Larry Gamm, PhD and Linnae Hutchison, MBA, MT,

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Rural Healthy People 2010 A Companion Document
to Healthy People 2010
Presentation to Healthy People Steering
Committee December 10, 2003

• Larry Gamm, PhD and Linnae Hutchison, MBA, MT,
• Southwest Rural Health Research Center, School of
  Rural Public Health, Texas AM University System
  Health Science Center
• http//www.srph.tamushsc.edu/rhp2010

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Project Funding

• The Southwest Rural Health Research Center
• (SRHRC) at the School of Rural Public Health,
• Texas AM University System Health Science
• Center gratefully acknowledges grant support
• for this project from the Federal Office of Rural
• Health Policy and Health Resources and
• Services Administration.

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Presentation Outline

• Describe the Rural Healthy People 2010 project
  and its components

• Review some key points and a model for practice
  for each of two rural health priorities

• Share some emerging themes, current activities
  and plans

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Rural Healthy People 2010 Purpose

• Identify and investigate rural health priorities
  related to Healthy People 2010s 28 focus areas
  and 467 objectives
• Present current rural health research and models
  for addressing rural health priorities
• Attract more rural people to impressive resources
  offered by Healthy People 2010

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Project Components

• Survey responses from over 500 national, state
  and local rural health leaders to
• Nominate models for practice
• Establish rural health priorities
• Literature reviews on 10 broad rural priority
  areas
• Identify and describe Models for Practice

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Rural Healthy People 2010 A Companion Document
to Healthy People 2010 2 Vols.
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Rural Healthy People 2010 Priorities

• Determining Rural Health Priorities
• Surveys sent to over 1000 rural health leaders

• National agency, foundation, research center
  experts

• State offices of rural health, state primary care
  offices and associations, and state rural health
  associations and

• Samples of local rural public health agencies,
  rural health clinics and community health
  centers, and rural hospitals.

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RHP2010 Top Five Priorities

• Access to Quality Health Services
• Heart Disease Stroke
• Diabetes
• Mental Health Mental Disorders
• Oral Health

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Top 16 Rural Health Priorities
Priority rankings based on average percentages
of four groups of state and local rural health
leaders choosing objectives as a priority. There
are virtual ties among some priorities.

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Literature Review Format

• Scope of Problem
• Prevalence and Disparities in Rural Areas
• Factors Contributing to Condition in Rural Areas
• Impact of Condition on Morbidity and Mortality
• Contributor to Other Health Problems
• Known Causes so that Solutions are Identifiable
• Solutions that are Feasible in Rural Areas
• Identified by Rural People as a High Priority
• Community Models Known to Work

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Models for Practice Format

• Blue Print
• Making a Difference
• Beginnings
• Challenges and Solutions

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General Themes in Rural Health

• Cannot generalize to all rural areas

• Glass is both half-full and half empty

• More serious health problems in rural than in
  many urban areas and, particularly, suburban areas

• Many rural populations lack access to insurance
  or to professionals to address these problems

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Rural Health Themes (cont.)

• Rural communities, disadvantaged and not, are
  addressing many of these problems

• Many of Models for Practice efforts reflect a
  search for local solutions even as advocacy is
  pitched to state and national policy-makers to
  address rural disparities

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All health is local key factors

• life-style, e.g., smoking, diet

• timely access to screening/treatment

• educational and social support to control disease
  or stay healthy

• gaining more education

• gaining decent jobs and health insurance

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Priorities Models for Practice

• Will highlight two rural priority
• areas treated in the Rural Healthy
• People 2010 companion document.
• Will provide capsule accounts
• of a two of the 55 Models for
• Practice included in the
• final document.

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DIABETES

• Sixth leading cause of death
• Sixth and seventh leading cause of
  hospitalization for men and for women,
  respectively, 45 and older
• Self-reported prevalence is 17 higher in rural
  than central cities and 11 higher than in all
  MSAs

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DIABETES

• Diabetes rates
• Higher in Southwest and Southeast
• Among obese and those with sedentary lifestyles
• Among Hispanics and African Americans
• Increasing rapidly among children

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DIABETES-PENNSYLVANIA

• Snapshot Laurel Health System
• National Diabetes
  Collaborative
• Problem Addressed Diabetes management
• Services Provided
• Diabetes registry and management system
• - Clinical and self-management
• - Analysis of patient health status
• Estimated financial impact of intervention
• Diabetes education by community partnership

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DIABETES (cont.)

• Population Served
• Six federally qualified health centers of large
  health care system
• Beginnings
• Community-needs assessment revealed 45 higher
  incidence of diabetes-related mortality than
  state average

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DIABETES (cont.)

