Older adults (those aged 65 and older) and people with disabilities have unique healthcare needs and often face
challenges to meeting these needs. In addition, accessible housing, transportation, employment, educational
programs, and specialized healthcare may be limited in many parts of rural America. Community organizations,
healthcare facilities, local governments, and other rural entities can help older adults and people with
disabilities by collaborating and creatively using limited resources to provide needed services.

This guide includes information about home-based services and community supports available to support aging in
place and independent living and discusses challenges for people receiving services and those providing them.
For information related to services for veterans with service-related injuries, see Rural
Veterans and Access to Healthcare
.

Frequently Asked Questions


What types of services and supports can help rural residents to age in place and live independently, and who
delivers these services?

Older individuals and people with disabilities may experience physical limitations and need to rely on others
for help with activities of daily living. This can be particularly challenging in rural areas. Home and
Community-Based Alternatives to Nursing Home Care
notes that a wide range of services can help
individuals live independently. Types of services that can support aging in place and independent living
include, but are not limited to:

  • Personal care – This can include help with bathing, toileting, dressing, eating, and grooming. Some
    personal care services, such as foot care, may be provided in community settings, such as senior centers.
  • Support services – Includes activities such as housekeeping, help with shopping, laundry, and yard
    work.
    Some businesses will deliver needed items free or for a small charge.
  • Nutrition services – Services can range from delivering meals to frail, homebound, or isolated
    individuals
    at home to providing meals in congregate settings like community centers. Nutrition service providers may
    also offer nutrition-related services, such as nutrition education and screening, nutrition assessment, and
    counseling. For more information, see the RHIhub’s Rural
    Hunger and Access to Healthy Food
    topic guide.
  • Home health – Medical services prescribed by a physician, which can be important for people who need
    short-term help after being discharged from the hospital, or who have chronic medical conditions or
    disabilities. See the RHIhub topic guide on Rural Home Health Services for
    additional information on these services.
  • Transportation – Reliable transportation allows people in rural areas to get the healthcare and other
    services they need and enables them to buy nutritious food and other items that promote good health. For
    more information, see the RHIhub Transportation to Support Rural
    Healthcare
    topic guide and the Rural Transportation Toolkit.
  • Home maintenance and modification – Older adults and individuals with disabilities often have limited
    budgets, underscoring the need for affordable, accessible housing. Life
    Starts at Home: Exploring How Housing Impacts Participation for People with Disabilities
    highlights
    how the accessibility and usability of housing impacts a person’s participation within the larger community.
    Additionally, AARP’s 2018
    Home and Community Preferences Survey: A National Survey of Adults Age 18-Plus, a Look at Rural
    Communities
    notes that 73% of rural adults surveyed want to remain in their communities and homes as
    they age. However, 40% of rural adults also report that they will need modifications to their home to meet
    aging-related needs. For more information, see Approaches
    for Improving Rural Housing Affordability
    in the Social Determinants of
    Health in Rural
    Communities Toolkit
    .
  • Care coordination – A care coordinator may make referrals to health and human services providers; help
    individuals schedule appointments or pick up medications; refer patients to community partners for services
    and resources; and manage the exchange of information between the patient, providers, and other human
    services organizations. For examples of care coordination programs, see the Rural
    Care Coordination Toolkit
    .
  • Respite care – Support provided for caregivers who are dedicating a substantial amount of their time,
    energy, and/or money to care of their loved one. For more information on respite care, see the Caregivers and Caregiver Well-Being section of the
    RHIhub Rural Aging in Place Toolkit.

Family caregivers, community business and nonprofit organizations, paid home care workers, senior centers,
tribal organizations, and volunteers can all provide help to people in rural communities. However,
home health services, which are specifically medical in nature, must be provided
by skilled medical professionals.

The National Academy for State Health Policy’s 2019 Toolkit:
State Strategies to Support Older Adults Aging in Place in Rural Areas
describes a variety of state
initiatives designed to help older rural adults remain in their communities. SASH®
(Support and Services at Home)
utilizes affordable housing communities throughout Vermont to provide
care and services to older adults and individuals with disabilities and promote independent living. The
ARcare Aging Well Outreach Network, run by the ARcare Federally Qualified
Health Center, provides services including falls prevention assessments, transportation to appointments,
medication management, and senior-specific exercise opportunities for Cross County, Arkansas residents over 50
years of age.

