Caregiving in rural areas
"If you take away their driving, how are they going to receive services that they need, like getting to the doctor? We have fairly good services within the metro area here, but out in the rural area, (it's difficult) trying to get people transported in to get health care or the things that we sort of take for granted…"
"I see that there's not a lot of services out there for the elderly for transportation, things that will help relieve the sons and daughters because that's a big problem. Transportation's huge. They can't drive anymore."
— statements from stakeholders attending several rural focus groups
Access to quality health services was identified as one the leading concerns in one survey of aging stakeholders and state and local rural health experts.  Most rural areas face a lack of health services, lack of infrastructure, high poverty levels, and geographic isolation. A lack of available and accessible support services can leave caregivers with limited options for getting the assistance they need.
The specific issue of family caregiver support may be more pressing in rural areas, where there is a higher proportion of the elderly. According to the U.S. Census Bureau, in 2005, an estimated 3.2 million individuals (nearly 15 percent of the total population) in Texas were 60 years or older. The concentration of elderly Texans is greatest – approximately 2.4 million – in what are considered to be rural counties.  Focus group participants in rural areas reported having less access to skilled nursing and other long- term care services compared to their urban and suburban counterparts. Without these formal services available, caregivers and care recipients in rural areas rely even more on family and friends for assistance.
The shortage of health care workers is one of the leading challenges of providing support to informal caregivers in rural areas. Service providers in rural areas face distinct challenges in recruitment and retention of workers due to a less educated workforce, limited continuing education opportunities, lower salaries, lack of prestige and high stress levels associated with the job.
According to the Family Caregiver Alliance's State of the States in Family Caregiver Support, more than 35 percent of state program administrators face a shortage of qualified service providers or direct care workers. This workforce shortage results in considerable unfilled need and is often cited among service providers as one of the main challenges in providing services and support in rural areas. Without these professional supports, informal caregivers can find themselves with little or no assistance as they care for their loved one themselves.
Lack of adequate transportation is also a major barrier for informal caregiving in rural parts of Texas. Geographic isolation results in family caregivers having to travel greater distances just to reach those they care for, in addition to transporting care recipients
to required services such as medical care. More than 20 percent of respondents who self-identified as caregivers to the 2008 Aging Texas Well Indicators Study reported that they travel more than 50 miles to provide care.  Older Texans in rural areas also experience poverty in greater numbers than their urban counterparts, and may be unable to afford reliable transportation or keep pace with fluctuating fuel costs.
High transportation costs also create a specific challenge for in-home service providers and their employees in rural areas of the state. Low or non-existent mileage reimbursement drastically affects a direct care worker's ability to cover the cost of fuel and vehicle maintenance, particularly when they are required to drive long distances to reach the individual for whom they provide services. This situation can further increase the workforce shortage problem described above, resulting in an even greater need for informal care.
Access to services
The challenge of finding and receiving community support is a particular concern in rural areas where limitations on providers, access to services, information, and ongoing support make it harder for individuals to care for loved ones in their homes. Institutional admission rates for rural elders are typically higher than in urban communities.  Caregivers in rural areas often do not access services because they are unaware of existing programs, do not know they are eligible, do not accept services until there is a crisis, and find services too geographically distant.  These concerns were echoed by participants in the focus groups.
One effort to address these issues occurred in the West Texas area, where six AAAs collaborated with the Texas Tech University Health Sciences Center to develop West Texas Cares.  This initiative focused specifically on caregiver outreach and education to meet the needs of rural family caregivers in West Texas. Additionally, the expansion of the ADRC program to five new sites (and a sixth sometime in 2010), including several rural areas, should address some of these challenges.
Caregivers in rural areas face a unique set of challenges, from population distribution to access to formal supports and a shortage in the workforce providing those formal services. The following recommendations were offered by stakeholders attending the focus groups to address the specific problems that caregivers encounter in rural parts of Texas:
- Examine the feasibility of higher mileage reimbursement for direct service workers to provide greater incentive to serve rural or remote areas of the state.
- Enhance ongoing efforts to increase the number of skilled health care workers in rural areas, including coordinating with local community colleges to offer educational and training opportunities.
- Develop outreach efforts to caregivers that consider that the need for information may be greater and/or different in rural areas than in urban and suburban parts of the state. These efforts should both address and be informed by these differences.
- Consider efforts to ensure that reimbursement rates for long-term care services keep pace with the rising cost of living and doing business in rural areas. Adequate funding and reimbursement rates are critical to address the shortages of direct care workers in rural areas.
- Consider expansion of consumer directed service options to include the use of vouchers for transportation services.
- Hutchison, L., Hawes, C., & Williams, L. (2005). Access to Quality Health Services in Rural Areas – Long-term Care. In Gamm, L. and Hutchison, L. (Eds.), Rural Healthy People 2010: A companion document to Healthy People 2010. Volume 3. College Station, TX: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Research Center. Retrieved July 15, 2009, from www.srph.tamhsc.edu/centers/rhp2010.
- Texas Department of Aging and Disability Services. (2007). Texas State Plan on Aging, 2008- 2010. Retrieved July 15, 2009, from www.dads.state.tx.us/news_info/publications/planning/stateplanonaging/2008-2010/stateplan2008-2010.pdf
- Feinberg, L.F, Newman, S.L., Gray, L. & Kolb, K.N. (2004, November) The State of the States in Family Caregiver Support: A 50-state study. Family Caregiver Alliance, San Francisco, CA.
- Texas Department of Aging and Disability Services. (2009). Aging Texas Well Indicators Survey, Overview Report, 2009. Retrieved July 15, 2009, from www.dads.state.tx.us/news_info/publications/studies/ATWindicators2009.pdf
- Texas Department of Aging and Disability Services. (updated November 12, 2008). Support for Caregivers. Retrieved July 15, 2009, from www.agingtexaswell.org/caregiving/
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April 11, 2012