Population Health in Rural America in 2020 Proceedings of a Workshop (2021) / Chapter Skim
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4 Rural Health Care in Action
4 Rural Health Care in Action
Pages 45-68
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From page 45... ...
on health care access in rural communities. He remarked that although fewer doctors in rural areas are making house calls and delivering babies in local emergency departments (EDs)
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FQHCs are administered by HRSA's Bureau of Primary Healthcare after being established in the 1960s as part of the war on poverty.3 Designed as a demonstration program to provide access to health and social services to medically underserved and disenfranchised populations, FQHCs are located in both urban and rural areas. Currently, about 40 percent of the 14,000 FQHC sites are in rural communities.
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From page 47... ...
These include long-term care facilities that serve Medicare and dual-eligible Medicaid patient populations, nursing homes, assisted living facilities, and residential services for people with disabilities.4 Other types of rural service providers include tribal clinics and hospitals, Veterans Affairs clinics and hospitals, home health care, hospice, occupational therapy, speech therapy, physical therapy, pharmacies, dentists, mental and behavioral health providers, and community health aides. Disparities in the Rural Health Care Landscape Moore outlined various disparities in the rural health care landscape.
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Innovations in the Rural Health Care Landscape Moore also described some of the innovations that are taking place in the rural health landscape to counteract some of the negative trends. Successful examples that can provide helpful insights include the Frontier Extended Stay Clinic, the recently closed Frontier Community Health Integration project, the Rural Community Hospital Demonstration program, and rural state innovation models.5 CMS has ongoing rural valuebased initiatives such as accountable care organizations (ACOs)
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TRIBAL HEALTH AND HEALTH CARE IN RURAL SETTINGS Daniel Calac from the Indian Health Council discussed the diversity among American Indian populations, the magnitude of American Indian/ Alaska Native health disparities, the factors affecting the quality of life, and the severity of the biomedical workforce shortage affecting this sector of the U.S. population.
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Congress ratified appropriations with the 1921 Snyder Act, landmark legislation that defined the governmental responsibility for American Indian health care. Service delivery for American Indians was transferred to the Public Health Service in 1954 before shifting again to the newly formed Indian Health Service (IHS)
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The life span of American Indians, at a 10 More information about the Centers for Disease Control and Prevention guidelines for advancing health equity and preventing chronic disease is available at https://www.cdc. gov/nccdphp/dnpao/state-local-programs/health-equity-guide/index.htm (accessed July 30, 2020)
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Factors Affecting the Quality of Life of Tribal Communities Calac highlighted some of the many factors that affect the quality of life of American Indians and Alaska Natives, including barriers to accessing health care that are geographic, educational, institutional, social, or financial. Distance to health care providers can be a geographic barrier to care, as can mountainous regions that are difficult and even dangerous to traverse.
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Traditional wraparound services include social work, behavioral health, nutrition and diet, pharmacy assistance, and patient navigation. More recently, wraparound services have included financial counseling, which assists individuals in managing nonmedical aspects of their lives to enable them to better manage medical issues.
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Wraparound Program Outcomes A number of studies have measured the effect of wraparound services on patient outcomes, said Menachemi. In one study, referrals by health care professionals to social service providers led to a decrease in patientreported needs, indicating that social services were able to address and eliminate some patient needs (Gottlieb et al., 2016)
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Menachemi and colleagues published a study of FQHCs in inner-city Indianapolis, Indiana, where wraparound services included social work, dietician assistance, and patient navigation (Vest et al., 2018)
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. Centers in rural locations were far less likely to offer wraparound services than their urban counterparts because of challenges in rural areas, including the stigma on behavioral health care issues (Pullmann et al., 2010)
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. THE ROLE OF COMMUNITY HEALTH WORKERS IN ADDRESSING THE NEEDS OF RURAL AMERICANS Timothy Callaghan from the Southwest Rural Health Research Center at Texas A&M University focused his presentation on the role of the CHW in addressing the needs of rural Americans and the unique barriers they face in accessing health services.
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Community Health Workers in Rural Versus Urban Settings The increasing numbers of CHWs are filling a vital role in the health care system, said Callaghan. The value of CHWs extends to rural areas, where they can help patients address the considerable barriers rural Americans face in accessing health care services.
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On addressing social determinants of health: "We help with insurance, and then we help with homelessness, and then we help with food, and then we help with moving, and then we help with dental access, and behavioral health access. And that's all before noon." (Community health worker in Minnesota)
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The average age of rural CHWs is about 3 years older than their urban counterparts, which is consistent with the demographics of the general population living in rural areas. Rural CHWs also tend to have lower levels of education, with 42.3 percent holding a bachelor's degree compared to 52.3 percent of urban CHWs.
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We can't give it to everybody, and everybody at some point has problems with food insecurities. Challenges in Building the Workforce of Community Health Workers Callaghan explained that beyond the lack of resources available for rural clients, there are challenges within the way CHW jobs are structured.
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The National Association of Community Health Workers,17 the American Public Health Association's CHW Section,18 and various training centers across the country have been promoting CHW workshops to help them fight the coronavirus pandemic and to ensure that CHWs are staying safe. Callaghan stated that research by his team suggests that CHWs are taking on new roles in response to the pandemic.
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However, telehealth sessions have the benefit of allowing the clinician to observe pediatric clients in their home environments, which is helpful for behavioral health services. The patient response to the shift to telehealth has been varied, added Calac.
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He suggested that the COVID-19 pandemic may present a critical opportunity to rethink decades-old challenges in public health -- even if it means political fallout for some leaders -- and to implement holistic changes to the health care system at large. Morris remarked that issues of structural urbanism, rural hospitals, hospital closures, and pick-your-provider services all relate to the central issue of health financing.
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He predicted that given current conditions and the trends of hospital closures, the health of rural communities will likely worsen owing to factors such as the need to travel longer distances for care. Coordinating Care in Rural Areas Morris questioned whether better use of wraparound services and CHWs could help ensure that care is coordinated, especially after people traveling long distances for specialty care return to their rural communities.
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Physicians may only be able to see an individual for 15 minutes at a time, but sending a public health worker, a public health nurse, or a dietician to work with a client in person or via telehealth allows for the provision of a higher level of care to the community. Morris asked why so little research has been conducted on the benefits to rural population health of coordinated care that includes wraparound services and CHWs.
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Morris asked about data sources to better understand and scale up social services support structures. Menachemi suggested that the fields of implementation science and health services research could contribute, but the "elephant in the room" is that social services are being funded unsustainably through charity, philanthropy, and grants instead of being built into the bedrock of the health care systems in rural communities.
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