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Quality Through Collaboration: The Future of Rural Health C The Rural Health Care Delivery System The quality of the rural health care delivery system is determined by the availability of providers and health care facilities to rural residents and the ability of those providers and organizations to give care that is needed and effective in generating positive health outcomes (Gregg and Moscovice, 2003; Rosenblatt, 2002). The availability of rural providers can vary significantly from one county to another, and many rural communities struggle to provide even basic health care services to their population. Typically, the smaller, poorer, and more isolated the rural community, the more difficult it is to ensure that basic health care needs are met (Rosenblatt, 2002). In most rural communities, the health care delivery system is a patchwork of primary care providers, clinics, hospitals, and other facilities that function through the private sector either independently in private practice or as part of a network. However, there are fewer health care organizations and professionals of all kinds in rural areas, and less choice and competition among them. Local safety net providers deliver a sizable amount of care to the uninsured, Medicaid enrollees, and other vulnerable populations (IOM, 2000). This appendix provides a brief overview of the rural health care systems for primary care, emergency medical services (EMS), hospital care, long-term care, mental health and substance abuse care, oral health care, and public health.
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Quality Through Collaboration: The Future of Rural Health PRIMARY CARE Access to primary care is the top-ranking health priority for rural areas (Gamm et al., 2003). Across the health sector, primary care is highly valued as the key mechanism for meeting the majority of health care needs of most individuals. Primary care practices provide essential care for a wide range of health problems; guide patients through the health system, including referrals; foster an ongoing relationship between clinicians and patients (and their families); support disease prevention, management, and health promotion; and build bridges to the local community (IOM, 1996). Shortages in the supply of primary care providers directly affect not only the health status of individuals, but also the rest of the providers in the delivery system. In rural areas, as in urban, the bulk of health care services are provided in primary care practice settings in the local community, such as small private practices, community health centers, and rural health clinics. The main differences between rural and urban providers are the health professionals engaged in primary care and the scope of practice; the actual structure of urban and rural practice settings tends to be similar. Primary Care Clinicians Rural primary care providers are more likely than urban to be family physicians or generalists with a broad scope of practice, and a greater proportion are more likely to be midlevel professionals (e.g., nurse practitioners, physician assistants). The scope of practice for rural physicians can include primary care subspecialties such as pediatrics, obstetrics and gynecology, gerontology, internal medicine, and general surgery for certain procedures, as well as the traditional primary care services for episodic care, preventive care, and chronic disease management. Because certain specialty services are unavailable in rural areas, many rural physicians also provide services characteristic of specialty practice, such as intensive care (51.4 percent), emergency department care (58 percent), and specialist procedures (e.g., sigmoidoscopy [29 percent]) (Phillips and Green, 2002). Some midlevel practitioners provide services in specialist areas as well. Following is a summary of the presence of these providers in rural practices. As this discussion is limited to clinicians having the greatest contact with patients, pharmacists also are included, but allied health professionals (e.g., laboratory technicians and radiologists) are not. Providers of emergency care, mental health and substance abuse services, and dental care are
