ACCESS TO QUALITY HEALTH SERVICES IN RURAL AREAS - PRIMARY CARE
by Larry Gamm, Graciela Castillo, and Stephanie Pittman
In light of
these and other challenges, the first listed Healthy People 2010 goal is to
improve access to comprehensive, high quality health care service.1 Many of the
access to primary care issues addressed by Healthy People 2010 are problems
experienced in many rural areas of the
This review addresses the following HP2010 objectives:
Affecting these objectives in many rural areas are shortages of primary care providers, including primary care physicians and non-physician primary care providers (NPPCPs), such as nurse practitioners (NPs) and physician assistants (PAs); and an under-representation of female and minority PCPs. Progress on these objectives should contribute to effective utilization of preventive services and primary care by all rural population groups to attain reductions in avoidable hospitalizations and to improve overall health status.
According to the Rural Healthy People 2010 survey, access to quality health services (which includes access to primary care) was rated as the top ranking rural health priority. Approximately three-quarters of the respondents named access as a priority.2 It was the most often selected priority among all four types of state and local rural health respondents in the survey and across all four geographic areas. Nine out of 10 leaders of state health organizations nominated access as a priority, while about two-thirds of the public health agencies, rural health centers and clinics, or hospitals did the same, a statistically significant difference among the groups.3 No significant differences across regions appeared, as access nominations appeared uniformly high across four geographic regions of the country. Also, in a preliminary survey of state and national rural health experts allowing them to state priorities in an open-ended fashion, three topics related to primary care¾access to primary care, access to health workforce, and access to health services¾were frequently named as a rural priorities.4 One or more of these three primary care topics was named by nearly two-thirds (65 percent) of those who nominated priorities in this preliminary survey.
Rural and urban populations are relatively equal in having a source of ongoing care (nearly 90 percent) and in having a usual primary care provider (approximately 77 percent). Rural residents are less likely, however, to have regular access to their usual primary care provider during evening or weekend hours.5
Hispanics are much less likely than white and African-American populations to have an ongoing source of care. And, rural Hispanics are less likely than their urban counterparts, 77 percent and 72 percent respectively, to have an ongoing source of care.6 Hispanics and African Americans record, respectively, an estimated 20 percent and 33 percent fewer primary care visits per person than white, non-Hispanic persons.7
Uninsured people under the age of 65 are 2.6 times less likely to have a usual source of care than people who have public or private insurance.1, 8 In 1996, 23 percent of rural residents under the age of 65 were uninsured compared to only 18 percent in urban areas.6
The
maldistribution of physicians in favor of urban areas is a continuing concern
affecting rural access to care. The maldistribution is especially pronounced
with respect to specialists and is likely to become an increasing problem with
primary health care.9 Although 25 percent of the nation’s population resides in
rural areas, less than 9 percent of active physicians in the
There has been a general increase in the number of physicians in both rural and urban areas over the past decade; however, a closer analysis of both national productivity data and estimates in two states of those physicians actually practicing suggests little growth in the effective supply of rural physicians and a decline of 9 percent in the supply of family physicians.12 Moreover, the ratios of physicians per 100,000 population for several other specialties that are frequently classified among primary care physicians—pediatricians, general internists, and obstetrician/gynecologists—are only one-third as large among rural populations as among urban populations.
