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Population Health in Rural America in 2020: Proceedings of a Workshop (2021)

Chapter: 4 Rural Health Care in Action

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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Page 56
Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"4 Rural Health Care in Action." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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4 Rural Health Care in Action The third session of the workshop focused on the national landscape of rural health care services, the role of tribal health care entities across rural America, the function of wraparound services in rural communi- ties, and the contribution of community health workers (CHWs) to rural health care. The session was moderated by Tom Morris from the Federal Office of Rural Health Policy at the Health Resources and Services Admin- istration (HRSA). RURAL HEALTH CARE LANDSCAPE Paul Moore from the Federal Office of Rural Health Policy at HRSA presented data on rural health provider infrastructure, explored chal- lenges and disparities in rural health care, and discussed the impact of the coronavirus disease 2019 (COVID-19) on health care access in rural communities. He remarked that although fewer doctors in rural areas are making house calls and delivering babies in local emergency rooms (ERs) than in the past, independent physicians in rural towns continue to feature prominently in the rural health care landscape (e.g., by staffing ERs as needed and making hospital rounds on their patients before they begin their in-office practice each day). 45 PREPUBLICATION COPY—Uncorrected Proofs

46 POPULATION HEALTH IN RURAL AMERICA IN 2020 The Rural Health Care Safety Net Moore explained that rural health care infrastructure largely com- prises small hospitals and clinics that have special reimbursement terms from the key public payers—Medicare and Medicaid. These public pro- grams designate three types of providers in rural areas: critical access hospitals (CAHs), rural health clinics, and federally qualified health cen- ters (FQHCs). Together, these types of care providers compose “the rural health safety net.” Moore provided more detail on these three types of provider designa- tions. CAHs were created as a special designation under Medicare by the Balanced Budget Act of 1997. These facilities have a limit of 25 beds or less and a limitation on length of stay, which currently averages 96 hours.1 Of the approximately 2,000 rural hospitals nationwide, more than 1,450 are CAHs. He added that in most rural communities, small rural hospitals and CAHs often serve as the linchpin of the health care system. Although a substantial number of local, county, or city-owned and managed hospi- tals are still in operation, system consolidation is on the rise. This is lead- ing to a mix of systems in some settings, including urban health systems that include some rural providers, mixed rural and urban systems, and private management affiliations and groups of hospitals. The designation “rural health clinic” was created in 1977 as part of the Rural Health Clinic Services Act.2 Rural health clinics receive certification from the Centers for Medicare & Medicaid Services (CMS) based in part on their location. These clinics, which receive special all-inclusive rate payments, can be either independent or provider based and must be staffed by both physi- cians and either nurse practitioners or physician assistants. FQHCs are administered by HRSA’s Bureau of Primary Health- care after being established in the 1960s as part of the war on poverty.3 Designed as a demonstration program to provide access to health and social services to medically underserved and disenfranchised popula- tions, FQHCs are located in both urban and rural areas. Currently, about 40 percent of the 14,000 FQHC sites are in rural communities. FQHCs provide a menu of services and are required to see all patients regardless of ability to pay, he noted. 1 More information about the critical access hospital designation is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/Downloads/CritAccessHospfctsht.pdf (accessed July 30, 2020). 2 More information about the rural health clinic designation is available at https://www. cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ Downloads/RuralHlthClinfctsht.pdf (accessed July 30, 2020). 3 More information about the FQHC designation is available at https://www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ fqhcfactsheet.pdf (accessed July 30, 2020). PREPUBLICATION COPY—Uncorrected Proofs

RURAL HEALTH CARE IN ACTION 47 These three types of designated providers are examples of how vari- ous federal policy levers, such as reimbursement, are used to support rural hospitals, clinics, and providers, said Moore. However, many other types of providers play important roles in the rural health care landscape. These include long-term care facilities that serve Medicare and dual-eligi- ble Medicaid patient populations, nursing homes, assisted living facilities, and residential services for people with disabilities.4 Other types of rural service providers include tribal clinics and hospitals, Veterans Affairs clin- ics and hospitals, home health care, hospice, occupational therapy, speech therapy, physical therapy, pharmacies, dentists, mental and behavioral health providers, and community health aides. Disparities in the Rural Health Care Landscape Moore outlined various disparities in the rural health care landscape. He remarked that despite the broad range of health care facilities and providers who serve rural areas, maldistribution within the health care workforce infrastructure is a major issue. While approximately 18 per- cent of the nation’s population are rural, only 10 percent of primary care practitioners and less than 7 percent of specialty care practitioners reside in rural areas. Furthermore, approximately 5 percent of rural counties do not have any family physicians. The negative effects on rural health care are evident across what Moore describes as the “five Ds”: death rates, disparities, distance, dol- lars, and departures. Death rates show that the life expectancy in rural areas is 3 years shorter than for people in urban areas. Furthermore, rural communities have higher death rates for heart disease and stroke. Rural women face higher maternal mortality rates than their urban counter- parts. Disparities are present in a number of health factors, in part because rural residents face higher rates of tobacco use, physical inactivity, obe- sity, diabetes, and high blood pressure. The disparity in the distribution of and access to health care providers extends beyond physical health care, he added. Rural populations face greater challenges with mental and behavioral health than people living in urban areas, yet they gener- ally have limited access to mental health care. Distance is also a factor, given that rural areas have limited or nonexistent public transportation infrastructure. Rural residents often face long distances between their homes and health care providers and do not always have access to a vehicle, making it difficult to access emergency care, specialty care, and preventive care. 4 More information about long-term care facilities is available at https://www.rural healthinfo.org/topics/long-term-care (accessed July 30, 2020). PREPUBLICATION COPY—Uncorrected Proofs

