Rising demand for long-term elderly care in the USA (rural segment) in comparison to service availability
This is a little better but you still have not got into a critical discussion among authors I know it is difficult to do but it is the difference between a good and poor review.
This review needs to be much more critical and also supported with more references..As it stands it is very descriptive and needs to be more critical for masters level work.
In a review you discuss different authors opinions on a subject and you also try and get a balanced view. For example: Brown (2000) feels that . Green (2004) agrees with this and goes on to say On the other hand a more recent study by Smith (2014) argues the opposite by stating .
So one can see that there are dissimilar opinions on this subject. But one can summize from this that
This is how you write a literature review. So have a go and take your time as it is very important! I have uploaded another article on how to review as well as reading it look at the chart that shows a good one and a poor one and appraise yours! Please dont upload chapters until I am happy with the one you are working on.)
Chapter 2 Literature review
This section of the dissertation will identify and evaluate articles, journals, government papers and other studies done earlier that may prove relevant in finding aims and objectives of the present research study.
The global market is facing the problem of ageing population, further, it is also increasing health issues and needs for long-term elderly care planning. The USA despite being the most developed nation, is suffering from the same problem. A lot has been said about long-term elderly care system in the global market. We will review the relevant studies for a complete overview of the market come to the conclusion(Ridley, 2012).
Our emphasis will be to present a holistic view of the long term elderly care system in the USA, especially in rural regions. To understand the true scenario, the analysis will be conducted on both demand and supply of healthcare in rural regions. It will also analyze problems encountered by service providers in achieving the goal. So, to begin with, a general scenario on elderly care, long term care will be discussed and then it will move on specific USA related information.
Elderly care can be defined as providing care to an ageing person, generally senior citizen i.e. person above 60 years of age. Sometimes specialized care is required to meets of senior citizens at different stages. It includes a wide range of services such as assisted living, nursing care, adult day care, home care and hospice care. It might be required due to various reasons such as physical problem, the cognitive problem of emotional problem. (Tout, 2013)
Long term care
There is no definite definition for long-term care; it varies from individual to individual also with the type of healthcare, long-term care does not cure an illness, rather it helps an individual in proper functioning and living. It includes personal care, supportive, special care, medical and social support. According to data, almost 80 percent of elderly care is being given by community and 20 percent are taking care in institutional setting(www.ruralhealthinfo.org, 2014).
There are five different type of long-term care services, it includes nursing homes, residential care communities, home health agencies, residential care communities, hospices, adult day services. People receive their long-term care from family members, informal caregivers and nursing home care (Friedland, 2015). Nursing homes are the one that is facilitated and licensed by the government to provide services; very less number of people avail this service, 1 percent of people aged between 65-74 take nurse home assistance. Residential care facilities are the one, who provide institutional care but are not licensed. Third is community-based homes that provide basic and supportive services. There are also individuals and family member as caregivers; almost 67.5 million informal caregivers are present in USA market (caregiver.org/, 2015).
Demand for elderly care
It is also crucial to understand the need for elderly care, the reason behind the need and how much elderly care services are required in the market.
According to data collected in the year 2010, 524 million people were aged 65 years of more; by the year 2015, this figure is expected to reach 1.5 billion. World population is rising at an increasing rate; according to research number of senior citizens in the global market will double from 11 percent in 2000 to 22 percent in 2050. Increasing population and it ageing leads to rising disease, social health, and healthcare. This issue is being encountered by both developed and developing nations. According to the report, UK is suffering from social care funding crisis; there is a very low level of investment in social care is given. Between year the 2010 to 2014, there is fall in investment in social care was 12 billion (deloitte.com, 2016).
