Rural Health Quarterly
TRUMPCARE What Does ‘Repeal & Replace’ Mean for Rural America?
A Publication of the F. Marie Hall Institute for Rural and Community Health
RURAL HEALTH AT THE CROSSROADS ‘Managing Challenges & Disparities in Rural Health’
FACT OR FICTION?
Google will help your self-diagnosis with it’s new symptom search. That’s great. But how do you know if it’s correct? 62% of us use our smartphones to look up information about health conditions.
QUALITY OF LIFE
Angelo State University completes an important yearlong study of West Texas health needs.
COMMUNITY HEALTH WORKERS
Since 1999, the CHW movement has grown far beyond expectations. Now, education is the key to equipping promatoras to work in healthcare teams.
OUR PREMIERE ISSUE A FEW WORDS FROM THE PUBLISHER
Rural Health Quarterly started out as a casual conversation regarding the 10th anniversary of the F.Marie Hall Institute for Rural and Community Health. How should we mark this important milestone? Is there something we could do to better serve the rural health community? Something big? Our answer to these questions is now BILLY U. PHILIPS, JR. literally in your hands. RHQ has been a labor of love. Our first issue looks at rural health from multiple, but equally important, angles—rural health research, education, public policy, technology and even behavioral health. Our goal is to report on all the challenges faced by rural health professionals, as well as to provide an interdisciplinary forum for sharing ideas related to rural healthcare. Not all news is bad news. We want to discuss problems and solutions. My words of thanks must be incomplete so that they aren’t a thousand lines long. First, I want to thank all the writers, researchers and editors who rolled up their sleeves to help us make this idea a reality. Second, I want to thank you, Dear Reader, for picking up this issue. Please let us know what you think. You, and you alone, have the final say in what comes next.
~ Dr. Billy U. Philips, Jr. 2 RHQ | ruralhealthquarterly.com
SENDING SURGEONS, CREATING SURGEONS Why one U.S. surgeon keeps returning to rural Kenya.
THE MACRA EFFECT
As the United States is shifting to a value-based care model, “MACRA” has become a popular buzzword among healthcare providers.
Sonny Perdue, the former governor of Georgia and Trump’s pick for Secretary of Agriculture, will play a key role in promoting US health policy.
REPEAL & REPLACE What does repeal of the ACA mean for rural America?
RURAL HEALTH QUARTERLY
Volume 1, No. 1 Winter 2017
Publisher Billy U. Philips, Jr., Ph.D., Executive Vice President and Director of the F. Marie Hall Institute for Rural and Community Health, Lubbock, TX Editor in Chief Scott G. Phillips // RURAL REPORTS 6-10
// RURAL RESEARCH 11-15
Section Editors Debra Flores - Health Education Travis Hanson - Health Technology Catherine Hudson - Rural Research Ronald N. Martin - Behavioral Health Copy Editor Melanie Clevenger Research Associate Debra Curti
// HEALTH EDUCATION 17-21
// PUBLIC POLICY 22-27
Editorial Assistant Milina Funderburg Contributors Traci Carroll Kristine Crane John W. Fitzwater Amanda Freeman Coleman Johnson Casey Jones Kenneth L. Stewart
// HEALTH TECHNOLOGY 28-36
What happens when our advancing technology shakes up the status quo?
A ROAD LESS TRAVELED Meet Liberty Mobility Now , the Uberlike service made for rural America.
// BEHAVIORAL HEALTH 37-42
SCHOOL CONNECTEDNESS Rural America has something to teach us all about education. When educators get to know each of their students personally, they are more likely to recognize, understand and address a troubled student’s struggles.
Contacts and Permissions Email RHQ at RHQ@ttuhsc.edu. For more contact information, permissions, reprints and writer guidelines, please visit our website at www.ruralhealthquarterly.com. Rural Health Quarterly (RHQ) is a publication of the F. Marie Hall Institute for Rural and Community Health at the Texas Tech University Health Sciences Center.
Teen intervention can be as simple as listening to their concerns.
Professional conferences are a way to catch up of the lastest trends in your field or to make connections that can last a lifetime.
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RHQ Rural Health Quarterly
Rural Health Quarterly (ISSN 2475-5044) is published by the F. Marie Hall Institute for Rural and Community Health, 5307 West Loop 289, Lubbock, TX 79414, and the Texas Tech University Health Sciences Center. Copyright 2017 â€” F. Marie Hall Institute for Rural and Community Health. Jacob Sanchez Diagnosed with autism
The F. Marie Hall Institute for Rural and Community Health is a multidisciplinary group of professionals who contribute to key programs in rural health research, education, outreach and recruitment. The Institute was established in February 2006 with a donation from F. Marie Hall to leverage the existing resources of Texas Tech University Health Sciences Center (TTUHSC) Office of Rural and Community Health and expand the impact of Texas Tech University Health Sciences Center in addressing the needs of the region and developing solutions that affect rural health beyond the bounds of West Texas. The articles published in Rural Health Quarterly do not necessarily reflect the official policies of the F. Marie Hall Institute or of the Texas Tech University Health Sciences Center. Publication of an advertisement is not to be considered endorsement or approval of the product or service. Rural Health Quarterly is published four times a year and distributed without charge upon request to individuals residing in the U.S. meeting subscription criteria as set forth by the publisher. RHQ ADVISORY BOARD Ogechika Alozie, Associate Professor/Chief Medical Informatics Officer, TTUHSC El Paso Paul Fowler, Director, Office of Strategic Initiatives, TTUHSC Coleman Johnson, Special Assistant to the President, TTUHSC Retta Knox, RN, Hart School-Based Health Clinic, Hart, TX Susan McBride, PhD, RN, School of Nursing, TTUHSC Linda McMurray, Executive Director at TTUHSC Larry Combest Community Health and Wellness Center Will Rodriquez, Senior Managing Director, TTUHSC Dr. Ken Stewart, Director of Community Development Initiatives, ASU, San Angelo, TX
Lack of eye contact is a sign of autism. Learn the others at autismspeaks.org/signs.
Dr. Julie St. John, Assistant Professor, TTUHSC Abilene Shari Wyatt, Rural Health Specialist, State Office of Rural Health, Texas Department of Agriculture
The Industry Leading Telemedicine Solution
HELPING PROVIDERS INNOVATE, TRANSFORM AND LEAD IN THE AGE OF REMOTE CARE Delivering the Last Mile in Healthcare
The regulators of Alabama’s dental profession haven’t enacted a state law passed three years ago to improve access to oral health care.
The Indian Health Service (IHS) has made $1.4 million available to tribal communities in the IHS Navajo, Phoenix and Tucson areas for methamphetamine and suicide prevention.
