Twenty-five percent of the total population in the United States are living in rural areas and compared with urban Americans and healthcare facilities in rural areas generally serve low-income, the elderly, and individuals who are less informed and armed with less knowledge concerning health care prevention measures. Moreover, rural individuals accessing healthcare in rural facilities face barriers to healthcare such as fewer doctors, hospitals and health resources in generation and face difficulty in accessing health services.
Statement of the problem
Hospital closures and other market changes have adversely affected rural areas, leaving State and Federal policymakers, and others concerned about access to health care in rural America. Considerable changes in the health care delivery system over the past decade have intensified the need for new approaches to health care in rural areas. Managed care organizations, for example, may not be developed easily in rural areas, partly because of low population density.
Research Questions
The primary research question in this study is the question of whether rural health care facilities overcome the ongoing challenges to provide quality medical care to their communities.
Rationale of the Research
The rationale of this research is based upon the following facts:
1.) Rural Healthcare and Barriers to Accessing Care: Many small rural hospitals have closed, while other health care supply of primary care physicians and other health care provider facilities are in financial straits. Unavailability of resources and transportation problems are barriers to access for rural populations.
2.). The supply of primary care practitioners and other health care providers in rural areas is decreasing. Some are leaving rural areas to join managed care organizations elsewhere.
3.) Barriers to Health Promotion and Disease Prevention. Goals for improving the Nation’s health over the next decade can be achieved only if rural populations are included in efforts to remove barriers to access and use of clinical preventive services.
4.) Barriers Related to Lack in Health Care Technology. Technologies including telemedicine offer promise of improved access to health care, but their most efficient and effective applications need further evaluation.
5.) Organizational Barriers of Service Provision to Vulnerable Rural Populations: Low population density in rural areas makes it inherently difficult to deliver services that target persons with special health needs. Groups at particular risk include: the elderly; the poor; people with HIV or AIDS; the homeless; mothers, children, and adolescents; racial or ethnic minorities; and persons with disabilities.
6.) Consumer choice and the rural hospital. Factors that drive changes in rural hospitals have a critical effect on consumer choice and access.
Significance of the Study
This study is significant in that individuals in rural areas are likely to continue to receive less healthcare as well as less effective healthcare if rural healthcare does not gain necessary knowledge, informed by research study as to what should be done to better deliver health care services to those in rural areas. This study is of significance to several groups including patients depending on rural healthcare services, the families of these patients, the rural communities at large and the insurance companies who provide insurance coverage for individuals in rural areas.
Methodology
The methodology of the proposed research is one of a qualitative nature in which data will be gathered through survey/questionnaires of individuals, physicians and business in the rural community at focus in the research in order to asses whether the needs of the community in terms of healthcare provision are being met. Data analysis will be both qualitative and quantitative in nature. After having administered and compiled data from the survey/questionnaires focus groups will be scheduled to gain further insight into the unmet needs of the community in health care services in needs assessment focus group discussions.