The increasing number of physicians who are women may further restrict the supply of rural physicians. Women account for almost 43 percent of all general physicians among the most recent medical graduates, but they are less likely to practice in rural areas than in urban areas.13 Only 13 percent of rural physicians are women compared to 19 percent of physicians in urban locations who are women. The disparities in percentages of female physicians practicing in rural areas are even more pronounced with respect to rural family practitioners/general practitioners (FP/GPs) and obstetrician-gynecologists.13
Minority general practitioners are more likely to serve minority populations and larger proportions of the poor and/or uninsured.14-16 Moreover, there is evidence that minority patients prefer to see physicians who are of the same ethnic/racial group as themselves.17 African-American and Hispanic-American physicians are much more likely than white physicians to come from a rural or inner city background and to have graduated with a National Health Service Corp service obligation. These minority physicians also report relatively larger proportions of their patients are poor, reliant on Medicaid, and reflect the same racial/ethnic background as their own.15
Non-physician primary care professionals, such as physician assistants, nurse practitioners, and certified nurse midwives (CNMs), are becoming more important and more common in rural and urban areas. In comparison to rural and urban physician-to-population ratios, NPPCP-to-population ratios appear to slightly favor rural settings. NPPCPs are able to provide needed primary care in most cases and, earning less than physicians, are better able to conform to the resource constraints in rural areas than physicians.18
Even in situations where a local physician is available in a rural community, as many as 30 to 40 percent of rural residents may rely on physicians outside of their locality for care. Reasons given usually are associated with seeking better care, or care that exceeds the skills or technologies available in the rural community.19, 20
The under-representation of female physicians in rural areas may also have an effect on the health of female residents of rural areas. It has been shown that female patients usually prefer female doctors and are more likely to receive pap smears and mammograms if done by a female physician, especially if the physician is an internist or family physician.13
One consequence of an undersupply and/or underutilization of primary care providers may be increased hospitalizations that might have been prevented with the timely provision of preventive services and primary care service. As many as 12 percent of all hospitalizations may be avoidable.21 Nationally, such hospitalizations have been found to be more prevalent among lower and middle income groups and among African Americans.21 A 10-state study finds both African Americans (especially adults), Hispanics (especially children), and the elderly in both minority groups more likely than whites to be hospitalized with preventable conditions.22
An
Studies reveal that primary care physicians who were raised in rural areas are more likely to practice in rural areas.24 One study found that greater than 50 percent of rural female physicians were raised in a town with less than 25,000 people.10 Several recruitment factors, especially family lifestyle factors, serve to differentiate between female and male physicians in their rural practice location choice. Social issues of interest to female physicians include rural-magnified challenges such as balancing work and family, maternity leave, availability of child care, and job opportunity for the spouse or partner.10, 25 Professional issues include such matters as work overload, lack of female colleagues, fewer opportunities for advanced training, and acceptance by the community.10
The undersupply of minority physicians in rural areas is no doubt related, in part, to the relatively smaller number of underrepresented minorities (URMs) who are enrolled in medical colleges and who are applicants to American medical colleges. The number of URMs enrolled in American medical colleges peaked in 1994, remained steady in 1995, and decreased by 5 percent in 1996. The enrollment of URMs has declined steadily from 1996 through 2001.26, 27 The decline is attributed in large part to reductions occurring at public medical schools and in states directly affected by 1996 court and referenda decisions on affirmative action.26-28
Access to non-physician primary care providers is limited in some instances by scope of practice regulations that vary from state to state, some national and state-specific reimbursement constraints, and by competition from urban areas for limited numbers of providers.29 NPPCPs practicing in rural, or in more remote rural settings experience greater autonomy or independence than those in other settings.30-32 Although such conditions may be attractive to some NPPCPs, it is possible that it may be offset by greater monetary benefits and professional support found in larger, urban facilities.29
Several state studies examine factors that appear to be associated with ambulatory care sensitive conditions (ACSCs) leading to avoidable hospitalizations, i.e., hospitalization that might have been prevented by proper utilization of primary care. There is unanimity in finding low income to be strongly associated with ACSCs; moderate support for greater prevalence of ACSCs among non-whites; and only mixed support regarding the impact of access to primary care physicians upon ACSCs.33-35
PROPOSED SOLUTIONS
Communities, often working through partnerships among providers, can help to develop programs to improve access to care and/or a regular provider to people who are uninsured or otherwise likely to underutilize health care. A number of solutions to access to primary care are dependent upon support from national and state policies affecting medical education and placement of medical graduates in rural and urban underserved areas. At the same time, medical schools can play an important role in developing, often with grant support, special tracks that emphasize family practice and rural placements.36
Access to primary care is vital to the achievement of Healthy People 2010’s goal of improving access to high quality health services. The objective of maintaining a regular source of care is exceptionally
difficult to achieve in rural America given the shortage of not only primary care physicians but also non-physician primary care providers, specialists, female physicians, and minority physicians. Given the higher proportion of elderly and poor in rural areas¾two populations often requiring more health care¾the consequences of provider shortages are significant.