The law calls for the creation of expanded duty assistants in the state to address dentist shortages in rural areas.
ihs.gov | 12.07.16
annistonstar.com | 09.24.16
ARKANSAS // ALASKA // An Anchorage hospital will tap satellite technology to connect critical care doctors 800 miles away to Unalaska Island, home to the Bering Sea crabbing fleet made famous by the Discovery Channel show “Deadliest Catch.” anchoragepress.com | 09.27.16
The Delta Regional Authority is investing about $26 million in projects aimed at strengthening Arkansas’s infrastructure and economy. The investment includes purchase of radiology equipment for the new McGehee Rural Health Clinic. arkansasonline.com | 11.30.16
LINCOLNSHIRE, ENGLAND Hospital chiefs have laid out their plans to create a ‘National Centre for Rural Health and Care’ in Lincolnshire.
Nasarawa state officials in Nigeria say they will upgrade primary health care facilities in rural communities in their attempt to fight malaria, a leading cause of the high infant mortality rate in Sub-Saharan Africa.
The centre is aimed at tackling NHS staffing shortages, and finding ways of recruiting staff in health care by making the rural aspect a key selling point. The United Lincolnshire Hospitals Trust currently has 318 full-time nursing vacancies, 38 consultant vacancies and 92 vacancies for other grades of doctor.
guardian.ng | 01.20.17
bostonstandard.co.uk | 17.11.16
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RURAL HEALTH REPORTING FROM ACROSS THE NATION AND AROUND THE WORLD
CALIFORNIA // New mothers living in rural areas in California are more likely to be rehospitalized within 30 days of giving birth than their urban counterparts. This is according to a recent Texas A&M study of the records of nearly half a million women who gave birth in California in 2011. The disparity remained even after adjusting for factors like the mother’s age, race and payment method. newswise.com | 10.12.16
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Regional and rural health services could fall further behind urban areas without urgent action, a new Australian Medical Association report warns. The report calls on the government to improve internet access and affordability across the nation. Rural doctors have frequently complained about unreliable internet access, not only for conducting dayto-day business, but also for caring for patients via eHealth and telemedicine. northernstar.com.au | 01.22.17
What’s news in your neck of the woods? Let us know: Email: Email your rural health news to RHQ at RHQ@ttuhsc.edu
U.S. Mail: Rural Health Quarterly, F. Marie Hall Institute for Rural & Community Health, 5307 West Loop 289, St. 301 Lubbock, Texas 79414
Voicemail: Prefer to call? Leave us a message at (806) 743-9891 FAX: (806) 743-7953
Web: Find more RHQ contacts at ruralhealthquarterly.com or follow us on Facebook at facebook.com/RuralHealthQuarterly.
The suicide rate in Summit County, CO has surged to its highest levels in 30 years and has become the second leading cause of death for people aged 15 to 34. A rural county, Summit doesn’t have the same mental health resources as larger metropolitan areas, and as many as 21 percent of local residents are uninsured.
The widow and children of a man who went to a rural Hawaii health center with a sore throat in 2013 and ended up dead will receive a $4.2 million settlement from the federal government.
summitdaily.com | 09.26.16
GEORGIA // A tax credit program designed to save rural hospitals in Georgia has fallen far short of its stated goal, and now state lawmakers are scrambling to fix it.
claimsjournal.com | 09.19.16
The Florida Atlantic University Nursing Program has received a $2 million grant to practice in rural and underserved communities. South Florida has a ratio of 1,299 to 1 for primary care and 597 to 1 for mental health care.
The program went live Jan. 3, but so far donors have applied for less than 2 percent of the available credits. State Rep. Geoff Duncan, R-Cumming, who sponsored legislation that created the program, has introduced a new bill aimed at making the credits more attractive.
Mores Creek Family Medicine, a rural medical clinic in Boise County that serves more than 1,000 patients, has closed its doors. The owner blames increasing medical costs, diminishing reimbursements, and the many regulations placed on physicians for the closure.
ctnow.com | 12.07.16
myajc.com | 12.07.16
ktvb.com | 09.09.16
SÃO PAULO, BRAZIL
CHIMBU, PAPUA NEW GUINEA
BELFAST, NORTHERN IRELAND Northern Ireland’s future doctors are being urged to “think rural.” In partnership with Ulster Farmers’ Union, a new study module entitled ‘Rural Health’ has been successfully piloted to students studying for their medical degree at Queens University Belfast. In 2016, third-year medical students had the chance to leave the hospital wards behind for three weeks to work in rural communities.
The Brazilian government said it plans to greatly reduce the number of Cuban doctors working in the country by expanding a program to address a chronic lack of physicians in remote rural areas.
Ten rural health centres in Chimbu, Papua New Guinea have scaled down operations due to a lack of funding from the government. They say they are running out of medical supplies and lack the funds to pay staff.
newswise.com | 10.12.16
wsj.com | 09.21.16
thenational.com.pg | 09.09.16 WINTER 2017 | RHQ 7
Rural Reports // ILLINOIS //
Gibson Area Hospital in Ford County, IL has extended a new five-year employment contract to CEO Robert Schmitt. Under the direction of Schmitt, the hospital has added nine rural health clinics and grown revenues by more than $150 million.
A recent report released by the University of Kentucky Institute for Rural Health Policy found poor overall health status and health care accessibility in Kentucky’s rural counties and the Appalachian region. uknow.uky.edu | 12.20.16
paxtonrecord.net | 09.07.16
LOUISIANA// INDIANA // Three new telehealth clinics are opening in Southern Indiana schools. Indiana Rural Health Association community outreach manager Jennifer Hill says the aim is to provide care to children in low-income, rural areas of Indiana.
A public health emergency has been declared in St. Joseph, La., the rural seat of Tensas Parish. Tests showed elevated lead levels exceeding the federal “action level” of 15 parts per billion in nearly 100 of the town’s homes and businesses. Residents are living off bottled water provided by the state.
wbaa.org | 01.04.17
washingtonpost.com | 01.06.17
MICHIGAN // Gun suicide rates in the mostly rural Upper Peninsula of Michigan are 50 percent higher than the state average. Statewide, Michigan has an average of one mental health professional for every 450 residents, according to data collected by the Robert Wood Johnson Foundation. In the U.P., the ratio is 608 to 1. Exclude Marquette County, and it increases to almost 700 to 1. mlive.com | 09.21.16
Seasons Center for Behavioral Health has been awarded a $150,000 nine-month planning grant from the Iowa Department of Human Services. The purpose of the grant is to fund the continued development of children’s mental health crisis services in rural Iowa and throughout the state.
More than 300,000 Minnesotans on public health programs could have to switch to a new plan next year after insurer Medica couldn’t agree on a new contract with the state of Minnesota.
