Home and community-based services (HCBS) are home-based services that enable people to remain in their own home while coping with disease, disability, and/or age. Expanding Veterans' access to HCBS is a VA priority because aging in place is a key goal for most older Veterans. Therefore, VA offers a range of HCBS to meet the needs of aging and/or disabled Veterans, the majority of which are provided by contracted community agencies. However, rural areas present challenges to HCBS delivery, such as workforce and transportation issues, as well as infrastructure barriers.
A study by VA HSR investigators examined rural-urban differences in HCBS use among Veterans enrolled in VA healthcare and found facility-level variation (Davila, 2026). Using VA data from FY2021-2022, investigators identified more than 6 million Veterans, with 34% residing in rural settings and 66% in urban settings. Findings showed that Veterans in rural areas were slightly less likely to receive HCBS than Veterans in urban areas; this difference widened after adjusting for demographics (i.e., age, gender, marital status), comorbidity (i.e., hypertension, depression, diabetes), and facility characteristics (i.e., facility culture, social work staffing, leadership priorities). Importantly, at each level of facility rurality, there were some VAMCs at which rural Veterans used HCBS at similar or higher rates than urban Veterans. U.S. region (e.g., northeast, west) was the facility characteristic most associated with HCBS delivery.
A recent editorial (Parikh, 2026) stated that this study’s findings highlight “a paradox that should command national attention: rural Veterans, despite being older and often carrying greater social and clinical vulnerability, were less likely than urban Veterans to use HCBS.” Further, “As clinicians, researchers, and policymakers confront the rapidly growing demand for LTSS [long-term services and supports], the experiences of these higher-performing VAMCs may offer one of the most informative roadmaps available—not only for Veterans, but for older Americans nationwide.”
