Abstract
Every state is required to submit a State Plan on Aging describing how it will use resources from the Older Americans Act (OAA), including a section specific to serving rural older adults. This paper describes a policy content evaluation of all 50 State Plans on Aging, focusing on Section 307(a)(10), which describes how states will serve rural older adults. We identified the most common and innovative approaches to using OAA funds to serve rural older adults across states. The most common information included about using OAA funds to serve rural older adults was describing the funding formula used to allocate resources. However, states varied in their definition of rural and in the details of their funding formulas. A minority of states also described additional approaches to serving rural older adults, including prioritizing Black, Indigenous, or rural residents of color; outreach; and targeted service delivery.
What this paper adds
This paper uses data from published State Plans on Aging to illuminate ways in which states plan to use Older Americans Act (OAA) funding to serve rural older adults. States vary in their definition of rural, leading to differences in which older adults are included in targeted funding, programming, and outreach. States also vary in their approaches to using OAA funding to serve rural older adults, with some only sharing how their funding formula accounts for rurality and others going beyond funding to share innovative approaches to outreach, evaluation, and service delivery.
Applications of study findings
Without consistency in how rural older adults are identified across states, state-based inequities in funding and service delivery for rural older adults may persist. Rural older adults experience disparities in health and access to care, relative to their urban counterparts, and innovative approaches to serving rural older adults outlined in State Plans on Aging may offer new insights into how to best meet their needs.
Introduction
As the U.S. population ages, and as the majority of older adults would prefer to age in place even if their health or functional status changes, it is increasingly important to understand how resources are allocated toward supporting home and community-based services (HCBS). The Older Americans Act (OAA) is a primary funding mechanism for HCBS and aging services more generally, providing states with resources to support their older adult populations. The needs of older adults vary by geographic location, however, with particular differences by rurality. Therefore, a clearer understanding of how states allocate resources to rural older adults via OAA funding is needed to illuminate strategies, inequities, and potential gaps. This paper addresses that need using a content analysis of the rural-specific Section 307(a)(10) from each state’s State Plan on Aging to examine the ways that states are using OAA resources to support rural older adults.
Aging in Rural Areas
Rural areas are aging at a faster rate than urban areas, with a higher percentage of older adults living in rural areas (Pender et al., 2019; Tuttle et al., 2020). Rural older adults differ from urban older adults, on average, in ways that may create more demand for aging services. For example, rural older adults tend to be in poorer health than urban older adults, and have higher rates of disability (Tuttle et al., 2020). Rural older adults are more likely to own their own homes (rather than rent), but also have lower incomes and less accumulated wealth (Tuttle et al., 2020). Altogether, this means that rural older adults may have more needs for home and community-based services (HCBS), but fewer financial resources with which to afford those services.
Rural communities also face challenges related to serving older adults well, including transportation barriers, limited access to health care, declining availability of long-term care and hospital services, and persistent workforce shortages (Douthit et al., 2015; Healy, 2019; Henning-Smith et al., 2018; Lahr et al., 2019; University of North Carolina Sheps Center for Health Services Research, 2022). Nearly 140 rural hospitals have closed in the last decade and rural nursing homes are closing more rapidly than urban nursing homes (Sharma et al., 2021; University of North Carolina, 2022). The COVID-19 pandemic has only exacerbated the situation, with higher mortality rates in rural areas, further stretching an already limited health care workforce (Henning-Smith, 2020b; Marema, 2021).
It is important to note that rural areas, and rural older adults, are not monolithic. They include tremendous diversity in demographic composition, socioeconomic status, access to health care and resources, and in environmental characteristics (Henning-Smith, 2020a; Kozhimannil & Henning-Smith, 2021; Tuttle et al., 2020). As such, it is important to understand how opportunities and funding for older adults in rural areas vary across the country, with states forming important divisions in funding and programmatic approaches. Further, “rural” itself is not a universally defined term; rather, there are multiple definitions of rural, most of which are recognized at the state and federal levels for different policy purposes (Bennett et al., 2019). However, using different definitions, such as those at the county level versus by population density, will lead to different conclusions about which older adults are considered “rural.” To the extent that there is variation between states in how rural is defined in State Plans, access to OAA funding and programming targeted to rural older adults will also vary.
