Care Deserts: Counties With No Licensed Residential Care

How to read this

Assisted living is the thinner of the two residential settings: 958 counties have no licensed assisted living community in our directory, against 341 with no licensed nursing home. Nursing home coverage is denser because federal certification produces a more complete national record than state assisted living licensing does.

The states at the top of this table are not necessarily the states where families struggle most. They are the states with the most counties whose licensed supply, as recorded, is empty. A large state with many small rural counties will rank high on a count that a state with few, larger counties cannot.

We publish in-home care and adult day counts in the download but never use them to define a desert. An in-home agency's address is a business address, and its caregivers routinely work across county lines, so treating its absence as an absence of care would be a claim the data cannot carry.

Methodology

We take every county represented in our Census place backbone, then count licensed providers in our directory against it. A provider is attributed to a county either from the county recorded on its own record or, where that field is blank, from the county of the Census place its mailing city matches. Providers with a license status our directory reads as closed are excluded.

A county counts as having no licensed residential care when our directory holds zero licensed assisted living communities and zero licensed nursing homes with an address in that county. Population aged 65 and over is summed from the Census places inside the county, so it is a floor for the county's older population, not a full count.

We report residential care only. In-home care agencies are counted separately and never used to call a county a desert, because an agency's mailing address is not its service area and treating it as one would invent a finding the data cannot support.

Sitewide cost and data method: Methodology · Data sources · Corrections

What this cannot tell you

This measures licensed supply recorded at an address, not access. A resident of a county with no licensed community may drive twenty minutes across a county line and have three to choose from. Counting a county as having none is a statement about our directory, not a statement that families there have nowhere to go.

Our directory is built from state licensing registries and CMS files, and those registries differ in how completely and how recently they publish. A county with thin coverage in its state registry will look emptier than it is. We do not correct for that, because correcting for it would mean estimating providers we cannot name.

County attribution is not complete. Where a provider record carries no county, we infer one from the Census place its mailing city matches, and a small share of records match neither. Those providers are absent from the county counts, which biases the desert count upward rather than downward.

Older-population figures are summed from Census places. Residents of unincorporated areas outside any recognized place are not counted, so the population attached to each county understates the real total, most in rural counties.

The in-home care and adult day columns in the download count counties with no provider of that type recorded at a mailing address inside the county. They are published for completeness, they are never used to define a desert, and they are not service-area coverage. Our in-home care coverage is also far more uneven between states than our residential coverage, so a state showing none of it is at least as likely to be a gap in our sources as a gap on the ground.