The Rural Long-Term Care Labor Force: An Overview

The Rural Long-Term Care Labor Force: an Overview
(An Informational Paper)

by Edith L. Stunkel, M.S.W.
Kansas State University Center for Aging
August, 1997

with funding from
The National Resource and Policy Center on Rural Long-Term Care and The Administration on Aging grant #90-AM-0697

Introduction

In 1990, approximately one-quarter of older persons in the United States resided in rural areas. The rural long-term care labor force provides essential services to those individuals who have developed chronic illnesses or disabilities. From "country doctors" to nurse aides, regional hospital-based physical therapists to home-based personal care attendants, the professionals and paraprofessionals in the rural long-term care labor force provide the continuum of care for the rural chronically ill and disabled. Information about the rural long-term care labor force is important to health care organizations, service agencies, educational and training institutions, governmental planners, and policy-makers. While it would appear that much is not known about this topic, this paper provides an initial examination of the available data and research.

Definitions: Rural Long-term Care Labor Force

The rural long-term care labor force is an elusive concept. Each part of the phrase contributes to the difficulty of defining and measuring it. "Rural" has many meanings, ranging from a generalization encompassing all areas that are not metropolitan to variably differentiated geographic areas based on density, population, distance from metropolitan areas, and economic base (Bowler et al.,1992; Coward et al., 1996a; Dellenbarger, 1988; Stoller, 1996). The diversity among rural areas has become more widely acknowledged, and researchers are using distinctions such as the Beale Codes to examine differences among rural places (Coward et al., 1993). The Beale Codes differentiate among six types of rural counties by creating a matrix of three population sizes by two levels of adjacency to metropolitan areas. The Economic Research Service of the U. S. Department of Agriculture further classifies nonmetro counties into six economic types (farming, mining, manufacturing, government, services, and nonspecialized) and five overlapping policy types (retirement-destination, Federal lands, commuting, persistent poverty, and transfer-dependent).

"Long-term care" is also a term without complete consensus. While chronicity is implied, long-term care often includes post-acute and rehabilitative care episodes. The target population of long-term care is somewhat nebulous, including: the frail elderly, neonates who require comprehensive care, the mentally and developmentally disabled, and persons with other chronic disabilities (Lapping et al., 1989; Magilvy, 1996; Newhouse, 1995).

The term "labor force," refers to health care and social service providers as well as informal caregivers and volunteers. These workers may be employed in institutional, community-based, and/or home-based settings (Brannon et al., 1996; Clark, 1991; Coates et al., 1990; Coleman, 1993; Coward et al., 1993; Coward et al., 1996b; Hicks, 1990; Horwitz & Rosenthal, 1994; Lapping et al., 1989; Stoller, 1996; Vogel & Coward, 1995; Wright et al., 1994 and 1995). The combination of all three terms further expands the complexity of defining and measuring the rural long-term care labor force (Beaulieu & Mulkey, 1995; Deaton & Nelson, 1992; Ricketts, 1996; Vogel, 1995). According to Magilvy (1996), "more differences exist in access and utilization of rural health and in-home services among rural counties and across rural areas than between rural and urban areas" (pp. 69-70). Pragmatically, the rural long-term care labor force may be viewed as that part of the health and long-term care labor continuum about which some data is known.

National Databases

There are no national databases which measure or document the rural long-term care labor force. Although the data on long-term care personnel are not available in any one national database, there are some resources which begin to measure this labor force. Few, if any, of these databases are specifically broken out by rurality, although software could theoretically be developed to cull only rural counties from the total set.

One might expect that the Bureau of Labor Statistics would have ample data about the rural long-term care labor force. Stofferahn et al. (1991) and Carter (1982), however, have reported how inadequate standard labor force data collection and reporting mechanisms are for rural areas. Furthermore, data about the wide range of health care personnel who comprise the long-term care labor force are not easily found in the current configurations of labor force data reporting.