48 POPULATION HEALTH IN RURAL AMERICA IN 2020 He explained that dollars pertains to the economics of rural areas, as rural populations are more likely to be uninsured or underinsured and typically have fewer affordable health insurance options than their urban counterparts. Departure refers to the closure of rural health care facilities: since January 2010, 130 rural hospitals have closed (Thomas et al., 2019). Of these, 43 were CAHs receiving cost-based Medicare reimbursement, which indicates that these CAHs were so financially vulnerable that this reimbursement was not sufficient to keep them open. The remaining 87 hospitals were noncritical access or prospective payment system hospitals with other Medicare designations. He added that many more rural hospi- tals are continuing to operate with a high degree of financial vulnerability. Innovations in the Rural Health Care Landscape Moore also described some of the innovations that are taking place in the rural health landscape to counteract some of the negative trends. Successful examples that can provide helpful insights include the Frontier Extended Stay Clinic, the recently closed Frontier Community Health Integration project, the Rural Community Hospital Demonstration pro- gram, and rural state innovation models.5 CMS has ongoing rural value- based initiatives such as accountable care organizations (ACOs), which are making good inroads in rural areas. The next generation of the ACO model includes state-located models, such as Vermont’s all-payer ACO system as well as the Pennsylvania rural health model.6 He noted that the latter model uses global budgeting and thus far, hospitals with global budgets appear more resistant to pandemic-induced fluctuations caused by the cancellation of elective surgeries and outpatient appointments. Impact of COVID-19 in Rural Areas The COVID-19 pandemic has created new challenges and opportu- nities in rural areas, said Moore. The increasing COVID-19 case num- bers in rural states appears to dispel the idea that rural communities with more space might fare better than urban areas. He noted that rural regions such as western Kansas and Oklahoma did not initially see the COVID-19 transmission rates that urban centers such as Manhattan and Chicago experienced, but those rural areas were experiencing a dramatic 5 More information about rural health models and innovations is available at https:// www.ruralhealthinfo.org/project-examples (accessed July 30, 2020). 6 More information about the Pennsylvania Rural Health Model is available at https:// innovation.cms.gov/innovation-models/pa-rural-health-model (accessed July 30, 2020). PREPUBLICATION COPY—Uncorrected Proofs

RURAL HEALTH CARE IN ACTION 49 increase in cases as of late June 2020.7 He remarked that the pandemic has shone a glaring light on enduring and far-reaching issues, including the racial, ethnic, and economic health disparities in rural areas, and it has underscored the need to improve access and surge capacity in rural areas. He suggested there are opportunities associated with COVID-19 as well, given that “a few months of pandemic accomplished in telehealth what years of advocacy could not.” Moore also proposed that alternative payment models and system designs may better align with the need to maintain access to quality health care services in the rural health care landscape than the current structures. TRIBAL HEALTH AND HEALTH CARE IN RURAL SETTINGS Daniel Calac from the Indian Health Council discussed the diversity among American Indian populations, the magnitude of American Indian/ Alaskan Native health disparities, the factors affecting the quality of life, and the severity of the biomedical workforce shortage affecting this sector of the U.S. population. The American Indian presence in the United States is highly diverse. Nearly 600 tribes currently live across the country, with more than 570 of these officially recognized by the U.S. federal govern- ment.8 Language varies between tribes, as indicated by the existence of more than 350 distinct dialects. Furthermore, native individuals may have distinct customs and diverse cultural norms that contribute to the level of care they deem appropriate. Substantial variety may exist even among nearby tribes, he added. For example, Calac’s organization near San Diego County serves nine individual reservations and tribes that are located within a 5-mile radius, all of which have their own unique customs. Historical Context for the Provision of Health Care to American Indians Calac provided some historical perspective about the lingering impact of colonialism and past treaties with the U.S. government on the way many tribal entities perceive health care. As part of negotiations between American Indian nations and the U.S. government, a prepaid health care plan was pledged for native people. However, a common sentiment is that this health plan was prepaid by the cession of the entirety of the 7 More information about rural and urban COVID-19 hotspots is available at https:// www.shepscenter.unc.edu/programs-projects/rural-health/rural-covid-research-and- figures/rural-and-urban-covid-19-hot-spots (accessed July 30, 2020). 8 See https://www.ncsl.org/research/state-tribal-institute/list-of-federal-and-state- recognized-tribes.aspx (accessed October 28, 2020). PREPUBLICATION COPY—Uncorrected Proofs

50 POPULATION HEALTH IN RURAL AMERICA IN 2020 American Indian peoples’ lands (Rhoades and Derre Smith, 1996). This perception is compounded by a rural health care system that is struggling to maintain an adequate level of increasingly complex care to American Indian populations. When American Indians traded land with fertile soil or river access to the United States, the treaty obligations and the needs of this population did not evaporate with their relocation, said Calac. The U.S. government has shifted responsibility for meeting these obligations to various agen- cies over time. Initially, a division within the Department of War oversaw health services to American Indians. In 1849, this responsibility was trans- ferred to the Bureau of Indian Affairs. Congress ratified appropriations with the 1921 Snyder Act, landmark legislation that defined the govern- mental responsibility for American Indian health care. Service delivery for American Indians was transferred to the Public Health Service in 1954 before shifting again to the newly formed Indian Health Service (IHS) the following year (Warne and Frizzell, 2014). The Indian Health Care Improvement Act of 1976 was another landmark piece of legislation, which offered assurances for the delivery of high-quality health care for the underserved Indigenous population. Indian Health Service in the 21st Century Calac explained that IHS currently has 12 service areas across the United States. Regardless of geography or the specific tribal entities, the burden of disease and health care disparities are common throughout these service areas.9 IHS operates 31 hospitals and 50 health centers, some of which are FQHCs. Two school-based IHS health centers enable service delivery to at-risk children, including the preventative health care needed at younger ages. IHS also oversees 31 health stations that were developed collaboratively by individual tribes and the IHS over the past 50 to 60 years. Calac said these stations offer more appropriate care than settings serving larger populations, because they provide an individualized level of care tailored to the communities they serve. Given the differences among the 570 distinct tribes, this type of community-specific approach is critical for meeting the specific needs of tribal entities. Many Indian health care clinics rely on grant funding to provide basic health care to tribal communities. Calac’s organization, the Indian Health Council, uses a facility model that has been replicated throughout California, a state that is home to 42 Indian health care clinics and 7 urban Indian health clinics. This type of facility offers a multidisciplinary range 9 More information about IHS areas and locations is available at https://www.ihs.gov/ locations (accessed July 30, 2020). PREPUBLICATION COPY—Uncorrected Proofs