Practice conditions and personal considerations may lead some physicians away from practice in rural
areas. At the same time, there is evidence that those who are from rural areas and/or who have trained in rural areas are more likely than others to pursue rural practice. Although physician assistants and nurse
practitioners are somewhat more likely than physicians to pursue positions in rural areas, the
opportunities in rural practice, e.g., greater practice autonomy, may be offset by more attractive practice
opportunities and salaries in urban settings.
Despite these challenges, viable solutions may exist through training programs with a rural focus for health provider students, loan repayment programs, recruitment of rural students, especially underrepresented minorities for medical school, and continued recruitment and retention efforts directed toward non-physician providers. The desirability of larger numbers of women enrolled in medical schools and in the medical profession needs to be followed by greater efforts to recruit medical students from rural areas and to recruit and retain more female and minority physicians in rural practice.
Finally, increased efforts are needed to reduce avoidable hospitalizations in rural areas, especially among poor and minority groups. Increasing the number of rural providers and their adoption of best practices in addressing ambulatory care sensitive conditions such as diabetes and asthma are important factors in reducing avoidable hospitalizations and improving the health status of the rural population.
The following models for practice are examples of programs utilized to address this rural health issue.
4.
Gamm, L., and
5. Center for Primary Care and Workforce Analysis. The
health care workforce in ten states: Education, practice, and policy.
8.
9.
Lishner, D.M.;
10. Barley, G.E.; Reeves, C.B.; O’Brien-Gonzales, A.; et al. Characteristics of and issues faced by rural female family physicians. Journal of Rural Health 17(3):251-258, 2001.
12. Ricketts, T.C.; Hart, L.G.; and Pirani, M. How many rural doctors do we have? Journal of Rural Health 16:198-207, 2000.
13. Doescher, M.P.; Ellsbury, K.E.; and Hart, L.G. The distribution of rural female generalist physicians in the United States. Journal of Rural Health 16:111-118, 2000.
18.
Baer, L.D., and Smith, L.M., eds. Non-physician
professionals and rural
21.
Pappas, G.; Hadden, W.C.; Kozak, L.J.; et al. Potentially avoidable
hospitalizations: Inequalities in rates between
24. Fryer, G.E., Jr.; Stine, C.; Vojir, C.; et al. Predictors and profiles of rural versus urban family practice. Family Medicine 29:115-118, 1997.
25. Ellsbury, K.E.; Baldwin L.M.; Johnson, K.E.; et al. Gender-related factors in the recruitment of generalist physicians to the rural northwest. WWAMI RHRC Working Paper #62, February 2001.
29. Krein, S.L. The employment and use of nurse practitioners and physician assistants by rural hospitals. Journal of Rural Health 13:45-58, 1997.
30. Chumbler, N.R.; Weier, A.W.; and Geller, J.M. Practice autonomy among primary care physician assistants: The predictive abilities of selected practice attributes. Journal of Allied Health 30:2-10, 2001.
31.
Martin, K.E. A rural-urban comparison of patterns of physician assistant
practice. Journal of the
32.
Muss, K.J.; Geller, J.M.; Ludtke, R.; et al. Implications for recruitment:
Comparing urban and rural primary care PAs. Journal of the
38.
O'Grady, M.J.; Mueller, C.; and Wilensky,
G.R. Essential research issues in rural health: The state rural health
director's perspective. Policy Analysis Brief, Series W, Vol. 5 No. 1.
Gamm,
L.; Castillo, G.; and Pittman, S. (2003). Access to Quality Health Services in
Rural Areas¾Primary Care. Rural Healthy
People 2010: A companion document to Healthy People 2010. Volume 1.
MODELS FOR PRACTICE
FOCUS AREA: ACCESS (PRIMARY CARE)
Program Name:
Location:
Problem Addressed: Access to Primary Care
Healthy People 2010 Objective: 1-4a
Web Address: None
SNAPSHOT
The Community Health Center of West Yavapai County (CHCWYC) began as a free clinic approximately seven years ago. The clinic became a community health center in January 2001 and plans to apply for 330 funding from the Bureau of Primary Health Care in the Health Resources and Services Administration (HRSA). The program has grown from seeing 25 patients per night, two nights a week, with a volunteer staff, to seeing 3,000 patients (uninsured and underinsured) in the first year. CHCWYC has a paid staff of seven and shares an additional four to five staff with the health department. The center is a 501(c)(3) non-profit organization. It was recently awarded a HRSA Community Access Program (CAP) grant allowing it to purchase equipment and software to set up a practice management system and an electronic medical record system. It is one of 16 programs to receive a Robert Wood Johnson Foundation (RWJF) grant to integrate mental health into primary care.