The Census Bureau provides four-digit SIC detail by county for the number of employees in each industry, including health services professions (physicians, dentists, chiropractors, optometrists, podiatrists, other health practitioners) and facilities (hospitals, medical and dental laboratories, home health care agencies, etc.). Rural counties, however, often have too few employees in some of these sectors to allow disclosure of the data and maintain employer confidentiality. These data also do not include government-related health providers and professions such as public health departments, county hospitals, and nursing home personnel.

Regularly collected national databases that may contain some information pertinent to the rural long-term care labor force include The National Medical Expenditure Survey (NMES), the Area Resource File (ARF) of the U.S. Department of Commerce, the National Health Care Provider Inventory of the Center for Disease Control (NHPI), U.S. Census PUMS-D, U.S. Census of the Population, AARP State Profiles, the Office of Shortage Designations of the Public Health Service, Bureau of Health Manpower, Medicare Provider-of-Service tapes (1990), and the Dartmouth Atlas of Health Care in the United States.

Other databases include non-reoccurring surveys such as the 1982 and 1984 National Long Term Care Surveys, the 1981 National Data Base on Aging (Clark, 1991), and the National Long Term Care Channeling Demonstrations of the 1980's (Coleman, 1993).

A recent request for applications by The Health Resources and Services Administration (HRSA) proposes a three-year Cooperative Agreement for a Center for Health Workforce Distribution Studies (Federal Register, 7-23-97, p. 39532). This cooperative agreement would "support research and analysis at the state level for one state or a few states only" regarding distributional issues in allied health, dentistry, nursing, and medicine. This one-time-only project would not necessarily lead to the application of research outcomes nationwide, however.

State Databases

Obtaining information about the rural long-term care labor force at the state level is akin to searching for the proverbial "needle in the haystack". Each state government has different entities which are responsible for the oversight and collection of long-term care data. In addition, entirely different agencies are usually responsible for the oversight and collection of labor force-related data. No specific information about the rural long-term care labor force has been discovered.

States collect data on Medicare and Medicaid, as required by federal law. These data, however, focus primarily on recipients rather than on their providers. The Medicare Cost Reports, (which contain information about providers), are maintained at the state level and are not combined into a national data set. Obtaining access to the provider information at the state level may be very difficult, as most states do not maintain the data in a readily useable form.

The accessibility of state-level data is irregular. Some states have census or health care information available through the internet. (See Kansas, Texas, and West Virginia internet sites described below). The scope of the data and the regularity with which such information is updated varies from state to state, and some information is erroneous. For example, recent internet inquiries into databases listed on the Information Network of Kansas resulted in many dead-end calls. The individuals listed as having knowledge of the databases appeared to be unable to provide the appropriate information.

The process of identifying each state’s data about rural long-term care providers would be arduous, and the resulting data would most likely not be comparable across states. Also, without regular updates such information would quickly become obsolete, as the investigation of the aforementioned Kansas internet site demonstrated.

Published Research

Professional Health Care Providers

Despite occasional aberrations (Clark, 1991; Schlenker & Shaughnessy, 1996), there is broad agreement that rural areas have comparatively fewer health care providers per capita than urban areas (Brannon, 1996; Coburn et al., 1996; Coward et al., 1993; Laws & Harper, 1992; Vogel, 1986). In 1995, the American College of Physicians reported that the number of physicians per 100,000 rural population was about 43% that of urban populations (Coburn et al., 1996, p. 207). A 1989 Institute of Medicine study reported that for ten major types of allied health professionals, the per capita rate was lower in nonmetropolitan than metropolitan counties (Brannon et al., 1996, p. 175). For instance, while rural areas have 25% of the country’s population, they had only 19% of the nation’s nurses in 1987 (Vogel, 1986, p. 288).

A 1987 study of non-metropolitan counties in Georgia revealed that 55% had no physical therapists, 67% had no opticians, 79% had no psychologists, 82% had no occupational therapists, 91% had no podiatrists, and 93% had no speech pathologists or audiologists (Ibid., p. 289). Lasala (1995) found "critical vacancies and staffing needs" for rural nurses in Virginia.