The Ageing population is a matter of concern for both developed and developing nations. For example, China, fast developing nation is suffering from the same issue; according to data in the year 2011 China had more than 185 million residents aged 60 years of more; among which 32 percent reported poor health issues (Tardif, 2014). Further, the focus has shifted from economic issues to ensure that older people participate in the different level of society. The global ageing issue needs to be integrated into the process of development. Key areas of concern include the ageing population and economic development of the nation. Second is the advance health and well-being of aged people and final is to enable supportive care environment. The primary demographics of the ageing population include better health alternatives that help in making people live longer and second are the decline in fertility rates, there is a falling number of babies. Fertility is the primary driver for the ageing population, almost all developed nations there is a low number of children per women which is less than the population replacement level (National Institute on Aging, 2015).
Deloitte conducted a research on issues that impact global health adversely (deloitte.com, 2016). According to this study, different factors include demographics, finance, operations, regulatory and innovation. The Demographic factor is a major concern to look upon, it includes the problem of ageing population, rising number of older people in the society. It also includes demography of rising number of chronic and communicable diseases. Operational factors that impact global health condition include infrastructure issues, waste, alternative care system. Regulatory factor includes laws and policies to protect patients from any form of medical fraud. Financing concern includes the ability of government to finance, public and private partnership, health reforms etc.
The ageing population is a matter of concern for government and public at large in the USA, it will have a strong impact on economic growth and needs; such scenario will lead to high demand with low supply of human resources and other facilities. There is a rising number of Americans looking for long term care in the USA, presently the figure is 12 million, which is expected to rise by 27 million by 2050 (thescanfoundation, 2012). The Primary reason behind this is, baby boomers that formed between 1946 and 1964 will turn 65 years of age by the year 2029, and the figure is expected to be 10000 every day. Further by the year 2030, 72 million of US population is expected to be of age 65 or above and by the year 2050 the figure is expected to be 89 million. The analysis states that people aged between 85 and above need elderly and supportive care, this figure is also expected to grow by 25 percent by the year 2030 and by 126 percent by the year 2050 (thescanfoundation, 2012). Further, regions in America that are projected to have higher needs for elderly long-term care include Alaska +217 percent, Nevada +147 percent, Arizona +119 percent (thescanfoundation, 2012). According to analysis, the ratio between the ageing population of people above 65 years of age and young people aged 20 to 64 will increase by 80 percent. Ageing population is an outcome of increasing life expectancy in the USA, which was 47 years in 1990, is 78 years in 2014 and expected to be 84.5 by the year 2050. Further, there is smaller families, fewer kids, fewer work contribution. Another problem is the lower saving rate for retirement by people, present scenario states that two third of senior citizen in America havent saved properly for their retirement (Jacobsen, Kent, Lee, & Mather, 2011).
The USA rural scenario
Almost 72 million people live in rural America and are being served by 2000 national hospitals in different regions. Rural population includes a higher number of older and unhealthy people in comparison to the urban region. Population coverage 65 in rural region is 19.8 percent in comparison to 12.9 percent in the urban region. Similarly, poverty is also high in rural region by 3 percent than urban scenario. The median age in a rural America is 40 years in comparison to national urban area which is 37. One-quarter of senior citizens is present in rural America. There is the difference in ageing population figure among various villages and towns (Morken & Warner, 2012). In Northeast region there is the highest number of ageing population; rural south and west have slightly more number of younger people.
Above diagram presents state wise representation of senior citizen population. Further need for healthcare by older vary heavily with age. According to analysis, the majority of percentage constitute young seniors that are people aged between 65 to 74 years of age; whereas only 12.9 percent of the rural population include older senior citizen group that is above 84 years of age (Kirschner, Berry, & Glasgow, 2010). In terms of diseases, rural population is suffering from various issues such as hypertension, emphysema, chronic Bronchitis, cancer and diabetes (AmericAn Hospital AssociAtion , 2011). Further on gender wise segregation, there is 55.7 percent of women senior citizens and 54.3 percent of men senior citizens (Housing Assistance Council, 2014). To third of senior citizen above 85 years of age are women. Rural America is less racially diverse than urban region.
Impact of ageing population and health issues
There is a strong impact of ageing population on healthcare demand and service needs.