THE MODEL
Blueprint: The CHCWYC service area
covers 8,000 square miles. The center is co-located with the Yavapai County
Health Department, with which it shares resources, including staff. The center
has close working relationships with a variety of partners including the health
department, hospital, laboratories, a mental health center, and the
A HRSA CAP grant awarded in 2001 allows the center to purchase equipment and software to set up systems for sharing of patient data and support patient tracking, demographics, insurance, etc. between their sites and with other provider partners who see the same clientele.
Beginnings: The free clinic began as a class project developed by a nurse in the community who was working on her BSN degree. The clinic almost immediately began seeing 25 patients each night, two nights a week. The success of the free clinic and subsequently of the center was and is attributable, at least in part, to the strong support and commitment of the medical community.
Making a Difference: Evaluation of this grassroots effort up to this point has focused on counting the numbers of people who come through the doors. The program recorded 3,000 uninsured patient visits in the first year plus approximately 400 Medicaid clients. A more sophisticated evaluation is anticipated in response to the CAP grant and RWJF funding; however, these are not yet in place.
Challenges and Solutions: Over the course of seven years, with seeing 25 clients every night, volunteer burnout became an ever-present problem. The move to a community health center daytime operation and the complexity of the computer system resulted in the discontinued use of volunteers. However, the loss of volunteers was offset by state tobacco funding ($358,000 per year) and revenues from Medicaid, Medicare, and self-pay that enabled the center to hire staff. The center hired its first full-time director, a full-time medical director (provider), a part-time physician, and a part-time nurse practitioner. The new mental health clinic has about 10 volunteers.
Currently, the center has two physical locations and plans to expand to three or four sites. There is a mountain range in between the main site and the other location(s). CAP funding will be used for electronic medical records and patient management systems that will support sharing of patient data, patient tracking, demographics, insurance, etc.
Space
has been an issue since the free clinic began. Co-location with the local
health department, which also enables the sharing of staff resources, has been
very successful. A new facility, with 11,000 square feet, is due to open in
2003. The facility represents a pooling of resources¾$500,000 received by the center from the
state for a building, $1.8 million from
Continued funding is always a problem. The center has been successful applying for funds that support caring for the uninsured, implementation of mental health services, and a computer infrastructure. The need still exists for funds that cover the staff who deliver the services. The center is applying to become a 330 funded Federally Qualified Health Center to help cover indirect service costs.
PROGRAM CONTACT INFORMATION
Peggy Nies, Director
Phone: (928) 771-3369
Fax: None
MODELS FOR PRACTICE
FOCUS AREA: ACCESS (PRIMARY CARE)
Program Name:
Location:
Problem Addressed: Access to Primary Care
Healthy People 2010 Objective: 1
Web Address: http://www.fairview.org/telemedicine
The Fairview
University of Minnesota Telemedicine Network (FUMTN) is an established means of
providing care to rural
Blueprint: The Fairview University of Minnesota Telemedicine Network exists to improve access to health care for rural individuals across the lifespan, strengthen linkages with rural practitioners, and foster integrated systems of care. The network currently includes the hub site and seven rural spoke sites. It provides services including cardiology, diabetic management, wound care, dermatology, homecare and hospice, child psychiatry, rheumatology, long-term care, orthopedics, pulmonology, and rural health clinic support by using interactive video-conferencing and store-and-forward telehealth technologies. Services encompass the wide span of technologies available, from low-bandwidth video conferencing and Internet access into a patient’s home, to high-band live interactive video-conferencing within system sites.
The hub site at
the
Making a Difference:
A Minnesota Department of Health statistical report on morbidity shows that
deaths from cardiovascular disease in the 11-county region around Todd, Wadena,
and Otter Tail Counties are the highest in the state of Minnesota. Decreased
access to cardiology specialists contributes to this problem.