For additional examples of home-based services and community supports in rural communities, see the RHIhub’s
Rural Aging in Place and Access to Care for Rural
People with Disabilities Toolkits
.


What other services and supports might people with disabilities need in order to live successfully in a rural
community?

People with disabilities may use some of the same services and supports as older adults to be able to live
independently in rural areas. However, rural residents with disabilities may also benefit from other services
and supports. For example, they may experience pain and other secondary conditions that may make it difficult to
hold a job. As a result, people with disabilities may need specialized training or rehabilitation services or
other assistance to overcome barriers to employment or pursue self-employment. Farm
Assessment and Rehabilitation Methods (FARM) Program
is one example of a program designed to help
disabled farmers continue or resume farming or find an alternative agricultural occupation.

People with disabilities may also need assistance connecting with community services and supports as they
transition from a facility back into the community or as they transition into adulthood. Centers for
Independent Living
(CILs) provide individuals with disabilities with services to help them live
independently, including referrals, independent living skills training, and peer counseling. CILs can also offer
additional services, including job search support, assistive technology information, and housing option
counseling.

People with disabilities and functional limitations also require additional supports in emergency situations.
Individuals who are hard of hearing may not hear sirens or other audible alerts, while those with vision
impairments may not see flashing lights or other signals. In an emergency, people who use assistive technologies
or durable medical equipment may need access to back-up sources of power. Additionally, people with functional
disabilities may need accessible transportation options or shelters if evacuation is necessary. For information
on preparing and responding to emergencies in rural communities, see RHIhub’s Rural
Emergency Preparedness and Response
topic guide.


Why is it important for people living in rural areas to have access to home-based services and community
supports?

Older adults and people with disabilities living in rural areas, like their urban counterparts, typically prefer
to live in their own homes, rather than in assisted living facilities or nursing homes. While they may be able
to thrive in the community, older adults and individuals with disabilities may also need some assistance in
carrying out key everyday activities such as bathing or cooking. Similarly, Differences in Social Isolation and
Its Relationship to Health by Rurality
highlights that while older adults in rural areas report larger social
networks than their urban counterparts, they experience increased risks of social isolation and loneliness.
Social isolation among older adults has been linked to poor health outcomes and increased healthcare spending.
As a result, rural areas may need to provide additional services and supports to keep older adults and people
with disabilities included and active in community life. Older adults and people with disabilities may also face
additional challenges in rural areas related to:

  • Transportation to medical appointments, grocery shopping, and other essential and leisure activities
  • Housing quality and affordability, including how to pay for needed repairs, modifications, and assistive
    technologies that would allow them to continue to live safely in the home
  • Availability of home-based
    services and community supports
    in their communities that will allow them to live independently at
    home.
  • Paid caregiver workforce shortages.
  • Support for informal caregivers to prevent feelings of isolation and burnout.

Meeting the Social Needs of Older
Adults in Rural Areas
demonstrates how home-based services and community supports can foster social
connections as well as connect residents with needs and services that promote health and wellness.


What are livable communities, and how do they facilitate aging in place and independent living in rural
communities?

Livable communities meet the full range of needs of all its residents. Partners for Livable Communities defines livability as “the sum of the
factors that add up to a community’s quality of life—including the built and natural environments, economic
prosperity, social stability and equity, educational opportunity, and cultural, entertainment and recreation
possibilities.” AARP also notes that a livable
community
will “enhance personal independence; allow residents to remain in their
homes and communities; and foster residents’ engagement in the community’s civic, economic, and social life.”
As a result, the exact characteristics of livability will be unique to each community.

The terms “aging in place” and “independent living” describe different aspects of
livable communities. People
who want to age in place are those who want to remain in a place of their choice, typically one
in which they have invested time and money, where they have an informal support network and which holds fond
memories for them. There are typically fewer housing options available in rural communities, making it difficult
to downsize or find accessible housing. Also, home repairs or modifications may be necessary for an individual
to remain in their community. Similarly, nutrition services may be necessary for adults who cannot safely cook
for themselves. For more information on aging in place in rural communities, see the RHIhub’s Rural Aging in Place Toolkit.