Rising chronic disease and differing healthcare demands
With changing technology and environmental scenario, healthcare needs of people also change. No one knows what kind of health requirement will be in the year 2050. According to forecast there will be increasing need of Geriatrician, by the year 2030, 30000 Geriatricians will be required in the USA; prensent availability is only 7500. The need for elderly care is also a positive outcome of higher life expectancy in the US due to developed technology and service availability; it is expected to increase in future also. Life expectancy for people born in the year 2010 is 79 years, whereas for people from during 1991 it was 52 years only. In terms of gender, women have a higher life expectancy (81 years) than men (76 years). However, there is a rise in chronic conditions among people. There is a rising concern for issues like functional impairment, Alzheimer disease etc. The analysis states that ageing population will suffer from higher chronic diseases such as heart disease, osteoporosis etc. (Garza, 2016). There is a shift in the type of health service require as one-time medication is different from ongoing treatment of several diseases and health problems (HE & M., 1994). There will be an ongoing relationship between doctor and patient, such treatment takes time and needs care, therefore it causes the need for long terms services such as nursing homes, personal care, adult day care, congregate housing etc. (Wiener & Tilly, 2002).
Rising government expenditure for providing long-term care
Rising expenditure is another key issue for long term care in US market, in the year 2012, total spending was $219 billion which is expected to increase to $346 billion by the year 2040. Further, in the year 2009, caregiver service was valued at $450 billion per year. Medicaid expenditure is also increasing at 25 percent annually since 1990. Similarly, expenses on the skilled nursing facility, home care is also on rising trend. Only seven percent of people in the USA receive Medicaid for assisted living, the cost of nursing care is very high, people prefer to receive home and community-based care as they are cost effective (www.cbo.gov, 2013).
An ageing population also put pressure on government expenditure, rising older population leads to increasing demand for new public healthcare policies, income support that impact financing of other development programs. An ageing population requires acute care that is financed through jointly by private and public sector. Presently Medicare is a major plan that is a social insurance program for everyone in the country. Financing for hospitals is through a payroll tax of 2.9 percent that is divided between employee and employer. There is rising Medicare expenditure in the region, in the year 2000 the figure was $223 billion. However, this program does not include prescription drugs outside the institution and have very limited number of nursing home and home healthcare. Therefore some states are trying to develop pharmaceutical assistance programs for the low-income elderly population who are ineligible for Medicaid; aimed to help people with low income but high medical expenses. There is intense demand for additional financing for acute care for elderly people (US Congressional Budget Office, 1999).
There is a special need for making plans for financing long-term care in the region, it includes community-based services, nursing home care through a combination of Medicare, Medicaid, government find programs, private sector insurance etc. Medicaid is the primary source of healthcare financing, it includes skilled, short-term care through health agencies but there is no provision for long term care. This service is majorly provided by private sector insurance but they finance less than 5 percent, this shows a lack of insurance coverage for traditional long-term care in the region (Centers for Medicare and Medicaid Services, 2000).
Slow down the economic growth
An ageing population has a strong impact on the economic condition of a region with rising expenditure on public. An ageing population has strong economic consequences, it has an immense impact on various federal programs and investments to be made. Social security, Medicare, and Medicaid are on unsustainable paths, there are a number of economic risks involved. Due to high life expectancy and low birth rates there will be an increase in a number of the beneficiary of such programs but lowering service providers; it further enhancing healthcare cost, total public expenditure and national resources (Gardner, 2012).
There is rising expenditure on Medicare, social securing and long term care which is expected to grow from 6.8 percent of GDP in the year 2000 to 13.2 percent by the year 2050. Rising ageing population is impacting in three ways to the economy, there is increasing demographic pressure that causes the government to spend more on Medicare than other programs. Secondly, older people have higher medical expenditure in comparison to younger people and finally, this expenditure is expected to rise with increasing healthcare cost per person (National Academy of Sciences, 2012).
