Sixty million people, or 19 percent of the total U.S. population, live in rural areas.1
They work primarily as farmers, farm workers, ranchers, or agricultural suppliers. Rural populations are more likely to be poorer, sicker, older, uninsured, and medically underserved than urban populations.2
Several national and local initiatives are underway to address rural health disparities. Innovations Exchange:
When you were a hospital administrator in rural Mississippi from 1987 to 2007, what health care problems did you encounter? Brock Slabach:
Field Memorial Community Hospital in Centreville, MS, serves a large percentage of low-income African Americans in Wilkinson and Amite counties in the Mississippi Delta region. The typical patient had comorbid chronic conditions such as hypertension, type 2 diabetes, heart failure, and obesity. Many patients were readmitted to the hospital within 1 month because they were unable to comply with their treatment or manage their conditions. Without the resources to create a comprehensive continuum of care, we could not refer patients to chronic disease management programs and home health care that could have prevented hospitalizations for Medicaid patients.
How did the hospital address these health care barriers?
We participated in the Rural Hospital Performance Improvement Project
funded by the U.S. Health Resources and Services Administration (HRSA). The goal was to improve the quality of care and the financial and operational performance for hospitals with fewer than 200 beds. The program was pivotal in providing the necessary tools to implement cutting-edge techniques and encourage ongoing monitoring and assessment of quality, financial improvement, and patient satisfaction. The hospital also participated in a community engagement project funded by HRSA’s Delta States Rural Development Network Grant Program
. The goal was to develop a continuum of services using a collaborative network of providers, and to engage rural community stakeholders in the process. The hospital participated with Jefferson Comprehensive Health Center in Fayette, MS, in community activities that focused on disease prevention services. Although the program was not self-sustaining, it prompted communities to think like community care organizations and to organize services more rationally. What national trends are facilitating the development of a continuum of care?
Hospitals are moving into a new era focusing on preventive services and cost reduction. Accountable care organizations, the National Partnership for Patients
, and the IHI Triple Aim Initiative
are challenging hospitals to take care of patients after they are discharged from the hospital, and to give more attention to population health. Rural hospitals can act as catalysts in their communities by defining their populations, conducting health surveys, and developing appropriate services based on community resources. As payers of health care inevitably move from volume-based to value-based methods of reimbursement, these considerations will become paramount.
Who would coordinate care across the continuum?
A community care organization (CCO) is a good model for managing patient care and preventing unnecessary hospitalizations. A CCO acts as a third party that coordinates health care services among providers such as primary care physicians, hospitals, behavioral health professionals, and dentists. CCOs can be local, community-based organizations or statewide organizations with community-based participation in their governance, or a combination of the two. The goal is to deploy resources to patients and track each patient’s care across the continuum. For example, a CCO could purchase a home monitoring device for a patient with type 2 diabetes, who would send glucose data to a database. A nurse who notices a spike in the patient’s glucose level can respond by calling the patient. The Rural Health Initiative , a nonprofit organization in Wisconsin, sent nurses to farms to conduct health screenings, make referrals as needed, and review occupational hazards. Can you comment on the program’s approach?
The initiative is a good example of a CCO that identified a population with health problems and developed a creative solution. The nurses encouraged healthy behaviors that can prevent or reduce the severity of chronic diseases and the need for emergency department visits. The free visits by the nurses were a key factor in the program’s success, because many farmers postponed medical care because they were uninsured or had high-deductible plans that required out-of-pocket payments for office visits. How unique was the nurses’ review of occupational hazards on the farms?
It is not uncommon for health professionals to review farm safety. The National Rural Health Association participates in AgriSafe
, an occupational health program that uses a network of health professionals to monitor farm safety and farm-related injuries and design programs to prevent those injuries.
Do you think that the Rural Health Initiative could work in other rural areas?
Yes. This is a superb model of care that will work in communities that deploy resources efficiently and allow nurses to provide preventive services and refer patients to physicians, nurse practitioners, or physician assistants when problems are uncovered during routine assessment.
What concerns are you hearing from members of the National Rural Health Association?
Their priority is to maintain financial stability so they can continue to provide desperately needed services in rural areas. Federal budget constraints and other economic pressures are jeopardizing the ability of hospitals, federally qualified health centers, rural health clinics, and traditional fee-for-service (Part B) clinics to provide services.
Several public policy issues are contributing to the financial uncertainty of our members. Several provisions allowing rural hospitals to operate under the Medicare Prospective Payment System (PPS) have expired. In addition, the moratorium on the implementation of Medicare’s Sustainable Growth Rate (SGR) will expire at the end of 2012. If Congress doesn’t extend the moratorium, physicians could lose an estimated 30 percent of their current fee schedule payments. If automatic spending cuts mandated by the 2011 Budget Control Act are implemented January 2013, Medicare reimbursement to rural providers will be reduced by 2 percent.
Members are also concerned about the rural health workforce and the need to deploy a sufficient number of trained professionals in rural communities. HRSA’s Bureau of Health Professions has designated several rural areas as health professional shortage areas involving primary care, dental, or mental health providers. Through its National Health Services Corps
, HRSA repays medical student loans for health professionals who are willing to work for 3 years in a medically underserved area. The National Health Services Corps also provides scholarships to medical students who are willing to serve in underserved communities. However, these efforts have only produced a 10 percent increase in physicians working in rural areas. Medical school graduates often complain that in rural practice they would work longer hours and provide more on-call coverage than in urban settings.
Rural hospitals are behind urban hospitals in implementing health information technology. I estimate that up to 40 percent of small rural hospitals will not adopt electronic health records and achieve Meaningful Use. The Centers for Medicare & Medicaid Services will penalize eligible professionals and eligible hospitals who have not achieved Meaningful Use by 2015 by reducing their Medicare payments by 1 percent.
What efforts are underway to increase the rural health workforce?
Researchers have found that medical students who have experience serving rural communities are more likely to return and practice there. This includes physicians born or raised in rural communities and medical students and residents who were trained in rural communities.
Medical schools have started to identify and recruit undergraduates from rural communities. For example, the University of Kansas has established a medical school branch in rural Salina, KS. HRSA’s Office of Rural Health Policy is considering the creation of rural residency training tracks that will interface with rural communities.
Rural hospitals are also using the State Department’s J1 visa waiver to recruit foreign medical graduates (FMGs) to work in rural areas. In exchange for a 3-year commitment to work in a health professional shortage area, FMGs who receive a J1 visa waiver are not required to return to their home countries for 6 months after they finish their training before returning to the United States. After meeting their commitment, FMGs are eligible to work towards a permanent visa and eventually apply for citizenship. In 1998, we recruited a doctor from Uruguay to work at Field Memorial Community Hospital for 4 years using the J1 visa waiver program. Mississippi requires a fourth year of service in addition to the Federal 3-year requirement. When I left the hospital in 2007, the doctor was still practicing in a rural community. About Brock Slabach
Mr. Slabach is the Senior Vice President for Member Services at the National Rural Health Association. He joined the NRHA in 2008 and has administrative responsibility for all areas of member services, including membership, communications, and meetings/exhibitions. Mr. Slabach, who was a rural hospital administrator for more than 21 years, has served on the board of the National Rural Health Association and the regional policy board of the American Hospital Association, as well as many regional and State boards involving rural health.Disclosure Statement:
Mr. Slabach reported having no financial interests or business/professional affiliations relevant to the work described in this article.