Medicare-certified home health agencies (HHAs) in Virginia were surveyed to determine which organizational factors (indigent goal, resources and operating values) could predict indigent service rates. Responding agency caseloads ranged from 0 to 80% (x = 7%) indigent. The contingency model (goal + resources), the operating values model (operating values) and the integrated model (goal + resources + operating values) were tested and found to be significant predictors of indigent service rates (p $<$.001). The integrated model afforded a fuller, richer explanation than the other models, in addition to its statistical capability. The three predictor variables for the integrated model: percent bad debt budgeted, agency type and time of service fee discussion with patients, accounted for 42% of the variance. Thus, agencies with high indigent service rates were more likely to have larger bad debt or charity care allocations, tended to be publicly based programs or Visiting Nurse Associations with proportionately less Medicare patients in competitive environments and were less likely to be organizationally integrated regarding economic accountability.

Anecdotal enrichment from interviews with six nursing supervisors illustrated the predictive factors and supported the hypothesized results. In general, agencies acted to secure their most predictable funding sources, and thus developed services as defined by those sources. Private nonprofit and proprietary agencies sought a share of Medicare funds, while public agencies operated for their share of state funds. Agencies with integrated economic accountability controlled resource distribution primarily by admitting only those patients with a fee source and then assuring reimbursement from the sources. Also, agencies with specified bad debt reserves and employee participation in budget planning served fewer indigent than agencies with little employee participation and no bad debt category.

Further study of the integrated model is recommended. Findings suggest a need to reassess and clarify the state's agenda for publicly based programs; and a need to develop indigent insurance and/or minimize differences between forprofit and nonprofit tax base advantages and access to charity funding. Additionally, nurses should recognize that they can choose to interpret and influence organizational goals and resources in ways that benefit society.