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In Focus: Improving the Quality of Rural Health Care Through Collaboration

Summary: A number of academic medical centers are using collaborative care models and distance learning programs to broaden the scope and improve the quality of health care services in rural communities. While varied in structure, many of these programs seek to expand the knowledge of local providers and enhance the linkages between urban and rural medical centers, in hopes of reducing disparities in care between the rural and urban populations they serve.

By Sarah Klein

Although 20 percent of Americans live in rural communities, less than 10 percent of the country's physicians practice in those areas. The scarcity of rural health professionals contributes to increased rates of hospitalizations for patients with conditions such as such as asthma and pneumonia, which might be avoided if patients receive timely and effective primary care.1 The scarcity also may be at least partially responsible for the greater incidence of chronic health conditions such as hypertension, heart disease, and emphysema among rural residents.

Poverty and lack of insurance also impede consistent and comprehensive access to medical care in rural communities. Nearly one-quarter of all adults in rural communities are uninsured, and nearly 60 percent of the rural uninsured come from families with a low income, defined as 200 percent of the federal poverty level or less.2 A lack of money, time, or both often prevent residents from traveling to the urban medical centers that offer the services they need.

A number of academic medical centers are attempting to address these challenges with innovative programs designed to increase the capacity of rural providers to deliver primary and specialty care. Many of these medical centers are using collaborative care models that link rural physicians, nurses, and caregivers with urban specialists to address needs that might otherwise require a referral to an urban medical center. This month's case study features the work of one such program at the University of New Mexico, which uses telemedicine, case-based learning, and disease management techniques to guide rural community providers in applying best practices for patients with hepatitis C.

But the University of New Mexico program is one of several. The University of Virginia Health System in Charlottesville is partnering with health systems, health departments, and community groups in and around Appalachia to identify and address local health needs. As part of the Blueprint for Health Improvement and Health-Enabled Prosperity—a strategic plan to address health disparities in southwest Virginia—the academic medical center is training nurse practitioners in Appalachia to perform video-colposcopies on women who exhibit cervical dysplasia. The procedure, which is critical to preventing and/or identifying cervical cancer, is monitored in real time by Peyton T. Taylor, Jr., M.D., a gynecologic oncologist at the health system, who mentors the nurse practitioners and provides them with ongoing training, which is necessary for credentialing. "He's a remarkable frontline caregiver teaching them to be remarkable frontline caregivers," says David Cattell-Gordon, the health system's director of rural network development.

The first of two trainees began working this past summer in a heath department office, where the health system has provided video equipment. Subsequent trainees will work in federally qualified health centers in the region, providing a diagnostic service that otherwise would not be available to uninsured women in this area.

The health system also has been helping Johnston Memorial Hospital, a 135-bed hospital in Abington, Va., establish a breast cancer program in its cancer center. Its medical staff will participate early next year via videoconference in the health system's tumor board, a multidisciplinary group of health care providers who meet to review diagnostic information and discuss treatment options. The health system is training four nurses in the area in advanced care coordination for cancer cases. "What we want to be able to do is improve outcomes from cancer in the region," Cattell-Gordon says.

The U.C. Davis Health System in California, meanwhile, is linking its specialists with rural primary care physicians who are treating patients with complex conditions such as HIV/AIDS and hepatitis C. The specialist, primary care physician, and patient meet as a group using videoconferencing equipment, but over time the health system is finding the primary care physicians are becoming more self-sufficient in providing such care and reserving consultation for more complex cases.3 The Sacramento, Calif.–based health system, which provides a wide range of telemedicine service to more than 80 locations in California and is reimbursed for those services through contracts with local providers and insurance, among other sources, also supports rural hospitals by providing infectious disease consultations to those hospitals that don't have infectious disease specialists on staff, using telemedicine linkages. "We're moving the expertise around to where it is needed," says Thomas S. Nesbitt, M.D., M.P.H, associate vice chancellor for strategic technologies and alliances at U.C. Davis School of Medicine.

Reaching Rural Residents
Some of the programs have gone a step further by trying to engage rural residents in health prevention programs. The University of Kentucky, for instance, has been working to address high rates of obesity and tobacco use in rural communities by encouraging residents to participate in tobacco cessation, exercise, and parenting programs.

Its Health Education through Extension Leadership (HEEL) program—a collaborative effort of the University of Kentucky’s College of Agriculture, its extension service, and the university’s health colleges—relies heavily on extension agents to reach rural residents. The agents, whose positions were created through the U.S. Department of Agriculture’s Cooperative State Research, Education, and Extension Service and whose salaries are paid by the U.S.D.A. and state and local governments to translate the research and innovation developed at land-grant colleges and universities to the public through educational programming, are influential in the counties where they live and work.

In Kentucky, the agents have helped to introduce public health researchers to local communities and revise approaches to prevention programs. "They know everyone in the community," says F. Douglas Scutchfield, M.D., director of the Center for Public Health Systems and Services Research at the University of Kentucky's College of Public Health in Lexington. And those relationships helped bridge a gap between the university researchers and rural residents. After holding a focus group about tobacco cessation in one community, the researchers "learned they weren't doing it right and that family was key. And that if in fact they could engage the family in helping [the smoker] quit they were going to have a better success," Scutchfield says.

