.87 (0.72-1.05)
Micropolitan areas 0.98 (0.87-1.10) 0.98 (0.87-1.10)
Covariates
Patients’ Clinical and Functional Conditions
The extreme/major level of illness severity at the index admission 1.19∗∗∗ (1.10-1.28) NA
The extreme/major level of risk of mortality at the index admission NA 1.21∗∗∗ (1.13-1.31)
Patients aged 65 and 74 0.92 (0.83-1.02) 0.94 (0.85-1.03)
Patients aged 75 and 84 0.95 (0.87-1.03) 0.95 (0.88-1.04)
African American 1.26∗∗∗ (1.13-1.41) 1.26∗∗∗ (0.12-1.41)
Other race 1.04 (0.85-1.27) 1.04 (0.85-1.26)
Female 0.90∗∗ (0.84-0.97) 0.91∗∗ (0.84-0.98)
Live alone 1.00 (0.92-1.09) 1.01 (0.93-1.09)
Dual eligible for the Medicare and Medicaid 0.97 (0.79-1.19) 0.97 (0.79-1.19)
Depression or hopeless 1.12∗ (1.02-1.23) 1.12∗ (1.02-1.23)
Levels of anxiety:
Not anxious all of the time Reference
Less often than daily 1.03 (0.95-1.13) 1.03 (0.94-1.13)
Daily or All of the time 1.15∗∗ (1.04-1.27) 1.15∗∗ (1.04-1.28)
Level of cognitive functions:
Being alert or oriented and able to focus and shift attention independently Reference
Required assistance under stress/unfamiliar conditions or in specific conditions 0.97 (0.90-1.05) 0.97 (0.90-1.05)
Required substantial help in routine situations or totally dependent 0.99 (0.77-1.26) 0.98 (0.77-1.25)
Level of dyspnea or shortness of breath:
Never felt dyspnea or shortness of breath Reference
When walking more than 20 feet or climbing stairs 1.14 (0.94-1.38) 1.14 (0.94-1.38)
When walking less than 20 feet or dressing 1.40∗∗∗ (1.17-1.68) 1.40∗∗∗ (1.16-1.68)
When under minor efforts, such as eating or talking 1.83∗∗∗ (1.51-2.20) 1.82∗∗∗ (1.51-2.20)
When at rest during day or night 2.30∗∗∗ (1.86-2.85) 2.30∗∗∗ (1.86-2.84)
Pressure or stasis ulcer 1.38∗∗∗ (1.21-1.57) 1.37∗∗∗ (1.20-1.55)
Required assistance in medication management 0.76∗∗∗ (0.66-0.88) 0.76∗∗∗ (0.66-0.88)
Level of ADL assistance:
Without any assistance in ADL Reference
Required assistance in 1 to 3 ADL 0.70∗∗∗ (0.61-0.80) 0.70∗∗∗ (0.61-0.80)
Required assistance in 4 to 6 ADL 0.95 (0.83-1.09) 0.95 (0.84-1.09)
Required assistance in at least 7 ADL or complete dependence in ADL 1.03 (0.91-1.17) 1.03 (0.91-1.17)
Intensity of home health visits per week (log-transformed) 0.49∗∗∗ (0.47-0.52) 0.49∗∗∗ (0.47-0.52)
Community Factors
Number of PCPs per 1,000 population 0.92 (0.78-1.09) 0.92 (0.78-1.09)
Number of acute hospital beds per 1,000 population 1.00 (0.98-1.02) 1.00 (0.98-1.02)
Income per capita ($1,000) 1.00 (0.99-1.00) 1.00 (0.99-1.00)

∗
P< .05; ∗∗ P< .01; ∗∗∗ P< .001.

(OR: 1.24; 95% CI: 1.02-1.51) or felt shortness of breath
with minor effort or at rest (OR: 1.52; 95% CI: 1.04-2.21
and OR: 1.82; 95% CI: 1.17-2.81 for minor effort and
at rest, respectively) or who had pressure/stasis ulcer
(OR: 1.63; 95% CI: 1.23-2.15) were likely to be at the
extreme/major level of illness severity for a preventable
readmission. Finally, we also observed that beneficiaries
who had pressure/stasis ulcer (OR: 1.60; 95% CI: 1.23-
2.09) or required 4 or more ADL assistance (OR: 1.38;
95% CI: 1.06-1.78 for 4-6 ADL assistance; OR: 1.38; 95%
CI: 1.08-1.77 for at least 7 ADL assistance or complete de-
pendence in ADL) were likely to be at the extreme/major
level of risk of mortality for a preventable readmission.
Discussion
Our study found that heart failure Medicare home health
beneficiaries living in remote rural areas were less likely
to have 30-day preventable readmission than those in
urban areas. Our finding is contrary to what one may
expect in rural populations, who, in general, have poorer
health outcomes and less access to care. Nevertheless, our