RURAL HEALTH CARE IN ACTION 51 of services, including medical, dental, and medical subspecialties, includ- ing optometry, acupuncture, and behavioral health; they also address public health issues affecting tribal entities. He added that this approach to a clinic as a “health village” rather than a “health facility” helps to engage people and imbue them with a sense of ownership of the clinics, thus encouraging people to access services. Health Disparities for American Indians and Alaskan Natives American Indians and Alaskan Natives experience many health dis- parities, said Calac. Determinants of health equity include • limitations in communication capacity and resources, • variability in health literacy, • lack of community engagement and awareness, • limited financial resources, • transportation challenges, • displacement effects, • variability in implementation, • crime and safety influences (real and perceived), and • lack of awareness of diverse norms and customs.10 He noted that health literacy is a fundamental component of health equity that is particularly relevant in the context of the COVID-19 pan- demic, such as understanding the difference between an antibody test and a polymerase chain reaction test, knowing what RNA means in terms of viral particles, and knowing the appropriate doses of over-the-counter medications, such as acetaminophen. Transportation is an aspect of health equity that is particularly relevant for rural communities, he noted. Mul- tiple challenges come into play when people in rural areas have long distances between their homes and health care, such as adequate infra- structure in terms of roads and access to vehicles. Finally, crime and safety influences on health equity can be seen in the opioid epidemic, which is heavily affecting rural areas. Calac added that challenges related to Mexican cartels trafficking heroin through rural areas, as well as human trafficking in these regions, are also continuing problems. These types of disparities in health equity result in disparities in measures such as life expectancy, he emphasized. The life span of American Indians, at a 10 More information about the Centers for Disease Control and Prevention guidelines for advancing health equity and preventing chronic disease is available at https://www.cdc. gov/nccdphp/dnpao/state-local-programs/health-equity-guide/index.htm (accessed July 30, 2020). PREPUBLICATION COPY—Uncorrected Proofs

52 POPULATION HEALTH IN RURAL AMERICA IN 2020 median 76 years, is 5 years shorter than the median 81 years of the general population. Calac stated that in more impoverished areas, such as in the Dakotas, and in areas distant from hospitals and major clinics, the average life span can be as much as 20 years shorter for some native populations. Factors Affecting the Quality of Life of Tribal Communities Calac highlighted some of the many factors that affect the quality of life of American Indians and Alaskan Natives, including barriers to accessing health care that are geographic, educational, institutional, social, or financial. Distance to health care providers can be a geographic barrier to care, as can mountainous regions that are difficult and even danger- ous to traverse. Educational barriers are evidenced by lower graduation rates. In 2014–2015, the American Indian population had a high school graduation rate of 71.6 percent, compared to 83.2 percent for the general population. This disparity is even greater at the postsecondary level, with 19.8 percent of American Indians receiving a bachelor’s degree versus 32.5 percent of all adults in the United States.11 Institutional challenges include the funding cycle for IHS, which is year to year instead of the protracted 5-year or 10-year budget cycle that corporations and many communities can rely on for funding individual programs. Furthermore, IHS programs are consistently underfunded by as much as 40 percent, with prominent shortages in funding for mental health. Calac said a social barrier is the ongoing and persistent trend of low use of preventative health care due to the perception of health care as the use of urgent or emergency care. Lastly, the financial barriers faced by the American Indian population are substantial. In 2014, approximately 28 percent of the Indigenous popula- tion was living in poverty, compared with 15.5 percent for all Americans.12 Per capita health care spending on American Indians is also lower than for other populations. In 2005, IHS spent an average of $3,099 per recipient, less than half of the $8,097 per capita rate for Medicaid recipients.13 Calac added that this disparity has not changed much since 2005, with IHS receiving lower per capita medical expense rates than even the Federal Bureau of Prisons. 11 More information about rates of high school completion and bachelor’s degree attain- ment among persons age 25 and over by race/ethnicity and sex is available at https://nces. ed.gov/programs/digest/d15/tables/dt15_104.10.asp?current=yes (accessed July 30, 2020). 12 More information about poverty rates among American Indian and Native American populations is available at https://www.census.gov/newsroom/facts-for-features/2015/ cb15-ff22.html (accessed July 30, 2020). 13 More information is available at https://www.aamc.org/news-insights/more-native- american-doctors-needed-reduce-health-disparities-their-communities (accessed July 30, 2020). PREPUBLICATION COPY—Uncorrected Proofs

RURAL HEALTH CARE IN ACTION 53 Calac noted the IHS health care workforce shortage across all types of health care providers. In 2015, IHS had vacancy rates of 16 percent for pharmacists, 24 percent for nurses, 26 percent for dentists, 32 percent for physician assistants, 34 percent for physicians, and 35 percent for advanced practice registered nurses. Furthermore, the matriculation rates of American Indian medical students are low. According to the Associa- tion of American Medical Colleges’ 2017 data for medical school gradu- ates, of the 93,000 individuals who graduated between 2012 and 2017, only 131 identified as American Indian or Alaskan Native—a number of graduates that is insufficient to meet the needs of 570 different tribal entities. Calac emphasized that this and the underfunding of IHS pose a major problem for the delivery of health care and the improvement of health care in these populations. WRAPAROUND SERVICES: IMPLICATIONS FOR RURAL AMERICA Nir  Menachemi from Indiana University provided an overview of wraparound services, wraparound program outcomes, challenges to the adoption of this service delivery model, and implications for rural health. He noted that although the majority of studies he presented were con- ducted in urban areas—mostly in FQHCs in inner-city urban areas—these types of wraparound services would also benefit rural areas. Overview of Wraparound Services Menachemi explained that the term wraparound applies to nonmedical services provided in conjunction with primary care. Traditional wrap- around services include social work, behavioral health, nutrition and diet, pharmacy assistance, and patient navigation. More recently, wraparound services have included financial counseling, which assists individuals in managing nonmedical aspects of their lives to enable them to bet- ter manage medical issues. Similarly, medical–legal partnerships have formed because legal services addressing challenges in people’s lives may increase their ability to focus on and maintain health. Traditionally, access to these types of services has been via referrals to outside agencies. How- ever, some FQHCs are now collocating these services with primary care and scheduling wraparound service providers to meet with patients at their primary care appointments, thereby increasing use of these services. Most wraparound services are designed to address one or more of the social determinants of health (SDOH), said Menachemi. Figure 4-1 depicts wraparound services related to each SDOH and the health outcomes associated with those SDOH. For example, social workers can assist with PREPUBLICATION COPY—Uncorrected Proofs