Literature Review
The California Healthcare Foundation, in its “Rural Health Care Delivery: Connecting Communities through Technology” report of December 2002 states : Challenges facing rural health care include scarcity of local medical resources and distance between patients, physicians and facilities.” (Turisco and Metzger, 2002) Furthermore, it is related in this report that there are insufficient numbers of primary care practitioners in rural areas. (Turisco and Metzger, 2002; paraphrased) In the instance where a patient is forced to travel from home to another area for accessing health care services resulting is a “range of difficulties” including: (1) time away from work; (2) additional expenses; and (3) the complications of coordinating care in different locales.” (Turisco and Metzger, 2002) This increases the chance the patient information will come up missing or incomplete and as well may result in care that is “delayed or fragmented.” (Turisco and Metzger, 2002) The physicians in rural areas as well as other health care providers experience negative impacts due to the low number of health care practitioners in rural areas as well as in the distance factor, which results in “limitations on productivity, communication and ongoing education.” (Turisco and Metzger, 2002) Research notes that there is more difficulty for the rural providers in communication with other providers of health care. There is much less in the way of opportunities to attend conferences and training due to the requirements of travel, which limits access to medical knowledge and research work. Lower efficiency results due to travel time involved in visiting patients in hospitals and nursing homes as well as in “…fewer face-to-face visits, and more time on the telephone with other providers and with patients.” (Turisco and Metzger, 2002)
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In a recent report relating to healthcare in rural India stated is that: “The number of patients is increasing exponentially each year, putting enormous pressure on healthcare delivery systems worldwide. Hospitals and specialists are concentrated in cities and are inaccessible to the rural poor.” (Tata Consultancy Services and Microsoft Corporation, nd) This report relates that several physicians in India along with Tata Consultancy Services (TCS) and the largest IT company in India collaborated in the creation of WebHealthCentre.com which is stated to be: “…a comprehensive healthcare portal like no other.” (Tata Consultancy Services and Microsoft Corporation, nd) Offered are “abundant health-related reference material, online medical consultation, online appointment scheduling, and online lab results for physicians.” (Tata Consultancy Services and Microsoft Corporation, nd) The WebHealthCentre.com website was stated to have been created with the Microsoft.NET Framework, Microsoft Windows 2000 Advanced Server, Web services and Microsoft SQL Server 2000. The requirements set out by the physicians in rural areas included:
Ease of use by a wide cross section of people;
Cutting-edge yet cost-effective technologies;
Simple log on by many different users and easy assignment of user rights;
Tight security to keep medical records confidential;
Structured data capture for future data mining;
Scalable to handle millions of users; and
Extensible to accommodate audio and video interface. (Tata Consultancy Services and Microsoft Corporation, nd)
Benefits resulting from implementation of this healthcare service delivery Network include:
Improved access to healthcare;
Better use of doctors’ time;
Rapid development, usability;
Scalable to millions of patients; and
Extensible to new technologies. (Tata Consultancy Services and Microsoft Corporation, nd)
Key features of WebHealthCentre.com are stated to include the following:
Online, real-time medical consultation with remote healthcare professionals.
PC or mobile-phone access to regional directories for hospitals, specialists, blood banks, medical appliance suppliers, and welfare agencies.
An online appointment scheduler that enables patients to make appointments with participating physicians.
An online lab report tool that helps diagnostic centers automate the process of uploading lab reports to the Web.
Access to test results through mobile devices.
Online access to electronic health records.
Medical image upload services.
Online sonogram viewing.
A medical student resource center.
Healthcare job listings.
Online shopping for healthcare supplies. (Tata Consultancy Services and Microsoft Corporation, nd)
The Agency for Healthcare Research and Quality (AHRQ) held an expert panel meeting to provide guidance on its new health information technology on July 23-24 2003. The focus of AHRQ is the implementation and evaluation of technologies, which have been shown to be effective in small and rural communities. Secondly, the AHRQ has set its’ focus upon supporting advancement in the HIT field through implementation and evaluation support for innovation in technologies for use in diverse health care settings.” (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) The Meeting Summary reports that “two general themes emerged from the discussion” which are those of: (1) Bringing people together; and (2) Providing technical assistance. (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) Activities recommended for achieving their goals are those as follows:
Support demonstration projects that involve HIT implementation and will lead to the creation of learning networks comprised of providers from various types of rural health care organizations.
Create learning communities that span geography; collect and analyze the outcomes associated with participation.
Once factors that facilitate learning communities and HIT implementation have been identified, engage CMS and other purchasers to define an appropriate reimbursement strategy.
Incorporate evidence-based primary care guidelines with rural relevance into technological templates. Clinicians are likely to accept clinical guidelines offered by the Federal Government at no cost.
Support local capacity development for HIT, including barrier analysis, education and other activities.