182 The Journal of Rural Health 32 (2016) 176–187 

c 2015 National Rural Health Association
Chen et al. Rurality and Postacute Care for Home Health

Table 4 Multivariate Regression Models for the Likelihood of Having Severity of Illness or Risk of Mortality at the Extreme/Major Level for a 30-Day
Preventable Readmission

Severity of Illness Risk of Mortality

at the Extreme at the Extreme
or Major Level or Major Level
Variables Odds Ratio (95% CI) Odds Ratio (95% CI)

Remote rural areas 0.64 (0.39-1.06) 0.75 (0.46-1.23)

Adjacent rural areas 0.67∗ (0.46-0.98) 0.96 (0.66-1.40)
Micropolitan areas 0.84 (0.66-1.07) 0.81 (0.64-1.02)
Covariates
Patients’ Clinical and Functional Conditions
The extreme/major level of illness severity at the index admission 2.26∗∗∗ (1.95-2.63) NA
The extreme/major level of risk of mortality at the index admission NA 2.51∗∗∗ (2.17-2.90)
Patients aged 65 and 74 1.16 (0.95-1.43) 1.01 (0.83-1.24)
Patients aged 75 and 84 1.08 (0.91-1.28) 1.11 (0.94-1.31)
African American 0.95 (0.76-1.20) 0.88 (0.70-1.10)
Other race 1.24 (0.82-1.88) 0.87 (0.59-1.29)
Female 0.88 (0.75-1.02) 0.82∗∗ (0.71-0.95)
Live alone 0.93 (0.79-1.10) 0.88 (0.75-1.04)
Dual eligible for the Medicare and Medicaid 1.40 (0.90-2.16) 0.94 (0.63-1.42)
Depression or hopeless 1.24∗ (1.02-1.51) 1.17 (0.97-1.41)
Levels of anxiety:
Not anxious all of the time Reference
Less often than daily 1.04 (0.87-1.25) 0.99 (0.83-1.18)
Daily or all of the time 0.71∗∗∗ (0.58-0.87) 0.76∗∗ (0.62-0.93)
Level of cognitive functions:
Being alert or oriented and able to focus and shift attention independently Reference
Required assistance under stress/unfamiliar conditions or in specific conditions 0.99 (0.85-1.16) 1.04 (0.89-1.22)
Required substantial help in routine situations or totally dependent 1.26 (0.76-2.10) 0.95 (0.59-1.54)
Level of dyspnea or shortness of breath:
Never felt dyspnea or shortness of breath Reference
When walking more than 20 feet or climbing stairs 1.10 (0.75-1.61) 0.93 (0.64-1.36)
When walking less than 20 feet or dressing 1.28 (0.89-1.85) 1.11 (0.77-1.60)
When under minor efforts such as eating or talking 1.52∗ (1.04-2.21) 1.14 (0.78-1.66)
When at rest during day or night 1.82∗∗ (1.17-2.81) 1.35 (0.88-2.06)
Pressure or stasis ulcer 1.63∗∗∗ (1.23-2.15) 1.60∗∗∗ (1.23-2.09)
Required assistance in medication management 0.84 (0.63-1.13) 0.82 (0.62-1.09)
Level of ADL assistance
Required assistance in 1 to 3 ADL 1.05 (0.80-1.38) 1.09 (0.83-1.42)
Required assistance in 4 to 6 ADL 1.32∗ (1.01-1.71) 1.38∗ (1.06-1.78)
Required assistance in at least 7 ADL or complete dependence in ADL 1.18 (0.91-1.52) 1.38∗ (1.08-1.77)
Intensity of home health visits 0.76∗∗∗ (0.69-0.83) 0.76∗∗∗ (0.70-0.84)
Community Factors
Number of PCPs per 1,000 population 1.25 (0.89-1.76) 1.32 (0.95-1.83)
Number of acute hospital beds per 1,000 population 0.97 (0.94-1.01) 0.97 (0.94-1.01)
Income per capita ($1,000) 1.00 (0.99-1.00) 1.00 (0.99-1.00)

∗
P< .05; ∗∗ P< .01; ∗∗∗ P< .001.

findings are consistent with a previous study based on di-
abetic Medicare beneficiaries, indicating that diabetic el-
derly in remote rural areas were less likely to have 30-day
readmission than those in urban areas.22 Increases in
travel distance to access care increase monetary and non-
monetary cost for patients and their families.26 Rural res-
idents, on average, travel longer and are poorer and more
sensitive to traveling cost than urban residents.27,28 It is
commonly found that rural populations were less likely
to utilize health care than urban elderly.29 Our study
population was homebound and had, on average, 4.2
diagnosed conditions.30 About 80% of our study sample
was aged 75 and older and 93% had shortness of breath.
Given their seniority, homebound status, and clinical
conditions, they were more likely to rely on their family
or community to arrange transportation to receive care.

