Putting the Family Perspective into Rural Health Care

1. Putting the Family Perspective into Rural Health Care Farm Foundation National Public Policy Education Conference Sept 20, 2004 Roberta Riportella, PhD University of Wisconsin-Madison University of Wisconsin Extension

2. Objectives • To understand a family perspective on creating health for families • To consider how rural families may be uniquely affected by changing demographics and health policy • To consider how a family perspective might lead to different solutions for creating health

3. Methods • Consider what we know about creating health • Consider who rural families are • Put those rural families into a model explaining families’ role in health • Consider what kind of system is in place to address risks and poor health outcomes for rural families

4. Direct Lifestyle Factors (50%) Cigarette Smoking Alcohol & Drug Consumption Nutrition Stress/Mental Well-Being Body Fitness Environment (20%) Biological Predisposition (20%) Health System (10%) Contributing Education, Income (SES) Self-Esteem Social Support Community Norms, Beliefs, & Expectations Direct and Contributing Factors to Health

5. Family Household in which we grow up, household which we create as adults Legal and non-legal attachments, mom,dad,kids,grandparents,extended family, guardians

8. Doherty, William J. (2002). A family-focused approach to health care.

9. Illness Appraisal • Disease is not merely a biological phenomenon • Disease: the sickness/diagnosis itself, bodily processes • Illness: the manifestation of disease in and through the individual experience of disease

10. Health Status • Health status of the adult rural population was more frequently described as fair/poor. (28% vs. 21%). • Chronic conditions in the adult population as diagnosed by physicians were also more prevalent in rural areas. (47% vs. 39%) http://www.nal.usda.gov/ric/index.html

13. Southeast Asian refugees • poorer health status • accepting perception of well-being • beliefs about cause of disease • beliefs lead to type of healer

14. Health Promotion and Risk Reduction • Socialization extends to the variety of habits, attitudes, behaviors, actions toward health, as well as attitudes toward using the formal health care system • What do we learn? • Who needs to be part of the “treatment?” • Are choices individual/family/societal responsibilities?

20. Complications to making positive choices • Food shopping limited, healthy foods expensive • No health clubs/indoor shopping malls for walking • Social life around taverns • Alcohol and smoking culture • Liquor stores • Good information (often confusing messages, internet-based)

21. Vulnerability and Disease Onset • Social support in the family • Social ties • Stress in family life

22. Acute Response • The immediate aftermath of illness for the family

23. Adaptation to Illness and Recovery • The family as the setting for care of the recovering or chronically ill member.

24. Implications • Delivery system: Differently trained health care providers • Teaching so providers can assess the influence of family factors on health and thereby • Understand individual as whole person and as member of larger units of family and social/cultural environment • Treat family members as partners in health care • Financing and organization of health care • Ability to pay/be insured • Coverage of all family members • Availability of providers

25. Geographic: Supply of ProvidersHealth Care Personnel • The supply of health care personnel represents one of the greatest contrasts between rural and urban areas in the United States. • While the rural population makes up 1/5 U.S. citizens, only 1/10 physicians practice in rural areas. • Specialists are concentrated in urban areas. Generalists are far more likely to practice in rural. One reason is rural physicians earn less money. http://www.nal.usda.gov/ric/richs/stats.htm#demographics

28. Geographic: Supply of ProvidersHealth Care Facilities • Rural hospitals • 2226/5134 in rural areas • Most fewer than 100 beds, mainly private nonprofits but also include those owned by state and local governments and for-profit hospitals. • Heavily dependent on Medicare • 1991-1995 363 rural hospital closures • 1999 only 24 closures http://www.nal.usda.gov/ric/richs/stats.htm#demographics

30. Community Activation of Family Health Care: An emerging model • Patients and families as partners with professionals • Families as producers of health promotion, not just consumers of health care • Learning, coping, and healing occur best within communities • Identify and activate potential communities • Community asset building perspective

31. Key Findings NACRHHS Report • Benefits to integrating behavioral health and primary care in rural settings • Access to oral health services in rural communities very limited • Rural elderly face significant challenges in accessing needed services • Not necessarily family-centered report

32. Behavioral health (BH) and primary care in rural settings • Primary care practitioners have major responsibilities for diagnosing and treating common mental illnesses (depression) • BH services are highly fragmented due to staff shortages • Separate facilities for mental and physical health care • Autonomous BH and primary care providers practice with informal referral relationships • Primary care and BH providers do not share joint responsibility for managing patients

33. Behavioral health (BH) and primary care in rural settings: Barriers • Higher percentage un- and under-insured for both physical and mental health • Medicare rules set standard. • Higher copays • Only certain professionals reimbursed (not marriage and family therapists) • Rural areas have less reimbursable providers to work under • Higher copays + less choice + cost sensitive consumers => less access