Under its
current grant schedule, FUMTN has created additional targeted spoke sites that
include one additional primary spoke site and four primary rural spoke sites,
one of which will serve a federally recognized Indian community. Additional
sites specific to
Beginnings: The lack of access to primary care was identified through
needs assessments that were coordinated by the Fairview-University of
The original
telemedicine program received three years of funding from the U.S. Office of
Rural Health; it then functioned independently of external funds for two years
with support from
Challenges and Solutions: The challenges encountered by telemedicine sites that have ultimately failed have involved lack of physician “buy in” of the program. The Fairview University Telemedicine Network believes that each potential site needs a “physician champion” who believes in and can educate the medical staff on the telemedicine process, programs, and advantages. This is especially important since telemedicine sites will not be successful without physician referrals.
Robin Klemek, RN, Telemedicine/Outreach Services Manager
415 North
Phone: (218) 631-7497
Fax: (218) 631-7596
MODELS FOR PRACTICE
FOCUS AREA: ACCESS (PRIMARY CARE)
Program Name:
Rural Health Network of
Location:
Problem Addressed: Access to Primary Care
Healthy People 2010 Objective: 1-4, 1-5, 1-6
Web Address: http://www.ruralhealth-floridakeys.org
The Lifelines
Project is a project of the Rural Health Network of Monroe County (RHNMC) (
Blueprint: Beginning in August 1999, RHNMC, a coalition of 36 agencies
and individuals who govern the Lifelines Project and all functions of the
network, has provided primary health care to persons in need in the Florida
Keys regardless of ability to pay. Lifelines is marketed to the uninsured,
underinsured, working poor, and homeless. Income levels of clients usually fall
below 200 percent of the federal poverty level (FPL), with a majority of
clients with incomes at or below $15,000 per year. Lifelines provides
outpatient, primary health care that includes such elements as pharmaceutical
assistance, discounted laboratory costs, health education, women’s health
exams, and referrals. All clients are asked to pay a $10 co-pay if they are
able. RHNMC has two mobile unit vans, staffed by two teams of medical practitioners
that include two paid registered nurses and advanced registered nurse
practitioners. The project also employs health educators, a health services
director, and a medical director. The vans travel the islands of the
Making a Difference: The
Lifelines Project provides health care to the uninsured with a level of service
that historically was not available in Monroe County before 1999. About 3,200
services are provided each year. Sixty clients were randomly selected from the
multiple service sites to complete a service satisfaction survey. All 60
clients responded positively to overall satisfaction with the services. The
health services director reports that 100 percent of the time, responses to
inquiries for appointments occur within 24 hours. The project has also reduced
the number of visits to the local emergency room, therefore reducing emergency
room costs for patients and providers. RHNMC has been successful in securing
interim funding from the Health Foundation of South Florida and Catholic
Charities. It also received sustaining funding for the first time in the
project’s history from the
Beginnings: The Lifelines Project
was created as the result of a reduction in health care services offered by the
local health department. In 1998, the director of the county health department
notified the RHNMC executive director that the residual services provided by
the health department in
Challenges and Solutions: The
The Lifelines Project advertises to prospective clients through advertisements on local access television, newsletters, brochures, and radio public service announcements. Changes in service location are placed in printed media ads, and brochures are distributed in neighborhoods of target populations. Additionally, the Lifelines Project markets to the community at large via the RHNMC website.
Mark Szurek, Ph.D.
Rural Health
Network of
Phone: (305) 293-7570
Fax: (305) 293-7573
MODELS FOR PRACTICE
FOCUS AREA: ACCESS TO PRIMARY CARE
Program Name: A Rural Minority Geriatric Care Management Model
Location:
Problem Addressed: Access to Primary Care
Healthy People 2010 Objective: 1
Web Address: None
Blueprint: The
Rural Minority Geriatric Care Management Model operates in a Federally
Qualified Community Health Center (FQHC), its satellite sites, and a rural
health clinic in
Making a Difference: Outcome measurements find these efforts to have significant success. These successes can be seen in the clients’ physical and financial status. For health care, 50 percent of the clients are up-to-date on preventive health services such as mammograms, prostate checks, flu shots, and cholesterol checks; 88 percent have had home environmental safety assessments with referrals, and 42 percent have been diagnosed with diabetes and are receiving ongoing management and education for this condition. Financially, 100 percent of those eligible have been linked with Supplemental Security Income, Medicare Disability, or Medicaid, as opposed to the 54 percent who were eligible but were not receiving benefits prior to the intervention. Fifty-seven percent of the clients receive medications from indigent drug programs; 54 percent receive energy assistance; 30 percent receive food stamps, and 35 percent receive mobile/congregate meals. The impact on the communities in which the program operates has been one of great accomplishment.