Studies of the health care labor force (rural as well as urban), focus primarily on physicians (Braden & Beauregard, 1994; Plichta, 1994; Ricketts, 1996; Scammon, 1994), with the assumption that "many consumers gain entrance to the health care system through physicians. Because of the physician’s gatekeeper role, a deficiency in the supply of physicians affects the availability of other health care services" (Hicks, 1990, p. 486). (This researcher, however, has not discovered documentation to support this assumption.)

Other research has attempted to measure the prevalence of registered and/or advanced practice nurses (Auman, 1984; Hilker et al., 1995; Lancaster et al, 1994; Lasala, 1995; Mahoney, 1991), allied health care professionals, (such as physical and occupational therapists, physician assistants, dentists, and pharmacists), (Hicks, 1990; Vogel and Coward, 1995; Wright et al., 1994 and 1995), and ancillary professionals such as morticians (Wright et al., 1994 and 1995). These studies also tend to focus on institutional health care providers, such as hospitals and nursing homes (Brannon et al, 1996; Brown, 1996; Coburn et al., 1996; Coward et al., 1996a; Schlenker & Shaughnessy, 1996). Some studies, however, have focused on community-based and home care of rural elders (Clark, 1991; Coleman, 1993; James, 1994; Newhouse, 1995). Absent from these studies are data about less visible formal care providers to the elderly such as nutritionists and dietitians.

Paraprofessional Health Care Providers

Although there is some research comparing the numbers of urban and rural health professionals, "data are not available on the relative shortages of nonprofessional staff in metropolitan versus nonmetropolitan facilities" (Brannon et al, 1996, p. 176) (italics added). It is also difficult to find data about home-based care providers to the elderly such as certified nurse aides and home health aides.

Long-term Care Provider Organizations

It is important to recognize the difference between labor force data and data that is related to long-term care provider organizations. For example, Schlenker (1996) pointed out that while rural areas have more home health agencies than urban areas, their smaller staffs result in only slightly higher per capita personnel. Furthermore, once travel time and geographic distance are taken into account, the effective personnel/provider ratio for rural areas is likely to be less than the absolute numbers imply.

In mental health, the National Rural Health Association (1992) reported that "only 7 percent of rural counties have a general hospital with psychiatric facilities versus 33 percent for urban areas." Relative surfeits, however, are reported in nursing home beds; Rowles (1996) summarized research based on 1990 Medicare data tapes that showed that rural areas had more nursing home beds per older resident than urban areas (62 rural beds per 1,000 older persons in rural areas versus 45 in urban areas).

Whether the data concerns facilities, beds, or numbers of personnel, distinctions among these measurements and the activity levels of the personnel must be measured in order to capture the effective level of long-term care service delivery in rural areas.

Other Issues

Further compounding the difficulties of measuring the rural long-term care labor force is the fact that there are no studies which focus exclusively on the long-term care labor force—rural or urban. Instead, terms such as availability and accessibility of long-term care services are most often cited. Krout enumerates six alliterative words related to accessibility: availability, awareness, appropriateness, acceptability, affordability, and adequacy (Magilvy, 1996, pp. 68-9). In a study of long-term care in rural Florida, Turnbull (1988) found deficiencies in the availability of types and numbers of services, knowledge about services by elders and their families, transportation to services, private and public funding resources, and uniform eligibility requirements. In Alabama, Spence (1993) found that accessibility to services by elderly African Americans was significantly affected by characteristics of the individual seeking services (age, marital status, awareness of service) as well as by geographic location. The accessibility of long-term care services to rural persons is a function not only of the personnel existing in those areas, but also of the awareness of rural residents about the available services and whether or not the services fit their perceived needs and pocketbooks.

Some research has tied rural long-term care to economic conditions. While rural areas in general have fewer health care providers than urban areas (see above section on Professional Health Care Providers), low-income rural areas are more disadvantaged still. In a study of southern states, Coward (1993) reported that 87% of persistent low-income rural counties "had fewer health care resources available for their elderly residents than did other places the same size inside or outside the region" (p. 368).

Internet Resources
(For further information, the following internet sites may be searched.)