54 POPULATION HEALTH IN RURAL AMERICA IN 2020 FIGURE 4-1  Wraparound services to address social determinants of health. SOURCES: Menachemi presentation, June 24, 2020; https://www.kff.org/ disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants- in-promoting-health-and-health-equity (accessed August 5, 2020). vocational training or housing issues, and dieticians focus on matters related to food and nutrition. Mental health counselors can help people provide information to manage stress and, to some degree, cope with discrimination, address social integration, and support systems. Wrap- around services can include anything that enhances an individual’s ability to maintain health or cope with disease, he added, because wraparound service providers are essentially working to mitigate the potentially nega- tive effects of certain SDOH. Wraparound Program Outcomes A number of studies have measured the effect of wraparound services on patient outcomes, said Menachemi. In one study, referrals by health care professionals to social service providers led to a decrease in patient- reported needs, indicating that social services were able to address and eliminate some patient needs (Gottlieb et al., 2016). Wraparound services also increased parent and caregiver perception that their children’s health needs were being met. Another study examined medical–legal wrap- around partnerships in which attorneys provide pro bono consultative services to people in health care settings; it found these partnerships address legal issues that exacerbate poor health (Sandel et al., 2010). An PREPUBLICATION COPY—Uncorrected Proofs

RURAL HEALTH CARE IN ACTION 55 example of how medical–legal partnerships can address such issues is the addition of legal forms to electronic health records, which can aid in pro- cesses such as rectifying substandard housing conditions for low-income patients. Other cases might involve a parent who is unable to afford a child’s medications because of failure of the other parent to make child support payments. Medical–legal partnerships address these types of situations in working toward the ultimate goal of increasing a patient’s ability to manage disease, he explained. Another example of wraparound services is the inclusion of mental health, child care, family services, and vocational training in substance use disorder treatment clinics. Menachemi and colleagues published a study of FQHCs in inner-city Indianapolis, Indiana, where wraparound services included social work, dietician assistance, and patient navigation (Vest et al., 2018). These wraparound services reduced hospitalizations and emergency department visits in the years following the rollout of these services. Another study that focused on nutritionists found that seeing a dietician can improve a patient’s diet quality, diabetes outcomes, and weight loss (Mitchell et al., 2017). The co-location of behavioral health wraparound services in primary care settings was the focus of another study, which found that this co-location can reduce wait times for treat- ments and increase both patient engagement in care and patient use of needed services (Possemato et al., 2018). Challenges to Adoption of Wraparound Services Both rural and urban areas are seeing a low uptake of wraparound services, noted Menachemi. He attributed this to the historic fee-for- service incentive structure—a somewhat perverse incentive structure that was implemented because most providers and facilities are set up to address acute issues rather than the chronic conditions that are largely driven by the SDOH. This effectively disincentivized wraparound ser- vices, despite the fact that wraparound services can reduce the need for future services that are costlier. The study conducted by Menachemi and colleagues on wraparound services in an Indianapolis FQHC indicated an average annual cost savings of approximately $2 million (Vest et al., 2018). He noted that under a fee-for-service structure, cost savings are actually a reduction in revenue, whereas under full capitation,14 it repre- sents true savings for the provider. Therefore, the financial incentives and 14 Under capitation, “providers receive a fixed per person (or ‘capitated’) payment that covers all health care services over a defined time period, adjusted for each patient’s ex- pected needs, and are also held accountable for high-quality outcomes.” See James and Poulsen (2016). PREPUBLICATION COPY—Uncorrected Proofs

56 POPULATION HEALTH IN RURAL AMERICA IN 2020 reimbursement model used will affect whether or not the use of wrap- around services is incentivized. He said that wraparound services are most frequently geared toward vulnerable groups, as this model is more readily adopted by FQHCs and clinics that disproportionately cater to vulnerable individuals. The focus of these settings, reflected in their goals and mission, is usually on ameliorating challenges and not necessarily on generating revenue. Implications of Wraparound Services for Rural Health Menachemi suggested that in many ways, rural settings may be ideal for wraparound services because rural populations tend to have many needs stemming from unfavorable social determinants. Therefore, he suggested exploring ways to integrate the expertise of various pro- viders working to mitigate the unfavorable ramifications of SDOH. He described several studies that illustrate the potential benefit of imple- menting wraparound services in rural areas. One study looked at a dental clinic that used the wraparound service of transportation assistance, find- ing that dental treatment completion rates increased with transportation assistance in place (Larson et al., 2019). The study also found that most wraparound services are supported via grants or philanthropy, making them vulnerable to funding disruptions. Menachemi said that this type of vulnerability is more likely when the financial model of delivering care is not aligned with the engagement of wraparound services. Another study looked at substance use disorder treatment centers in both rural and urban areas (Bond Edmond et al., 2015). Centers in rural locations were far less likely to offer wraparound services than their urban counterparts because of challenges in rural areas, including the stigma on behavioral health care issues (Pullmann et al., 2010). He said that many of the barriers to wraparound services in rural areas are the same barriers seen in access- ing medical and primary care: transportation issues, limited funding, service availability, a shortage of wraparound service providers, and long distances between facilities all pose challenges to accessing wraparound services in rural locations. Menachemi remarked that the issues that have historically impeded access to primary care and dental services are being overcome, which may provide an opportunity for wraparound services to play a role in enhancing care in rural areas. He added that telehealth—which is rapidly expanding due to the COVID-19 pandemic—could potentially be used as a platform for delivering wraparound services. The use of wraparound services via telemedicine has not yet been studied, but he suggested that it could be useful if geographic access is a limiting factor. However, PREPUBLICATION COPY—Uncorrected Proofs