AL.com | 09.27.16
twincities.com | 12.01.16
KU Medical Center has launched a five-year, $10 million study to compare weight management models at 36 rural primary care clinics in four states.
Maine Health Access Foundation has awarded $240,000 to five organizations to develop approaches to improve health and health care access in Maine’s rural communities. The grant program results from research conducted following the closure of health facilities in a number of Maine’s rural communities.
anchoragepress.com | 11.30.16
mainebiz.biz | 01.17.17
picayuneitem.com | 12.30.16
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The Picayune Family Health Center is offering free lab work for patients without insurance. Part of the Southeast Mississippi Rural Health Initiative, the health center is known for helping residents who struggle to afford the care they need.
NORTH DAKOTA //
Free rural medical care clinics will be available for Southeast Missouri residents thanks to the joint efforts of several Baptist associations in the area. A mobile medical clinic RV unit has been donated and a plan to staff it for rural health clinics has been organized.
A proposal to allow licensed dental therapists to practice in underserved rural communities is being opposed by the state dental assocation. Currently, only three states allow dental therapists to work.
mbcpathway.com | O1.14.17
MONTANA // CAIRHE, a research center at Montana State University, has been named a state research center by the MSU Board of Regents. CAIRHE is coordinating a statewide effort to address health disparities affecting Montana citizens in rural and tribal communities. montana.edu | 09.26.16
NEW MEXICO // A telemedicine program born at the University of New Mexico is set to become a national model for providing rural healthcare. The US Senate has approved the Expanding Capacity for Health Outcomes (ECHO) Act. The bill calls for a national network of hub-and-spoke telemedicine platforms to provide education and collaboration opportunities for healthcare providers in hardto-reach areas. mhealthintelligence.com | 11.29.16
NEW YORK //
NEBRASKA // The U.S. Department of Veteran Affairs at the Grand Island VA Medical Center has a plan to attract more health professionals to rural Nebraska. The Rural Health Training Initiative will offer free housing for medical students who are doing rotations in Central Nebraska. nebraska.tv | 01.13.17
Seven hospitals across Upstate New York were awarded funding from the State Department of Health to develop new residency programs in rural areas. The programs will help reduce regional workforce shortages by creating new opportunities for residents to train in areas of the state that are geographically isolated. madisoncountycourier.com | 01.18.17
NORTH CAROLINA //
inforum.com | 01.18.17
OHIO // Ohio leads the nation in deaths due to opioid overdoses. The toll climbed from 2,106 in 2014 to 3,050 last year. Ohio outpaces New York and California, states with much larger populations. ohio.com | 01.02.17
OKLAHOMA // A disproportionate number of Oklahoma residents living outside of urban centers show signs of untreated mental-health problems and substance abuse, an Oklahoma Watch analysis found. The 10 Oklahoma counties with the highest suicide rates have populations living mostly in rural areas or small towns. mcalesternews.com | 09.07.16
The EPA has written a stern letter of concern to North Carolina regulators over the health of minority communities near hog farms.
Oregon received a five-year extension from the federal government to continue operating Medicaid under its own model. In some rural areas, as many as 40 percent of the population is on the program.
newsobserver.com | 01.18.17
bizjournals.com | 01.13.17
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Rural Reports // PENNSYLVANIA //
WEST VIRGINIA //
CMS announced that it intends to provide Pennsylvania with $25 million to help fund the implementation of the “Pennsylvania Rural Health Model.” The model calls for participating hospitals to receive fixed, global budgets from participating payers, including Medicare, set in advance to cover the cost of all the inpatient and outpatients services they provide.
Utah is now offering a $10,000 tax credit to mental health providers who work with veterans, Native Americans, the homeless, or rural residents.
More than $6 million from a court settlement has been transferred to West Virginia University and Marshall University to aid in research and rural health. The order ended a decade-long class action lawsuit that sought medical monitoring for coal preparation and waste water treatment workers who had been exposed to a chemical neurotoxin.
medcitynew.com | 01.13.17
SOUTH CAROLINA // Lowcountry AIDS Services (LAS) will be expanding its HIV testing and prevention efforts into rural areas of Berkeley and Dorchester counties as well as into high-risk areas of Charleston.
kuer.org | 01.03.17
VERMONT // Opioid-dependent adults who live in rural states are often put on long waiting lists to get into substance abuse treatment programs. However, research conducted in a Vermont treatment program suggests an “Interim Buprenorphine Treatment” (IBT) regimen for waitlisted opioid-dependent adults shows promise. psychcentral.com | 12.26.16
To help fund the program, LAS has received a $35,400 grant from the Roper Saint Francis Physicians Endowment.
Faced with a shortage of obstetricians and gynecologists, especially in rural areas, the Department of Obstetrics and Gynecology at the University of Wisconsin School of Medicine and Public Health has started the nation’s first rural-residency program to train and provide care to women in rural Wisconsin.
WYOMING // WASHINGTON //
Since 2013, 15 rural hospitals — located in counties with no more than 60,000 residents — have closed across Texas. In some parts of Texas, patients must drive to another county to see a doctor. In fact, 27 counties have no physicians and 22 only have one doctor. Officials worry that more of the state’s 163 rural hospitals could close in 2017 if they face more cuts to Medicare and Medicaid.
Accredited in October 2016, the Elson S. Floyd College of Medicine at Washington State University is now accepting applications for the charter class. Unlike traditional medical schools that train students in university-owned, campusbased teaching hospitals, this new college will train students in community hospitals and rural clinics across the state.
star-telegram.com | 11.25.16
seattletimes.com | 01.17.17
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barnesville.com | 12.07.16
charlestonchronicle.net | 12.07.16
doverpost.com | 12.07.16
The Wyoming Department of Health says families should test the radon levels found in their homes to see if a potential health risk exists. Radon, the second leading cause of lung cancer, is an invisible, odorless, tasteless gas found in homes, especially older structures. The Wyoming Integrated Cancer Services Program has low-cost radon test kits available for individuals and families to purchase. k2radio.com | 01.19.17
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TOP 5 RURAL RISKS
Rural Research //
FACT OR FICTION? GOOGLE WILL HELP YOUR SELF-DIAGNOSIS WITH IT’S NEW SYMPTOM SEARCH. THAT’S GREAT. BUT HOW DO YOU KNOW IF IT’S CORRECT?
