March 10, 2025 — Contextual social determinants of health (SDoH) – for example, rural residence and neighborhood economic factors – may affect access to community-based rehabilitation services for older adults with traumatic brain injury (TBI) , suggests a study in the March/April issue of Journal of Head Trauma Rehabilitation (JHTR). The official journal of the Brain Injury Association of America , JHTR is published in the Lippincott portfolio by Wolters Kluwer .
Contextual SDoH factors have complex effects on use of community-based rehabilitation services after TBI, beyond those linked to individual-level SDoH, according to an analysis of Medicare data by Monique R. Pappadis, PhD, and colleagues of University of Texas Medical Branch, Galveston. The findings "indicat[e] the need to improve access to rehabilitation services for persons with TBI living in communities with greater social needs," the researchers write.
How does contextual SDoH affect rehabilitation for older patients with TBI?
Patients aged 65 and older are a high-risk group for TBI, with a higher risk of death and other adverse outcomes compared to younger patients. For TBI patients who are discharged home from the hospital, access to community-based rehabilitation services – delivered at home or in an outpatient facility – can have a major impact on recovery and functioning.
Previous studies have found that individual-level SDoH such as age, gender, race, and ethnicity can affect access to rehabilitation care after TBI. However, little is known about the possible impact of contextual-level SDoH, referring to geographic or neighborhood factors affecting health risks and access to care.
To assess how contextual SDoH affect community-based rehabilitation services, the researchers analyzed data on 19,117 Texas Medicare fee-for-service beneficiaries, aged 65 or older, discharged home after TBI from an acute hospital or post-acute care facility from 2014 through 2018. The study focused on SDoH variables reflecting the demographic and socioeconomic characteristics of the neighborhoods where patients lived, along with other community factors.
'Intricate relationship' between SDoH and community-based rehabilitation
Forty-eight percent of older adults received home health rehabilitation services after discharge from the hospital, while about 14 percent received outpatient rehabilitation services. The remaining patients – nearly 38 percent – received no community-based rehabilitation care.
For patients who receive community-based rehabilitation services, contextual SDoH factors had complex and varied effects on the first site of care:
- Patients living in higher-income areas, as well as in areas with higher unemployment rates, were less likely to receive home health visits.
- Patients living in rural areas or in areas with high uninsurance rates were less likely to receive outpatient rehabilitation care.
- Patients with better access to healthy foods (living near grocery stores) were more likely to have home health visits.
- Patients living in areas with severe housing problems (such as overcrowding or high housing costs) were more likely to have outpatient visits.
On its own, neighborhood ethnic/racial makeup was not significantly related to site of rehabilitation care. There was a trend toward older adults living in areas with a higher percentage of Black/African American residents being more likely to receive home health services and less likely to receive outpatient care. Another trend found that older adults living in areas with a higher percentage of Hispanic/Latino residents tended to be less likely to receive home health services.
Overall, "some contextual-level SDoH were associated with a decreased likelihood of an outpatient visit but an increased likelihood of a home health visit," Dr. Pappadis and coauthors write. Lower use of outpatient rehabilitation in rural areas or areas with high uninsurance rates likely reflects disparities in access, such as lack of transportation or inability to meet copays. But other "seemingly contradictory" findings – such as the lower use of home healthcare in higher-income areas – "suggest that access to care may not always be ensured by financial means alone."
To address these disparities, "targeted interventions are required, especially for rural, Black, and Hispanic/Latino communities," Dr. Pappadis and coauthors conclude. "The intricate relationship between healthcare access and community socioeconomic factors necessitates sophisticated strategies to increase equity."