The term independent living can simply refer to an arrangement in which people with
disabilities live in a community rather than in an institutional setting. Interpreted more broadly, it is a
philosophy which promotes the idea that people with disabilities have the same civil rights as people without
disabilities, and should make their own decisions about how they will live, work, and participate in society in
the least restrictive environment. This approach focuses on ensuring that communities meet the needs of all
people who live there.

Universal design principles should be
considered when designing rural infrastructure. Universal design goes beyond meeting accessibility standards and
seeks to address usability concerns for people of all ages and abilities throughout the entire design of a
building or community. Curb cuts are one example of universal design. Originally designed to improve access for
individuals with mobility and visual impairments, curb cuts also assist cyclists, families with strollers, and
travelers with luggage, among many others.

By embracing the concepts of aging in place, independent living, and universal design, communities can help
individuals remain and thrive in their homes or community setting of their choice, no matter their age or
ability. For information on evidence-based and promising models and resources to support organizations and
communities in creating rural livable communities, see the RHIhub’s Rural Aging in
Place
and Access to Care for Rural People with Disabilities
Toolkits.


What resources are available to find services for older adults and individuals with disabilities who wish to
remain in their homes?

The National Institute on Aging’s webpage Aging in Place: Growing Old at Home
offers suggestions for planning ahead to stay at home, lists the kinds of supports that may be needed, and
offers contact information for various agencies and programs that can provide help and guidance. It notes that
resources can include:

  • Friends, family, and neighbors
  • Community businesses and nonprofit organizations
  • Geriatric care managers
  • Senior centers
  • Area Agencies on Aging
  • Tribal organizations
  • Federal, state, and local government resources

The World Health Organization defines
age-friendly environments
as ones that:

“foster health and well-being and the participation of people as they age.
They are accessible,
equitable, inclusive, safe and secure, and supportive. They promote health and prevent or delay the onset of
disease and functional decline. They provide people-centered services and support to enable recovery or to
compensate for the loss of function so that people can continue to do the things that are important to them.”

Centers for
Independent Living
are community-based, consumer-controlled nonprofit organizations funded by the
Administration for Community Living (ACL) to provide individuals with disabilities a range of services to
promote independent living. While CILs can offer more services, they are required to provide information and
referral services, independent living skills training, peer counseling, and services that facilitate transition
from nursing homes and other institutions to the community. ACL maintains a state-by-state list of
Centers for Independent Living.

The Grantmakers in Aging publication Guiding Principles for the
Sustainability of Age-Friendly Community Efforts
notes that “Champions for age-friendly
communities can
be found in neighborhoods, elected offices, non-profit organizations, universities, and businesses.”
Churches
and local nonprofit organizations may be helpful in providing services or referrals. Age-Friendly and Dementia-Friendly Winnemucca and Humboldt County
describes how the rural community of Winnemucca, Nevada, worked to create an age-friendly and dementia-friendly
community that expanded to Humboldt County.

The National PACE (Programs of All-Inclusive Care for the Elderly)
Association
supports and promotes programs that provide comprehensive medical care and community-based
services to help older people live as independently as possible for as long as possible. RHIhub’s Rural Services Integration Toolkit
highlights the work of Senior CommUnity Care (Delta and Montrose
Counties, Colorado), an example of a rural PACE program. For a list of currently operating PACE centers, search
Find a PACE Program
in Your Neighborhood
.

The Eldercare Locator, 1.800.677.1116, provides access
to state and local Area Agencies on Aging, as well as community-based organizations and services addressing a
range of concerns, including housing, transportation, elder abuse prevention, and more. Churches and civic
groups may also be able to make referrals to local sources for services.


What are the workforce and training challenges related to providing home-based services and community supports?

State
Solutions to the Home Care Workforce Crisis in Rural America
notes that many workers providing
home-based services in rural areas work only part-time, earning less on average than workers in urban areas.
According to the report Preventing
Caregiver Turnover
, low wages are a major factor in the high turnover rate among home care workers. This
results in a heavier workload for employees who do remain, and creates losses in productivity, morale problems,
and a lack of care management. In addition, National Survey of Area Agencies
on Aging 2020 Report: Meeting the Needs of Today’s Older Adults
reports that workforce challenges have
resulted in 62% of AAAs delaying the start of services for individuals, 59% increasing the size of staff
caseloads, and 49% starting or extending waitlists for services.