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Quality Through Collaboration: The Future of Rural Health discussed in their respective sections. A more thorough discussion of the rural health workforce is provided in Chapter 4. Physicians Overall, rural areas have a lower complement of physicians than do urban areas. In 2000, there were 119 physicians (including both generalists and specialists) per 100,000 population in rural areas, compared with 225 physicians per 100,000 population in urban areas (Larson et al., 2003). Restricting the analysis to generalist physicians may be a better proxy for physicians providing primary care. Using county-level data, the gap between rural and urban is reduced, with rural areas having about 57 generalist physicians per 100,000 population, compared with 78 generalists per 100,000 population in urban areas. Statewide estimates tend to gloss over the wide variability in provider shortages and surpluses at the individual county level, however. For example, Wisconsin’s statewide average of 68 primary physicians per 100,000 population (2000 data) is higher than the national average of 59 per 100,000, but the state’s median of county averages is 31 physicians per 100,000 population. This indicates major differences in the distribution of physicians among Wisconsin counties, with many falling far below the statewide and national averages (WHA, 2004). This effect is rather common. A 23 state study confirmed that there were about 35.5 physicians per 100,000 in the most rural areas (Rosenthal et al. 2003). Overall, in 1999, 91 percent of towns with 2,500 to 5,000 population in 23 states had a general practitioner or family physician—a gain of 5 percentage points over 1979 (Rosenthal et al. 2003). Osteopathic physicians also have a presence in rural areas at 5 percent. Larsen and colleagues (2003) found that osteopaths are more likely to practice as generalists or to become family physicians (46 percent) than are allopathic physicians (11 percent) and more likely to choose to practice in rural areas (18 versus 11.5 percent). Specialist physicians in rural areas have a relatively low presence compared to their urban counterparts. A study by Baldwin et al. (1999) found that only 6.2 percent of such physicians are located in rural areas. Specifically, 7.9 percent of gastroenterologists, 17.6 percent for general surgeons, 10.8 percent of obstetrics/gynecologists, 12.7 percent of opthalmologists, 12.9 percent of orthopedic surgeons, 13.3 percent of otolaryngologists, and 11 percent of urologists are located in rural areas. Rosenthal et al. (2003) reviewed the growth of specialists in rural communities over a 20-year period, finding sizable growth in the presence of many specialties (see Table C-1). Selected specialties—emergency medicine (19.2 percent) and psychia-
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Quality Through Collaboration: The Future of Rural Health TABLE C-1 Percentage of Communities with Nonfederal Physician Specialty Services 1979–1999 Specialty Number of Physicians Population in Thousands 2,500–4,999 5,000–9,999 10,000–19,999 General and family practice 1979 11,869 86 96 99 1999 21,919 91 96 99 Internal medicine 1979 9,467 23 52 84 1999 20,654 41 69 93 General surgery 1979 6,071 44 77 96 1999 5,275 38 63 88 Obstetrics and gynecology 1979 3,978 15 35 77 1999 7,092 15 41 82 Psychiatry 1979 3,203 9 17 40 1999 6,155 9 26 53 Pediatrics 1979 3,429 12 25 68 1999 9,356 16 43 84 Radiology 1979 3,042 9 30 73 1999 4,909 13 36 68 Anesthesiology 1979 2,303 11 19 40 1999 5,914 7 20 64 Orthopedic surgery 1979 2,409 7 17 47 1999 3,927 7 28 69 Opthalmology 1979 2,147 4 14 62 1999 3,328 3 18 60 Pathology 1979 1,840 4 15 50 1999 2,747 4 13 49 Urology 1979 1,340 2 10 47 1999 1,879 2 13 57 Otolaryngology 1979 1,127 2 6 29 1999 1,685 1 10 46 Dermatology 1979 795 1 3 15 1999 1,475 2 7 33 Neurology 1979 724 1 4 13 1999 1,901 1 7 28 SOURCE: Rosenthal et al., 2003.