The smoking cessation program is still in its pilot stage; however, a 10-week weight loss course the extension agents have promoted is showing results. Of 1,829 people who participated in a weight loss program offered in roughly half the counties across the state, 722, or 39 percent, succeeded in losing 5 percent of their body weight, and 80 percent of those surveyed three months later reported they were maintaining the loss. The HEEL program, which also works to improve cancer screening, mental health awareness, and self-care for diabetes patients, receives an annual appropriation of  $650,000 through Congress. It uses its county-level programs as pilots and leverages data from them to apply for grants that enable it to expand programs elsewhere, Scutchfield says.

Having dedicated, local agents can be crucial to reaching residents of rural communities, where cultural barriers include distrust of outsiders, says Burton Halpert, Ph.D., associate professor of sociology and medicine at the University of Missouri Kansas City. Halpert tapped the agents' expertise in the 1990s to increase childhood immunizations in rural communities as part of a U.S.D.A. rural health initiative. Rural residents "tend to be older, more independent, and less trusting of outsiders," Halpert says.

Using Extension Centers to Bring Evidence-Based Care to Rural Practices
Extension centers, which were created nearly a century ago to help modernize American farms by applying the research and technology developed at land-grant colleges and universities, have traditionally focused on agriculture, home economics, and youth development, but the notion of using extension offices and their agents—or a similar model—for health care has been gaining traction.4 In June, Kevin Grumbach, M.D., a professor of family and community medicine at U.C.S.F. School of Medicine, and James W. Mold, M.D., M.P.H., director of research for the department of family and preventive medicine at the University of Oklahoma Health Sciences Center, proposed establishing a national Health Care Cooperative Extension Service to help primary care practices implement chronic care models, advanced access scheduling, group medical visits, and other innovations.5

The Substance Abuse and Mental Health Services Administration (SAMHSA) created a similar program for mental health services in 1993, when it funded 11 extension centers (now 14 regional centers) around the country to increase the use of evidence-based models of treatment. The Prairielands Addiction Technology Transfer Center was one of the first. Housed at the University of Iowa College of Public Health in Iowa City, the center trains providers and health care facilities in five states on evidence-based models of care, disseminates academic research, provides guidance to new substance programs at health care facilities, and conducts training on topics shown to have an impact on outcomes, such as the use of interviews to elicit a patient's motivations for changing his or her behavior. The program also has identified local problems, such as low rates of certification for drug and alcohol counseling among minority providers, and helped to address them, says Anne Helene Skinstad, Ph.D., Psy.D., program director. The center operates on a budget of $500,000 per year, which is funded by SAMHSA, matching funds from states, and grants from foundations.

Building on the extension center model, Congress already has appropriated $643 million for the Health Information Technology Extension Program, which will create regional centers to provide technical assistance and guidance to rural and urban health providers as they implement electronic health record systems using money from the American Recovery and Reinvestment Act.

The health reform bill passed by the U.S. House of Representatives in November would increase incentive payments for primary care doctors practicing in underserved areas and would provide billions of dollars in new funding for community health centers, which play an important role in rural health care. The bill also would expand the National Health Service Corps to address work shortages in high-need areas.

Funding the Model
Finding funding for academic medical centers that enhance the capacity of rural providers to deliver medical care may depend on the programs' ability to demonstrate the cost-effectiveness of their work. There is not a great deal of research on the topic, but many see anecdotal evidence. Rob Sprang, M.B.A., director of Kentucky Telecare, remembers the child in the Medicaid program who made eight visits to a primary care physician and one emergency department visit for a skin condition before a pediatric dermatologist accurately diagnosed the problem through a telemedicine visit as flea bites. 

Currently, many of these programs rely on a mixture of grant funding and revenue from contracts with correctional institutions and other facilities that have difficulty recruiting health care professionals. The physicians that provide consultations via telemedicine are paid by Medicare, Medicaid, and some private insurers, but "we are not where it is at parity with a face-to-face visit," Sprang says. He says many physicians participate because they feel an obligation to help the rural communities. They know "there are patients that cannot or will not travel for economic reasons."

But the lack of stable funding is distracting. "It's this anxious mix of foundations and grants and clinical revenues from here and there. We're always cobbling together an approach, rather than having the foundation solidly in place so we can demonstrate outcomes," Cattell-Gordon says.

[1] J. N. Laditka, S. B. Laditka, and J. C. Probst, Health Care Access in Rural Areas: Evidence that Hospitalization for Ambulatory Care–Sensitive Conditions in the United States May Increase with the Level of Rurality, Health and Place, published online January 10, 2009.
[2] Rural Health Research and Policy Center, Profile of Rural Health Insurance Coverage: A Chartbook, June 2009.
[3] Although such programs have the potential to raise concerns among specialists about competition, they have not in Davis. "There aren't a lot of specialists anxious to go and practice [in rural communities]," says Dr. Nesbitt.
[4] Many of the programs described in this piece are headquartered at academic medical centers at state schools. While not all are land-grant universities, many share a commitment to serve the health needs of residents in their states.
[5] K. Grumbach and J. W. Mold, A Health Care Cooperative Extension Service: Transforming Primary Care and Community Health, Journal of the American Medical Association, June 2009 301(4):2589–91.

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