The Older Americans Act and State Plans on Aging
The Older Americans Act (OAA) was passed by the U.S. Congress in 1965 in an attempt to better support older adults across the country (Congressional Research Service, 2021; United States Congress, 2020). Specific goals set forth in the OAA include ensuring the best possible health for older adults, access to comprehensive long-term services, opportunities for employment, adequate income in retirement, and more (Congressional Research Service, 2021). The structure of the Aging Network (an umbrella term for all local, state, and federal agencies that operate under the OAA to service older adults) is outlined in Title II of the original legislation (Congressional Research Service, 2021).
The Administration on Aging (AoA) serves as the federal authority for all issues concerning older adults and administers grant funding to states to be used for social services, research, and training (United States Congress, 2020). The AoA directs grant funds to State and Territorial Units on Aging (SUA), which make up the next level of the Aging Network. According to a federally approved Intrastate Funding Formula (IFF), each SUA then allocates funds to the Area Agencies on Aging (AAAs). All AAAs are nonprofit, but they may choose to operate in the private or public sector. Within the Planning and Service Area (PSA) to which the AAA is assigned, the AAA delivers services to older adult residents either directly or via contracted service providers (Congressional Research Service, 2021).
OAA dollars fund a wide variety of items, but the largest proportion by far (73% in fiscal year 2021) is spent on state and community programs serving older adults (Congressional Research Service, 2021). These programs are outlined in Title III of the OAA and include a range of services for nutrition, caregiver support, health promotion, and more (Congressional Research Service, 2021). In addition to those activities in Title III, in FY2021, 19% of OAA funds went toward Title V programs, which offer community service opportunities (e.g., at day care centers, schools, and hospitals) for unemployed older adults with low-income. Less than 3% of OAA funds were allocated to each of the following: the AoA (Title II), research projects and training related to aging (Title IV), Native American organizations (Title VI), and vulnerable elder rights protection activities (Title VII) (Congressional Research Service, 2021).
As a requirement of receiving OAA funding through Title III, each state must designate a state agency to lead this work and that agency must develop and administer a multi-year State Plan on Aging (Congressional Research Service, 2021; United States Congress, 2020). Section 307 of the OAA details the required information to be included in State Plans. Notable among these requirements is that the plans must cover a two-to-four-year period and be based on information from the Area Plans developed by each AAA. Additionally, the State Plans must ensure that the SUA will hold public hearings (or other means of gathering community input) to evaluate the effectiveness of services they deliver. Section 307 requires that State Plans offer descriptions of the agencies’ methods for serving the needs of those with “greatest economic or social need” and historically under-resourced populations (United States Congress, 2020). In fact, every State Plan on Aging is required to include section 307(a)(10) focused on serving rural older adults. The instructions for that section read, “The plan shall provide assurance that the special needs of older individuals residing in rural areas are taken into consideration and shall describe how those needs have been met and describe how funds have been allocated to meet those needs” (Barkoff, 2021).
Understanding how states use OAA funding, totaling more than $3 billion in fiscal year 2021 (Congressional Research Service, 2021), and what approaches are taken to support rural older adults is critical to illuminating where gaps in service provision might remain and what disparities exist between states. This study uses a policy content evaluation of all 50 State Plans on Aging to identify approaches to serving rural older adults.
Methods
For this study, we conducted a policy content evaluation (Centers for Disease Control and Prevention, 2015) of all 50 State Plans on Aging, specifically focusing on the language included in Section 307(a)(10), in which states provide details about how they will serve rural older adults. For states that did not provide text for Section 307(a)(10), we searched the entire State Plan to find whether rural older adults were mentioned and, if so, in what capacity. Previous studies have used State Plan data similarly to look at how states intend to serve under-resourced populations (Adams & Tax, 2017).