Databases

Center for Disease Control (CDC): National Health Provider Inventory
http://www.cdc.gov/nchswww/about/major/nhcs/nhcs.htm

Provides a description about CDC databases, but viewers need to order CD-Rom or datatapes in order to access the data itself.

Databases for Assessment of Community Health in Rural Areas
http://utsph.sph.uth.tmc.edu/www/utsph/CS/basedata.htm

An informative outline of national and Texas databases related to rural community health issues. Includes brief description of the quality and scope of data in each database.

DataStar Web
http://dsweb.krinfo.ch/4986ad79/WBSTART/1/c7dbfed7/

A fee-based database search site sponsored by Knight-Ridder. The url above is the free test-site with practice files offering a range of sample databases.

Medline
http://www.ncbi.nlm.nih.gov/PubMed/

National Library of Medicine's search service to access the 9 million citations in MEDLINE and Pre-MEDLINE (with links to participating on-line journals), and other related databases.

MedWeb: Databases
http://www.gen.emory.edu/MEDWEB/keyword/Databases.html

MedWeb: Public Health Sites
http://www.gen.emory.edu/medweb/medweb.ph.html#Sites

Huge web sites with a list of over 100 hyperlinks to many health-related resources. Categories range from specific diseases to types of health care and broader topics such as rural health, projects, and institutes and agencies. Does not appear to have information on rural long-term care labor force.

National Rural Health Services Research Database
http://www.muskie.usm.maine.edu/rhsr/rhsrWelcome.htm

Funded by the Federal Office of Rural Health Policy, this site maintains a database of currently funded rural health services research projects in the U.S. Database is searchable by funder, research institution, or principal investigator. No subject search is available at present.

NIH Projects: CRISP (Computer Retrieval of Information on Scientific Projects)
gopher://gopher.nih.gov:70/11/res/crisp

A searchable database of NIH funded research and intramural research projects. Includes descriptions of research being conducted at university rural aging population centers (see also university sites below).

Science Citation Index and Social Science Citation Index
http://www.isinet.com/

Produced by the ISI (Institute for Scientific Information), these two databases cover 4,400 scientific and 1,400 social science journals worldwide, together with selected coverage of related material. The multi-disciplinary set of ISI databases totals 300 million references. Order form found at url http://www.isinet.com/prodserv/citation/wosfrm.html.

Sociometrics WWW Home Page
http://www.socio.com/data.htm

Five data archives and nearly 350 data sets, selected for inclusion by a National Advisory Panel. The Data Archive of Social Research on Aging (DASRA) contains data and documentation from The Longitudinal Study of Aging 1984-1990, The Longitudinal Retirement History Study 1969-1979 and The National Long Term Care Study 1982-89. Pertinence to current rural long-term care labor force is low.

Health Care Organization Sites

Association of Clinicians for the Underserved
http://www.clinicians.org/

New grassroots interdisciplinary organization dedicated to the development and support of those who serve poor and underserved populations (urban and rural). No data on numbers of members available.

Rural Health Connections
http://rhc.coos-bay.or.us/

Useful networking site for rural health care providers. Hosts email lists for rural nurse aides, nurses and doctors. Contains policy analyses of rural health issues, history of federal legislation affecting rural health, and hypertext links to information about Oregon health providers through the Oregon Office of Rural Health (http://www.ohsu.edu/aa-RuralHlth/rscfile.html).

Rural Recruitment and Retention Network
http://www.biostat.wisc.edu/clearinghouse/3rnet/

45 state-based organizations such as State Offices of Rural Health, AHECs, Cooperative Agreement Agencies and State Primary Care Associations that help health professionals locate practice sites in rural areas throughout the country. No statistics on rural providers, however.

Search American College of Physicians (ACP)Online
http://www.acponline.org/search/iaquery.exe

Word search of American College of Physicians journal articles. No data about rural providers.

