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Quality Through Collaboration: The Future of Rural Health (2005)

Chapter: Appendix C The Rural Health Care Delivery System

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Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
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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.

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
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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

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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-

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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.

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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).

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

FIGURE C-1 Locations of critical access hospitals (as of November 18, 2003).

NOTE: Developed with data from the U.S. Census Bureau (2003); U.S. Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) (2003); and CMS Regional Office, Office of Rural Health Policy, and State Officers Coordinating with Medicare Rural Health Flex Program (2004). Core Based Statistical Areas (CBSA) are current as of the December 2003 update. Nonmetropolitan counties include micropolitan and counties outside of CBSAs. Produced by: North Carolina Rural Health Research and Policy Analysis Center, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. SOURCE: FMT, 2004b.

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

FIGURE C-2 Full-time, hospital-based registered nurses per 100,000 population (average for each state’s rural counties, 2,000).

SOURCE: Larson and Norris, 2003.

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

nursing homes in the near future (Phillips et al., 2003). Rural elders differ from their urban counterparts in several ways: they are more likely to be poor and less educated, to live in homes that are substandard (although fully owned), to lack health insurance coverage, and to be in poor health (Coward et al., 1994; Ricketts, 1999).

Long-term care in rural areas is characterized by greater reliance on institutionally based care in hospitals and nursing homes than is the case in urban areas. About one of every four U.S. residents aged 75 or older lives in rural America, yet over 40 percent of the nation’s nursing home beds are in rural areas (NRHA, 2001a; Phillips et al., 2003). Utilization of nursing homes is highest in small towns (121.5 nursing home residents for every 1,000 persons aged 75 and older) and lowest in urban areas (82.3 nursing home residents), but even isolated areas (99.0 nursing home residents) and large towns (106.7 nursing home residents) see higher use of nursing homes among the very old than that in urban areas (Phillips et al., 2003). If alternatives to institutional care, such as assisted living facilities, were available, about $2–$5 billion in Medicaid spending could be saved per year (Clark, 1998).

Although older rural residents are more likely to use nursing home care, such care in rural areas differs from that in urban areas in two ways. First, nursing homes located in rural areas are less likely to have certified skilled nursing beds or special care units; they provide mainly custodial care (Ricketts, 1999). Second, nursing homes in rural areas have lower staffing ratios for both nurse aides and licensed nursing staff (Abt Associates, 2001). Physical therapists and social workers are also in short supply given the higher incidence of disability and frailty among rural residents (Ricketts, 1999).

Quality concerns have been raised regarding the care provided in both urban and rural nursing homes and the adequacy of oversight mechanisms (MedPAC, 2001), 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). (See Chapter 4 for further discussion of the challenges rural areas confront in recruiting an adequate nursing workforce.) Rural nursing home patients are also more likely to experience multiple transfers from nursing facility to hospital, an indication that rural facilities experience difficulty in managing medically complex patients (Coburn et al., 1999). Data and information are less plentiful on differences in the availability, use, or quality of home health care in rural versus urban areas. According to recent Medicare claims data (which pertain to post–acute care, short-term home

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

health use), urban and rural providers treat a clinically similar mix of patients—Alzheimer’s disease, congestive heart failure, diabetes, stroke, hip procedure and fracture, and chronic obstructive pulmonary disease—with similar functional status (MedPAC, 2001). Rural patients received more total visits (43.8 per year) than their urban counterparts (37.5 per year), but fewer rural patients received therapy visits. Studies of the quality of home health care generally do not differentiate between rural and urban areas, but there is a sizable evidence base documenting safety and quality shortcomings in home health care overall (GAO, 1997; IOM, 2001).

MENTAL HEALTH AND SUBSTANCE ABUSE CARE

After access to primary care, access to mental health services is cited by Gamm and colleagues (2003) as the second-highest priority for improving rural health delivery system. In both urban and rural areas, a growing portion of mental health services are being provided by primary care clinicians, but for different reasons. Mental health conditions1 cover a wide range of conditions and severity—from those that are less severe, such as generalized anxiety disorder, to those that are more severe, such as schizophrenia. Substance abuse2 refers to dependence upon and excessive consumption of alcohol, illicit drugs, and/or tobacco. 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); serious mental illness is a diagnosable mental disorder found in persons aged 18 and older that is so long-lasting and severe that it seriously interferes with a person’s ability to take part in major life activities (USDHHS, 2000); serious emotional disturbance is a diagnosable mental disorder found in persons from birth to age 18 that is so severe and long-lasting that it seriously interferes with functioning in family, school, community, or other major life activities (USDHHS, 2000).

