Information about the use and perceived future availability of Home and Community-Base Services (HCBS) for the rural older adult is limited  . HCBS is a federally funded program that is designed to meet the needs of people who prefer to obtain long-term care services and supports in their home or community, rather than in an institutional setting  . Rural older adults continue to experience less access (e.g., limited transportation, longer travel distances, etc.) to community-based services    ; are socially isolated  , and are less aware of potential services leading to lower overall service use  . It is this lack of access, social isolation, and limited service awareness and subsequent use that leaves rural older adults without adequate care and services that might promote overall health and a higher quality of life.
Recognizing needs of rural older adults are constrained by a lack of knowledge on factors impacting rural aging in place  , the overall goal of this project was to develop an instrument for gathering information about HCBS. This needs assessment, which identifies older adults’ HCBS use and satisfaction, and possible future service use along with perceived needs, was developed by the current author and was used to survey older adults in rural western Nebraska and throughout the Eastern Plains of Colorado. These regions were selected for their proximity to one another, similar distance to urban services, and comparable population density. As a result, data from 176 rural older adult participants were used to measure the Older Adult Service Usage Assessment’s (OASUA) reliability, content and construct validity (convergent and discriminant), and factor structure.
1.1. HCBS Measurement Need
The study builds upon current Affordable Care Act’s Medicare and Medicaid innovative initiatives (March 2016) that call for population-specific, effective long-term home-based services  . What is known about HCBS use comes primarily from institutional reports rather than individual measurement  . If there is individual measurement, data rely on caregiver reports to assess services and needs of older rural people  , does not focus on older adults  , or measures only home care satisfaction  .
Using the need component of the Social Behavior Model  , the current study focused on the perceived service needs of older persons in rural communities for the development of the OASUA. An earlier version of this model  , which was originally not adapted for older people, was tested by Sonnega et al. (2016). In this first national HCBS service use study, the researchers found many common HCBS services were not available in the 19 community-services identified. The HCBS user in this national study included individuals who were female, low SES, black or Hispanic minority status, on Medicaid, over the age of 75, and not employed. Creation of an instrument that measures a more comprehensive number of individual community-based services used by rural older adults was necessary.
1.2. Older Adult Service Usage Assessment (OASUA)
The OASUA was developed to measure current and future perceived need and expressed use of HCBS programs along with service satisfaction. The OASUA generates information based on dimensional HCBS use. Survey items were derived from Area Agency on Aging (AAA) fliers of services available within these rural areas. Operating from a foundation of perceived and expressed needs, the first 43 service items assess current or recent service use on a 6-point scale (i.e., 0 = no use, 1 = single use, 2 = multiple uses but not weekly, 3 = weekly, 4 = twice a week, 5 = more than twice week) along with service satisfaction (i.e., 0 = not satisfied, 1 = limited satisfaction, 2 = some satisfaction, 3 = moderately satisfied, 4 = very satisfied, 5 = extremely satisfied). The second 43 items measure perceived future service utilization (i.e., no use, single, use, multiple uses but not weekly, weekly, twice a week, more than twice week) and potential future needs (i.e., not needed, limited need, some need, moderate need, very needed, extremely needed). This scoring format allows for a possible indication on awareness of service availability and frequency of specific service use.
Scoring of the OASUA. The easily scored structure of the OASUA allows for individual or group identification on the total number of services used to date, frequency of specific services, satisfaction with prior services, total number of services predicted for future use, potential frequency of future identified services, and the perceived need of specific services required for the future. Access to services is indicated with completion of the OASUA along with the potential for additional prompts to be added. Self-administration time for the OASUA is approximately 10-15 minutes. Individuals with lower literacy rates may require additional time or assistance. Anyone with literacy below the 6th grade or who use English as a second language should be provided assistance. The benefits of using the OASUA include ease of use, speed of completion, ease of scoring, and applicability to a wide range of older adults. The OASUA is a measure that focuses on service use and is a valid and reliable instrument. The OASUA generates information based on dimensional HCBS use (e.g., current expressed service use and satisfaction, and future possible use and perceived needs). It appears to also be reliable, demonstrates content validity (service use), while also measuring convergent validity and discriminant validity.
As a result of the service rural service gap for use and perceived availability of services, the intent of the study was to (a) develop an appropriate assessment of service use for older adults; and (b) evaluate reliability, validity, and factor loadings for the OASUA. Development of such an instrument has the potential for promoting healthy community-based living through measurement of community services used by older adults either through a single point of measure or by identifying service use changes over time.