We accessed State Plans on Aging through the ADvancing States organizational website (ADvancing States, 2020). ADvancing States, formerly the National Association of States United for Aging and Disability (NASUAD), was founded in 1964 as the association for state long-term services and supports agencies (ADvancing States, 2020). In three instances (IN, PA, and WA), the complete State Plan was not available through ADvancing States; in those cases, we searched for the plan directly on the individual state’s website. In all cases, we used the most recent State Plan available. For 21 states, the plan published on the ADvancing States site had expired in 2019, 2020, or 2021. In these cases, we searched for updated plans on the state’s website. Twenty states had updated plans available, although three of them (ID, NJ, and SD) were in draft form. For those three states, we used the draft document, as it provided the most current information and was the document available to the public. One state (WI) did not have a more recent plan published, so we used the most recent version available, although it was expired.
Analysis
Once we obtained all State Plans, we compiled the full text of 307(a)(10), along with information about the state and its plan, including the plan years, the percentage of the state that is rural (Iowa State University, 2022), the percentage of the state that is age 65 and older (Kilduff, 2021), and the percentage of older adults (65+) in the state who live in rural areas (Smith & Trevelyan, 2021). In each case, we relied on U.S. Census data, including the U.S. Census definition of rural. The Census defines rural as anything outside of an “urban area”; urban areas include urban areas with populations of 50,000 or more people or urban clusters with a population of 2500-49,000 people (US Census Bureau, 2015). We also noted what definition each state was using to identify rural areas, as indicated in their State Plan.
From there, we reviewed the entire text of 307(a)(10) for each state and assigned codes to the state approaches to serving rural older adults in order to identify the most common approaches, as well as innovative strategies. We used content analysis to assign codes, with one researcher from the team leading the coding (Hsieh & Shannon, 2005). Codes were developed for each type of approach to serving older adults, and were then collapsed into broader categories. The codes and categories were reviewed by a second member of the research team and any discrepancies between researchers were discussed until consensus was achieved. Finally, when a state’s Section 307(a)(10) referenced a funding formula, we analyzed the formula to identify which factors, if any, were used in allocating funds to rural areas, again developing and assigning codes to each factor.
Results
Definition of Rural in State Plans
States differed in their definition of rural used in their State Plans (see Figure 1). The majority of states (n = 29) used the U.S. Census definition to define rural in their State Plan. In doing so, states varied in their description/translation of that definition. Some simply referenced the U.S. Census definition, others referred to “territory, population, and housing units not classified as urban,” and others used a population density measure of communities or counties with “with <100 people per square mile.” An additional 16 states used county-based measures, designating non-metropolitan counties as “rural.” Among those, some referenced the Office of Management and Budget definition, some referenced the U.S. Department of Agriculture definition, and some referred to non-metropolitan counties “outside of a Metropolitan Statistical Area.” The remaining 5 states did not provide a clear, specific definition of rural in their State Plan. Rural definition used in state plans on aging.
Inclusion of Section 307(a)(10)
Aging and Rural Demographics and Inclusion of Section 307(a)(10), by State.
Note. Percent rural, percent 65+, and percent 65+ in rural areas are all derived from U.S. Census data. All five states that without Section 307(a)(10) list rural residents as a priority population elsewhere in their State Plan.
*Rhode Island includes Section 307(a)(10), but notes: “N/A; Rhode Island has no rural areas.”
Approaches to Serving Rural Older Adults
Strategies for Serving Older Adults in Rural Areas, as Listed in State Plans on Aging, Section 307(a)(10).
Note. Data from 45 states that included Section 307(a)(10) in their State Plan on Aging. Categories are not mutually exclusive; states may be represented in multiple rows. AAA = Area agency on aging.
The OAA requires that funding formulas account for “the geographical distribution of older individuals in the State” (United States Congress, 2020). Most of the 40 states with a published funding formula based it on the percentage of older adults living in rural areas (rural population factor) or on population density within defined areas of the state. Five states (DE, NH, ND, RI, and WY) that included Section 307(a)(10) did not list a funding formula, but noted that because their entire state is one Planning and Service Area (PSA), a formula was not needed to allocate funds. Nine states that included Section 307(a)(10) only listed a funding formula as their approach to serving rural older adults.