You’ll catch a cold if you go out in the cold weather unprotected. . . Cracking your knuckles will cause arthritis. . . Sexually transmitted diseases (STDs) can be contracted from toilet seats. . . Performing a biopsy or cutting into cancer can cause it to spread. . . Vaccines cause autism. Catherine Hudson
These statements have been proven false but there are people that still believe them to be facts. What HEALTH RESEARCH constitutes a fact? Is it the source of the informaF. Marie Hall Institute tion? Is it the reputation of the individual relayfor Rural and Community ing the information? Many myths are perpetuated Health simply because of where or how the information is obtained. After all, if some celebrity endorsed it, a family member said it, or if it’s on the internet, it has to be true, right? With the evolution of technology, the days of reading a physical newspaper to get news and information are nearly nonexistent. People rely on the internet, and surprisingly social media, to inform them and ultimately shape their decisions and opinions. Because of this, it is imperative that research and the dissemination of the facts be emphasized. Those in academia have an obligation to provide communities with evidence-based information and it is important to know where and how people get their information, particularly related to health, so that it can be conveyed appropriately. According to the Pew Research Center, statistics show that 90 percent of American adults now own a cell phone and 64 percent a smartphone. That’s an increase of almost 30 percent since 2011. What’s interesting is that of those who have smartphones, 10 percent rely on them, depending on their data plan, as their only source of internet access. This includes 15 percent of young adults (age 18-29), 13 percent of households with annual incomes of less than $30,000 and minorities (12 percent of African Americans and 13 percent of Hispanics). It was determined in 2014 that more than half (62 percent) of all smartphone owners use their device to look up information about a specific health condition. That is more than those that do online banking (57 percent). A person’s age and level of education followed by health and disability status are the most significant predictors of who uses the internet to seek out health information. With the many social media platforms out there, Facebook is at the top of the list when it comes to news and information. Around two-thirds (64 percent) of U.S. adults use the site, and about half of those users rely on it as their news source. So what does all of this mean? We should know our audience and seek to inform them accordingly. The erroneous information will still be out there, so educating the public about reputable information sources is equally as important as providing accurate data. DIRECTOR FOR RURAL
A recent study from the Centers for Disease Control and Prevention (CDC) demonstrates that Americans living in rural areas are more likely to die from five leading causes than their urban counterparts. The top five leading causes of preventable deaths among rural Americans in 2014 include: Heart Disease Cancer Unintentional Injuries CLRD* Stroke
25, 000 19,000 12,000 11,000 4,000
“This new study shows there is a striking gap in health between rural and urban Americans,” said CDC Director Tom Frieden. “To close this gap, we are working to better understand and address the health threats that put rural Americans at increased risk of early death.” Several demographic, environmental, economic, and social factors might put rural residents at higher risk.
To address the gap, health care providers in rural areas can: •
• • • • •
Screen patients for high blood pressure and make control a quality improvement goal. Increase cancer prevention and early detection Encourage physical activity and healthy eating Promote smoking cessation Promote motor vehicle safety Engage in safer prescribing of opioids for pain.
* chronic lower repiratory disease
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AARP gives you the information to help care for your loved ones, just like they did with you once. You donâ€™t have to do it alone and itâ€™s okay to ask for help. Visit our website or call now to get practical health and wellness tips to provide even better care for those who once took care of you. We provide you information to give care and give back.
Rural Research //
ASU COMPLETES STUDY OF WEST TEXAS HEALTH NEEDS
ommunity Development Initiatives (CDI) at Angelo State University was privileged during 2015 to lead an important yearlong study of regional health needs. CDI conducted the Survey of Health and Behavioral Health Needs of the Poor & Extremely Poor in West Texas between January and December of 2015.
DR. KENNETH L. STEWART
DR. CASEY JONES
Professor, Director of
Retired professor of
MORE INFORMATION //
The study covered 20 counties including Coke, Concho, Crockett, Edwards, Irion, Kimble, Kinney, Mason, McCulloch, Menard, Mills, Reagan, Runnels, San Saba, Schleicher, Sterling, Sutton, Tom Green, Upton and Val Verde. CDI and 72 community-based organizations across the region collaborated to complete a detailed face-to-face interview with a sample representing the more than 39,000 residents of the 20 counties living in poverty. CDI-trained members of many local communities were included in the study to help conduct interviews. Working along with CDI’s own research staff, they completed 597 interviews,
20-County Study Region
Methodist Healthcare Ministries of South Texas and the San Angelo Health Foundation provided support for The Survey of Health and Behavioral Health Needs of the Poor & Extremely Poor in West Texas. The observations expressed in this article are strictly those of the authors and do not necessarily reflect the views of Methodist Healthcare Ministries or the San Angelo Health Foundation. Susan McLane served as project director for The Survey of Health and Behavioral Health Needs of the Poor & Extremely Poor in West Texas. Cera Cantu served as research assistant to the project. Contact the authors at firstname.lastname@example.org or email@example.com. This article first appeared in the San Angelo Standard-Times, June 2, 2016:
Map image created by Susan McLane and Cera Cantu, Community Development Initiatives, Angelo State University.
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Legend (all data points are average ratings of the 38 Key Informant(s):
Informant rating of number of people potentially affected
Informant rating of consequences of not addressing the need
Impact: Informant rating of impact on vulnerable populations
Feasibility: Informant rating of likelihood that community takes action
Overall Average Priority Score
TOP SEVEN HEALTH NEEDS
Prioritized by 38 key informant community leaders and stakeholders in Tom Green County. Increase ability to address needs of growing numbers of seniors and children
Prevent diabetes and reduce hospitalization for diabetes
Increase investment in community health needs
Reduce cost and other barries
Increase services for depression
Increase services for alcohol and drug abuse
Source: Survey of Health and Behavioral Health Needs of the Poor and Extremely Poor in West Texas, Angelo State University, Community Development Initiatives, 2015.
including 280 (46.9%) with respondents from the more than 14,000 “extremely poor” residents in the region who live on incomes below half of the poverty level. Interviewers collected information on more than 170 health-related factors. These included 31 items modeled on questions answered in 2013 by respondents representing the general adult population of Texas in an annual survey called the Behavioral Risk Factor Surveillance System (BRFSS). Conducted statewide by the Texas Department of State Health Services, the BRFSS is part of a national CDC (Centers for Disease Control & Prevention) effort to track and monitor behavior and health risks in the overall population. By including 31 related items, the project gained the ability to compare responses of poor and extremely poor residents to the general regional population as reported in the BRFSS results. A general result of these comparisons is that the level of health risk among poor residents in the region is much higher than the general population. For instance, most knowledgeable citizens recognize that people in poverty often do not have a personal doctor, and frequently have trouble paying the cost of going to see one. However, many would not anticipate the large gaps the survey revealed between the poor and the overall adult population on these important factors 14 RHQ | ruralhealthquarterly.com
affecting access to health care. Many people also know that low income adults are more likely to smoke or use tobacco products. Fewer would guess, however, that 25 percent more local adults in poverty are current tobacco users. In fact, more than four of every ten (43.4%) of the 275 Tom Green County residents interviewed in survey of the poor and extremely poor reported they smoke or use tobacco. This compares to an estimate from the 2013 BRFSS of 18.7 percent for the overall adult population of the county. A higher level of exposure to second-hand smoke in the home is a related issue for local residents living in poverty. Meanwhile, the American Lung Association’s recent 2016 State of Tobacco Control report gives Texas a straight “F” grade for creating access to tobacco cessation services, despite estimates that smoking costs Texans over $8.8 billion annually and more than 28,000 die from smoking-related causes. Obesity is another significantly elevated health risk within the local poverty population. The interview data indicates that 44.6 percent of the poor in Tom Green County are obese compared to 32.8 percent of the overall county population according to the BRFSS. The added level of difficulty reported by the poor in getting access to fresh fruits and vegetables aggravates the problem.