Beginnings: In 1997, the South Carolina Department of Health and Human Services provided funds to the Medical University of South Carolina (MUSC) to establish a “Healthy Community Outreach Initiative.” MUSC faculty submitted proposals for community programs that were peer reviewed by a panel of MUSC faculty. This community outreach model was chosen for funding for three years. In 2001, the program director submitted a request to the Duke Endowment and received funds to expand and extend the program an additional two years, with the goal of sustainability. The project director believes that a five-year time period is needed to facilitate infrastructure for community programs. The program targets primarily older African-American adults who have low incomes and are underinsured. This group was specifically targeted because of their need for education, advocacy in navigating the health care system, and assistance with linkages to public benefits and social services.
Challenges and Solutions: Maintaining funding for programs such as the Rural Minority Geriatric Care Management Model is challenging; however, the initiative has been successful in this area. A funding award from the Duke Endowment expanded the program to include five additional health center sites and extended the program for an additional two years. Also, the health centers were willing to pay a percentage of the coordinators’ salaries over the two-year extension and currently, as the grant funding cycle nears completion, the health centers have committed to retaining the geriatric coordinators as full-time staff. This allows for 100 percent sustainability to be achieved after funding has ceased. Finally, to further ensure future success, the staff publicizes project outcomes, continues to develop ongoing linkages with community agencies and programs to enhance community capacity building, and provides a system of care for older adults.
PROGRAM CONTACT INFORMATION
Esther M. Forti, Ph.D., RN
Associate
Professor and
Department of Health Professions
Phone: (843) 792-5487
Fax: (843) 792-0679
MODELS FOR PRACTICE
FOCUS AREA: ACCESS TO PRIMARY CARE
Program Name: St. Mary’s County Health Department Medical Assistance Transportation Program
Location: St.
Mary’s County,
Problem Addressed: Access to Primary Care
Healthy People 2010 Objective: 1-4, 1-5, 1-6
Web Address: http://www.smchd.org
The St. Mary’s County Health Department Medical Assistance Transportation Program is a safety net program designed to transport medical assistance patients by a variety of methods to their medical appointments in local and semi-local areas. These individuals have no other means of transportation and would not otherwise be able to attend their appointments and receive care. The program also provides transportation to non-medical assistance individuals for a nominal fee if they have an open seat and are traveling in the same direction.
Blueprint: The
Medical Assistance Transportation Program is grant funded by the Maryland State
Department of Health and Mental Hygiene and is managed by the St. Mary’s County
Health Department. Collaborative efforts and partnerships are relied upon for
some areas of service delivery. The primary focus of the Medical Assistance
Transportation Program is to get the medical assistance population of St.
Mary’s County,
All individuals
who participate or are eligible for the state Medical Assistance Transportation
Program qualify to receive the services of this program. The program provides transportation
to scheduled and urgent same-day trips to local and tri-county medical
appointments as well as trips to the
The St. Mary’s
County Health Department Medical Assistance Transportation Program has a
reciprocal agreement with a neighboring county (
Making a Difference: The St. Mary’s County Health Department Medical Assistance Transportation Program currently runs approximately 1,500 trips per month, totaling 15,000-20,000 miles. These trips are critical to enabling the medical assistance population to access needed medical care.
Beginnings: The
program began providing transportation services to the citizens of St. Mary’s
County in fiscal year 1993, and the program was fully implemented in fiscal
year 1994. The problem with transportation was identified by examining the high
numbers of missed appointments by this medical assistance population.
Non-compliance of patients with medical instructions and poor immunization
rates for children within this population were also recognized as problems that
could be partially attributed to a lack of transportation. In one instance, a
vulnerable individual was lost in
Challenges and Solutions: The program has experienced challenges in persuading the local government to extend/expand bus routes to where the lower income individuals live and to where the medical providers are located. In addition, the increased costs of ambulance transports threaten the program’s ability to continue 24/7 access to this service. Helping the riders develop responsibility skills for keeping appointments, calling to cancel, and being on time continue to be important challenges.
