Hidden in Plain Sight: Reaching Underserved Populations in Home-Based Care

 In Preparing for the Future

Are you convinced that there isn’t an underserved population in your service area? Well think again.

Health equity is gaining more traction than ever. CMS has prioritized increasing access to high-quality care resources that decrease health spending and support patients and families. The 2025 proposed hospice rule includes language around the domains of social determinants of health (SDoH), measuring equity in service provision, standardization of sociodemographic data and more. Unfortunately, the existing disparities in healthcare didn’t happen overnight, and it will take time to swing the proverbial access pendulum. The consistent collection of data is integral to developing resources that improves the patient experience and family caregiver support.


Wooden blocks depicting people or audiences being strategically arranged and connected with lines

Various terms have been used when describing those impacted by health disparities – underserved populations, vulnerable communities and disadvantaged populations to name a few. But the term for those who can benefit from an intentional strategy for outreach and health literacy education is not what’s most important. Instead, it’s imperative that home-based care organizations take the time to identify who is missing from your existing patient population and take steps to best meet them where they are. There have been assumptions that underserved populations are based on one’s race or ethnicity, but this way of thinking is limited and doesn’t account for geography, infrastructure and other cultural elements that lead to countless families struggling to navigate a life-limiting illness in the communities you serve.

The idea of identifying an underserved population and developing a plan to not only reach them but meet needs that may be unfamiliar to you as a provider can be overwhelming. But in the words of Teddy Roosevelt, “Nothing worth having comes easy.” It’s important to start somewhere, and what better starting position is there than doing your homework? While waiting for sociodemographic data to become standardized, there is existing information available to help gain a better understanding of the gaps and opportunities to build important connections in your community. The NHPCO Facts and Figures is a good starting point to explore nationwide Medicare hospice benefit utilization by demographic. The 2023 edition demonstrates that women are 10% more likely to utilize hospice services and that 75% of Medicare hospice decedents identify as white. The CMS data tools are resources for diving deeper into state- and county-specific data related to Medicare disparities by population and the SDoH. Utilizing the CMS SDoH tool can provide data, such as the social vulnerability index by county, that can support the development of internal resources to address the needs of the local patient population. This can help understand the social needs of the counties you serve and compare counties if warranted. Knowledge gained by applying an equitable lens to research, clinical training, employee experience strategies and patient/family caregiver education can have a positive impact on patient satisfaction, retention, organizational culture and future growth.


Selective focused group of wooden figures representing people, focusing on the center figure

Addressing health equity and underserved populations has been a challenge in home-based care due to continuous competing priorities and data collection barriers presented by electronic health records. It’s become abundantly clear that this is an area in which home-based care organizations can opt to proactively address and become a trusted partner in their communities instead of playing catch up when it’s mandated by CMS.

Access to meaningful data and an equity-focused strategic plan to operationalize new insights can make a significant difference in the day-to-day experience of your employees, the number of patients and families you serve, and the quality of care provided. Transcend is here to help through customized research and AI-driven insights to improve access to care. To learn more, please email hello@transcend-strategy.com.

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