The Journal of Rural Health 32 (2016) 176–187 

c 2015 National Rural Health Association 183
Rurality and Postacute Care for Home Health
For home health beneficiaries in remote rural areas, hav-
ing to travel a long distance makes accessing facility-based
health care even more challenging. Thus, our findings
of low 30-day preventable readmission for heart failure
Medicare home health beneficiaries in remote rural areas
may reflect unmet postacute care needs that are currently
not well understood, rather than reflect good quality of
postacute care during the period of home health care.
Among those readmitted to the hospital for a pre-
ventable condition, we found that beneficiaries in
adjacent rural areas had a lower likelihood of having
extreme/major level of illness severity for a preventable
readmission, compared to beneficiaries in urban areas.
Although evidence related to health or health behaviors
for the elderly in adjacent rural areas and micropolitan
areas is lacking, studies showed that more than 50%
of the rural population has the same physician for
more than 5 years, and rural physicians are satisfied
with their relationship with their patients and clinical
autonomy.31,32 Given our definition for remote rural,
adjacent rural, and micropolitan areas, the resources in
adjacent rural and micropolitan areas are better than
resources in remote rural areas. It is likely that heart
failure home health Medicare beneficiaries in adjacent
rural areas do not have the disadvantage of long driving
distances which affects those in remote rural areas. This
population has the benefit of continuity of care from
the same providers. The longer-term patient-provider
relationship helps physicians who understand patients
well and can detect changes in patients’ clinical condition
at the early stage. However, further investigation is re-
quired to understand the mechanisms underlying the low
likelihood of having an extreme/major level of severity
of illness for a preventable readmission in adjacent rural
areas.
Furthermore, our findings regarding risk factors for
preventable readmissions have critical implications for
clinical practice. In addition to rurality, our model in-
cluded many risk factors for readmission which are rel-
evant during the initial hospitalization and as the pa-
tient receives home health care. We found that patients
with the extreme/major level of illness severity or of risk
of mortality during the index admission are at elevated
risk of experiencing 30-day preventable readmission. Fac-
tors related to these 2 variables should be identified and
communicated between hospital discharge coordinators
and home health professionals during the care transition
process to facilitate home health professionals’ prioritiza-
tion of patient care. Furthermore, patient demographics
and several clinical conditions assessed in the beginning
of a home health care episode are significantly associ-
ated with 30-day preventable readmission. These risk fac-
tors include African American race, experiencing anxiety
184
Chen et al.
daily or all of the time, depression/hopelessness, pressure
or stasis ulcer, and dyspnea with specified conditions.
Home health professionals can use the risk factors identi-
fied in this study to identify high-risk patients who may
benefit from early intervention in an effort to further re-
duce 30-day preventable readmission.
Along with the risk factors identified above, we found
that patients who required assistance in medication
management or assistance with 1 to 3 ADLs are less
likely to experience 30-day preventable readmission,
compared to those who did not require assistance in
medication management or ADL, respectively. The
conditions for preventable readmission in our study,
such as short-/long-term complications of diabetes,
require patients rigorously follow medication regi-
mens. Home health beneficiaries, on average, have
8 medications.33 Medication errors within this popula-
tion are of immense concern.34 As discussed previously,
the majority of our study sample was aged 75 years and
older and had multiple clinical conditions. Their health
literacy and capabilities to follow the rigorous medication
regimens were critical to reduce preventable readmis-
sion. Home health professionals should be encouraged
to assess beneficiaries’ health literacy and medical man-
agement capabilities. Such assessments may include
repeatedly educating and monitoring home health
elderly who independently manage their medication or
do not receive the ADL assistance through the phone or
telehealth.
Finally, patients’ conditions, such as depression or
hopelessness, dyspnea, ADL assistance, and pressure or
stasis ulcer are positively associated with the likelihood
of being at the extreme/major level of illness severity
or of risk of mortality for a 30-day preventable read-
mission. Although these clinical conditions are assessed
at the beginning of home health care, these conditions
are also likely to appear during the index admission.
Hospitals may need to reassess patients’ clinical condi-
tions or ensure that patients are able to receive con-
tinuous care in the community before patients are sent
home. Home health professionals also need to coordi-
nate with physicians when home health professionals as-
sess patients with those conditions in the beginning of
home health care in efforts to strengthen opportunities