As more medical care for people with multiple chronic conditions takes place in the home, the care provided in
the home becomes more complex and requires additional skills. As described in the Government Accountability
Office report Medicaid Home- and Community-Based Services:
Selected States’ Program Structures and Challenges Providing Services
, recipients of home- and
community-based services may have complex medical and behavioral needs and may display aggressive behaviors. In
response, some organizations may offer specialized behavioral health training to help workers deal with these
situations appropriately.


What does a lack of home-based services and community supports in a community mean for older adults, people with
disabilities, and their families?

Caregiving in the U.S.
2020
, a report from AARP and the National Alliance for Caregiving, offers a national profile of unpaid
family caregivers for rural adults. Notably, family caregivers of older adults living in rural areas often
do not live in a rural area themselves and continue to work while serving as a primary caregiver. The report
also highlights that caregivers are likely to find it difficult to find available, affordable services in rural
communities.

The report Transportation, Distance, and
Health Care Utilization for Older Adults in Rural and Small Urban Areas
notes that people who do not
have access to reliable transportation are more likely to delay getting needed healthcare or forego it entirely.
This can result in a need for emergency care or a hospitalization that could otherwise have been avoided. For
more information on the consequences of a lack of transportation for rural residents who have disabilities or
are older, see the RHIhub Transportation to Support Rural
Healthcare
topic guide.

Rural people who are unable to find necessary supports in their community may have little choice but to relocate
to a nursing home. According to the policy brief Are
Rural Older Adults Benefiting from Increased State Spending on Medicaid Home and Community-Based
Services?
, rural Medicaid beneficiaries were more likely to use skilled nursing facilities than urban
Medicaid beneficiaries. Similarly, Rural
Long-Term Services and Supports: A Primer
describes how rural residential care facilities, such as
assisted living facilities, serve populations with more diverse needs than facilities in urban areas. This may
reflect that there are few long-term care options in rural areas, in addition to the possible lack of other
support services in the community.


How can home-based services and community supports help informal caregivers?

The August 2019 publication Supportive
Services and Caregiving for Rural Adults: Policy Brief and Recommendations to the Secretary
from the
National Advisory Committee on Rural Health and Human Services (NACRHHS) notes that nearly 44 million family and
friends serve as informal, unpaid caregivers to older adults and individuals with disabilities each year.
According to the Centers for
Disease Control and Prevention
, one in four rural adults provide care or assistance to a friend or
family member with a health concern or disability. Over half of these caregivers provide care for over two
years, and 30% spend at least 20 hours per week providing care. As a result, informal caregivers can incur
psychological, physical, and financial stress when caring for another individual.

Home-based services and community supports can benefit friend and family caregivers as well as patients. For
example, reliable, accessible transportation services can allow caregivers to maintain regular work hours with
the peace of mind that their loved ones can visit grocery stores, attend community centers, or travel to medical
appointments. The Missouri Rural Health Association’s HealthTran program coordinates non-emergency medical transportation for
individuals who need routine and preventative medical care. Similarly, adult day centers provide supervised
care to dependent adults, relieving caregivers from attending to their family members continuously throughout
the day.

The policy brief Perspectives
on Rural Caregiving Challenges and Interventions
examines strategies for supporting informal caregivers.
Key informants noted that increased financial support, development of a national strategy, and expanded access
to resources would all be beneficial for informal caregivers. On a local level, the following strategies are
helpful:

  • Increase awareness of caregivers’ needs through workplace programs and churches
  • Provide infrastructure to enable rural families to more easily access technology services
  • Offer training to caregivers, so that they will feel more prepared and confident in their ability to help
    loved ones
  • Improve Medicaid services
  • Expand family leave policies and economic incentives for caregivers
  • Offer screening for caregiver depression and isolation

The 2019 Milbank Memorial Fund report In Support of Family
Caregivers: A Snapshot of Five States
notes that as demographics change and the country has a larger
percentage of older Americans, there will be a need for public policies to support family and unpaid caregivers.
For example, the Maine housing administration provides up to $3,800 in tax credits for home modifications for
older adults, and Minnesota used grant funding from its Live Well at Home program to partner with Chicago REST
(Respite Education Support Tools) to increase the availability of respite care for caregivers.

Resources for
Caregiving in Rural Communities
gives descriptions and contact information for several national and
state-level programs that provide services.