Minority Health Sites

Minority Health Project Database Details: AHCPR
http://www.minority.unc.edu/minority/databases/mhd/details/ahcpr.html

Statistics on health care usage, expenditure, and insurance. Most of these databases are specific to certain ethnic groups (Blacks, Hispanics (general, elderly, and rural), Indians, and Alaskan Natives) as well as to low income, elderly, and HIV-related groups. No provider information.

Minority Health Project Database Details: INDEX
http://www.minority.unc.edu/minority/databases/mhd/details/index.html

The Minority Health Database Catalog is an on-line catalog containing descriptions of national and sub-national (state and local) information on the health of racial and ethnic minority populations in the United States.

State and County-level data Sites

American Public Health Association (APHA)
http://www.apha.org/

Provides information to public health professionals rather than information about public health professionals.

Information Network of Kansas
http://www.ink.org/public/hcdgb/

The home page of the Health Care Data Governing Board cited above regarding difficulties in maintaining updated data information.

Kansas County Economic Development Profile Reports
http://www.ukans.edu/cwis/units/IPPBR/ksdata/ksdata.htm

Provides county-by-county economic and community development data, as well as the capability to search across variables and develop tables and graphs for all counties.

REIS Data Base
http://www.lib.virginia.edu/socsci/reis/reis1.html

The Regional Economic Information Service data base provides local area economic data for states, counties, and metropolitan areas for 1969-1994. No long-term care provider information is available.

Texas Data Sources for Selected Health Facts
http://www.tdh.state.tx.us/programs/shd&pa/page4.HTM

Lists data sources for health-related topics, including health care providers (physicians, dentists, nurses, and underserved areas). Most recent provider information cited is from 1995.

U.S. County Economic Typologies
http://151.121.66.126:80/epubs/other/typolog/

State-by-state economic data provided by the Economic Research Service of the U.S. Department of Agriculture. No rural-urban distinctions and no information about the long-term care labor force.

West Virginia 1997 County Profiles
http://wvbph.marshall.edu/profiles/prointro.htm

Provides 31 selected health indicators and compares each county to state and national averages. Does not include information about provider availability.

University sites

Dartmouth Atlas of Health Care
http://www.dartmouth.edu/~atlas/

Web site contains table of contents with sample data, text and statistics from the Atlas. Full document must be purchased. Includes geographic information about hospitals and physicians. Does not appear to have rural-urban distinctions.

Michigan Center for Rural Health
http://www.com.msu.edu/othermed/r-health/index.htm

SIU Rural Health Resources
http://www.siu.edu/%7Ecrhssd/rhres.htm

Southern Illinois University Center for Rural Health and Social Service Development hosts this site which has user-friendly hypertext to many of the sites listed in this report.

University of Kansas Data Access and Support Center
http://gisdasc.kgs.ukans.edu/dasc/dascfaq.html

Extensive geographic information systems databases for the State of Kansas. No rural labor force provider information.

U.S. Census Bureau and related sites

Census Data Access Tools
http://www.census.gov/main/www/access.html

Census Database Help Page (Texas data)
http://brcsun15.tamu.edu:8000/html/open3.html

Basic census data by topic available by block group and census tract for the State of Texas.

Census Home Page
http://www.census.gov/

Census TIGER Page (automated mapping of census data)
http://www.census.gov/ftp/pub/geo/www/tiger/

These three pages provide access to U.S. Census data available through the World Wide Web. Specific information about long-term care providers, however, is not one of the domains of Census data.

IPUMS (Integrated Public Use Microdata Series)
http://www.hist.umn.edu/~ipums/

Publicly accessible computerized database includes 23 high-precision individual-level samples of the United States population censuses from 1850 to 1990. Uniform codes allow comparisons across years.

LOOKUP
http://cedr.lbl.gov/cdrom/doc/lookup_doc.html

Sponsored by UC Berkeley Library, provides access to Census information through several sites, and provides technical assistance in accessing the information.

PC Demographics
http://www.pcdemographics.com/

A commercial tool to access Census data by ZIP Codes or counties.

NOTES

1. There are 2,276 nonmetro counties of which 2,259 have been classified into one of the six economic types and 1,197 have been classified into one or more of the five policy types (Cook, 1996).

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