• Outcomes
• 10,000 to 20,000 cost savings for each averted
  stroke, MI, or coronary artery bypass
• Consistent monitoring of HgA1c levels, annual
  foot exams, immunizations, controlling blood
  pressure, and lipid profile performed
• Increased primary care revenue
• Challenges
• Institutionalization (met)
• Funding

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Diabetes/Hypertension-Mississippi

• Snapshot Delta Community Partners in Care
• Problem Addressed Diabetes and hypertension
  outreach case management
• Services Provided
• Case management
• Financial Assistance
• Transportation to provider clinics for assistance
• Referral and follow-up of social issues that may
  cause barriers in a patients response to care
• Individualized health education/self care
  planning
• Organized support services

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Diabetes/Hypertension (cont.)

• Population Served
• 11 county rural area in the Mississippi Delta
  region of northwest Mississippi
• Under- or uninsured between the ages of 21 and 64
  who have a diagnosis of diabetes, hypertension,
  or both.
• Beginnings
• Concerns of the local medical community
• Greater than expected numbers of patients in ERs,
  or with hypertension, strokes and undiagnosed
  diabetes
• Coalition of 19 partners

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Diabetes/Hypertension (cont.)

• Outcomes
• Decrease in past year from
• 1.01 visits to ER to 0.65
• 0.68 outpatient visits to 0.31
• 6.37 nights hospitalized to 3.4
• 26.74 sick days to 15.77
• Knowledge of both hypertension and diabetes
  increased, as well as the patients ability to
  control their own blood pressure and blood sugar
• Challenges
• Continuation of funding

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ORAL HEALTH

• Surgeon Generals Report acknowledgement of
  orals health importance to overall health
• Identified as the 5th highest ranking rural
  health priority with variation by respondent type
• Contributor to many other health problems
• Causes access to preventive care limited,
  linkages with tobacco, alcohol consumption, lack
  of flouridation

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ORAL HEALTH (cont.)

• Variation in dental disease incidence by age,
  gender, ethnicity, SES, and rurality
• Hispanic and African American children have
  higher rates of dental caries
• Rural versus urban
• Rural children - higher dental caries rates
• Fewer rural adults have dental visit in the past
  year
• Edentulism higher in rural areas

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ORAL HEALTH (continued)

• Why is oral health worse in rural areas?
• Differences in access and utilization
• Economic challenges
• Dental workforce shortages
• Proposed Solutions
• Dental insurance reform
• Flouridation, sealants
• Dental professionals supply

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ORAL HEALTH-MARYLAND

• Snapshot Choptank Community Health System
• Services Provided Oral health services at
  schools (using portable equipment)
• Problems Addressed
• Screenings, cleanings, education
• Fluoride applications sealants
• Referral to community health clinic

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ORAL HEALTH (cont.)

• Population Served
• Low-income elementary school age children in 2
  rural counties
• Beginnings
• No dental providers to this population group
• Local dentist initiated school-based program

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ORAL HEALTH (cont.)

• Outcomes
• Increased percentages of elementary children
  screen and treated for oral health needs
• Challenges
• Recruitment of hygienists and allied dental
  providers (met)
• Parent awareness (met)
• Funding (met)

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Recurring themes across priorities

• Less access to insurance, health professionals,
  regular care in rural settings

• Disparities across income, education, and ethnic
  groups

• Medical and social co-morbidities, e.g.,
  depression, obesity, diabetes, oral health,
  tobacco use, substance abuse

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Themes across Models

• Some rural providers and community partnerships
  offer Make Do strategies

• Others are developing health promotion,
  screening, and care management strategies that
  may become affordable options in rural areas

• Common challenge of funding and stretching local
  resources

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In Conclusion

• Rural health disparities are real for much of
  rural America.

• Access to insurance and health professionals may
  be the levers to major change

• Prevention and care management models are
  essential in rural areas

• Providers in models take a community
  problem-solving focus

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In Conclusion (cont.)

• Funding challenges promote dual strategy of
  opportunism in external funding and stewardship
  in managing local resources

• Community-based models and their evaluation
  should be encouraged evaluation activities need
  to become transparent to the conduct of work

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Whats next?

• Additional rural priorities and associated models
  for five more HP2010 focus areas - web-based
• Infectious disease and immunizations
• Injury and violence prevention
• Educational Community-Based Programs
• Public Health Infrastructure
• Access to Long Term Care and Rehabilitation
  Services

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• Contact Information
• Rural Healthy People 2010
• Southwest Rural Health Research Center
• gamm_at_srph.tamu.edu
• Telephone [phone]
• http//www.srph.tamushsc.edu/rhp2010/
• Southwest Rural Health Research Center
• School of Rural Public Health at the
• Texas AM University Health Science Center