The excess number of people in poverty who report being diagnosed with depression is one of the most telling findings from the survey. One of two (50.2%) poor and extremely poor residents of Tom Green County confirmed to interviewers that they were told by a professional they had depression or anxiety. A comparable item in the 2013 BRFSS indicated that medical or mental health professionals similarly diagnosed 15.1% of the county’s overall adult population. Gregory Rowe, executive director of the regional MHMR Services, touched on the potent importance of this disparity in his excellent recent appeal to raise awareness of mental illness. In the May 12 edition of the Standard Times, Mr. Rowe wrote, “. . . people living with a serious mental illness die 25 years earlier than other Americans, largely because of other treatable medical conditions that are complicated by mental illness.” Based on these and other findings from the survey, CDI identified hundreds of needs for reducing health risks across the 20 counties in the study region. These included 20 challenging issues for Tom Green County. To gain a sense of the priority that should be attached to various needs, the project team contacted a wide variety of key informants comprised of community leaders and stakeholders who work every day in health care, or in the trenches providing services to the poor. Thirty-eight key informants in Tom Green County rated each of the 20 issues identified by CDI from the survey results. The key informants used a rating system to assign priorities. They rated every issue on each of four separate factors including: 1) Prevalence - the number of people potentially affected; 2) Significance - the consequences of not addressing the need; 3) Impact - the impact on vulnerable populations; and 4) Feasibility - the likelihood that the community takes action. Informants used higher ratings on a five-point scale to assign a greater sense of Prevalence, Significance, Impact, or Feasibility to an issue. Of course, lower scores signaled less priority.
TOP SEVEN PRIORITIES The average of the four ratings provided the overall priority score for each issue. The process resulted in the following seven top priorities for Tom Green County: 1) increase ability to address needs of growing numbers of seniors and children; 2) prevent diabetes and reduce hospitalization for diabetes; 3) increase investment in community health needs; 4) prevent obesity; 5) reduce cost and other barriers to care; 6) increase services for depression; and 7) increase services for alcohol and drug abuse. Concerted efforts to work together as a community on any one of these priorities could lead to immense improvements in the quality of life among the county’s poverty population while averting countless early deaths from preventable causes and saving millions or billions of dollars in avoidable economic costs to the community. To us, the most challenging result from the rating process is the relatively timid sense of feasibility
HEALTH RISKS A comparison of behavior and health risks of the poor of behavior and health risks of the poor with BRFSS with BRFSSComparison estimates forpopulation the general population in Tom estimates for the general in Tom Green County Green County. Activity limited by poor physical, mental, or emotional health conditions
Does not have a personal doctor
Could not see a doctor during past 12 months because of cost
Diagnosed with depression
Obese (BMI greater than or equal to 30)
Current smoker or tobacco user
Difficult to access fresh fruits and vegetables
Secondhand smoke exposure in home
56.6% 87% 50.2% 44.6% 30.4%
*These columns report the Survey of the Poor & Extremely Poor in West Texas results for Tom Green County. **These columns include results from the Texas BRFSS conducted by the Texas Department of State Health Services
2013. The BRFSS estimates reported for Tom Green County are riskadjusted by Community Development * in These columns report the Survey Poor & Extremely Poor incounties. West Texas demographic characteristics of the Initiative at Angelo State University to account for of the the specific Source: Survey of Health and Behavioral Health Needs of the Poor & Extremely Poor in West Texas, Angelo State results for Tom Green County. University, Community Development Initiatives, 2015.
**These columns include results from the Texas BRFSS conducted by the Texas Department of State Health Services in 2013. The BRFSS estimates reported for Tom Green County are risk-adjusted by Community Development Inititatives at Angelo State University to account for the specific demographic characteristics of the counties. Source: Survey of Health and Behavioral Needs of the Poor & Extremely Poor in West Texas, Angelo State University, Community Development Initiatives, 2015
conveyed by the key informants. Feasibility, as noted, refers to the assessment by key informants of the likelihood of the community taking action on a given health-related need. For the top Tom Green County priorities, feasibility ratings from the 38 key informants ranged from 2.9 (for the need to reduce cost and other barriers to care) to 3.7 (for addressing the needs of seniors and children). The average feasibility rating for the top seven priorities was 3.3 on the 5-point scale. This finding shows the key informants generally held only a moderate sense that community actions to address priority health needs are feasible. The finding clashes with much stronger assessments from key informants that the top priority health needs strongly impact vulnerable groups and carry significant consequences if not addressed. Like the beloved journalist and Texas commentator Molly Ivins quipped, “It’s a low-tax, low-service state - so shoot us. The only depressing part is that, unlike Mississippi, we can afford to do better. We just don’t.” For the sake of a vibrant community and sustainable economy in the future, we hope Tom Green County’s local leaders and citizens will come together to work in ways like never before to solve just one of the challenging, high priority health and behavior risks.