RURAL HEALTH CARE IN ACTION 57 telehealth may not be as helpful in relieving the financial barriers to service provision in many rural communities, so the proliferation of tele- health could widen disparities in rural areas if financial and other barriers prevent access (Kim et al., 2020). THE ROLE OF COMMUNITY HEALTH WORKERS IN ADDRESSING THE NEEDS OF RURAL AMERICANS Timothy Callaghan from the Southwest Rural Health Research Cen- ter at Texas A&M University focused his presentation on the role of the CHW in addressing the needs of rural Americans and the unique barriers they face in accessing health services. He presented data to define CHW roles, explored differences between CHWs in urban and rural environ- ments, highlighted challenges in the growing CHW field, and described CHW efforts to combat the COVID-19 pandemic. Overview of Community Health Workers CHWs are individuals who help bridge the gap between the pub- lic—including the most vulnerable members of the community—and the health and social services that are available, Callaghan explained. CHWs are distinct from many other health care providers in that CHWs often come from the communities in which they serve. Being a community member enables CHWs to promote trust within the community and con- nect vulnerable individuals to the services they need. He noted that the literature on CHWs as well as anecdotal personal experiences demonstrate that CHWs often possess unique cultural competence and a personal understanding of their communities and their patients, which equips CHWs to help those patients overcome barriers to accessing health care services. The CHW workforce is growing rapidly, he added. The Bureau of Labor Statistics projected that the CHW workforce would increase by up to 13 percent between 2018 and 2028.15 In Texas, the number of CHWs in the field has increased by more than 500 percent in just the past few years (Callaghan et al., 2019). Community Health Worker Roles To describe the roles of CHWs in rural and urban settings in the United States, Callaghan used two sources of original data from research 15 More information about the CHW job outlook is available at https://www.bls.gov/ OOH/community-and-social-service/health-educators.htm#tab-6 (accessed July 31, 2020). PREPUBLICATION COPY—Uncorrected Proofs

58 POPULATION HEALTH IN RURAL AMERICA IN 2020 conducted with support from the Federal Office of Rural Health Policy.16 The first source is a series of focus groups held with CHWs in rural and urban parts of California, Florida, Massachusetts, and Minnesota in 2018 and 2019. The second came from a large 2019 survey of more than 1,400 CHW participants from 45 states, Puerto Rico, and the District of Colum- bia. Callaghan explained that when CHWs were asked to describe their own roles during the focus groups and surveys, three themes emerged: (1) linking clients to resources, (2) focusing on SDOH, and (3) providing insights to other health care providers about clients that might otherwise be missed (see Box 4-1). CHWs in both urban and rural areas highlighted their roles in linking clients to resources, suggesting that in being a part of the communities they serve, CHWs are enabled to better understand the needs of clients because they may have experienced these needs themselves. The CHW role of serving as a bridge to agencies and services is similar in both rural and urban areas. He added that the resources that CHWs help their clients link up with often extend beyond health care resources. This is evident in another role that survey respondents and focus group participants described: addressing SDOH. Rather than focusing on one single area, CHWs fill in a variety of gaps, from address- ing SDOH to navigating aspects of the health care system to providing links to wraparound services. The third role that emerged from the focus groups is that CHWs can provide insights about patients that might be missed by other health care providers. Not only do CHWs understand the communities they serve, they also enter the homes of patients, which provides the opportunity to glean critical holistic information about their patients’ lives that may be affecting their health. Community Health Workers in Rural Versus Urban Settings The increasing numbers of CHWs are filling a vital role in the health care system, said Callaghan. The value of CHWs extends to rural areas, where they can help patients address the considerable barriers rural Americans face in accessing health care services. These barriers include transportation issues, limited numbers of providers, barriers to hospital access, and limited social programs. Callaghan suggested that if CHWs are uniquely positioned to help link clients to resources, they might be even more important in rural areas where those resources are scarce. The 16 These were original data sets collected for a Federal Office of Rural Health Policy– funded project. The project description can be found at https://www.ruralhealthresearch. org/projects/100002452 (accessed April 9, 2021), and the first policy brief about this can be found at https://srhrc.tamhsc.edu/docs/chw-policy-brief.pdf (accessed April 9, 2021). PREPUBLICATION COPY—Uncorrected Proofs

RURAL HEALTH CARE IN ACTION 59 BOX 4-1 Community Health Workers’ Reflections on Their Roles On linking clients with resources: “We are this bridge between the agencies, their resources, and the community. Promotores [CHWs] are very successful … because we have this connection with people, we go to their level, we understand people because we belong to the community, we know their needs, a lot of times we experience them.” (Community health worker in rural California) “I would say … linking clients to resources. That would be to providers whether it’s medical, dental, where you can get vision, where you can get a hearing screen- ing, diapers, whatever the resources that the clients need. Linking them to those resources.” (Community health worker in Los Angeles, California) On addressing social determinants of health: “We help with insurance, and then we help with homelessness, and then we help with food, and then we help with moving, and then we help with dental access, and behavioral health access. And that’s all before noon.” (Community health worker in Minnesota) “If you’re worried about homelessness, if you’re worried about where your next meal’s coming from, or child care, or all these things that are directly related to your family, you’re not focusing on your health. You’re focusing on these things. So, that’s where we come into play…. Nine times out of ten, they don’t even identify anything health related. It’s mostly social.” (Community health worker in Boston, Massachusetts) On providing insight about clients that might otherwise be missed: “Especially if you go into the home, you had the opportunity to see the whole client, not just the COPD [chronic obstructive pulmonary disease], not just the diabetes, not just the person who is vulnerable…. You had the opportunity to see the per- son as they live. And that’s something that your doctor doesn’t get to see or your nurse in the hospital doesn’t get to see. You just have a better understanding of where they are.” (Community health worker in rural Florida) “Then we can go back and relay to the doctor and the nurses what kind of prob- lems [patients have]…. They [medical providers] actually get an insight  on who their patients are and get to know them a little bit better because of us.” (Com- munity health worker in Massachusetts) SOURCE: Callaghan presentation, June 24, 2020. PREPUBLICATION COPY—Uncorrected Proofs