With an ageing population, there is rising disability rate in the USA, according to analysis, with rising life expectancy and facilities there is a reduction in a number of people with disability from 26 percent in 1982 to 19.7 percent in 1999. However, people with disability have a higher amount of medical needs and expenditures. There is a huge financial burden on the government for public programs and other social security programs, the social security actuaries projects will grow from $10 trillion to $111 trillion by 2050 (Wiener & Tilly, 2002).
However, there are critics o this view, according to an article in Forbes magazine, gaining population can help in economic development, as they live longer they might choose to continue to work and contribute to society. it will help in boosting national wealth and help them in saving longer and more. There are companies such as health care, senior housing, leisure, insurance and biotech which will be benefited from this demographic shift and enjoy higher markets due to ageing population. The analyst also claims that little strategies can help using graying of the population as a boon for the economy. For example, BMW made workplace ergonomics for older employees to support them to work for longer period of time, few of such initiatives include providing of custom shoes, easier to read a computer screen, it helps in increasing company productivity by 7 percent and reduction to defect rates to 0 percent. Similarly, other big brands such as Xerox, Unilever are also implementing such training programs that help people working for a longer period of time, it helps in enhancing employee productivity and retention (Mutual, 2014).
Supply of long-term elderly care in the USA
Researches states that there are five key long-term services delivered in USA market, they vary in geographic distribution. Data were collected on service providers in four regions i.e. Northeast, Midwest, South, and West. According to data collected, the South region has the best supply of elderly care; there is 32.4 percent of adult daycare service centers, 48.3 percent of home health agencies, 42.4 percent of hospices, 34.5 percent of nursing homes in this region. However, western region has the highest number of residential care providing communities. Below is the diagrammatic representation that includes information on the supply of the different type of elderly care in all four regions.
According to data adult day service center in America in total can serve 276,500, 1 to 780 is the daily allowable capacity. There is total of 1,669,100 certified beds in 15,770 nursing homes; generally, nursing homes have an average of 106 beds. There are 22,200 residential care communities that provide 851,400 beds. Supply of residential care and nursing home beds also vary dramatically between regions. The analysis shows that Midwest has the largest number of nursing home beds (Clair, Doeksen, & Eilrich, 2014).
Areas with low supply of care providers
Rural regions have different types of problem that cause hindrance in the supply of proper healthcare system, one such is a lack of insurance. According to data, 22.3 percent of non-elderly rural people were uninsured whereas in the urban region this figure is 21.4 percent. Further, there is also a disparity in the type of services available in urban or rural areas; there are certain health services which are rarely available in rural America. It includes different services such as obstetric services; there is significant fall in a number of the hospital providing obstetric services in the rural region. Another is a scarcity of mental healthcare service providers; there are problems of lack of time, lack of proper financial reimbursement that causes hindrance in service delivery. To overcome this problem telehealth services is promoted that help in providing continuous medical training to practitioners. Similarly, dental services are also very limited in the rural community, majority of health insurance plans does not include dental services. In the year 2009, there was a crisis in rural dentistry, according to which 60 percent of the rural region reported a shortage of dental healthcare professionals. There is almost unavailability of substance abuse services in the rural region, almost 82 percent of rural residents do not have access to detox provider (www.ruralhealthweb.org, 2015).
Characteristics of long-term care providers in rural region
Three types of ownership structure that long-term care organizations have, it includes for-profit, nonprofit and government-owned. All long term care providing formats, accepts daycare are for profit.
(L,M, & Park-Lee E, 2016)
According to the diagram above, 44.2 percent of adult day centers, 80 percent of home health agencies, 60.2 percent of hospice, 69.8 percent of nursing homes and 81.8 percent of residential care community operated under a for-profit model of business. Whereas, 50.5 percent of adult day centers, 15 percent of home health agencies, 25.9 percent of hospice, 24.1 percent of nursing homes and 16.9 percent of residential care community operated under a nonprofit model of business and remaining were government owned.