Provide sustained technical assistance (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003)
Evaluation of the process in rural and small communities includes: (1) scope of the project; (2) goals; (3) critical success factors; and (4) technical assistance.” (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) Community grants have been focused on the provision of ‘personal digital assistant (PDA) systems in assisting with the decision support role. The initiative is stated to include: (1) development of toolkits; (2) leveraging known tools; (3) developing capacity; and (4) disseminating best practices. (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003)
Ormond, Wallin, and Goldenson report in the work entitled: “Supporting the Rural Health Care Safety Net” (2000) state: “The policy – and market-driven changes in the health care sector taking place across country are not confined to metropolitan areas. Rural communities are experiencing changes impelled by many of the same forces that are affecting urban areas.” However, due to the demographical differences and other facts existent only in rural life the health care system can be differentiated from those in urban areas in various ways. According to Ormond, Wallin, and Goldenson, it is that difference that highlights the importance of giving consideration “explicitly” to the “impact of competitive forces and public policy developments on rural health care systems and the patients and communities they serve.” (2000) The changes that are occurring in the health care sectors are resulting in many providers being threatened in both rural and urban areas however, health care provider failures in a rural area is likely to a much greater impact as compared to health care provider failure in urban areas. “Because alternative sources of care in the community or within reasonable proximity are scarce, each provider likely plays a critical part in maintaining access to health care in the community. For this reason, in most rural communities all providers should be considered part of the health care safety net – if not directly through their care for vulnerable populations, then indirectly through their contribution to the stability of the community’s health care infrastructure.” (Ormond, Wallin, and Goldenson, 2000) The study reported by Ormond, Wallin and Goldenson is based on case studies in rural communities in the states of Alabama, Minnesota, Mississippi, Texas, and Washington selected in representation of “…a broad range of pressures facing rural providers.” (2000) A debate is stated to exist in terms of ‘limited services’ models for hospitals who fear that more insured patients or those who are wealthier will be reluctant to use this facilities. Challenges to full-service facilities in rural areas include “recruitment and retention of health care professionals and of ensuring the financial viability of local hospitals.” (Ormond, Wallin, and Goldenson, 2000) Also related is the fact that health care providers are very reluctant “to locate in communities without a hospital…” while simultaneously when there is not a strong physician practice in an area, hospitals “find it difficult to attract patients.” (Ormond, Wallin, and Goldenson, 2000) Constraints upon a rural hospital of either a full or limited service hospital include its rural location. “The population required to support given service, such as a hospital or particular physician practice is spread over a much greater area. Low volume can mean high average costs, a factor that rural health officials feel is not always taken into account in reimbursement.” (Ormond, Wallin, and Goldenson, 2000) Demographical and socioeconomic differences in rural areas places demands upon health care system providers in terms of the need for treatment for more elderly people which are those “more likely to have chronic health care needs.” (Ormond, Wallin, and Goldenson, 2000) Furthermore, due to the lack of access to mass and major media in rural areas, the individuals residing in these areas are much less likely than those in urban areas to be aware of the availability of health care and public programs. Insurance coverage in rural areas is also a factor because rural areas have higher self-employment than urban areas, and specifically relating to farming operations making it very likely the employer-sponsored insurance in minimal. Of those who are insured in rural areas, it is likely that many of these are under insured with high premiums and low benefits as compared to those insured in urban areas. “The social structure of rural communities may make the stigma attached to participation in public programs greater, particularly in the case of Medicaid.” (Ormond, Wallin, and Goldenson, 2000)