2  

Substance abuse includes alcohol, tobacco, and illicit drug use. Although alcohol and tobacco are by far the two most prevalently abused substances and are significant causes of morbidity and mortality (Hutchison and Blakely, 2003), abuse of alcohol and illicit drugs frequently co-occurs with mental illness (Barry et al., 1996; Coridan and Heffron 2000 [Updated Spring 2002]). Marijuana is the most commonly used illicit drug, followed by cocaine and hallucinogens.

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

important contributor to the other and to other serious medical conditions, and effective treatment of either requires attention to the other by providers that have competency in the behavioral and social treatment of both.

Mental health conditions and substance abuse exact high social costs (potentially long-term) and financial costs that other illnesses typically do not impose for families, communities, and legal systems, as they are the leading causes of disability-related conditions.3 Access to care and support mechanisms for patients and their families are critically important to appropriate treatment and management of these conditions; however, adequate services are often not available. Primary care providers often fill the gap in mental health services in rural areas. In contrast, cost and limited coverage of mental health and substance abuse services deter many urban patients from seeking out primary care providers for these services.

Recent estimates indicate that about 16.5 percent of the U.S. population over age 18 have a mental disorder and 7.6 percent a substance abuse disorder in any given year (Narrow et al., 2002). The 1999 Surgeon General’s report estimated that 20 percent of children had mental disorders with mild functional impairment, with a subset of 5–9 percent having severe functional limitations (USPHS, 1999). The prevalence of mental health conditions and substance abuse in rural areas is comparable to that in urban areas, with some notable exceptions (Hartley et al., 1999; Kessler et al., 1994; NCHS, 2001). Rural areas suffer from a higher incidence of suicide and suicide attempts than their urban counterparts; rural residents are less likely to request care for mental health (Fox et al., 1999; Rost et al., 2002); and rural youth have higher rates of abuse of alcohol, tobacco, methamphetamines, and inhalants (Butterfield et al., 2002; Donnermeyer and Scheer, 2001; Hutchison and Blakely, 2003; OAS, 2003).

The rural elderly, who constitute a larger portion of the rural than the urban population, have a higher incidence of depression compared with other populations—particularly those with multiple chronic conditions taking four or more medications (Crystal et al., 2003; Okwumabua et al., 1997). Rural women are at greater risk for depression and stress-related disorders than rural men, and these conditions are less likely to be diagnosed by a rural practitioner (Shelton et al., 1995). 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-

3  

Mental illnesses and substance abuse rank first and second as leading causes of disability-related conditions.

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

sequences of substance abuse relative to urban women. Children with mental health conditions, substance abuse, or dual diagnosis are 2–4 times more likely to be children of poverty, the welfare system, or the juvenile system (Glied et al., 1997). Some minorities who reside in rural areas, such as Native Americans and Alaska Natives, have a higher incidence of abuse for certain substances (Freese et al., 2000). For example, the alcohol-related death rate among Alaska Natives is 34 per 100,000, compared with 14 per 100,000 for the U.S. population overall (Stillner et al., 1999). The association of mental health conditions and substance abuse with stigma is stronger in rural areas, where there is less anonymity and more overlap in social settings (religious, professional, and personal) (NFCMH, 2003). As a result, rural residents are less likely to have knowledge about mental health conditions and substance abuse, perceive the need for care, and participate in care (Fortney and Booth, 2001).

Access to mental health and substance abuse services varies widely by population density, with rural residents facing a distinct disparity in scope and availability of services (Donnermeyer, 1997). While urban populations can navigate through a variety of treatments offered by multiple providers to gain the necessary care, rural populations must rely on the limited medical and behavioral therapeutic support available to them. Mental health and substance abuse professionals can include psychiatrists (specialist physicians), clinical psychologists, counselors, social workers, and therapists with master’s level training (Ivey et al., 1998). All of these providers, particularly those with master’s level training, are in short supply in rural areas. Data show that 87 percent of the 1,669 mental health professions shortage areas are rural counties. Of the 1,253 rural counties with populations of 2,500–20,000, 75 percent have no psychiatrist, and only 50 percent have a clinical psychologist or social worker (Bird et al., 2001).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) per 9,000 persons, or a combination of less than 1 psychiatrist per 20,000 population and 1 mental health provider per 6,000 persons. These ratios are lower for areas with greater than average needs (poverty, relatively greater numbers of youth or elders, prevalence of alcohol or substance abuse). Designation as a shortage area qualifies a rural community to receive a National Health Service Corps or state placement, as well as making it eligible for other workforce programs.

