Restructuring – the introduction of changes that alter the way health care is delivered for maximum efficiency and least cost – layered with rurality and with rural gender ideologies and practices, results in rural long-term care settings that have particular consequences for the women working in them, and for the residents and communities that they serve. This research investigated how rurality affects the implementation of patient classification in Ontario long-term care homes. Methods involved interviews and focus groups with front-line long-term care workers, administrators, and key participants. The findings revealed that rural long-term care delivery takes place when a restructured work environment intersects with gender ideologies and practices that take on particular characteristics when developed and sustained in a rural context. These factors shape the labor market and working conditions for rural women. We argue that this produces a uniquely rural experience for long-term care workers and conclude that those implementing classification systems must consider contextual factors as well as practical and financial exigencies.

The nursing home case-mix classification system, Resource Utilization Groups Version III (RUG-III), has been tested and refined for long-term home care clients. The study sample included 804 individuals seeking home care through the Michigan Care Management Program or the Home and Community Based Waiver for the Elderly and Disabled. Clients were classified, and RUG-III models were derived using the Minimum Data Set for Home Care (MDS-HC). A refined home care model, RUG-III/HC, was developed incorporating Instrumental Activities of Daily Living (IADLs) to the nursing home RUG-III classification. The model explained 33.7 per cent of the variance of per diem cost, using cost weighted formal and informal care as the dependent variable. Resource use within groups was relatively homogeneous. The case-mix index (CMI) of weighted formal and informal care time spanned an eight-fold range. Further analysis is suggested regarding the inclusion of informal care as a cost in case-mix classification for long-term home care clients.