Service Provision
Above and beyond describing their funding formula for serving rural older adults, the next most common approach listed was service provision, which was mentioned in 23 State Plans (51%) among those who included Section 307(a)(10). Specific types of services included transportation (eight states), nutrition (e.g., meal delivery; seven states), socialization opportunities (e.g., gathering sites; six states), in-home services (three states), health promotion programs (e.g., fitness classes; three states), Medicare benefits counseling (two states), COVID-19 vaccine distribution (one state), volunteer opportunities (one state), and mental health services (one state).
Eight states mentioned ways they are increasing access to services for older adults in rural areas For example, Oregon is expanding access to services by coordinating with statewide referral services; rural Area Agencies on Aging (AAAs) in Montana have relocated staff to operate within rural communities out of local offices, senior centers, and even their own homes, (instead of from main offices); and Colorado’s AAAs have worked to identify new service delivery models to improve access for rural older adults.
Seven states pointed to their efforts to evaluate services delivered and to identify gaps. For example, South Carolina uses an Advanced Information Manager (AIM) system to generate reports showing whether target populations are receiving services; New Mexico imposes specific performance measures and reporting dates for each of its service objectives; and Iowa uses data on the number of rural residents served by agency and service to identify gaps and inform policy changes.
Other Innovative Approaches
Nine states (20%) noted that they partner with other organizations like churches and non-profit organizations to reach older adults in rural areas. Another common approach was communication and outreach, which nine states (20%) mentioned. One of the nine, Alaska, also noted that their outreach methods were multi-lingual and included health fairs and public service announcements.
Three states (7%) mentioned utilizing technology as a tool for reaching rural older adults. Michigan has implemented a web–based aging information system “to retrieve and analyze data regarding services provided to older adults and their caregivers” (Michigan Department of Health & Human Services Aging & Adult Services Agency, 2020), and South Carolina makes use of geographic information system (GIS) mapping to show where clients reside. Oregon’s State Plan committed to expanding the virtual delivery of certain programs in light of limitations from the COVID-19 pandemic and ease of access for rural residents.
States without Section 307(a)(10)
Five states (AR, HI, SD, TX, and WI) did not include Section 307(a)(10), but all five listed rural older adults multiple times as priority populations within the full text of their State Plan. Arkansas and Hawaii also detailed their funding formula elsewhere in the State Plan, and both incorporated a rural factor. Rhode Island’s State Plan included Section 307(a)(10), but the section stated, “Rhode Island has no rural areas” and listed no specific approaches. (Rhode Island used county-level definitions to delineate rurality; by Census definitions, 9.3% of Rhode Island is rural; see Table 1).
Discussion
Rural populations are aging, with an older age structure than urban populations (Bipartisan Policy Center, 2018). The majority of rural older adults would prefer to age in place (Henning-Smith et al., 2021), that is, they would prefer to remain in their homes and communities even if their health status changes. As such, it is vitally important to understand how they are being supported in doing so. Knowing how states plan to use OAA funding to serve older adults in rural areas is especially important, given that those older adults typically have poorer health outcomes, worse access to care, and fewer financial resources, compared with older adults in urban areas (Tuttle et al., 2020).
Using a policy content evaluation of State Plans on Aging, Section 307(a)(10), we identified ways that different states plan to use OAA resources to serve rural older adults. We found that most (45) states had a published State Plan including Section 307(a)(10). Of those, the most common approach was to lay out a funding formula for distributing funds to rural areas. Some states went above and beyond that in describing their funding formulas, including recognizing the specific needs of rural Black, Indigenous, and people of color (BIPOC) older adults and the need for multi-lingual outreach.
States’ OAA funding formulas are required, and important. However, on their own they may not be sufficient. States also need to identify innovative ways to serve rural older adults—including addressing the unique needs that exist at the intersection of rurality and other socio-demographic characteristics. Further, in response to rural-urban disparities in access to care and support services, State Plans should pay special attention to developing strategies for improving access (as we saw in state plans for OR, MT, MS, IN, VT, and CO). Such strategies might include locating services in rural areas, addressing workforce issues, conducting rural-specific evaluation of services, and using virtual technology to ensure that rural and remote older adults’ needs are met. However, all of those approaches also require policy investment at the state and federal level into basic rural infrastructure, including transportation and broadband Internet, as well as investment in programs and policies to increase the rural health care workforce.
We also found that states varied in their definition of rurality, with some states using county-level definitions and other states using U.S. Census definitions. There is no one, perfect measure of rurality (Bennett et al., 2019). However, without consistency across states in how rural is defined, there may be inequities between states in how rural older adults are served ((Henning-Smith et al., 2020). For example, one state noted that it did not have any rural older adults. That is true, by county-level definitions, but not by Census definitions.
To the extent that states vary in their definitions of rurality, their investment in rural older adults, and their level of innovation in serving rural older adults, inequities between states in outcomes and services for older adults will persist. These inequities also have implications for loved ones and family caregivers who may live in another state and may have difficulty navigating an older adult’s resource and service availability if it looks very different from what is available in their own state. Policymakers at the state and federal levels should consider increasing consistency in definitions of rurality to reduce state-based inequities, and they should also find ways to incentivize innovation and investment for rural older adults. In its next iteration of the OAA, the U.S. Congress may consider refining its definition of rurality as it applies to Section 307(a)(10), so as to ensure equity across states in allocating resources to rural older adults.
The approaches laid out in State Plans have very likely been impacted by the COVID-19 pandemic, which has upended service delivery, funding, and workforce availability, especially in rural areas (Henning-Smith, 2020b). Many of the State Plans we reviewed were written prior to the pandemic, although a few were written during the pandemic and acknowledged changes in their approach in response. Future research is needed in the coming years to see how states made short and long-term changes to serving rural older adults using OAA funds as a result of the pandemic. For instance, states may have had to find new ways to innovate in the face of more severe workforce shortages. They also may have been propelled into new models of service delivery, including virtual services. To the extent that rural older adults have been excluded from virtual opportunities because of limited broadband Internet or technology (Henning-Smith, 2020a; Kozhimannil & Henning-Smith, 2021), states may have needed to adopt additional ways to innovate to meet their needs. All of those changes can, and should, be reflected in future iterations of State Plans.
Limitations
We used the most recently published State Plan on Aging that we could find for each state. However, in a few instances, that plan was in draft form and may still change before it is finalized or implemented. In those instances, we used the most up-to-date version of the State Plan on Aging available through each state’s website, which represents the most current information available to the public on the Plan. Given the importance of transparency and accountability in State Plans, information included in published plans, even in draft form, should be examined; however, draft plans are subject to change. We also relied solely on the text from the State Plans on Aging, which is only one window into how states are serving older adults, including those residing in rural areas. Additional research is needed to better understand state-level differences in approaches to serving rural older adults across a broader range of policies and funding programs. Such research may include additional sources, including key stakeholder interviews, state-level data on clients served, and county and state-level data on older adult’s program involvement and health outcomes.
Conclusion
Meeting the needs of rural older adults is increasingly urgent as rural populations age and health care resources become ever sparser in rural areas (Healy, 2019; Tuttle et al., 2020; University of North Carolina, 2021). States play a critically important role in allocating federal resources for aging services through the OAA. In our evaluation of State Plans on Aging, detailing how states will use OAA funds to serve older adults, including rural older adults, we found that many states provide a funding formula for prioritizing rural older adults, but offer few other details. Some states go above and beyond what is required in the State Plan, offering insights into innovative methods of reaching and serving older adults living in rural areas, with even fewer prioritizing the intersections of race, income, language, and/or rurality. Additional attention to how states use their State Plans on Aging to meet the needs of rural older adults, and to inequities between states in approaches, is an important step toward health equity for older adults in rural areas across the U.S.
Supplemental Material
Supplemental Material - Approaches to Serving Rural Older Adults in State Plans on Aging: A Policy Content Evaluation
Supplemental Material for Approaches to Serving Rural Older Adults in State Plans on Aging: A Policy Content Evaluation by Carrie Henning-Smith, Mary Anne Powell, and Megan Lahr in Journal of Applied Gerontology
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under PHS Grant No. U1CRH03717-13-00. The information, conclusions and opinions expressed in this manuscript are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.
Supplemental Material
Supplemental Material for this article is available online.
References
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