Getting to the root: Examining within and between home health agency inequities in functional improvement

Shekinah A. Fashaw-Walters, Momotazur Rahman, Olga F. Jarrín, Gilbert Gee, Vincent Mor, Manka Nkimbeng, Kali S. Thomas

Research output: Contribution to journalArticlepeer-review


Objective: To quantify racial, ethnic, and income-based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs). Data Sources: 2016–2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data. Data Collection/Extraction Methods: Not Applicable. Study Design: We use multinomial-logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five-category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins. Principal Findings: Of the 3+ million Medicare beneficiaries with a HH start-of-care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual-level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low-income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% CI:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income-based disparities persisted within HHAs. Black-White, Hispanic-White, and AIAN-White disparities were largely driven by between-HHA differences, whereas income-based disparities were mostly due to within-HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities. Conclusions: Both within- and between-HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes.

Original languageEnglish (US)
JournalHealth services research
StateAccepted/In press - 2023

Bibliographical note

Funding Information:
This work was supported by the National Institute on Aging (1R36‐AG068199). Authors Shekinah A. Fashaw‐Walters, Gilbert Gee, Olga F. Jarrín, Manka Nkimbeng, and Kali S. Thomas have no potential conflicts of interest to declare. Dr. Vincent Mor is a paid consultant to NaviHealth, Inc., and chairs their Scientific Advisory Board. NaviHealth is an independent entity within OPTUM. The company offers post‐acute care (PAC) management and services to more than 1.5 million beneficiaries in all regions of the country through its partnerships with health plans and health systems. We would also like to acknowledge Cyrus Kosar for his support with the analytic coding.

Publisher Copyright:
© 2023 Health Research and Educational Trust.


  • Medicare home health
  • disability, post-acute care
  • functional improvement
  • health disparities
  • home health agency

PubMed: MeSH publication types

  • Journal Article


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