Quality Through Collaboration The Future of Rural Health (2005) / Chapter Skim
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Appendix C The Rural Health Care Delivery System
Appendix C The Rural Health Care Delivery System
Pages 220-248
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, hospital care, long-term care, mental health and substance abuse care, oral health care, and public health.
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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.
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(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)
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APPENDIX C 223 TABLE C-1 Percentage of Communities with Nonfederal Physician Specialty Services 19791999 Population in Thousands Number of Specialty Physicians 2,5004,999 5,0009,999 10,00019,999 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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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)
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. 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.
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. 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)
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. Because of workforce constraints, nearly half of rural hospitals provide emergency care through nurse practitioners and physician assistants.
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. Currently, new federal grant programs for domestic preparedness are supplying increased resources to states to enhance emergency responder capabilities (including EMS)
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An IOM study on EMS and emergency room care is currently in progress, with a series of reports to be released in 20052006. 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.
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. 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.
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Medicar for of Participating (# Not County or with Hospitals Analysis County Eligible Centers Access Nonmetropolitan Not Policy dinating Critical Metropolitan Nonmetropolitan State and Services, Coor update. ch Human ficers 2003 Resear Of and State Health December Health Hill.
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232 (2003) above State 2,000)
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, but these concerns may be even greater for rural facilities. A large proportion of rural nursing homes have nurse staffing ratios that fall below the minimum considered essential for the delivery of safe care (Phillips et al., 2003)
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Although mental health conditions and substance abuse have traditionally been associated with different treatment settings, program and funding mechanisms, and research literatures, there is increasing evidence that many individuals have both conditions as each is an 1 For the purposes of this discussion, mental illness, mental disorders, and serious mental illness are distinguished as follows: mental illness refers to all diagnosable mental disorders (USDHHS, 2000) ; mental disorders include schizophrenia, affective disorders such as depression, and anxiety disorders such as bipolar disorder (Regier et al., 1993)
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. The rate of substance abuse is lower for women than for men in general; however, rural women experience greater severity of alcohol problems, more comorbidities, and more deleterious con 3Mental illnesses and substance abuse rank first and second as leading causes of disabilityrelated conditions.
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.4 This averages to fewer than 2 specialty mental health organizations per rural 4 A federally designated mental health professions shortage area includes rural communities (a catchment area as defined by state mental health planners) with less than 1 psychiatrist per 30,000 population, 1 mental health provider (physician, clinical psychologist, clinical social worker, advanced practice psychiatric nurse, or marriage and family therapist)
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Community mental health centers were created by Congress in 1963 to provide a broad range of mental health services to people regardless of their ability to pay. These facilities have been an important source of mental health and substance abuse services for many rural communities, but less so in recent years.
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. 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)
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. 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)
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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)
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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.
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1996. Characteristics of persons with severe mental illness and substance abuse in rural areas.
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2003. Opportunities for Health Centers to Expand/Improve Access to Mental Health and Substance Abuse, Oral Health, Pharmacy Services, and Quality Care Management Services During Fiscal Year 2003.
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2001. Access to substance abuse services in rural areas.
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1998. The substance abuse treatment system: What does it look like and whom does it serve?
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1995. Rural emergency medical services: Patients, destinations, times, and services.
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2003. The NHSDA Report: Substance Abuse or Dependence in Metropolitan and Non-Metropolitan Areas.
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: The National Substance Abuse Treatment System: Facilities, Clients, Services, and Staffing. Rockville, MD: SAMHSA, OAS.
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