60 POPULATION HEALTH IN RURAL AMERICA IN 2020 CHW survey data indicate that 28.9 percent of CHWs primarily serve rural clients, while 43.4 percent primarily work with urban clients. Callaghan reported that in both rural and urban areas, CHWs are employed in a variety of settings: hospitals, doctors’ offices, clinics, non- profits, academic institutions, and community outreach organizations. However, certain trends emerge when looking at the percentages of urban and rural CHWs working in each of these settings. For example, urban CHWs are more likely to work in hospitals and in community outreach settings than their rural counterparts. He attributed this to a lack of hos- pitals in rural areas and the long distances rural CHWs would have to travel to go door to door for community outreach. Instead, rural CHWs are more likely to be working in doctors’ offices and clinics. Additionally, they are more likely than urban CHWs to work in roles that are harder to define or categorized as “other” because their work does not fit neatly into the specified category descriptions. The demographic characteristics of rural and urban CHWs also dif- fer, said Callaghan. The average age of rural CHWs is about 3 years older than their urban counterparts, which is consistent with the demographics of the general population living in rural areas. Rural CHWs also tend to have lower levels of education, with 42.3 percent holding a bachelor’s degree compared to 52.3 percent of urban CHWs. An overwhelming majority (90 percent) of CHWs in the survey data were female. This trend is even more pronounced in rural areas, where only 6.2 percent of CHWs are male, than in urban areas, where 12.5 percent are male. Beyond demographics, the work performed by CHWs looks different in urban versus rural areas. Callaghan highlighted two key differences that were evident in the focus groups. The first is that urban CHWs tend to be specialists that are highly focused on a specific task (e.g., enrolling individuals in a program), a certain subpopulation, or a specific disease like diabetes. In contrast, rural CHWs tend to be generalists. They are more likely to address all of the needs of the individuals because there may be no equivalent health care workers in the area to address patients’ various needs. As a CHW in rural Minnesota remarked: In an urban setting often they’re adding a CHW specialized in diabetes, specialized in prenatal care, specialized in something that they can really train that individual, and they have a large enough population that they can serve just that population, and that it really makes that difference in those urban areas. And I think the big thing I’ve seen different for us in a rural area is we have to be very generalist. Callaghan noted that in addition to the reduced number of programs in rural areas, CHWs in these regions also have fewer resources available PREPUBLICATION COPY—Uncorrected Proofs

RURAL HEALTH CARE IN ACTION 61 to which their clients can be linked. Even where there are programs avail- able in rural areas, they tend to be more limited than in cities. In contrast, patients in some urban areas can be overwhelmed with the number of resources that are potentially available to them, as was articulated by an urban CHW: Everybody in Boston that has something going on has been offered some kind of program. Really, they’re so overwhelmed by, “Oh, we have five different programs, I don’t want another program.” In the same state of Massachusetts, a rural CHW responded: In rural areas here, there’s less transportation, there’s less resources, there’s less funding. Sometimes it can be trying. We have a program right now that CHWs work with: if you’re struggling with food, we can give you a gift card for a certain amount, each person in the house, but that’s limited. We can’t give it to everybody, and everybody at some point has problems with food insecurities. Challenges in Building the Workforce of Community Health Workers Callaghan explained that beyond the lack of resources available for rural clients, there are challenges within the way CHW jobs are struc- tured. Even as this field grows, CHW study participants repeatedly noted key barriers to expanding the workforce in ways that would particularly benefit rural America. Two of the barriers emerged as most prominent in the study. The first issue is the variety of terminology used to describe CHW positions. Callaghan and his team identified dozens of terms for CHWs such as promotor(a), health educator, and health navigator. The absence of a widely accepted nomenclature poses challenges to the profes- sionalization of this field, as terminology is important in the creation of regulations and consistent standards. Without an agreed-upon term for CHWs, confusion might arise as to whether state and federal laws and regulations are applicable. For example, if a law is passed in Texas focused on CHWs, people working under the title of promotor(a) or health educa- tor may be unclear as to whether the law applies to them. The second major challenge repeatedly cited by CHWs was payment, with respect to both sources of funding and practices for billing. Many CHWs reported working in grant-funded positions that do not provide them with long-term security, because their jobs may disappear with the end of the grant cycle. Challenges in billing practices relate to the lack of billing codes for services to address SDOH and other social factors PREPUBLICATION COPY—Uncorrected Proofs