Power analysis indicated a minimum of 88 participants from each of the two regions was required to complete a comparison at an alpha of 0.05. A total of 176 face-to-face interviews were conducted with comparison groups of older adults residing in rural eastern Colorado and western Nebraska. The Older Americans Act of 1965 defined an older adult as any individual over the age of 60. This Act provides guidelines for service eligibility for older adults  . Through interview or guided self-completion, which allows for definitions to be provided and probes to be used, the OASUA was administered. Participants were obtained via convenience sampling, which has been found to be an effective manner to obtain entrance into difficult to obtain communities such as older adults aging in place. For the current study, participants were excluded if they did not meet the age or region criteria. If required, cognitive impairment would have been assessed using the Mini Mental State Examination with a cut-off score of 20/30 or below needed for participation. No such assessment was mandated. Information was provided on specific services of interest with the completion of each survey.
2.2. Western Nebraska and Eastern Plains of Colorado Participants
Participants were selected from the western portion of Nebraska and from the Eastern Plains of Colorado because minimal research on older adult service use has been completed for these regions. Limited prior research from rural Nebraska and Colorado suggests the importance on the development of a needs assessment and the identification of older adult HCBS perceptions. The current study is significant in that it occurred in two states with similar rural regions that are experiencing modest success for HCBS and with an older population (65+) growing faster than state growth rates in the same demographic   . All counties that are part of the current study have a health professional shortage, are eligible for Center for Medicaid Services-Rural Health Clinics Program, and for Federal Office of Rural Health Policy grant programs  . Additionally, no data for Colorado are included in the Medicaid Analytical Extract (MAX) for either the 2008 or 2011 extract and each state’s HCBS program differs in its eligibility criteria, funding amounts, and possible service use  . The development of this instrument, which specifically measures the frequency of current service use and satisfaction, and future use and perceived service needs, was created for initial use in these two areas.
Participants included 117 females (66.5%) and 59 males (33.5%) who were primarily Caucasian (n = 169, 96.0%) residing in rural western Nebraska or the Eastern Plains of Colorado. Participant average age was 75.77 years (SD = 7.57, range = 60 - 96 years) with 22.2% having a bachelor’s degree or higher level of education. Those who completed the measure were generally married at the time of interview (56.8%) as compared to those who were widowed (26.7%), divorced (14.2%), or never married (2.3%). The primary source of income was Social Security (84.7%), 35.8% indicated having only one source of income, 30.7% reported two sources, 24.4% stated three sources, 6.3% four sources, and 2.8% reported five sources (e.g., social security, savings, investments, pension, and land). No differences between the comparison groups were indicated for age (Nebraska, M = 76.2; Colorado, M = 75.2), F(1, 174) = 0.838, h = .374, p = 0.36. Between group differences were identified for gender, c2(1, N = 176) = 4.30, p = 0.03, education, c2(10, N = 176) = 21.59, p = 0.02, marital status, c2(3, N = 176) = 9.84, p = 0.02, and income of participants, c2(12, N = 176) = 26.88, p = 0.01.
3.1. Exploratory Factor Analysis
Exploratory factor analysis (EFA) was used to analyze the OASUA using principal components extraction with varimax (orthogonal) rotation. On initial running, the variable of case management demonstrated no current or potential future participant use; therefore it was eliminated. With this variable removed, 37-items were extracted meeting the criteria of an eigenvalue of 1.0 or greater, which accounted for 88.8% of the total variance. The first item loading accounted for 15.9% of the variance. All items factored into the theoretical components without significant cross loading. Results are shown in Table 1.
The scree test, factor eigenvalues, and amount of variance accounted for yielded four factors, which were all greater than 0.40. Sixty items loaded onto factor one. Most of the 60 items, with the exception of current health insurance use, related to services participants’ felt would be used in the future or were items of future perceived need. Ten items loaded onto the second factor. These items were related to participants’ current use and service satisfaction in the areas of service referral (i.e., adult protection services, consumer affairs and legal counsel, counseling and support groups, information and referral, elder abuse consultation) and need for durable medical equipment. The third factor loaded 10 items. Items centered on current and future older adult activities (i.e., senior center activities, religious programs, senior meal sites); as well as, the perceived need for information on grandparents raising grandchildren. Older adult activities and program availability may have relevant connections for those interviewed. Eleven items loaded onto the fourth factor. These items were health related (i.e., health insurance satisfaction and perceived future need; current use, satisfaction with, and perceived future need for hearing and vision clinics; current home health care use; current use and satisfaction with respite care; and current and future use of veteran services) or dealt with future use of senior low rent housing/non-subsidized. Senior low rent housing may be part of this last factor with the recognition that as overall health declines financial consequences follow. A decline in finances directly impact type and quality of housing.
3.2. Reliability of the OASUA
Cronbach’s α was used to assess the internal consistency of responses within the OASUA. The scale demonstrated overall excellent reliability (Cronbach’s α = 0.95), with subscale reliabilities ranging from 0.76 to 0.94 (current services used: 0.76; service satisfaction: 0.77; future service utilization: 0.92; future perceived service needs: 0.94).
