The Medicare hospice benefit pays for essential services in patient homes and in facilities (e.g., inpatient hospice and hospitals) to address management of terminal illnesses and related conditions. Overall utilization of hospice has increased over time, but a smaller percentage of rural decedents receive hospice care compared to urban decedents, and disparities in utilization increase as rurality increases. No recent studies have examined variation in hospice availability in rural versus urban communities and during the COVID-19 pandemic. Differences in hospice quality and care practices of providers serving rural versus urban beneficiaries have also not been well studied. To address these gaps in knowledge and provide updated information on rural hospice care, this project will use publicly available, provider-level data on hospice from 2018-2022, including Medicare Compare-Hospice and the Post-Acute Care and Hospice Provider Utilization and Payment Public Use Files, to address the following research questions:

1. Does availability of hospice providers differ based on the rural-urban status, including intra-rural variation, demographics, and socio-economic status of communities?
2. Does provider-level hospice quality differ based on rural-urban status, controlling for provider characteristics (e.g., profit status, freestanding versus facility-based, size) and types of beneficiaries served (e.g., sociodemographic characteristics, risk scores, and primary diagnosis)?
3. Do provider-level hospice care practices, including specific types of hospice care (e.g., routine home care), services delivered (e.g., nursing visits and minutes), and location of care (e.g., home, nursing facility, inpatient hospice, inpatient hospital) differ based on rural-urban status controlling for provider characteristics and types of beneficiaries served?

This project will provide a comprehensive picture of hospice availability and provider-level quality and care provision in rural versus urban communities. Findings on potential disparities in care can be used to inform Medicare policy to help ensure rural beneficiaries have access to high-quality hospice services.