A brief analysis was also conducted on different types of services and type of format that provide maximum service. This discussion includes information on the proportion of providers in each service offered, it include social work; mental health or counseling; therapies (physical, occupational, or speech); skilled nursing or nursing; pharmacy or pharmacist; and hospice. According to data collected, all five sectors of providers offer social work services, as per data percentage of social service provided include 100 percent by hospices, 88.9 percent of nursing homes, 82.3 percent of home health agencies, 75.6 percent of residential care communities, 63.5 percent of adult day centers. Next is mental health services is provided by 97.2 percent of hospices, 86.6 percent of nursing homes, 77.8 percent of residential care communities, and 47.3 percent of adult day centers. Third is therapeutic services, this service is majorly given in nursing homes, hospices and home health agencies; though the majority of residential care and adult day services also provide it. Nursing services are provided by all home health agencies, hospices, and nursing homes, whereas 76.1 percent and 70.1 percent of residential and adult day services provide it. In terms of pharmacist services, it is provided by 97.4 percent of nursing homes, 92.6 percent of residential care communities, 34.9 percent of adult day services, and 5.5 percent of home health agencies. Hospice services are majorly provided by residential care communities, nursing homes; however very low percentage of adult day service, home health agencies provide it (National Center for Health Statistics, 2013).
According to Weisgrau, (1995) there are a number of problems encountered by rural region due to shift in patient care patterns; presently there is a rise in outpatient setting care than inpatient. Rural hospitals also encounter competition from the large urban service provider, however, rural hospitals have the problem of lagging revenues which impact service delivery adversely. As there is a need for continuous investment in resources for staff management but unfavorable economies of scale makes it difficult to invest due to rising fixed and overhead cost. Researches show that closure of a hospital in rural region impacts access to service; it also impacts physical income and practice opportunities leading to poor retention and shortage of care providers. There is a need to provide assistance to stabilize the viability of rural hospitals, it includes supporting the development of limited service hospitals, support to strengthen the financial and managerial capability of rural hospitals (Weisgrau, 1995).
Models of long-term care
This section aims to evaluate two American models of the elderly long-term care service delivery system. It includes the social health maintenance organization (Socio HMO) and second is the program of all-inclusive care for the elderly, also known as PACE. Both the programs are in operation since twenty years, initially, these models look similar but they are completely unique. Six key elements that help in describing these models include status, targeting, benefits package, financing, delivery system, enrollment and clinical management.
Social HMO is a funded by federal government, it combines both health and social long-term care aimed towards the elderly population. It offers an integrated management that aims to deliver health care services at lower cost. This service is open for people from 65 years and above, enrolment is voluntary for this service. This model uses Medicare benefits, it includes acute medical care, inpatient hospitalization, home care services etc. prepaid capitation and funds from Medicare, Medicaid help in financing this model. Its delivery system is based on the traditional healthcare system, network include individual care providers, groups, etc. there are four sites through which one can enroll themselves for this service (Kodner & Kyriacou, 2000).
Another is PACE model that is based on Lok senior health services; it is for elderly people from 55 years or above age. It aims to serve people suffering from acute disabled elderly persons. It receives monthly capitation from Medicaid and Medicare; people who are not registered in Medicaid need to pay the small amount on monthly basis (Bodenheimer, 1999). This model focuses primarily on day health services, its network primarily includes salaried staff. Different researches have been undertaken to evaluate the impact of these two long term elderly care models. Result states that it helped in reducing the cost of treatment, better integration, and health of individuals (Kodner & Kyriacou, 2000).
Problems in delivering long-term care system
Government always aim to serve its people in the best way, still, issues occur. Despite huge investments, various policies and grants there are issues with complete access to healthcare facilities by people. Researches show several barriers that cause problems in delivering healthcare services to elderly people.