for home health elderly affected by heart failure to safely
stay in the community.
In addition to clinical implications, our findings
hold critical implications for the home health financial
incentive program proposed by MedPAC. First, like other
studies which found that place matters,35,36 our findings
indicated that where Medicare home health beneficiaries
live affects the likelihood of preventable readmission and
the level of illness severity for a preventable readmission.
The Journal of Rural Health 32 (2016) 176–187 
c 2015 National Rural Health Association
Chen et al.
Although our study found that increases in intensity
of home health visits reduce preventable readmission,
and the likelihood of presenting with extreme/major
level of illness severity or extreme/major level of risk of
mortality upon preventable readmission, home health
professionals cannot completely overcome the external
challenges that already exist in the communities where
patients live. Second, we found that patients with the ex-
treme/major level of illness severity or of risk of mortality
during the index admission are more likely to have a
30-day preventable readmission than their counterparts.
These beneficiaries are likely to be unwelcomed by
HHAs, given that 88% of HHAs are for-profit.1 Although
the purpose of the home health financial incentive pro-
gram is to reduce the readmission rate while improving
quality of home health care, access to home health for
postacute care for these high-risk patients is likely to be a
great concern under the home health financial incentive
program. Efforts should be made to mitigate the potential
for unintended consequences resulting from the home
health financial incentive program targeting reducing
preventable readmission. Toward these efforts, the model
that will be used to calculate the penalty rate for HHAs
under the financial incentive program should include the
risk factors during the index admission, the risk factors
appearing in OASIS, as well as the characteristics of
communities where patients live.
There are limitations in our study. First, our study
was based on administrative data and did not include
other clinical conditions, such as vital signs and labora-
tory results. Second, patients’ socioeconomic status, such
as education and health literacy, and coordination be-
tween hospital, physicians, and home health profession-
als are likely to affect 30-day preventable readmission
and the level of illness severity and of risk of mortal-
ity for a preventable readmission for our study sample.
These variables were not available and are beyond the
scope of our data sets. Third, our study was based on
a cross-sectional study design, which did not allow us
to observe the change in outcome measures from time
to time and to control unobserved factors, such as so-
cial context and culture in the community, which were
likely to affect the outcome measures in our study. Fi-
nally, one should carefully consider the population of in-
terest before generalizing our findings to other popula-
tions because health plans may apply different mecha-
nisms to provide postacute care for Medicare beneficia-
ries enrolled in the Medicare Advantage program or other
programs.
Despite the limitations, our findings provide perspec-
tives for future research. Given the multiple clinical con-
ditions and physical limitations, Medicare home health
beneficiaries are one of Medicare’s most vulnerable pop-
The Journal of Rural Health 32 (2016) 176–187 
c 2015 National Rural Health Association
Rurality and Postacute Care for Home Health
ulations. In remote rural areas, the low preventable read-
mission for home health elderly in our study was likely a
result of unmet need of postacute care. Although reduc-
ing readmissions is the nation’s top priority, it is imper-
ative to identify the unmet postacute care needs among
Medicare home health beneficiaries in remote rural
areas. Additionally, the factors that affect the likelihood
of preventable readmission for home health beneficiaries
are complex. The rural homebound elderly and their
families may have different preferences for care from the
urban homebound elderly when they need hospital care
for deteriorating clinical conditions or newly developed
complications. Applying both qualitative and quantitative
research designs to explore the mechanisms for meeting
the needs of home health elderly living in different levels
of rurality would help policy makers and stakeholders ad-
dress the needs of these vulnerable elderly. Furthermore,
the impact of rurality on other quality indicators, such
as 30-day mortality rate, emergency visits after hospital
discharge, or patient safety for Medicare home health
beneficiaries is largely unknown. Future studies focusing
on other quality indicators are recommended. Moreover,
Medicare home health beneficiaries directly referred by
the physicians in the hospital may be different from those
referred by their PCPs a few days after hospital discharge.
Investigating the differences in beneficiaries’ functional
and clinical conditions between these 2 referral sources
is recommended. Finally, several programs, such as the
HRRP and increases in Medicare Part D prescription
drug coverage, have been implemented under the
ACA. The impact of the ACA on quality of postacute
care for Medicare home health beneficiaries warrants
examination.
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