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

county, compared with 13+ such organizations in urban areas (Hartley et al., 1999). A full 20 percent of rural counties lack any mental health services, versus 5 percent of urban. Rural children with serious mental illness are particularly disadvantaged in obtaining the care they need, given a lack of specialized mental health professionals for children and adolescents (Wolff et al., 2001). Moreover, fewer rural than urban hospitals offer inpatient psychiatric services5 (Hartley et al., 1999). Consequently, primary care clinicians provide mental health services annually for 10 to 20 percent of those living in rural areas (DeGruy, 1996; Ivey et al., 1998) and up to 65 percent of those living in frontier areas (Mohatt et al., 2003). On average nationally, 6 percent of generalists provide mental health services (USPHS, 1999).

The types of organizations that provide care are rather sparse as well. 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. Although community mental health centers were quite effective in reintegrating patients discharged from institutional mental health settings back into the community, a shift to block grants, funding cuts, and the movement toward deinstitutionalization caused many of these facilities to shift their focus to care solely for severely impaired adults and children (Wagenfeld et al., 1994). Because the federal government no longer provides direct support to these centers, official federal designation as a community mental health center is no longer provided, and all qualification requirements to receive financial support are determined by the state.

Treatment for substance abuse is funded largely by the public sector, with 90 percent of such care provided through a diverse range of outpatient settings (e.g., hospitals—10 percent, residential facilities—19 percent, community mental health centers—18.7 percent, and other outpatient settings—44.2 percent)6 (Horgan and Levine, 1998). Only 2 percent of substance

5  

Although the effectiveness of inpatient hospital mental health care for children is increasingly questioned (Glied and Cuellar, 2003) and some state mental hospitals may be underutilized, there are widely published accounts of a lack of needed psychiatric beds as the existing supply is reduced in response to declining reimbursement levels (Appelbaum, 2003).

6  

Nationally, about one-quarter of metropolitan hospitals provide outpatient treatment for alcohol and drug abuse; in rural areas, however, only one-tenth offer such services (CASA [National Center on Addiction and Substance Abuse], 2000).

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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.

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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).

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

BOX C-1
Ten Essential Public Health Services

  1. Monitor health status to identify community health problems.

  2. Diagnose and investigate health problems and health hazards in the community.

  3. Inform, educate, and empower people about health issues.

  4. Mobilize community partnerships to identify and solve health problems.

  5. Develop policies and plans that support individual and community health efforts.

  6. Enforce laws and regulations that protect health and ensure safety.

  7. Link people to needed personal health services, and ensure the provision of health care when otherwise unavailable.

  8. Ensure a competent public health and personal health workforce.

  9. Evaluate the effectiveness, accessibility, and quality of personal and population-based health services.

  10. 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-

Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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).

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Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
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Suggested Citation:"Appendix C The Rural Health Care Delivery System." Institute of Medicine. 2005. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. doi: 10.17226/11140.
×

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Building on the innovative Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Quality Through Collaboration: The Future of Rural Health offers a strategy to address the quality challenges in rural communities.

Rural America is a vital, diverse component of the American community, representing nearly 20 % of the population of the United States. Rural communities are heterogeneous and differ in population density, remoteness from urban areas, and the cultural norms of the regions of which they are a part. As a result, rural communities range in their demographics and environmental, economic, and social characteristics. These differences influence the magnitude and types of health problems these communities face.

Quality Through Collaboration: The Future of Rural Health assesses the quality of health care in rural areas and provides a framework for core set of services and essential infrastructure to deliver those services to rural communities. The book recommends:

  • Adopting an integrated approach to addressing both personal and population health needs
  • Establishing a stronger health care quality improvement support structure to assist rural health systems and professionals
  • Enhancing the human resource capacity of health care professionals in rural communities and expanding the preparedness of rural residents to actively engage in improving their health and health care
  • Assuring that rural health care systems are financially stable
  • Investing in an information and communications technology infrastructure

    It is critical that existing and new resources be deployed strategically, recognizing the need to improve both the quality of individual-level care and the health of rural communities and populations.

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