Poor status of health insurance
There is insurance model of healthcare service delivery system, which shows that people who do not have health insurance have lower access to services. According to data among 41 million uninsured people, twenty percent lives in the rural region. Further, there are two types of rural region, one which is adjacent and others that are non-adjacent i.e. remote rural regions. According to data, in the year 2002, 24 percent of people in non-adjacent rural areas were uninsured and 18 percent in adjacent rural regions were uninsured. Among insured people majority, more than 60 percent were under private insurance (www.cfra.org, 2014). According to analysis, people in the rural region who are uninsured include low income families. Due to poor income these people likely to delay medical care. Though the government has implemented the Affordable care act and insurance coverage in rural areas, that aim to help such low-income people, but two third of uninsured rural people belong from the state that does not have expanded Medicaid (Ziller, Coburn, Loux, Hoffman, & McBride, 2003).
Further people who are insured also do not have complete access to healthcare facilities, as rural region people are highly prone to the problem of underinsurance. According to data, among insured rural individuals, only one among four have insurance that include coverage for preventive care; majority of individuals are dependent on private individual insurance plans that cover 63 percent of medical cost whereas group plans covers 75 percent of medical costs; further to this, more than 50 percent of insurance plan cover only 30 percent of medical cost leading to high burden on individuals. As they are insured under private insurance there is no medicine coverage, which causes an 18 percent increase in total medical expenditure of a rural person in comparison to the urban person. Among insured rural individuals, 35 percent are not covered under dental coverage. In terms of expenditure, a rural individual has to spend 20 percent of their income on healthcare expense; their out of pocket expense on health care is ten percent more than urban people. Lower and the uninsured group of people have higher out of pocket medical expense and costs.
Shortage of workforce
First and foremost is the availability of practitioners and service providers; there must be an adequate supply of doctors, nurses and informal service providers to deliver health services and long-term care. With rising need for labor supply in long-term elderly care segment, it is difficult to match demand and supply of professional help. There will be rising demand for nurses, long-term care workers, personal attendants etc. However, scenario shows that majority of long-term care is being delivered by unskilled women from racial and ethnic minorities. There is the problem of low wages, poor benefits, difficult working condition, and heavy workloads. It is very difficult for workers to work in this field due to lack of facilities and resources, it also makes the job unattractive making recruitment and retention a difficult task to achieve. According to HRSA data warehouse, sixty percent of primary medical health professional shortage areas include non-metropolitan regions. There is large projected gap between long-term service requirement and growth in labor force, the nursing workforce is also ageing and it is expected to remain constant by the year 2020 causing a 20 percent decline in supply in terms of need (www.ruralhealthinfo.org, 2014). There is needed to make this industry lucrative, work profile better with proper resource and facility availability. Though there is rising demand for elderly care but there is a significant shortage of workers in the regions, the risk of contracting age also leads to several aliments such as restricted mobility, dementia, and diabetes and heart problems (Levitz, 2015). Their health care industry is facing immense problem in meeting market health care needs, there is a shortage of caregivers in terms of family members to professional help. Earlier people relied on their family members for care-giving as according to data issued by Pew Research Institute, 39 percent of American household provide care to their family members with age 45 to 64, however recently there is a decline in a number of family caregivers (Labrador, 2014). In the year 2010 there were 7 potential caregivers present for every elderly person, by the year 2030 this figure gives to 4to 1 and by 2050 only 3 to 1 caregiver will be available. (Institute for the Future of Aging Services, 2007). Apart from this, there were people who are unwilling to provide assistance due to geographical displacement, tough working schedules or other reasons (RI & Wiener, 2001).
Rural people have to travel long to get access to healthcare services, especially services that are rarely available in the rural region. It causes a rise in cost and time. There are no public transit facilities available for patients to get medical appointments in rural regions; further elderly people with chronic conditions might suffer due to lack of reliable transportation facilities.
Rural region is suffering from developed services, there is no anonymity and privacy concern maintained. In the case of sensitive services such as mental health, sexual abuse, pregnancy etc. people might have privacy concern and might feel uneasy. In such situation, there is a need for integrating behavioral health services with primary care (www.ruralhealthinfo.org, 2014).