62 POPULATION HEALTH IN RURAL AMERICA IN 2020 of health outcomes, said Callaghan. The challenges involved in funding CHW positions can discourage health care providers from hiring CHWs despite the improvements they can have on patient outcomes. Community Health Worker Efforts to Combat COVID-19 Callaghan noted that extensive efforts to train CHWs across the coun- try to address the global pandemic began almost as soon as COVID-19 started spreading across the United States. In Texas, for example, the first training sessions were held in early March, including a session in South Texas for promotores along the Texas–Mexico border. The National Associa- tion of Community Health Workers,17 the American Public Health Asso- ciation’s CHW Section,18 and various training centers across the country have been promoting CHW workshops to help them fight the coronavirus pandemic and to ensure CHWs are staying safe. Callaghan stated that research by his team suggests CHWs are taking on new roles in response to the pandemic. A prominent role is contract tracing, which is vital to understanding the spread of the disease. Cal- laghan said that CHWs are well qualified for this role because they come from the communities they serve, enabling them to provide culturally appropriate support and establish trust with patients in a way that might be more difficult for contract tracers from outside the community. CHWs’ pandemic-expanded roles also include tasks such as making masks for vulnerable individuals and picking up groceries for individuals who might be too vulnerable to go into stores themselves. As CHWs continue to perform their previous roles, they have had to adapt their work in order to practice social distancing—including increased use of teleconferencing technologies to safely connect to clients. Certain challenges that have emerged during the pandemic particu- larly affect rural CHWs, said Callaghan. Because of a lack of Internet access in many rural areas, some rural CHWs cannot use teleconferencing with their clients, making it more difficult to provide socially distanced services. In addition, many CHWs have been laid off because of the reduced funding many organizations have experienced during the pan- demic. Additionally, billing for in-person services addressing SDOH is even more difficult when these services are provided online. 17 More information about the National Association of Community Health Workers is available at https://nachw.org (accessed August 6, 2020). 18 More information about the American Public Health Association’s CHW Section is avail- able at https://www.apha.org/apha-communities/member-sections/community-health- workers (accessed August 6, 2020). PREPUBLICATION COPY—Uncorrected Proofs

RURAL HEALTH CARE IN ACTION 63 DISCUSSION Telehealth Mental Health Services During the Pandemic Morris asked about the role of telehealth services in response to the COVID-19 pandemic—particularly the delivery of mental health services for youth and older adults. Calac replied that at the Indian Health Council facility where he works, the behavioral health wing continues to serve clients at nearly the same capacity (roughly 90 percent) of pre-pandemic levels through the use of telehealth services for both adult and pediatric client populations. He noted that a disadvantage of delivering mental health services through telehealth, especially for pediatric patients, is that it limits the amount of observation data that a clinician can collect. However, telehealth sessions have the benefit of allowing the clinician to observe pediatric clients in their home environments, which is helpful for behavioral health services. The patient response to the shift to tele- health has been varied, added Calac. Some individuals are frustrated by the platforms and by the limited capacity in some areas. Creative efforts have been made to address these issues by using nonsecure platforms that patients may be more familiar with (e.g., FaceTime, Zoom) in between scheduled sessions. Other clients enjoy being in their home environment for telehealth appointments because the setting feels less formal, he noted. Rural Health Care Financing Challenges Morris asked about the types of research that may be needed to deter- mine which hospitals are at the highest risk of closure, about the role of the COVID-19 pandemic in determining that risk, and about long-term improvements that are needed beyond basic reimbursement changes and pilot programs. Moore responded that financially fragile systems are vulnerable because they lack reserves, so any disruption can heavily impact vulnerable entities. The stressors that came with the pandemic, like cancelled outpatient procedures, had an immediate negative effect on the finances of rural facilities. He explained that these types of facili- ties generally are not structured to provide a high volume of inpatient services, so their budgets are often based on outpatient procedures that may comprise 60 to 80 percent of their total business. At the same time that rural facilities were seeing a decline in patients, urban areas were working to handle surges in patients with COVID-19, noted Moore. Consequently, underutilized rural hospitals were identified in some discussions as a potential resource to meet the increased need for medical care. Although these rural hospitals may be underutilized for elective and preplanned procedures, the surge capacity in rural hos- pitals might quickly disappear as individuals requiring hospital care for PREPUBLICATION COPY—Uncorrected Proofs

64 POPULATION HEALTH IN RURAL AMERICA IN 2020 COVID-19 in rural areas would still require the nearest ER. Moore was also concerned about the possible underreporting of COVID-19 cases in rural areas and the potential for rural health systems to exceed their capacity if rural regions experience the type of escalations in case numbers that were initially seen in urban centers. Moore added that long-standing disparities have become more prominent as the COVID-19 pandemic has begun to put additional stress on systems. Rural facilities already tend to have limited resources, and because smaller health facilities are often at the tail end of the supply chain, it is unclear whether health facilities will have the capacity to respond to a surge of COVID-19 cases in rural areas. Calac remarked that the COVID-19 outbreak in the Navajo nation in Arizona highlights the need for better processes around emergency preparedness in the future. He added that the pandemic affects different tribes in different ways, so improved processes and preparedness will need to be tailored to their specific settings. For instance, California has a general population of 33 million people and is home to more than 60 tribal entities, so an effective outbreak response in that state will look different than the response in Arizona. Regions in close proximity to the U.S.–Mexico border also face setting-specific challenges related to the COVID-19 pandemic. For instance, it has been difficult to translate and implement social distancing policies in border towns in Texas, where hospitals have seen an influx of patients from across the U.S.–Mexico bor- der. Similarly, southern San Diego County has a much higher COVID-19 infection rate than northern San Diego, suggesting that proximity to the border may exacerbate certain challenges faced by communities affected by COVID-19. Menachemi contended that 70–80 percent of all of the challenges in the U.S. health care system stem from chronic underfunding and chronic underappreciation for public health, which put a strain on vulnerable facilities. He suggested that the COVID-19 pandemic may present a criti- cal opportunity to rethink decades-old challenges in public health—even if it means political fallout for some leaders—and to implement holistic changes to the health care system at large. Morris remarked that issues of structural urbanism, rural hospitals, hospital closures, and pick-your-provider services all relate to the cen- tral issue of health financing. Small tweaks in financing or health sys- tems, such as increasing reimbursement by a small percentage, will not adequately address the situation. Menachemi agreed and responded that tweaking reimbursement within current structures would not be suf- ficient, as “reimbursement” implies medical care reimbursement rather than health care reimbursement. He added that the United States does a much better job at providing medical services than keeping people healthy or preventing diagnosed diseases from becoming more severe. PREPUBLICATION COPY—Uncorrected Proofs

