Rural–Urban Variability in Home and Community‐Based Service Use Among Veterans

BACKGROUND: Home and community-based services (HCBS) are home-based services that enable people to remain in their own environment despite challenges related to disease, disability, or age. In rural areas, service availability may be lower. The purpose of this analysis was to examine rural-urban differences in HCBS use among Veterans enrolled in the Veterans Health Administration (VHA) and identify facility-level variation. METHODS: This cross-sectional study used data from fiscal year 2022 (10/1/21-9/30/22). We incorporated rurality for Veterans (dichotomized as rural/urban based on Rural-Urban Area Commuting Codes) and facilities (proportion of rural Veterans served). VHA payment files identified HCBS use. Regression analyses sequentially adjusted for demographics, comorbidity, Area Deprivation Index (ADI), and facility fixed effects to produce a risk ratio (RR) of HCBS use among rural Veterans (RR > 1.0 indicates higher HCBS use among rural vs. urban Veterans). RESULTS: Of over 6 million enrolled Veterans, 34.1% (n = 2,055,746) were identified as rural. Compared to urban Veterans, rural Veterans were more likely to be older (64.1 ± 16.1 vs. 61.0 ± 17.4 years, p < 0.001), male (92.0% vs. 88.8%, p < 0.001), and white (80.5% vs. 63.7%, p < 0.001). HCBS were used by 5.04% (n = 103,605) of rural Veterans and 5.21% (n = 206,608) of urban Veterans. The unadjusted rural HCBS RR was 0.97 (95% confidence interval (CI) = 0.96-0.97). After adjusting for demographics, comorbidity, ADI, and facility fixed effects, the adjusted RR of HCBS for rural Veterans was 0.92 (95% CI = 0.91-0.93). There was substantial variability across facilities, with rural Veterans ranging from 60% less likely to 167% more likely to use HCBS than urban Veterans (RRs: 0.40-2.67). CONCLUSION: While rural Veterans were less likely to use HCBS overall, there was substantial variability across facilities. These findings demonstrate that some VAMCs counteract the overall trend by ensuring rural Veterans receive HCBS at rates comparable to urban Veterans.