3.3. Validity of the OASUA
The convergent validity of OASUA was examined by considering the relationship between the subscales. The rationale being that current or recent service use would predict future service use and perceived needs, as well as satisfaction with services experienced. Using a Pearson’s Product-Moment Correlation, the total number of current services used correlated with total perceived future service use, r(173) = 0.59, p < 0.001, and with total number of future perceived service needs r(174) = 0.43, p < 0.001). A correlation was evident between future service utilization and future perceived needs r(173) = 0.84, p < 0.001). Discriminant validity was apparent with the total number of services used not being related to total reported service satisfaction r(166) = −0.03, p > 0.05). The number of the services used was correlated with increases in future use and perceived need.
Table 1. Factor loadings for exploratory factor analysis with varimax rotation of OASUA.
Note: F = Future Use; PN = Perceived Need in Future; S = Satisfaction; U = Current or Recent Use.
Service satisfaction did not correlate with future service utilization r(165) = −0.14, p > 0.05, but was negatively correlated with future perceived needs r(173) = −0.20, p < 0.01). This finding suggests lower current satisfaction with service use has the potential to be related to higher future perceived service needs.
This study was intended to develop and examine the psychometric properties of the OASUA with an older adult population. The EFA indicated a four-factor solution. The OASUA is an 86-item instrument designed to measure current service use and satisfaction (43-items), as well as future service use and potential service needs (43-items) supporting older adults. The OASUA provides an indication of awareness on service availability along with frequency of use. Case management as a variable choice was eliminated from the OASUA for two reasons: no participant indicated use of this service, which was removed from the EFA and following an ensuring review case management was not listed as one of the 19 services indicated in a national survey for HCBS availability  . These same researchers listed tax preparation assistance in the list of 19 services and as a result this variable was added to the OASUA keeping it an 86-item measure for future investigation. Table 2 provides a subsequent revision of the OASUA.
Findings from this study give support for the need component of the Social Behavior Model and recognition for older adults’ informed choices in service awareness and potential utilization as mandated by the Older Americans Act Reauthorization of 2016 (https://www.congress.gov/bill/114th-congress/senate-bill/192). One method to promote informed choice is the measurement of HCBS service availability and use by individuals programs are intended to serve. Measurement of the older adult’s aging experience as tied to service utilization and frequency of use, along with a needs assessment is of particular importance in rural settings. The limited availability and access found in rural areas is recognized as some of the most significant barriers to the use of services and long-term care  . The OASUA can be used as a single point of measure or to evaluate changes in community-based service use, satisfaction, future service use, and/or perceived needs over time. Older adults should be recognized as the consumers they are and who have the ability to evaluate community-based services.
5. Limitations and Conclusion
The intent of this research was to develop a service needs assessment. Several limitations exist: 1) the current study included a predominantly Caucasian rural sample; 2) participants for this study resided in two different states; however, the service offerings were similar in number and structure allowing for thoughtful comparison; 3) all collected data was self-report and interpreted as such; 4) convenience sampling was used to identify the population of interest. The sampling method employed was chosen because HCBS person level data was only available to employees of the AAA. A random sample was approached by randomly
Table 2. Older adult service usage assessment.
sampling facilities where older adults congregate to create a sampling frame of places. From the randomly selected settings list, individuals were sampled-as they self-selected whether to participate; and 5) measurement of service use via survey method is less reliable when a single assessment is obtained. Multiple measurement points would allow for increased accuracy and the examination of linear relationships. As a result of these limitations, further data collection should occur within other states and with more diverse sampling. Despite these limitations, the OASUA is an instrument that could be administered multiple times throughout a calendar year to improve participant recall and provide for a more complete picture of service use and allowing for measurement of predictive validity. With multiple measurements, changes in perceptions can be identified.
In conclusion, OASUA can be used to gauge current service use and frequency, overall satisfaction with services; as well as perceptions of future service use and frequency, and potential need for services in the future. The OASUA may help to inform stakeholders and potential insurers on the service needs in these two states along with other rural areas. This measure may provide community-based service providers with an increased awareness of region specific current and future service use and needs for rural older adults and the associated satisfaction. As the population continues to age, bettering HCBS use through effective communication of service availability may improve the overall aging experience. Sustained measurement of service use and perceived needs could play a role toward furthering healthy aging and informing funding policy with regard to service cost effectiveness. Future research may want to ascertain additional information regarding service use management strategies (e.g., telemedicine, family and extended support) and additional community-based services (e.g., tax preparation assistance, etc.) thereby allowing for an adjustment to ineffective individual approaches. Findings from the current study may not be generalizable to all rural areas; however, understandings gained may be transferable to regions with similar services and circumstances.
Publication of this article was funded in part by the University of Northern Colorado Fund for Faculty Publication.