RURAL HEALTH CARE IN ACTION 65 He suggested that the concept of health should be infused into the way society perceives health care, because many people think of health care merely as better medical care, but an insurance card does not solve life problems that are exacerbating one’s health issues; it only helps patients cope better with the health issues they have, and it is not the most cost- effective method of promoting health, he added. Callaghan said the current paradigm of the health care system is focused on profit maximization, which will continue to lead to more problems in rural areas. When profit maximization is the goal, rural areas are at a disadvantage because health care work in rural areas is typically less profitable than operating large urban hospitals. Callaghan suggested incentive structures need to be changed so that both health needs and the SDOH are addressed. He predicted that given current conditions and the trends of hospital closures, the health of rural communities will likely worsen owing to factors such as the need to travel longer distances for care. Coordinating Care in Rural Areas Morris questioned whether better use of wraparound services and CHWs could help ensure that care is coordinated, especially after people traveling long distances for specialty care return to their rural communi- ties. Although his presentation focused on licensed or credentialed indi- viduals, Menachemi clarified that CHWs certainly fit the definition of wraparound service providers. With the shortage of traditional wrap- around service providers in rural areas, CHWs who are already work- ing as generalists could feasibly be quickly trained to do the jobs that a half dozen professionals would perform in settings with more resources. However, he cautioned that this is a “path of least resistance” in that rather than building a health care workforce of highly trained individuals in rural areas, CHWs with less training become even more overburdened. This could perpetuate the problems of structural urbanism, he added. Callaghan noted a debate in the CHW community over training and education. Many CHWs say they do not want additional training and education, because they value being a part of the community and feel that training would shift them from being a community member to being an “other.” This gives rise to the question of whether additional training and education would affect the way patients relate to CHWs. He added that the effective provision of wraparound services in rural communities—for rural patients who have transferred home from large urban hospitals, for example—requires the type of robust coordination of care and communi- cation between urban and rural health providers that is not commonplace. PREPUBLICATION COPY—Uncorrected Proofs

66 POPULATION HEALTH IN RURAL AMERICA IN 2020 Leveraging the Strengths of Rural Areas and Tribal Nations Morris asked about the strengths of tribal nations and rural areas that policy makers should better understand. Moore responded that “rural areas are resource restricted, but they’re relationship rich.” He suggested that a strong sense of community and responsibility are rural strengths that would contribute to the delivery of effective care if needed changes could be made to the health care system. He used the analogy of electrical infrastructure to point out that governments take responsibility for run- ning electrical lines in rural areas, but property owners are often respon- sible for the last quarter mile connecting their properties to the public infrastructure. Similarly, social services are needed in rural communities to manage health before expensive medical issues arise. Rural communi- ties can rise to meet this challenge if there is proper health infrastructure in place, he suggested. A market where efficiency is driven by volume will not work in rural areas, Moore said. Rural communities do not have more volume to contribute to the system, so efficiency has to be driven by decreasing use of services in situations where it can be avoided. He suggested that CHWs and social services can contribute in this regard by addressing issues early on and preventing them from developing into expensive medical issues. Moore said the relationship-rich culture of rural communities is well equipped to carry out this type of early intervention. Calac agreed that strong social structures, as well as the component of resiliency, have persisted in rural communities. This has allowed people to rely on one another for support in facing challenges related to access- ing health care, he said. Unfortunately, this strength has proven to be an Achilles heel in the face of the pandemic, as individuals accustomed to relying on one another are being asked to stay at home and risk com- pounding their geographic isolation with social isolation. However, he suggested that the ability to tap into their resiliency will allow rural peo- ple to persevere. CHWs and wraparound services are another strength, he added. Physicians may only be able to see an individual for 15 minutes at a time, but sending a public health worker, a public health nurse, or a dietician to work with a client in person or via telehealth allows for the provision of a higher level of care to the community. Morris asked why so little research has been conducted on the ben- efits to rural population health of coordinated care that includes wrap- around services and CHWs. Menachemi responded that in most other developed nations, social workers do not deal with health care issues, but in the United States, social workers are patching up gaps in the health care system. He suggested that this is one of the many problems caused by the chronic underappreciation and underfunding of public health. In contrast to countries with well-organized and well-functioning health care systems that treat medicine and public health as two sides of the same coin, in PREPUBLICATION COPY—Uncorrected Proofs

RURAL HEALTH CARE IN ACTION 67 the United States they are treated as different structures that require dif- ferent training. Most people in the medical care delivery system do not interact with their local public health agency and have little interaction with their state agency, with the exception of data reporting required by law. Menachemi suggested that there is much room for partnerships and innovation in rural areas. By leveraging the strengths of relationships and trust in rural communities, innovations could be developed in rural areas and then scaled up to urban settings, he added. Morris asked about data sources to better understand and scale up social services support structures. Menachemi suggested that the fields of implementation science and health services research could contribute, but the “elephant in the room” is that social services are being funded unsustainably through charity, philanthropy, and grants instead of being built into the bedrock of the health care systems in rural communities. PREPUBLICATION COPY—Uncorrected Proofs

PREPUBLICATION COPY—Uncorrected Proofs

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Rural America is economically, socially, culturally, geographically, and demographically diverse. This multidimensional diversity presents complex challenges and unique opportunities related to delivering health care and improving health outcomes and health equity in rural communities.

To explore issues related to population health in rural America, the Roundtable on Population Health Improvement of the Board on Population Health and Public Health Practice of the National Academies of Sciences, Engineering, and Medicine convened a public virtual workshop, "Population Health in Rural America in 2020" on June 24-25, 2020. The workshop planning committee was composed of rural health experts representing public health, health care, and tribal health. Presentations and discussions focused on rural America in context, rural health vital signs, rural health care in action,assessment and implementation strategies for improving the health and health equity in rural populations, and rural health policy.This Proceedings of a Workshop summarizes the presentations and discussions from the workshop.

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