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Quality Through Collaboration: The Future of Rural Health try (4.8 percent)—are discussed in more detail in their respective sections later in this appendix. Nurse Practitioners A good deal of primary care also is provided by nurse practioners. Nurse practioner training programs began as certificate-level training for registered nurses, but master’s degree training has grown significantly (Berlin et al., 1999). In 2000, there were over 58,000 employed nurse practioners, 22 percent of whom practiced in rural areas (Hooker, 2002). Approximately 85 percent of nurse practioners practice in primary care (Hooker, 2002). Certification requirements established by the American Nurse Credentialing Center ensure that the nurse practioner workforce meets certain standards. However, there is no national dataset comparable to the American Medical Association Physician Masterfile to monitor this workforce in terms of supply, credentials, and where and how they are deployed (Phillips et al., 2002). Physician Assistants Physician assistants are health care professionals licensed to practice with physician supervision (AAPA, 2003). In 2000, there were about 45,000 practicing physician assistants, 23 percent practicing in rural areas. Unlike nurse practioners, who for the most part practice in primary care, physician assistants are equally divided between primary and specialty care (usually hospital-based). For this group of professionals, there is little overall difference in statewide average staffing levels between rural (13 per 100,000 population) and urban counties (14 per 100,000 population) (Larson et al., 2003). Rural areas with relatively low physician assistant staffing ratios are located in the southeastern states (except for West Virginia, with double the average ratio), some of the northeastern states, and a few of the western states. Pharmacists In 2000, 196,000 pharmacists were active in the United States (Hart et al., 2002; HRSA, 2000). About 60 percent of pharmacists work in retail or community pharmacies; the remainder work in institutional settings, such as hospitals and clinics. Although increases in the number of pharmacists have outpaced the rate of population growth, rural areas are experiencing supply
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Quality Through Collaboration: The Future of Rural Health problems. Comprehensive surveys of urban–rural pharmacist supplies are not available at this time. However, current vacancy rates of up to 18 percent have been noted for the Veterans Administration and the Indian Health Service alone (HRSA, 2000). Other major concerns among many rural pharmacists are the lack of relief coverage and the lack of round-the-clock service availability, particularly in high-demand areas such as those with a large population of elderly residents (Casey et al., 2001). Primary Care Settings Most primary care services in rural communities are provided in small private practice settings. According to the American Academy of Family Physicians, physicians practicing independently in groups of four or fewer provide over 70 percent of care throughout the country. Data have not been stratified for rural counties; however, survey data for family and general practice physicians, who constitute about half of physicians in rural areas, indicate that 23 percent practice solo, 10 percent in two-person partnerships, 39 percent in family practice groups of two or more, and 20 percent in multispecialty groups (Personal communication, G. Tolleson, June 2, 2004). More detailed information differentiating rural and urban physician office practices is needed to determine configurations that may be useful as a model for developing the rural health care delivery system. Some primary care is provided through community health centers and rural health clinics that may qualify through the Centers for Medicare and Medicaid Services for special federal funding programs if they meet certain criteria. In 2002, 428 of the 843 total community health centers were located in rural areas (LaLonde, 1975). Community health centers may qualify under Section 330 of the Public Health Service Act to receive federal grants covering the cost of primary care and support services (e.g., transportation, translation) to low-income people living in medically underserved areas (Bloom et al., 2001). Technical assistance provided through the Health Resources and Services Administration (HRSA) is focused on chronic care management, disease registries, and quality improvement. Sizable expansion of the community health centers program is planned in the next 5 years (BPHC, 2002). While rural health clinics do not receive federal grants, those that maintain a defined set of core services can receive Medicare and Medicaid cost-based reimbursement for care provided by physicians, nurse practitioners, physician assistants, nurse midwives, clinical psychologists, and clinical social workers. As of 2004, about 3,500 rural health clinics were in
