Rural Health - The Foundation of the Community

1. Rural Health - The Foundation of the Community Pam Danner, MBA Director, Rural Health F. Marie Hall Institute for Rural and Community Health

2. 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

3. 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

4. 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

5. 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

12. 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

13. 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

14. Barriers to Health in Rural Areas • Transportation • Seeking help when you’re not anonymous • Language • Educational level • Resources

16. Facilities • Hospitals • Community Health Centers • Comprehensive healthcare • Primary patient population - underserved • Rural Health Clinics • Non urbanized area • MUA or HPSA

17. 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

19. 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.

20. 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

21. Physician Recruitment • Allow rural hospitals to offer employment contracts • Exempt small hospitals from Corporate Practice Act

22. Medicaid/CHIP funding • Preservation of access to services for low-income Texans • Oppose any further reduction in reimbursement to rural providers

23. Tort Reform • Continuation of liability reform measures passed in 2003 • Currently total liability for non-economic damages (pain and suffering) cannot exceed $750,000

24. Worker’s Compensation • Allow rural hospitals to “opt-out” and strengthen healthcare networks • Only large employers are allowed to self-insure

25. Self-Referral • Limit the practice of self-referral and do away with duplication of services in rural areas

26. Workforce • Nursing shortage and other skilled professionals

27. Why don’t they choose Rural? • Professional isolation • Stigma, “rural is for underachievers” • Seeing patients around town..”never off” • Community leader

31. Provider Shortages Ratio of providers per 100,000 population. Source: HRSA Bureau of Health Professions and Texas Department of State Health Services

32. 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.

34. 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

35. Historical approaches/ short-term fixes • National Health Services Corp • J-1 visa programs • Loan forgiveness • Community collaborations • Bonuses

36. 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

37. 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

38. 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.

39. 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

40. Spring 2007: Dental Outreach event in Hereford, Texas. Almost 900 rural residents from surrounding communities received free dental care.

41. 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)

43. 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.

44. Nelson Pharmacy in Brownfield has partnered with Yoakum County Hospital (Denver City) to use telemedicine for providing pharmacy services to residents of Plains, Texas.

45. 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.

46. 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.

47. 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

48. Questions?