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CHW Workforce Development Bridge To Excellence Offers:
CHW Certification Online
CHW Telemedicine Training
CHW-DOL Apprentice Program
CHW Employer Training
Intermediate Level Training in MI, PN and Chronic Disease Management
Health Education //
COMMUNITY HEALTH WORKERS EDUCATION IS THE KEY TO EQUIPPING PROMOTOR(AS) TO WORK IN HEALTH CARE TEAMS
Community Health Workers (CHW), also known throughout the Educational backgrounds for CHWs varies, ranging from on-thestate of Texas as Promotor(as), have been around for decades, job training to bachelor prepared workers. Some states, like Texas, and the value they bring to diverse programs has been docuhave a mandated certification/training process. CHWs are prepared mented extensively. Some community to work in health care through program specific modules geared health workers are men, but most are towards identified disease processes such as hypertension, women who are typically well-known diabetes and asthma. Training CHWs to work as patient navigators leaders in their communities. Historically, and chronic disease managers is common in many health care they began as a volunteer workforce facilities. CHWs also received motivational interviewing training mostly for public health and non-profit along with different chronic disease management models. organizations, disseminating educaOne of the advantages of utilizing CHWs for health care teams tion and resources throughout colonias is the cultural competency and humility they bring. CHWs also Dr. Debra Flores along the border and other impoverished receive additional cultural competency, health literacy and interpersonal skill training. Natural attributes demonstrated by CHWs MANAGING DIRECTOR FOR neighborhoods. Just as health care has evolved, the include being a leader in their communities. Outreach, education, T-CORE, WEST TEXAS AHEC F. Marie Hall Institute same is true of the CHW para-profession. recruitment and other abilities demonstrated by CHWs are characfor Rural and Community The breadth of the job functions and duteristics of effective job functions that have made them valuable Health ties CHWs are capable of performing has members of the health care workforce. CHW education revolves also expanded. The trend has also shifted around the needs of the industry seeking to hire them. The value from volunteerism to full-time paid employment for CHWs. the health care industry is beginning to place on CHWs will propel This shift began in 1999 when Texas became the first state to the growth and synergy of institutions that train CHWs in order to recognize CHW contributions and, through House Bill 1864, maintain the marketability of the profession. established a temporary committee that could make recommendations towards the training and certification of community health workers. Since 1999, the CHW movement has grown beyond expectations. According to the 2015 annual report prepared by the Department of State Health Servicesâ€™ Promotor(a) or Community Health Worker Training and Certification Advisory Committee, the number of certified CHWs has grown exponentially from 573 (2008) to 3,628 (2015). A total of 1,150 were trained or grandfathered into the program in 2015 alone. So how many CHWs are entering the health care workforce? Texas data is not available to answer this question, but the Department of Labor has national data reporting industries with the highest levels of CHW employment include outpatient care centers, general medical and surgical hospitals, and physician offices. Texas is also listed as one of the states with the largest CHW populations, and the Texas labor market projects that the A promotor(a) or community health worker is a trusted member of the community and has a close underfield will grow by 26% from 2010 to standing of the ethnicity, language, socio-economic status, and life experiences of the community served. 2022.
WINTER 2017 | RHQ â€ƒ 17
SENDING SURGEONS, CREATING SURGEONS CAPACITY BUILDING AT TENWEK HOSPITAL IN RURAL KENYA Why would an American surgeon return year after year to a remote rural hospital in the heart of the Kenyan Highlands? Faith, hope & love.
DR. JOHN W. FITZWATER TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER Assistant Professor of Surgery, Pediatric Surgery
A friend from South Africa once told me, “When you travel to a strange place, where you first arrive will always feel like home.” He had sensed that Kenya was a deeply personal place for me, like another home. Since first visiting there in 1995, I have been privileged to return on several three-to-nine-month stints. So, while capacity building sounds sterile and dispassionate, it is in fact a very heartfelt topic for me. One is amazed how widespread poverty and its effects are across the low and middle income countries (LMIC), and yet how little resources it would take to have an enormous impact. All of us have the means to participate and create meaningful, durable change.
18 RHQ | ruralhealthquarterly.com
TENWEK HOSPITAL is a sight to behold. To better understand the work being done there, let me take you to the setting. For those who have never been to Africa, it can be a difficult to imagine. Kenya is not the brown, desolate place often pictured by many Americans. Tenwek Hospital is on the rolling hills of the Kenyan Highlands at 6,700 feet at the edge of tropical rainforest. Understanding the region also means grasping the size of Africa. The Mercator map projection we are accustomed to seeing in the classroom makes Kenya look deceivingly small. It is actually similar in size to Texas (Kenya: 225,000 square miles, Texas: 270,000). Both are highly populous, though Kenya has approximately 50 percent more people (Kenya: 47 million, Texas: 28 million). While predominantly Christian (83 percent), it has a large Muslim population (11 percent) that has been present for many generations along the coast and toward Somalia. As is typical of LMIC’s, Kenya is very heavily weighted toward younger ages. The GDP of Kenya is $142 billion (Texas $1.4 trillion). Kenya is the star of East Africa in terms of tourism, internet connectivityand cash crops like tea and coffee. It is also the regional hub for trade, an excellent environment to encourage capacity building.
A GROWING ECONOMY Agriculture is the backbone of Bomet County, Kenya with tea farming and dairy production leading in the sector. Food crops such as maize, beans, irish potatoes, millet, cabbages, onions, bananas and pineapples are grown both for subsistence and sale in the county and distant markets.
In Bomet County, where the hospital is located, most homes are still made from mud, dung, and sticks with a traditional conically shaped thatch roof, though increasingly corrugated steel roofs are used. The area around Tenwek Hospital is probably best described as “densely populated rural.” Each farm, usually under a half acre, abuts another small farm. Tea dominates the agriculture in the area, and tea processing factories dot the horizon. Standing at one factory you can almost always see another one off in the distance. Tenwek Hospital was first founded in 1937 by missionaries with World Gospel Mission and has since expanded into what we would recognize as a robust teaching hospital with a catchment area of around 600,000 people. After the first doctor, Ernie Steury, arrived in 1959, rapid growth followed. An active community health program was started in 1983 followed by
The area around Tenwek Hospital is probably best described as ‘densely populated rural.’
WINTER 2017 | RHQ 19
a nursing school in 1987. In the 1980’s, the nearby river was harnessed for hydroelectric energy which provided reliable electricity. One decade later, the scope of the hospital changed dramatically with the addition of accredited training programs. General government internships were begun in 1995. Building on this, accredited residencies in general surgery (2007) and orthopedic surgery (2014) were added. With the addition of a computed tomography (CT) scanner in 2011 and electronic medical record (EMR) in 2013, Tenwek Hospital has radically transformed since 1937 into a 300 bed, modern hospital that rivals or surpasses the capabilities of national referral hospitals in many service lines. For the visiting surgeon from a Western country, a quick visit to any other “typical” mission hospital in Africa is a reminder of how close to American medicine Tenwek Hospital is. It is easy to take for granted the fairly modern equipment, capability for high-level operative endoscopy, laparoscopy, readily available anesthesia, and a reliable supply of almost all basics for surgery. But caring for a patient is about far more than attempting to provide the most advanced Western technology at affordable costs. And in fact, it is not the previously mentioned strengths of Tenwek Hospital compared to other hospitals that distinguishes it from other referral centers such as the national referral hospitals. It is set apart by its underlying vision: “Tenwek Hospital is a Christian community committed to excellence in compassionate healthcare, spiritual ministry, and training for service to the glory of God.” When the inevitable crises of any organization strike, it is this mission, obeying Christ’s command to “love your neighbor as yourself” that redirects and reenergizes their efforts.