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Quality Through Collaboration: The Future of Rural Health operation—many of these independent practice providers. Rural health clinics also are a highly valued safety net provider for rural communities, often delivering up to 45 percent of services provided for this purpose (Gale and Coburn, 2003). EMERGENCY MEDICAL SERVICES Emergency care encompasses a continuum of health services including prehospital medical services; emergency services provided at the hospital or health center; and the trauma system, which often serves as the network of coordinated care (Probst et al., 1999). Access to and the quality of emergency care, particularly EMS, is a major concern among state offices of rural health and has direct consequences for morbidity and mortality. Efforts to evaluate the quality, status, and utilization of emergency services in specific terms have been hampered by the overall lack of data and the lack of formalized reporting requirements in most states. Prehospital care is characterized by the availability of ambulance service, quick first-responder rates, and rapid transport times to hospital emergency rooms. Several studies have documented that first-responder rates and transport times are longer in rural areas (Gamm et al., 2003), and rural emergency patients are far more likely to die en route to the hospital than their urban counterparts (Morrisey et al., 1995). Rural EMS confront major challenges including sizable geographic distances between patients and trauma centers and fragmented prehospital transport services, which are usually coordinated more closely with public safety than with the local health care system. Nationwide data are not available, but some state-specific data and studies indicate that the level of training of emergency medical technicians (EMTs) in rural areas is lower than that in urban areas (Morrisey et al., 1995). There are four primary levels of training for emergency medical technicians: First responder—entry-level position for volunteer fire departments, police departments, search-and-rescue teams, and first responder units. EMT-basic—entry-level position in EMS ambulance providers that offer basic-level medical and trauma care and limited medications. EMT-intermediate—midlevel position in EMS that provides medications and establishes intravenous lines (IVs). EMT-paramedic—advanced-level position that provides numerous
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Quality Through Collaboration: The Future of Rural Health medications, IVs, advanced airway procedures, and advanced medical and trauma care. In many rural communities, EMTs are volunteers, and most are probably trained as first responders. EMT training is generally funded by local tax dollars. Few rural areas can afford a full-time paramedic. An EMT’s skill level is influenced by experience, especially in responding to serious, life-threatening conditions. This is another challenge for rural areas. One study found that rural counties averaged only about 3.3 ambulance runs per week, with 43 percent of runs including the provision of oxygen, one in five establishing an IV line, and only 1.5 percent involving cardiopulmonary resuscitation (Morrisey et al., 1995). Because of workforce constraints, nearly half of rural hospitals provide emergency care through nurse practitioners and physician assistants. A physician sees the patient concurrently in 50 percent of these emergency departments staffed by midlevel practitioners (one-third to one-fourth of patients) (Williams et al., 2001). It is not uncommon to staff shifts in emergency rooms of small rural hospitals with nurse practioners or physician assistants, with physicians on call for more complex cases. A 1999 survey of 940 short-term acute care hospitals with emergency departments (21 percent rural) found that the average number of physicians available to the emergency department was highest in academic medical centers (13.57) and lowest in rural hospitals (4.74). The vast majority of rural emergency physicians are neither residency trained nor board certified for emergency medicine (39 and 33 percent, respectively, versus 72 percent in both cases in urban hospitals) (Moorhead et al., 2002). In addition, rural physicians’ scope of practice entails multitasking and cross-functioning, as they often run outpatient primary care clinics, care for inpatients at their local hospital, serve a role in hospital administration, direct local EMS, and care for patients who present for emergency care (Williams et al., 2001). Other pressures that compromise the rural emergency care system have been identified and include the lack of or low level of pay for services, lack of universal access to 911 and radio “dead spots” from crowded frequencies, perceptions of increased personal liability, increased exposure to danger (biological, chemical, violence, critical incident stress) in providing EMS, the paucity of rural physicians trained to provide medical supervision of local EMS operations, equipment that tends to be old and dated, lack of leadership, and scarcity of resources to support EMS systems (OMB, 2000). These factors pose severe challenges for the provision of quality emergency