Mary C. Wood
St. Mary’s County Health Department Medical Assistance Transportation Program
Phone: (301) 475-4330
Fax: (301) 475-4350
MODELS FOR PRACTICE
FOCUS AREA: ACCESS (PRIMARY CARE)
Program Name:
Location:
Problem Addressed: Access to Primary Care, and Recruitment and Retention of Rural Health Professionals
Healthy People 2010 Objective: 1
Web Address: http://wvrhep.org
The West Virginia
Rural Health Education Partnerships (RHEP) was created to train health
professionals in rural, underserved communities. State law enables rural,
community-based facilities to provide this training in underserved, rural areas
of the state. The higher education system requires a three-month rotation and
service learning for degree completion for 10 disciplines of health
professional students in a state-supported program. Students spend 20 percent
of their time in the community on prevention and health education service
projects. Local boards, site coordinators, and field faculty help the students
choose projects that meet the community needs. The program is state funded and
consists of 13 regional partnerships and over 47 rural counties in the largely
rural
Blueprint: The program was first developed in 1992 and fully implemented in 1996 with the purpose of addressing three problems: recruitment and retention of the health care workforce in rural, underserved areas; access to primary health care for the underserved population; and rural health leadership and service learning for health professionals. It is a statewide partnership of local rural communities, higher education (19 state and private health professional schools and programs), and state government.
The program
consists of 13 regional partnerships, each with its own board, and covers 47
rural, underserved counties in
The program employs an executive and associate director, administrative secretary, director of research and evaluation, and 17 site coordinators and secretaries. Moreover, the program receives volunteer services from over half of the faculty preceptors and all 200 community member partners. It is funded by appropriations from the state legislature through a direct line item in the higher education budget.
The recruitment/retention program is critical to
the state since West Virginia is the second most rural state in the country,
with 64 percent of the population living in communities with under 2,500 people
and spread over 24,000 square miles. The program covers 47 counties, or 85
percent of all counties in the state. The rural population of these counties
represents 1,117,133 of the state’s 1.7 million people. Eighteen of these
counties are 100 percent rural, and all others are more than 50 percent rural.
The state is very mountainous with many secondary two-lane highways and roads.
In 1999,
Making a Difference: The Rural Health Education Partnerships program primarily focuses on providing prevention and education services to predominantly rural, low-income populations of all ages. In 2001, 216,127 community service contacts were made, and of these 148,593 were prevention and education to the general public; 16,808 were prevention and education for adults, and 50,726 were prevention and education for children. These services are provided by approximately 120 health profession students per month and represent 10 disciplines; 1,402 student rotations were completed in 2001 for a total of 6,822 weeks of training. The program trains and recruits rural physicians in addition to supplying manpower to rural health care facilities through the use of students. An online tracking system called TRACKER© is used to evaluate the program, schedule rotations, and track the practice location following training. This helps the program identify how successful it is in recruiting and retaining health care professionals in rural areas.
Beginnings: In 1990-1991, the
Challenges and Solutions: Some of the initial challenges included extending the training in rural, underserved communities as a degree requirement; working with lead agencies and some partners in building a partnership that was not a traditional hierarchical organization; devising a decision-making model that was equally shared among all partners; and developing full trust within the partnerships to share resources.
These challenges were overcome by developing a clear, open, and concise system of communication; involving all partners in defining vision, values, mission, strategies, outcomes, and policies regarding operations; and spending time to develop trust. This was facilitated by encouraging partnership interaction and consistently engaging community members and students in the process as the focal point of the partnerships’ outcomes. Keeping the focus on the community and the role of the community members as the stewards of the partnership helped to facilitate shared power in decision making.
The program is marketed through local newspapers, websites, and personal advertisements by practitioners. Presentations are also made at civic clubs, churches, social events, and special annual events. The program has been featured in a number of professional publications and is the recipient of numerous awards, including recognition by the U.S. Surgeon General. Examples include receipt of a Community-Campus Partnership, Inc. Award for Leadership, a spotlight in the New York Times, and a publication in the Journal of the American Medical Association.
PROGRAM CONTACT INFORMATION
Hilda Heady, MSW
Office of Rural Health