For more information on the challenges and opportunities informal caregivers experience in adopting technology
to aid their caregiving efforts, read the Rural Monitor article Informal Caregiving and Technology in Rural
America
.


What is the Medicaid Home and Community-Based Services Waiver Program?

In the past, long-term support services funded by Medicaid have typically been delivered in nursing facilities
or other institutions. However, Medicaid’s home and community-based services waivers (HCBS or 1915(c) Waivers)
allow states to develop programs to meet needs of Medicaid beneficiaries who want to remain in their own homes
or communities. States can apply for multiple waivers to tailor programs and services to specific groups
identified by age or diagnosis. Waiver programs must:

  • Show that the services provided under the waiver will not cost more than the same services provided in an
    institution.
  • Ensure that people’s health and welfare will be protected
  • Establish standards for providers to meet the needs of the participants
  • Develop and follow a plan of care that is individualized and person-centered

Key
State Policy Choices About Medicaid Home and Community-Based Services
highlights the variation in how
these services are provided at the state level. However, Are
Rural Older Adults Benefiting from Increased State Spending on Medicaid Home and Community-Based
Services?
, a 2016 report from the Maine Rural Health Research Center, examines how urban and rural older
adults utilize these services differently.

For more information, see Medicaid’s Home
& Community-Based Services 1915(c)
.


What other funding opportunities are available for rural home-based services and community supports?

Local agencies such as Area Agencies on Aging, Aging and Disability Resource Centers, Centers for Independent
Living and nonprofit or faith-based organizations are often the best funding sources for rural home-based
services. For a list of grant programs and organizations that have funded activities to support aging in place
and independent living, see the Funding & Opportunities
section of this topic guide.


What are some food and nutrition programs for seniors in rural communities who spend most of their time at home?

The Administration for Community Living’s Administration on Aging administers the Nutrition Services Program, which
provides grants to states to promote nutrition services programs for older adults. These include:

  • Home-delivered meals
  • Meals served in group settings, such as community centers
  • Nutrition screening
  • Assessment
  • Education
  • Counseling

The programs are intended to reach people age 60 and above who have the greatest social and economic needs.
Section 339 of the Older
Americans Act of 1965
provides nutrition services programs the ability to also serve spouses of any age,
people who provide volunteer services during meal hours, and people with disabilities. Priority is given to the
following groups:

  • Low-income adults
  • Members of minority groups
  • Seniors in rural areas
  • Seniors who have limited proficiency in English
  • Seniors at risk for needing institutional care

According to the Administration on
Community Living
(ACL), “home-delivered meals are often the first in-home service that an older
adult
receives, and the program is a primary access point for other home and community-based services.” A 2015
research brief, Older
Americans Benefit from Older Americans Act Nutrition Programs
, highlights the connection between the
health and ability of recipients of these services to remain at home.

Meals on Wheels America has more than two million staff
members and volunteers who deliver meals to frail, homebound, or isolated seniors. The organization notes on its
website that it serves “virtually every community in America,” and provides funding, leadership,
education,
research, and advocacy support.

Some rural communities have food pantries, which may provide food and other basic products. The Rural
Monitor
article Food Pantries Serving More
and More of the Rural Poor
gives examples of rural food pantry programs which are funded by federal
programs, state governments, foundations, businesses, religious organizations, and individuals.

For more information about nutrition programs for rural seniors, see RHIhub’s Rural Hunger and Access to Healthy Food topic guide.


Where can I find information on community-based transportation services?

People in rural areas often have difficulty finding adequate transportation. Those with medical needs requiring
specialized care available only in larger communities may find it particularly challenging to access affordable,
long-distance transportation to these locations.

The National Aging and Disability Transportation Center (NADTC), a
partnership between the Federal Transit Administration, Easterseals,
and the National Association of Area Agencies on Aging, promotes
transportation availability and accessibility for older adults, people with disabilities, and their caregivers.
It offers training and webinars, and Resources & Publications that are available for download.

The National Rural Transit
Assistance Program Directory of State RTAP Managers
offers a searchable directory of state Rural Transit
Assistance Program managers, and VirtualCAP provides information and
resources used by Community Action Agencies to help people become self-sufficient in rural and urban areas.

For more information, see RHIhub’s Transportation to Support Rural
Healthcare
topic guide and the Rural Transportation Toolkit.