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Quality Through Collaboration: The Future of Rural Health TABLE C-2 Federal Allocations to States for Domestic Preparedness Fiscal Year 2002 Fiscal Year 2003 Fiscal Year 2003 Name of program State Domestic Preparedness Program State Homeland Security Grant Program I State Homeland Security Grant Program II Total allocation $315.7 million $566.3 million $1.3 million Total EMS allocation $11 million $21.1 million $18.3 million Average EMS allocation $250,526 $458,886 $542,649 Median EMS allocation $114,694 $226,467 $333,495 SOURCE: ODP, 2004. care, from first response through initial stabilization and subsequent treatment (OTA, 1989; Rawlinson and Crews, 2003). The lack of a national coordinated strategy or infrastructure for EMS has left most systems unprepared and fragmented. The majority of EMS systems are regulated by state health departments (71 percent) or other agencies (e.g., governor’s office, public safety department, EMS advisory council) (24 percent) according to figures from July 1989, yet fewer than 31 percent of states have a coordinated statewide EMS plan, and most operate in silos from the local level. The lack of funding has a significant impact on the current state of rural EMS systems. After initial sizable investments by the federal government beginning in 1966, funding for such systems essentially ended in 1981 (USDOT, 1998). Currently, new federal grant programs for domestic preparedness are supplying increased resources to states to enhance emergency responder capabilities (including EMS) and critical infrastructure that will assist local communities in addressing many of these problems (Mohr, 2003). All 50 states and territories have received three allocations, as outlined in Table C-2; however, states need to accelerate the allocation of funds to the local community. In addition, training for first responders is being provided through the National Domestic Preparedness Consortium, as well as other training partners. Areas of immediate improvement are also part of federal initiatives such as HRSA’s program to allocate up to $25 million in grants to rural areas for the purchase, placement, and training in the use of automated external
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Quality Through Collaboration: The Future of Rural Health defibrillators in rural communities (HRSA, 2003). Lasting improvement in the quality of EMS will require that new programs be designed with evidence-based standards and procedures, a systems approach to functions and operations, implementation of cutting-edge information and communications technology and telemedicine systems to supplement care, and clearly defined methods for measuring quality and outcomes. An IOM study on EMS and emergency room care is currently in progress, with a series of reports to be released in 2005–2006. HOSPITAL CARE In the majority of rural communities, the hospital is the central focus of health care delivery, often providing outpatient, home health, skilled nursing, and other long-term care in addition to inpatient care. Hospitals have had a major role in ensuring the provision of health services in rural areas where no other providers are available, and have been an essential part of the social and economic identity of the local community, often constituting the largest or second-largest employer in the area (Moscovice and Stensland, 2002). Statistics from the American Hospital Association’s (AHA) 2000 Annual Survey indicate that, of the total of 4,927 nonfederal, acute care community hospitals in the United States, 44 percent or 2,178 are located in rural counties. Over 70 percent of hospitals with 100 or fewer beds are located in rural areas (see Table C-3) (Colgan, 2002). TABLE C-3 Hospitals in Rural Areas, Year 2000 Hospitals by Bed Size Rural Urban Under 25 255 066 25–49 711 220 50–99 655 417 SOURCE: Colgan, 2002. The structure, function, and role of hospitals in the U.S. health care system have been changing rapidly and significantly. From the 1980s through the mid-1990s, about 1,072 hospitals were confronting serious financial difficulties and were forced to close, convert, or merge; of these, 438 were rural (Ricketts, 1999). Rather than close down, many rural hospitals converted to modified inpatient health care facilities and expanded outpatient services (Ricketts, 1999).