PAACS: BUILDING AFRICAN CAPACITY
The statistics describing medical and surgical capacity in Africa are stag20 RHQ | ruralhealthquarterly.com
gering. When counting the number of physicians per 1,000 population, the United States has 2.5 per 1,000. Kenya has 0.2. When it comes to surgeons, the United States has 65 per 100,000 population. Kenya has a mere 1.9 surgeons per 100,000. While this seems low, it is considerably higher than many other African nations (Ethiopia: 0.6, Tanzania: 0.3, South Sudan: 0.3). Pediatric surgeons are best measured per million population. There are 18 pediatric surgeons per million in the United States (England: 29, Germany: 23). Nigeria has a paltry 0.5 per million. Kenya likely has fewer than 0.2 per million population. Most practice in the capital city. What can be done to build capacity? In 1996, a group of missionary surgeons in Africa met at a retreat and deliberated over what could be done to meet this desperate need for better trained physicians. This led to the foundation of the Pan-African Academy of Christian Surgeons (PAACS). Since the first graduate completed training in 2004, they have graduated over 67 surgeons serving in eighteen African nations. In addition to serving the least and the most impoverished, they are also involved in training the next generation. Several have returned as faculty and program directors. In 2012, Brian Till described his firsthand experiences with PAACS in “The Atlantic.” Entitled “God’s Surgeons in Africa,” the words below the headline were telling: “A Christian organization is educating surgeons who stay around despite little pay or prestige — sometimes despite real danger.” Within the vision of PAACS is this essential kernel of spiritual commitment that drives the surgical training. And so far, this has borne fruit with every graduate remaining on the continent. While this might seem like Western paternalism at its worst, it is instead a partnership. Trainees are carefully selected for their shared values and commitment to serve his or her people, no matter their socioeconomic status or desirability.
A DEEPER MOTIVATION
I often recall a particular conversation I had with one of my Tenwek Hospital colleagues, an internal medicine doctor. Through a gritted, tense smile he said, “You know, John, I’ve lost 965 patients on the adult medicine ward over the last two years.” He was smiling, but it was clear he was deeply distraught by the loss of human life. How do you process this? It is not as easy as you might think. And this is where your sense of purpose is crucial. Is it about achieving fame and glory? We can easily agree that is not an acceptable rationale. But what about a seemingly more innocuous reason, and one I have heard discussed among surgical academicians: to hone one’s surgical skills? Not only is this questionable ethically, it does not encourage working with the least reached, the most impoverished or the most difficult to care for. Even love for our fellow man is not sufficient. Why? The endless hurt, unending disease, and the often-thankless hurting humans wear you out and burn you out. While this may seem pessimistic, it is not. It is a recognition of the need humans have for a deeper, spiritual meaning and motivation. It is a realistic evaluation of our capacity to continue serving others amid great challenge and adversity. While a love of fellow humans is not sufficient, it is the essential motivation when it is grounded spiritually. God gives us the strength and the love for others that we cannot find in ourselves. We would do well to heed the encouragement of the Apostle Paul: “Don’t just pretend to love others. Really love them. Hate what is wrong. Hold tightly to what is good. Love each other with genuine affection, and take delight in honoring each other. Never be lazy, but work hard and serve the Lord enthusiastically. Rejoice in our confident hope. Be patient in trouble, and keep on praying. When God’s people are in need, be ready to help them. Always be eager to practice hospitality” (Rom. 12.9-13)
TENWEK HOSPITAL // Located in Bomet, Kenya, Tenwek Hospital started as a single-nurse dispensary in 1937 and is now a 300bed hospital and training center serving as a referral hospital that receives patients from throughout the country. Medical residents are trained in surgery, orthopedics, and family medicine to provide specialized care at Tenwek and across East Africa. (Photos courtesy of John W. Fitzwater) WINTER 2017 | RHQ â€ƒ 21
Public Policy //
THE MACRA EFFECT
MEDICARE ACCESS & CHIP REAUTHORIZATION ACT TIES PAYMENT TO PERFORMANCE As the United States is shifting to a value-based care model, “MACRA” has become a popular buzzword amongst healthcare providers this last year. MACRA, which stands for the Medicare Access and CHIP Reauthorization Act, is a historic Coleman Johnson Medicare reform law that permaSPECIAL ASSISTANT TO nently repealed THE PRESIDENT Texas Tech University the sustainable Health Sciences Center growth rate (SGR) methodology for determining updates to the Medicare physician fee schedule. The replacement payment program is known as the Quality Payment Program, which rewards the delivery of quality patient care through either the Merit-based Incentive Payment System, known as MIPS, or Alternative Payment Models, known as APMs. With over 2,000+ pages of policy that make up this complex rule, it is no surprise that many clinicians are not quite sure the effect MACRA will have on their practices. However, despite the fact that many do not know of this rule, just like the mantra that “ignorance of the law is no excuse,” clinicians will need to adhere to the guidelines this next year whether they are ready or not. MIPS ties payments to performance based on a compilation of quality measures: • Physician Quality Reporting System (PQRS), •
Physician Value-based Payment Modifier (VM),
Medicare Electronic Health Record (EHR) Incentive Program.
MIPS will focus on quality and prac22 RHQ | ruralhealthquarterly.com
tice-based improvement activities to award an overall score to clinicians, called the Composite Performance Score (CPS), which will determine what kind of payment adjustment, either penalty or bonus, that a clinician will get for the corresponding payment year. Top performers will have the potential for bonuses as high as 14 percent in 2019. Those who do not perform will be financially penalized, with the lowest 25 percent seeing revenue cut by 9 percent by 2022. Initially, MIPS eligible clinicians will includes physicians, PAs, NPs, clinical nurse specialists, certified registered nurse anesthetists; however, this may be expanded to other groups starting in year three of program implementation. MIPS does not apply to hospitals or facilities at this time. APMs move providers towards true value-based payments, which go beyond the MIPS quality scores by incorporating quality with shared risk to the providers. A qualified APM includes a Medicare Shared Savings Program Accountable Care Organization; a Center for Medicare & Medicaid Innovation Center model (CMMI); a Medicare Health Care quality Demonstration Program; or a demonstration program required by federal law. Several requirements exist for successful provider participation in APMs. Providers who meet these requirements will receive a 5 percent annual lump sum bonus every year from 2019 to 2024 and will be exempt from the MIPS program. Below are some aspects of the rule to consider as clinicians ramp-up for program implementation.
TRANSITION TIME 2017 is a transition year to allow providers time to ramp-up the program and performance thresholds. CMS has also envisioned that calendar year
2018 will be a transitional year as well.
FLEXIBLE IMPLEMENTATION OPTIONS For the transition year, clinicians may choose a variety of ways to participate in a way that is best for them, their practice, and their patients. This includes three options to submit data to MIPS and a fourth option to join Advanced APMs in order to become qualifying APM Participants. •
To avoid a Medicare reimbursement reduction in 2019, eligible clinicians must submit data on at least one MIPS measure.
