Rural Health - The Foundation of the
CommunityPam Danner, MBA
Director, Rural Health
F. Marie Hall Institute for Rural and Community Health
Complex Health Issues Providing access to care for the large and
growing number of uninsured persons Caring for the aging population Aligning financial incentives for payers,
providers and patients Integrating population-based services with
personal care services
These problems are made worse in rural areas: Geographic isolation/Transportation barriers Growing minority populations with increased
health risks Populations that are generally older and less
affluent Shortages of financial, human and capital
resources High poverty rates Lower educational levels Lack of healthcare specialists
Objectives Assess how geographic isolation, low
population density and other “rural” factors contribute to and exacerbate already complex health problems
Understand problems related to supply and demand of health personnel in rural areas
What is Rural? It’s not urban…for real For our purposes, a county is designated
as rural if it’s population is less than 50,000
The Rural “Picture of Health” Rural Americans:
are less likely to have employer-provided insurance tend to get less preventive care and medical treatment
than urban people exercise and play sports less die from accidents at higher rates are more likely to die after breast cancer diagnosis are more likely to have lost all their teeth by age 64 are more likely to have untreated dental decay are less likely to have fluoridated water supply
According to the Center for Disease Control
Rural health issues cont. on average, income is $7,417 lower than in
urban areas 40% of rural 12th graders reported using alcohol
vs. 25% of urban counterparts up to 90% of rural first responders are volunteer have higher mortality rates
40% higher for children and teens than in urban areas
Federal Interagency Forum on Child and Family Stats
Barriers to Health in Rural Areas
Transportation Seeking help when you’re not anonymous Language Educational level Resources
Facilities Hospitals Community Health Centers
Comprehensive healthcare Primary patient population - underserved
Rural Health Clinics Non urbanized area MUA or HPSA
Rural Hospitals: Some of the Issues Uninsured/underinsured Physician recruitment Medicaid/CHIP funding Medicaid Managed Care CHIP Eligibility Tort Reform Worker’s Compensation Physician Self Referral Workforce
Critical Access Designation Rural public, non-profit or for-profit hospital Located more than 35 miles from any other
hospital Makes available 24-hour emergency care
services Provides not more than 15 beds for acute
care Annual average length of stay < 96 hrs.
Uninsured/Underinsured Improved access to equitable and high
quality healthcare Expand essential services to the vulnerable
uninsured
Texas has the highest rate of uninsured people in the nation. 24.6% in 2005
Physician Recruitment Allow rural hospitals to offer employment
contracts Exempt small hospitals from Corporate
Practice Act
Medicaid/CHIP funding Preservation of access to services for low-
income Texans Oppose any further reduction in
reimbursement to rural providers
Tort Reform Continuation of liability reform measures
passed in 2003 Currently total liability for non-economic
damages (pain and suffering) cannot exceed $750,000
Worker’s Compensation Allow rural hospitals to “opt-out” and
strengthen healthcare networks
Only large employers are allowed to self-insure
Self-Referral Limit the practice of self-referral and do
away with duplication of services in rural areas
Workforce Nursing shortage and other skilled
professionals
Why don’t they choose Rural? Professional isolation Stigma, “rural is for underachievers” Seeing patients around town..”never off” Community leader
Provider Shortages
Ratio of Primary
Care Doctors
Ratio of PAs
Ratio of NPs
Ratio of Pharmacists
Ratio of RNs
Ratio of
LVNs
U.S.,
2000
69 14.4 33.7 71.2 780.2 240.8
Texas, 2005
68.5 14.7 17.7 73.7 628.6 269
West Texas,
2005
41.7 16 13.4 50.9 364.5 424
Ratio of providers per 100,000 population. Source: HRSA Bureau of Health Professions and Texas Department of State Health Services
What did that table mean? West Texas has far fewer health care
professionals than the state and national averages, except for PAs and LVNs.
PAs – about par with the state and national average. Many communities are using these mid-level providers as physician extenders
For LVNs, which is the lower level of nursing licensure, West Texas has almost double the number of the state and nation.
Perceptions/Reality of Rural Practice and Living Lower reimbursement and higher overhead Longer hours Lack of relief coverage Lower quality education for children Limited cultural activities Limited availability of quality housing
Historical approaches/ short-term fixes
National Health Services Corp
J-1 visa programs
Loan forgiveness
Community collaborations
Bonuses
Problem with these “fixes” These programs don’t foster long-term
relationships between participants and communities
Participants in these programs “do their time” and leave, creating a rotating cycle of need in the community
What can be done? Recruitment and Retention Programs Pipeline Programs
West Texas AHEC Patient Care Programs
Mobile Clinics Rural Health Clinics/Community Health Centers
Health Education Programs Department of State Health Services West Texas AHEC
Telemedicine
Hypothesis
People from rural communities are most likely to pursue a health care
career in a rural community.
People from West Texas are most likely to pursue a health care
career in West Texas.
Rural Health Support and Education Initiative
Implement a longitudinal, comprehensive program to Support practitioners in rural West Texas Expand the educational pipeline to supply new
practitioners Focus research on improving rural health Area Health Education Centers to provide
infrastructure for regional outreach
Spring 2007: Dental Outreach event in Hereford, Texas. Almost 900 rural residents from surrounding communities received free dental care.
Telemedicine TTUHSC started utilizing telemedicine in 1990 Primarily used in correctional settings Also used to increase access to health care for rural
communities Primary care (Hart School Based Clinic) Specialty care (Childress Oncology and El Paso Burn
Follow-up) Supportive services (Turkey, Earth, and
Plains/Brownfield telepharmacy)
Earth, TX
Turkey, TX
Patients from Turkey and Earth that see a doctor from Plainview via telemedicine, and then receive pharmacy services via telemedicine from the TTUHSC Pharmacy in Lubbock.
Nelson Pharmacy in Brownfield has partnered with Yoakum County Hospital (Denver City) to use telemedicine for providing pharmacy services to residents of Plains, Texas.
Telemedicine is used to provide follow-up care to burn patients in the El Paso and Eastern New Mexico areas so that they don’t have to travel 600+ miles roundtrip to be seen by the burn specialist and care team.
Hart, Texas is a community of 1,200 people that has no local health care professionals except for the school nurse. The school has developed a school-based health clinic, where students can be seen by a doctor through a weekly visit or through telemedicine. The clinic also has a Class D Pharmacy, dental services (visiting dentist) and nutritional services.
Telemedicine as a tool Telemedicine can enhance access, but
challenges Equipment and connectivity costs have decreased
but still a challenge for some communities Reimbursement for providers is improving but still
limited Referral patterns and private insurance issues for
network versus non-network Licensure issues HIPAA compliance and patient privacy
Questions?
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