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Quality Through Collaboration: The Future of Rural Health Congress responded by establishing the Medicare Rural Hospital Flexibility Program in 1997 (MedPAC, 2004). The “Flex Program” supports critical access hospitals (CAHs) which are limited-service hospitals located in rural areas having up to 25 beds and providing 24-hour emergency care and short-stay (up to 96 hours) inpatient services (CMS, 2004). With the Flex Program, the number of CAHs has grown substantially—to 928 as of May 2004. Fully 90 percent of CAHs are located in medically underserved areas, where there are fewer residents per square mile and a higher proportion of those over age 65 (see Figure C-1) (Doeksen et al., 1997; FMT, 2004a; HRSA, 2004). More specifically, 42 percent are located in areas of <2,500 population, 28 percent in frontier areas. Although the average volume is relatively low at 4.6 patients per day, hospitals that converted in 1999 have been able to maintain modest profit margins. For example, at conversion, average total margins were negative 2.5 percent, then rose to positive 2.3 percent 1 year after conversion and to positive 3.7 percent 2 years after (Stensland et al., 2004). To expand their revenue base further, many CAHs are building networks with other provider groups and adding outpatient services (e.g., mammography, pharmacy, radiology, pathology, surgery, rehabilitation). Rural hospitals struggle, even more so than urban, to attract and maintain adequate numbers of nurse professionals. Rural counties lag behind urban in the number of full-time, hospital-based registered nurses, with rural counties having 213 registered nurses per 100,000 population as compared with 281 per 100,000 for urban counties (see Figure C-2). Rural hospitals also are more dependent upon various types of advance practice nurses, such as nurse anesthetists, who provide anesthesia services in about two-thirds of rural hospitals (AANA, 2004). Workforce supply is a key issue for many rural hospitals, discussed extensively in Chapter 4. LONG-TERM CARE Long-term care encompasses a diverse array of services provided over a sustained period of time to people of all ages with chronic conditions (IOM, 2001). Long-term care ranges from minimal personal assistance with basic, everyday activities to skilled nursing care, and can be provided in a variety of settings, including nursing homes, residential care facilities, and people’s homes. Most users of long-term care facilities are individuals over age 65 (IOM, 2001). A 2000 study found that over 9 million individuals aged 65+ resided in rural counties; 4.3 million of these were aged 75+ and most likely to use
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Quality Through Collaboration: The Future of Rural Health abuse treatment centers are located in rural areas and most often within a community health center, compared with 9 to 21 percent for urban areas (SAMHSA, 2003). More recently, the Bureau of Primary Health Care has been expanding the role of federally qualified community health centers in mental health and substance abuse services7 for underserved populations, in recognition of the fact that between 1996 and 2001, mental health and substance abuse encounters in community health centers grew by over 50 percent8 (Lambert and Agger, 1995; Williams, 2003). Rural programs that aim to increase workforce capacity have been most successful by adjusting the regulatory and financing framework to better support the training, recruitment, and retention of master’s-level practitioners. As discussed in Chapter 4, developing a workforce of advanced practice psychiatric nurses, is one method for increasing the supply of mental health clinicians in rural areas (Hartley et al., 2004; Merwin and Mauck, 1995). Another method is to offer additional training and reimbursement to primary care clinicians who provide mental health services to better support them in this role. Improved data collection on all clinicians providing mental health and substance abuse services also is important and would generate an understanding of the distribution and quality of these services in meeting the needs of rural patients. The IOM’s forthcoming study on access to and quality of mental health and substance abuse services will be available in fall 2005. ORAL HEALTH CARE In 2000, the Surgeon General published the report Oral Health in America, reestablishing that oral health is essential to the general health and well-being of all individuals and that the two are inseparable. Oral health includes not only the teeth, gums, and surrounding tissues, but also the hard and soft palate; the musocal lining of the mouth, throat, tongue, and lips; the 7 Federally qualified health centers’ primary health services are viewed as appropriate for preventing, screening, diagnosing, treating, and managing all forms of common mental illness, such as depression, anxiety, and attention deficit hyperactivity disorder (ADHD). However, their role is viewed as limited to treatment and follow-up for more severe mental disorders, such as schizophrenia, bipolar disorder, or psychotic depression, once these illnesses have been diagnosed and stabilized by specialists (BPHC, 2003). 8 Some Medicaid Managed Behavioral Healthcare arrangements have been creative in sharing scare mental health professionals by including community mental health centers in networks of providers as well as supporting primary care providers in supplying mental health services.