34. Behavioral health (BH) and primary care in rural settings: Strategies • Diagnosis and treatment by a fully integrated clinical team • Co-location of providers • Dual certification of providers • Unknown efficacy of these approaches • Use of Rural Health Centers (3500) authorized to provide mental health but few do (only recover 50% cost; paid less than FQHC)

35. Factors limited oral health • Lack of fluoridated community water supplies • Older populations (lifetime of risks, old habits) • Increased poverty • Less food choice (soda bottle babies) • Limited access to oral health care

36. Rural oral health status • Untreated dental caries • 31.7% rural, 25.2% urban • Lost all teeth • 16.3% rural, 8.8% urban (45-64 yr olds) • 37% rural, 27% urban (65+)

37. Access to Oral Health Care • Factors limiting access • Geographic isolation/lack of adequate transportation • Lack of dentists participating in publicly financed programs (~16% nationwide) • Low public financing (<2/3 prevailing rate) • Population thought to miss appts, not comply with advice • Administrative burden • Uneven distribution of practitioners • Poor coordination between dental and medical care • Lack of dental insurance • Cultural attitudes toward dental care • Professional competition issues

38. Health challenges for rural older adults • 40% of all older adults report good health • Rural older adults report fair to poor health 1½ more than urban older adults • Continuous poverty • Difficulty accessing transportation • Distance to care • Lack of knowledge of available services • Lack of nearby younger family caretakers • Shortage of qualified workers

39. Rural elderly face significant challenges in accessing needed services • 1.6 million older adults in nursing homes • Fewer home and community based services makes nursing home use greater in rural • 66.7/1000 beds rural • 51.9/1000 beds urban • Medicaid 10.1% rural, 8.2% urban

40. Emerging Issues • Obesity and wellness • Higher rates of chronic disease and limitations on activities of daily living • Higher rates of obesity • Regular physical activity reduces risk yet inactive leisure time more common among rural residents. • Strategies • Steps to a Healthier US community grant program (CDC) for diabetes, obesity and asthma prevention • Targets prevention efforts: physical inactivity, poor nutrition, tobacco use • $13.7 million, $4.4 to small cities and rural communities • At-risk populations (ethnic, low-income, disabled, youth, senior citizens, uninsured, underinsured=rural) • Small city/rural communities component (Washington, NY, Arizona, Colorado)

41. Emerging Issues: cont’d. • Access to specialized services (terminal illness) • Travel far for diagnosis and treatment • Lack of hospice care • Health system changes • Vulnerability of rural providers to rapid increase in insurance plans that intend to have consumers avoid providers with higher prices • Consumers may travel greater distances, further jeopardizing infrastructure of providers for those who cannot travel

42. Families need to be supported in their roles as creators/maintainers of health • Knowledge • What works, what doesn’t • Resources • Income • Insurance • Formal support (health care system)

43. References • Doherty, William J. (2002). A family-focused approach to health care. In K. Bogenschneider (ed). Taking family policy seriously: How policymaking affects families and how professional can affect policymaking. Mahway, NJ: Lawrence Erlbaum Associates. • The 2004 Report to the Secretary: Rural Health and Human Service Issues. The National Advisory Committee on Rural Health and Human Services. ftp://ftp.hrsa.gov/ruralhealth/NAC04web.pdf

44. References: cont’d. • Rural Health Policy Institute, U of Nebraska, http://www.rupri.org/HealthPolicy/ • http://www.rupri.org/ruralHealth/presentations/mueller111202.pdf • http://www.ers.usda.gov/emphases/rural/gallery/ • Trends in the Health of Americans Chartbook: http://www.cdc.gov/nchs/products/pubs/pubd/hus/metro.htm

45. References: cont’d. http://www.shepscenter.unc.edu/research_programs/Rural_Program/mapbook2003/totalpopulation.pdf • Map book • http://factfinder.census.gov/servlet/BasicFactsServlet • Geographic Comparison Table Census 2000 http://factfinder.census.gov/servlet/GCTTable?_bm=y&-geo_id=01000US&-_box_head_nbr=GCT-P1&-ds_name=DEC_2000_SF1_U&-_lang=en&-format=US-1&-_sse=on

46. References: cont’d. • Uba, Laura. Cultural barriers to health care for Southeast Asian Refugees. Public Health Reports, 107, 5, Sept-Oct 1992: 544-548. • Fadiman, Anne. The Spirit Catches You and You Fall Down. New York, The Noonday Press, 1997.