The range of services offered in rural hospitals is limited by the size of the area it serves as compared to the population within that area. Many of the hospitals in the study reported by Ormond, Wallin and Goldenson “relied on a local primary care physician for core services…but augmented his or her capabilities by making arrangements with other, nonlocal providers. The core services each hospital offers depend primarily on the capabilities of their physicians.” (2000) In order that a hospital be able to support a visiting specialist program it is a requirement that the hospital have the staff that is appropriate and qualified to assist “in the various specialties and physicians be able to monitor recovery, as well as the necessary space and equipment for procedures.” (Ormond, Wallin, and Goldenson, 2000) The rural hospital is not in the position to provision all the services needed within the community it serves and this makes a requirement of having a referral system of a reliable nature. Stated to be a “mainstay of the safety net in rural areas” just as is the case in urban areas is the community health center.” (Ormond, Wallin, and Goldenson, 2000) Another important provider of care in rural areas is the local health department. Another problem in rural areas is transportation for patients in that in rural areas there is oftentimes no public transportation. Internal strategies reported to be used by rural health care providers are inclusive of: “…increasing the stock of physicians and other health professionals, tailoring facilities and services to the needs of the community, and expanding, downsizing, or diversifying as needed.” (Ormond, Wallin, and Goldenson, 2000) Other stated strategies are inclusive of “cooperation among rural providers and developing links with urban providers through mergers, management contracts, and joint projects.” (Ormond, Wallin, and Goldenson, 2000) Initiatives have been developed for recruitment of physicians and other health professionals who are “familiar with life and medical practice in rural areas”. (Ormond, Wallin, and Goldenson, 2000) Those who are recruited for practice in rural areas are likely to remain after recruitment. All five states in this study report that they provide support: “…for the development of rural health professionals by requiring, facilitating, or funding training opportunities in rural areas so that students become familiar with the particular demands and satisfactions of rural medical practice, or by funding education either through scholarships for aspiring providers from rural areas or through loan forgiveness for providers agreeing to locate in rural areas.” (Ormond, Wallin, and Goldenson, 2000) Only the state of Washing is stated by this report to have a formal residency program. Service expansion is reported to be utilized by rural hospitals and clinics for enabling them in meeting a “broader range of health care needs in their communities.” (Ormond, Wallin, and Goldenson, 2000) Areas of expansion included: (1) the construction or renovation of a physician plant; (2) the addition of new medical services; and (3) diversification beyond traditional acute services.” (Ormond, Wallin, and Goldenson, 2000) In fact, “growth and expansion” as compared to downsizing “appeared to be the more common, and seemingly more successful, route.” (Ormond, Wallin, and Goldenson, 2000) Expansion is also noted in outpatient services offered by hospitals and clinics. Cooperative efforts among rural providers as these health care providers collaborate in order to ensure the capability of serving their communities will continue is noted in this report stating that “cooperation with other rural providers is also a mainstay of rural hospitals’ strategy to ward off encroachment by urban health care systems.” (Ormond, Wallin, and Goldenson, 2000)
The work of Rygh and Hjortdahl entitled: “Continuous and Integrated Health Care Services in Rural Areas: A Literature Study” makes a review of literature that examines possible methods of improving healthcare services in rural areas. Stated by these authors is the fact that: “Healthcare providers in rural areas face challenges in providing coherent and integrated services.” (Rygh and Hjortdahl, 2007) This study proposes a need for “greatly flexibility in traditional professional roles and responsibilities, such as nurse practitioners of community pharmacists managing common conditions.” (Rygh and Hjortdahl, 2007) Further stated is that the “substitution of health personnel with lay health workers or paraprofessionals often in combination with interdisciplinary teams, is among measures proposed to alleviate staff shortage and overcome cultural barriers.” (Rygh and Hjortdahl, 2007) Other findings of this study include that for those working in rural areas called for is “flexibility of roles and responsibilities, delegation of tasks, and cultural adjustments by the healthcare practitioners.” (Rygh and Hjortdahl, 2007) This study states that rural case management is greatly dependent upon a locally based case manager and that the highest ranked skills for rural case managers are: “the ability to be creative in the coordination of resources, multidimensional nursing skills, excellent communication skills, high-caliber computer skills and excellent driving skills.” (Rygh and Hjortdahl, 2007) Stated is that: “Case management in a rural environment requires a much broader and generalist knowledge base, it covers all levels of prevention and transverses all age groups. Rural case management is a distinct specialty area of practice, with a distinct knowledge base and skills level, and nurses should be prepared at the advanced