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Quality Through Collaboration: The Future of Rural Health salivary glands; the chewing muscles; and the upper and lower jaws. Equally important are the nervous, immune, and vascular systems that animate, protect, and nourish the oral tissues, and provide connections to the brain and the rest of the body (USPHS, 2000). The Surgeon General’s report confirms that oral health means much more than healthy teeth—it means being free of chronic oral–facial pain conditions, oral and throat cancers, oral soft tissue lesions, birth defects (e.g., cleft lip and palate), and scores of other diseases and disorders that affect the oral, dental, and craniofacial tissues. Oral exams play a critical role in the detection of nutritional deficiencies, as well as a number of systemic diseases (e.g., microbial infections, immune disorders, injuries, and some cancers). Oral health is often overlooked as an important contributor to overall health and in times of high health care costs, is often abdicated to pay for general health care services. Inadequate access to oral health care results in significant financial costs and expenses that go beyond dental diseases. Despite significant gains over the past 50 years in understanding of the common oral diseases and in dental care, lack of access to oral health care has led to a “silent epidemic” for many vulnerable populations, particularly poor children, the elderly, and many members of racial and ethnic groups (USPHS, 2000). Socioeconomic status and ability to pay are the most influential factors in determining access to oral health care services. The prevalence of dental caries (cavities) is twice as high among low-income than other children, and only 3 percent of rural children receive dental sealants, versus 23 percent of children overall. Racial disparities also are evident among children: 36 percent of African American and 43 percent of Hispanic children have untreated dental caries, compared with 26 percent of whites (ODPHP, 2000). Periodontal disease is more frequent in African Americans and low-income adults—35 percent of adults with less than high school education versus 28 percent of high school graduates and 15 percent of those with some college (Cho, 2000). Rural low-income seniors record higher rates of total tooth loss (47 percent) compared with seniors near metropolitan areas (34 percent) (NCHS, 2001). Data also indicate that 11 percent of rural residents have never seen a dentist (NRHA, 2001b). According to the Rural Healthy People 2010 report, oral health ranked fifth among 28 health areas as a priority for improvement in access and quality for 35 percent of respondents, especially state organizations, community health centers and rural health centers, public health agencies, and hospitals (Gamm et al., 2002). As with issues related to other health care providers, rural areas are marked by a lack of access to dental services resulting from an inadequate supply of dentists, including those who accept Medicaid or other discounted
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Quality Through Collaboration: The Future of Rural Health fee schedules; reluctance of dentists to participate in managed care programs; and the absence of a coordinated screening and referral network (NRHA, 2001b). In metropolitan areas, there are about 43 dentists per 100,000 population, compared with 29 in rural counties, or about 1 dentist per 3,448 residents9 (Larson et al., 2003). A survey of dental practices in the rural areas of four states (Alabama, California, Maine, and Missouri) found a relatively stable, aging workforce (average ages of 50 years or greater) whose members had practiced in the same location for an average of 16 years (California) to 20 years (Missouri), usually with assistance from both dental hygienists and chair-side dental assistants (Larson and Norris, 2003). Over 60 percent of respondents in all four states identified significant unmet need for dental care in their communities. Access to oral health care is also impeded by financial barriers. Public health insurance programs (i.e., Medicare, Medicaid, the State Children’s Health Insurance Program) do not cover routine dental care, and Medicare provides coverage only for services received in conjunction with inpatient care (CMS, 2001). With the increased funding received in recent years, some community health centers have expanded their services to include dental care. For example, the Midtown community health center in Weber County, Utah, received federal funding for dental care in 2002 and created a partnership with the local university’s (Weber State University) dental hygiene program (Nichols, 2004). The university offered the community two offices for dental care at minimal cost, and in exchange the Midtown dentist provides supervision for the dental hygiene students, who provide preventive care and patient education for free as part of their curriculum. Another example involves the community health center of Central Wyoming, which obtained funding through a grant from HRSA and the City of Casper to establish a center for oral health care (North, 2004). This community health center sponsors a dental residency program with dental schools in neighboring states. 9 The federal government designates a health professions shortage area for dentistry if a rural area (county, part of a county, or group of counties with populations at least 40 minutes’ travel time apart) has fewer than 1 dentist per 5,000 persons, or fewer than 1 dentist per 4,000 population for areas with greater than average need (at least 20 percent of the population earning less than the federal poverty line, lack of a fluoridated water supply) or insufficient provider capacity (in terms of the number of appointments per dentist annually, the availability of appointments, and average waiting times) (BHPR, 2004).