Poor health literacy
Health literacy has a strong impact on the person ability to understand information requirements and health-related instruction; it also facilitates in reducing dependency and allows smooth access to healthcare. However, in rural communities, there is the prevalence of lower education level. Lower health literacy leads to poor prevention and health screening, poor health status and high risk of hospitalization. Education attainment beyond basic level helps in becoming more health conscious, healthy lifestyle and higher life expectancy (Young, Weinert, & Spring, 2012).
Healthcare technology in rural region
There is a strong correlation between quality of healthcare and technology. According to research, at least 44000 deaths annually are due to clinical errors, which also cause financial losses around $17 billion. Different type of technologies such as computerized order entry system, electronic medication administration, and record keeping aims to reduce miscommunication and foster quick and accurate treatment. Technological development helps in enhancing coordination, reducing error, time and cost to service delivery. Rural regions fail to adopt healthcare information technology due to limited access to capital, lack of finance, poor infrastructure to support and lack of qualified staff to operate the same. Rural hospitals spend only 2 percent of their operating budget on technology, which is further less in non-adjacent rural hospitals. Few technologies that are widely accepted in rural health units also include lab order entry and electronic medical records (The Rural Health Research and Policy Analysis Centers, 2010).
Lack of financing
Finance is the key factor to deliver any service successfully. However, long term care is becoming expensive day by day; it has outpaced inflation in America. Average annual cost of a private room in the nursing home is $90,520. There is no trend of planning for long-term care among Americans, therefore majority of expenditure are borne by government programs, Medicare and out of pocket expenses (Weisgrau, 1995). Major funding comes from taxes, the majority of people failing to plan long term care. Further, Medicare does not include long-term care service, only Medicaid covers it. Next key factor is private financing, it accounts for 22 percent, and it includes payment from insurance, saving or borrowed from someone. According to research future baby boomers needs to rely more on their savings as there is a decline in defined benefit pension plans in the market. Further, the rural region has much more trouble in financing proper healthcare due to intense competition, due to financing issue it also fails to attract proper practitioners (Calmus, 2013).
The rural sector also suffers from various environmental issues that increase their healthcare needs. It includes quality of air, water, and other environmental factors. The primary cause of such issue is poor infrastructure that fails to provide adequate support to public health. Rural American encounter high health hazards due to exposure to pesticides, chemicals, and air pollution and animal wastes. According to a recent report on rural water infrastructure in the USA, several challenges have being highlighted, it includes lower use of water management system, lack of technical expertise, problem of ground water contamination due to mines, agricultural sources, landfills, road salt etc. Further air quality also has strong impact on individual health; rural region encounters the problem of high degree of air pollution due to unpaved roads, pesticides, crop harvesting, livestock feeding, mining etc. Third is poor housing quality, which fails to meet basic health needs. Basic concerns related to housing in rural America and healthcare include poor plumbing and water system, heating and cooling methods, safety concerns and weatherization needs (www.ruralhealthinfo.org, 2016).
Above analysis helped in understanding the overall elderly long-term scenario in America and its rural region. Long-term care is different from general medication and health system due to the sensitivity of care and duration involve. With an ageing population, there is rising concern towards the high demand of long-term care in America. A large percentage of people stays in rural region, which is less developed and low facilities availability. There is a lack of specialist health system and adequate facilities in the rural America, however, demand is high. Further, the government is trying its best to deliver a strong supply of elderly care in America but there is a large number of factors that causes the barrier in service delivery. It includes issues of shortage of workforce, the ageing population, high poverty, low literacy, poor infrastructure, poor health literacy in rural America; there is a lack of insurance coverage also which causes a rise in out of pocket expenditure and makes service availability costly for rural people. The high cost of medication but low financial ability makes overall accessibility poor. There is a need to make better strategies that help in enhancing healthcare access for long-term elderly care in rural regions.
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