practice level.” (Rygh and Hjortdahl, 2007) This study further relates that evidence exists of the success of: “…collaboration at the interface between primary and secondary sectors may improve access, continuity of care and the quality of service delivery in rural areas.” (Rygh and Hjortdahl, 2007) This study defines telemedicine as “Medicine practiced at a distance” therefore encompassing “diagnosis, treatment and medical education.” (Rygh and Hjortdahl, 2007) The state of Maine is stated to have a “well-functioning telemedicine” services system using telemedicine in a “broad array of interactive videoconferencing applications, including mental health and psychiatry, diabetes management, primary care, pediatrics, genetics and dermatology.” (Rygh and Hjortdahl, 2007) According to this review telemedicine has the potential to be a tool of a valuable nature in achievement of healthcare access in rural areas although the cost-effectiveness of telemedicine has yet to be documented. (Rygh and Hjortdahl, 2007; paraphrased)
The work entitled: “Providing Hospice and Palliative Care in Rural Frontier Areas” states that the National Rural Health Association (NRHA) “…believes that all Americans are entitled to an equitable level of health and well-being established through health care services, regardless of where they live. An important but often overlooked aspect of health and well-being is assurance of appropriate care and support when people are experiencing chronic, progressive illness and/or approaching the end of their lives.” (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005) In order to study this area of service provision the method for defining and assessing needs is stated to be through a needs assessment to include recruitment of a group of members of the community for participation in identifying the needs and creating a method of assessing results. Data is gained from various sources an may include the following:
Demographics of the community;
disease statistics (county health department and state vital statistics division);
List of health care organizations/agencies that provide related services;
A definition of unmet or under-met service needs;
Identification of the unique characteristics that differentiate palliative care and/or hospice services from other services in the community;
Vital statistics, including cause of death, age at death and location of death;
Loss data;
Community residents’ satisfaction with current hospice and/or palliative care services, obtained through interviews; and
Community members preferences about hospice and palliative care. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005)
Recruitment of individuals in this type study are stated to include:
Community residents;
Representatives from other community service providers such as a librarian, store owners, chiropractor or dentist;
The president of a fraternal organization, the Rotary Club, another service club or the Chamber of Commerce;
Pastors or leaders of local faith communities;
Someone involved with the local food pantry or other emergency relief organization;
An influential local business person such as the feed store owner;
A county extension staff person active in community events and volunteer work;
Someone who organizes the town’s annual parade, festival or other special events;
Someone who works on civic clean-up and beautification; and
Representatives from other small organizations and entities in each of the countries the provider serves. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005)
This study speaks of the creation of “capacity building” in expansion of the service provision and in meeting unmet or undermet needs in rural areas. Capacity building strategies include education and training of staff for skills development needed in broadening the services provided. Community education in establishing a broader understanding of what services and opportunities are available for care is also stated to be a strategy for capacity building as service utilization will be increased as well. Capacity building strategies as well are stated to include outreach strategies for development and sustaining partnerships and collaborations as well as in sustaining and supporting growth of expectations related to hospice and palliative care services. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005; paraphrased) Stated as practical examples of the training and education of staff and the philosophy used by rural providers in the creation and sustaining of program capacity are those as follows:
Development and adoption of service performance parameters;
Education of the board and/or local leaders in national trends such as palliative care, open access, managed care, chronic care management and the nursing shortage;
Establishment of an ethics committee comprised of community members, hospital representatives, palliative care and hospice program staff, and church members to review specific ethical considerations/cases and to address projects such as advance care planning and advance directives;
Importing best practices in enhancing service definition and outreach;
Offering support for local and offsite continuing staff education an subsidies for staff to pursue relevant credentials;