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Quality Through Collaboration: The Future of Rural Health BOX C-1 Ten Essential Public Health Services Monitor health status to identify community health problems. Diagnose and investigate health problems and health hazards in the community. Inform, educate, and empower people about health issues. Mobilize community partnerships to identify and solve health problems. Develop policies and plans that support individual and community health efforts. Enforce laws and regulations that protect health and ensure safety. Link people to needed personal health services, and ensure the provision of health care when otherwise unavailable. Ensure a competent public health and personal health workforce. Evaluate the effectiveness, accessibility, and quality of personal and population-based health services. Conduct research to obtain new insights and develop innovative solutions to health problems. SOURCE: NACRHHS, 2000. PUBLIC HEALTH Public health services are provided through the state-level agency and by local public health agencies (LPHAs) at the county level, as well as some hospitals, private practice physicians, and community groups. The characteristics of the local community determine which organizations provide these services. In general, a paucity of data has been collected on a regular basis regarding the rural public health infrastructure; the data that are available focus on LPHAs. State public health agencies have been responsible primarily for overall immunization programs, infectious disease control and reporting, health education, health statistics, and most important the licensing and regulation of institutional and individual providers that deliver health care services. However, most services are provided by LPHAs that serve a single county, or in certain cases multiple counties (i.e., large geographic areas in the western United States). About 3,000 LPHAs form the public health system; two-thirds of these are located in small towns with populations of less than 50,000 and median annual expenditures of $621,000 (ORHP, 2002). Some states (e.g., Maine, Pennsylvania) have no LPHAs outside of major cities, and in those that do, the agencies lack personnel and financial resources for population health interventions and enhanced sur-
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Quality Through Collaboration: The Future of Rural Health veillance capabilities. Moreover, workforce recruitment and retention are more difficult in rural areas because of the geographic distance, fewer educational and training opportunities, and less technology diffusion. Efforts are under way by the U.S. Department of Health and Human Services (DHHS) to develop the rural public health infrastructure. In 1994, the Public Health Functions Working Group, an expert committee convened by DHHS, identified 10 essential public health services (see Box C-1). Earlier IOM committees have recommended that these essential services be available to all communities, regardless of how small or remote they may be (IOM, 1988, 1992, 1997a, 1997b; NRC, 2002). Yet the public health system remains underfunded, and the country lacks a comprehensive, long-term plan to build and sustain this infrastructure at the state and local levels (IOM, 2003). Rural areas often have little or no public health infrastructure (Johnson and Morris, 2000). REFERENCES AANA (American Association of Nurse Anesthetists). 2004. Nurse Anesthetists at a Glance. [Online]. Available: http://www.aana.com/crna/ataglance.asp [accessed June 30, 2004]. AAPA (American Academy of Physician Assistants). 2003. 2003 AAPA Physician Assistant Census Report. [Online]. Available: http://www.aapa.org/research/03census-intro.html [accessed April 6, 2004]. Abt Associates. 2001. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II Final Report. [Online]. Available: http://nccnhr.newc.com/uploads/ExecutiveSummary.pdf [accessed June 30, 2004]. Appelbaum PS. 2003. The “quiet” crisis in mental health services. Health Affairs 22(5):110–116. Baldwin LM, Rosenblatt RA, Schneeweiss R, Lishner DM, Hart G. 1999. Rural and urban physicians: Does the content of their Medicare practices differ? Journal of Rural Health 15(2):240–251. Barry KL, Fleming MF, Greenley JR, Kropp S, Widlak P. 1996. Characteristics of persons with severe mental illness and substance abuse in rural areas. Psychiatric Services 47(1):88–90. Berlin LE, Bednash G, Scott D. 1999. 1998–1999 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Washington, DC: American Association of Colleges of Nursing. BHPR (Bureau of Health Professions). 2004. Health Professional Shortage Area Dental Designation Criteria. [Online]. Available: http://bhpr.hrsa.gov/shortage/hpsacritdental.htm [accessed April 21, 2004]. Bird DC, Dempsey, P, Hartley, D. 2001. Addressing Mental Health Workforce Needs in Underserved Rural Areas: Accomplishments and Challenges. Portland, ME: Maine Rural Health Research Center, University of Southern Maine.
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Representative terms from entire chapter: