Rural Patients Face Gaps in Hospice Access, Care Intensity

Hospice use and the delivery of hospice services differ across the rural-urban continuum, with older adults in isolated rural areas less likely to receive hospice care or higher-intensity services than their urban counterparts, according to a research letter published today in JAMA.¹

Hospice Care Delivery Varies Across Rural-Urban Continuum

Compared with those in urban areas, the 23% of older adults residing in rural communities are more likely to die in nursing homes, less likely to receive paid caregiving support at home, and more often rely on unpaid family caregivers. Among decedents, fewer people in rural communities receive hospice care.²

The intensity and type of hospice services may vary depending on where care is provided, including private homes, nursing homes, and hospice facilities.¹ Most hospice care is provided at the routine level, researchers explained, but higher-intensity care, such as continuous home care, may be used for patients with complex symptom management needs; hospice experience may also vary by length of stay.

Despite these disparities, prior research has not examined whether hospice care is delivered differently across the rural-urban continuum.³ To address this knowledge gap, researchers conducted a study examining how hospice care varies across the rural-urban continuum in length of stay, care setting, visits by hospice staff, and rates of higher-level hospice care.¹ They used the 2013 to 2022 Master Beneficiary Summary File to identify eligible decedents aged 66 or older with 1 year of Medicare claims, as well as a subcohort of decedents with a hospice claim within the final 365 days of life.

The researchers linked each decedent’s zip code to a Rural-Urban Commuting Area code, categorizing rurality as urban (codes 1-3), large rural city or town (codes 4-6), small rural city or town (codes 7-9), or an isolated small rural area (code 10). They then used hospice claims and Medicare data to assess hospice use and outcomes across these communities.

Hospice Use, Care Delivery Differed by Rurality

The researchers identified 21,098,329 decedents, 10,854,275 (51.5%) of whom had a hospice claim in the last year of life. Unadjusted rates of hospice use were highest for urban areas (52.4%), followed by large rural towns (49.2%), small rural towns (46.9%), and isolated rural regions (44.8%). However, the gap in hospice use rates between urban and isolated rural decedents narrowed from 2013 (7.8 percentage point difference) to 2022 (4.4 percentage point difference).

Among hospice recipients, those in isolated rural areas had a shorter mean length of stay than those in urban areas (59 vs 61.6 days). For recipients in isolated vs urban areas, the last location of hospice care was more often private (53.5% vs 49.4%) or nursing homes (25.6% vs 18.6%) and less often assisted living facilities (7.2% vs 11.3%) or inpatient hospices, hospitals, and other facilities (13.7% vs 20.7%).

In addition, nurse visits per 30 days in hospice were more frequent in isolated rural vs urban areas (mean, 13.2 vs 12.5 visits per 30 days), whereas aide visits were less frequent (5.9 vs 6.3 visits per 30 days); social worker visits did not differ between groups. Lastly, patients in hospice care within isolated rural areas were less likely to receive general inpatient or continuous home care than those in urban areas (12.7% vs 21.1% and 0.5% vs 2.5%, respectively).

More Research Needed on Rural-Urban Hospice Disparities

The researchers acknowledged their study’s limitations, including that it did not formally analyze differences in patient characteristics that may influence differences in hospice use across the rural-urban continuum. Because of this, they suggested areas for further research.

“Future research should identify the drivers of these differences, including the financial drivers of differences in care across the rural-urban continuum, and evaluate the consequences of limited access to higher-intensity care, including if nursing homes are substituting for gaps in access to higher-intensity hospice,” the authors concluded.

References

1. Ankuda CK, Covinsky K, Jing B, et al. Rural-urban disparities in the delivery and intensity of the Medicare hospice benefit. JAMA. Published online August 24, 2026. doi:10.1001/jama.2026.16190
2. Chapter 9: hospice services. MedPAC. March 15, 2024. Accessed August 24, 2026. https://www.medpac.gov/document/chapter-9-hospice-services-march-2024-report/
3. Hirko KA, Xu H, Rogers LQ, et al. Cancer disparities in the context of rurality: risk factors and screening across various U.S. rural classification codes. Cancer Causes Control. 2022;33(8):1095-1105. doi:10.1007/s10552-022-01599-2