Offering support for local and offsite continuing staff education and subsidies for staff to pursue relevant credentials;
Appointing full-time or substantially part-time physicians and advanced practice nurses as soon as feasible and involving these individuals in professional and community outreach;
Establishment of bridge programs and/or extended palliative home care;
Improved/extended utilization of volunteers in meeting caregiving requirements. For hospices, this may include volunteer participation in providing continuous care as allowed by regulations; and
As needed, referrals to other organizations. (Providing Hospice and Palliative Care in Rural Frontier Areas, 2005)
The work entitled: “Planting the Seeds for Improving Rural Health Care” relates the ‘Chronic Care Model’ which portrays the “essential involvement of the community, the design and function of the health care system and effective interaction between patients/families and their team of caregivers, producing optimal clinical outcomes.” (2005) The following figure labeled figure 1 shows the ‘Chronic Care Model’:
Figure 1
Chronic Care Model
Source: Planting the Seeds for Improving Rural Health Care (2005)
Components of this program include the following:
Use of a rapid-cycle method for implementing quality improvements;
Use of a standard set of changes for teams to implement;
Sharing a vision of the ideal system of care developed by clinical experts;
Monthly reporting of process and outcome measurements;
Three ‘learning sessions’;
A final ‘national forum’ during which teams attend sessions with expert faculty to share progress, best practices, and lessons learned. (Planting the Seeds for Improving Rural Health Care, 2005)
The work entitled: “Practical Tips and Information Resources for Developing Collaborative Relationships Between Rural Community Health Centers (CHCs) and Rural Hospitals” asks the question of “Why Collaborate?” and answers this question by stating that collaboration strengthens community health infrastructure; improves efficiency levels; and provides joint economic advantage. Collaboration is stated to be a process “through which parties who see different aspects of a problem can explore constructively their differences and search for (and implement) solutions that go beyond their limited vision of what is possible.” (Taylor-Powell, et al., 1998) There are five levels of relationships in building collaborative interorgnaizational relationships around health issues in a rural community which are: (1) networking; (2) cooperating; (3) coordination; (4) coalitions; and (5) collaboration. These five levels of relationships according to purpose, structure and process are shown in the following ‘Community Linkages- Choices and Decisions’ matrix.
Figure 2
Community Linkages – Choices and Decisions
Source: Practical Tips and Information Resources for Developing Collaborative Relationships Between Rural Community Health Centers (CHCs) and Rural Hospitals (2005)
The following are examples of the ways that CHCs and hospital partnerships are able to collaborate. These initiatives may also be used by any rural hospital, CHC or primary care provider:
Joint training, recruitment, human resources, and clinical direction;
Shared case managers;
Working together on ‘disease collaboratives’;
Shared medical laboratory;
Partnership establishment enables organizations in qualifying for funding through grants for which they would not otherwise have been eligible to receive; and
Shared electronic patient medical records systems; (Practical Tips and Information Resources for Developing Collaborative Relationships Between Rural Community Health Centers (CHCs) and Rural Hospitals (2005)
This study states findings that a number of activities specific to an individual site have the potential for wider replication. Those activities are stated to be as follows:
Local foundations can support rural health-related activities; namely physician recruitment and retention.
Collaboration of CHCs, hospitals, nursing homes, and assisted care facilities in the same location can serve a large rural area and make efficient use of scarce resources; namely physicians.
Affiliation with a large regional hospital can be a positive experience that is supportive of community-based services.
Collaboration may be a vehicle for expanding benefits to CHC patients; namely as a result of the collaborative, a hospital utilizes the CHC’s sliding fee scale for laboratory services provided to CHC patients.
Case management for discharge planning and care coordination between the CHC, home health care agency, and the hospital can improve patient care.
Electronic patient medical records systems that integrated the CHC and the hospital medical records are the key to future collaboration and the development of a comprehensive model of a health care system for the rural community. (Practical Tips and Information Resources for Developing Collaborative Relationships Between Rural Community Health Centers (CHCs) and Rural Hospitals (2005)
There are important factors identified for organizing a successful collaboration which include: (1)
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