To qualify for value-based incentive payments, eligible clinicians must submit data on more than one MIPS measure on at least 90 days of 2017 to earn a neutral or small payment adjustment in 2019.
For those that submit all required MIPS data for 2017, eligible clinicians may receive a moderate value-based payment adjustment.
Qualifying clinicians participating in an Advanced APM that receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM will be eligible for a 5 percent valuebased incentive payment in 2019 and will not be required to report any MIPS data.
TECHNICAL ASSISTANCE CMS is selecting contractors to implement technical assistant program for small practices, rural practices, and practices in medically underserved health professional shortage areas.
SMALL PRACTICE EXCLUSION Many small practices will be excluded from the requirements in 2017 due to the low-volume threshold, which is less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients. For providers at a CAH, only the portion of charges paid under the Medicare physician fee schedule counts toward the $30,000 threshold, not the facility payment to the CAH.
VIRTUAL GROUP OPTION Solo and small practices may join virtual groups (consisting of no more than 10 clinicians) and combine their MIPS reporting; however, this will not be implemented in the 2017 transition year.
AG MATTERS AG P
TRUMP’S NOMINEE FOR AGRICULTURE PLAYS KEY PUBLIC HEALTH ROLE //////////////////////////////////////////////////////////////////////////////////////// BY CARMEN HEREDIA RODRIGUEZ, KAISER HEALTH NEWS
resident Donald J. Trump selected Sonny Perdue, the former governor of Georgia, to be his secretary of agriculture. Although consumers may simply think of the Department of Agriculture (USDA) as responsible for overseeing the farming industry, it also plays a key role in promoting health. The department is influential in maintaining the nation’s health in four key areas:
EXEMPTED PROVIDERS Some providers that are excluded from MIPS include clinicians that are newly enrolled in Medicare, Qualifying APM Participants (QPs), certain Partial Qualifying APM Participants, Rural Health Clinics and Federally Qualified Health Centers. For those clinicians who have not yet taken steps to prepare for MACRA, there is a chance that a Trump presidency will dismantle the Affordable Care Act, significantly impacting MACRA, which may result in a windfall for those that did not want to participate and have held out. However, “undoing” the existing regulations will take some time, so it is still up in the air how this will all play out. For those that take the risk of a “wait and see” approach and decide to do nothing, the final rule did confirm that if a MIPS eligible clinician chooses to not report even one measure or activity in 2017, they will receive the full negative 4 percent payment adjustment in 2019. The question that will need to be asked is whether gambling the potential negative 4 percent adjustment is worth it. Although there might be some interest in avoiding the performance pressure under MACRA in taking the chance that a Trump presidency may do away with it altogether, not participating wipes out the chance to gain a bonus for high performance, which may be a considerable funding source for some clinicians.
Although food insecurity across the nation has declined in recent years, the USDA found 12.7 percent of all households in 2015 faced hunger. The department helps address this problem by managing the nation’s food assistance initiatives. The Supplemental Nutrition Assistance Program (SNAP) is among the best known of those efforts. SNAP, formerly called food stamps, provides a monthly stipend to eligible residents through an Electronic Benefit Transfer, or EBT, card to use at any qualifying grocer. Since its inception, SNAP has become the nation’s largest safety net for the hungry, feeding more than 44 million Americans last year. Other pivotal food assistance comes through the Women, Infants and Children (WIC) program, which provides benefits to pregnant and nursing women and children up to their fifth birthday. WIC has assisted 53 percent of all infants born in the U.S. Older children also receive help through USDA initiatives that provide low-cost food at school. Kids from families with incomes below 185 percent of the poverty threshold (nearly $38,000 for a family of three) can receive breakfast, lunch, dinner and snacks there for little to no cost. The National School Program
SONNY PERDUE (PHOTO BY BRUCE TUTEN)
helped serve low-cost lunches to an average of more than 30 million kids each day in 2015. When school is not in session, the Summer Food Service Program distributes meals at public areas such as churches and playgrounds. This program helped feed 2.6 million children every day during the program’s peak month of July in 2015.
Supporting Rural Medicine The Department of Agriculture provides a variety of grants to help rural communities meet their health needs. Among those efforts is the Distance Learning and Telemedicine Grants, which distributes millions of dollars to strengthen telecommunications in rural communities and increase access to resources such as teachers and doctors. The money has been used in a variety of ways, including setting up a telepharmacy dispensing system in Alaska and connecting a medical school to rural clinics in Georgia. Access to clean water is also a priority for the department. Water and waste CONTINED ON PAGE 37
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REPEAL & REPLACE
WHAT DOES THE END OF OBAMACARE MEAN FOR RURAL AMERICA? BY KRISTINE CRANE
A year ago, Dave Schumann, a farmer living just outside of Wellman, Iowa, a town of 1,400, noticed that his health insurance premiums had doubled. Schumann, age 58, was paying around $800 monthly to get coverage for himself and his wife. The price surge—for two healthy adults—didn’t make sense to Schumann, so he enrolled in Samaritan Ministries International, a health cost sharing co-op that mimics the collectivist coverage of the Amish and Mennonite communities that populate this part of Iowa, the second biggest farming state in America (after California.) Those communities—recognizable by their horse-and-buggy-travel, hand-sewn garments and simple, white farmhouse homes—also believe that the Church should take care of their healthcare. In 1965, Congress passed a law giving them the right to opt out of Social Security, Medicaid, and other governmental benefits. The Affordable Care Act was an extension of that. Similarly, the Samaritan Ministries, a group of some 80,000 devout Christians across the country that’s based in neighboring Peoria, Illinois, share the burden of each other’s care. Peoples’ payments to each other are often accompanied by hand-written get-well notes. The one condition is that the insurance can’t be used for abortions or drug or alcohol-abuserelated problems. Schumann pays $420 a month into the Samaritans’ collective pot, which is what he was paying before the ACA went into effect. He signed up for Samaritan Ministries just in time, too. In October, he confronted his own health problem: appendiceal cancer, a rare tumor that involves removing the appendix, and then, in Schumann’s case, washing out the surrounding tissue with a hot chemotherapy bath. It was the start of harvesting season when Schumann’s symptoms came on: loss of appetite and intense cramping that made him regret crawling the grain bin one day. He went to the town nurse, who ordered him straight to the ER in the nearest city twenty minutes away, Iowa City. At the University Hospital there, Schumann would get the tests and treatment he needed— and all of it, for a total price that he thinks might near his cap of $280,000. 24 RHQ | ruralhealthquarterly.com
Source: Kaiser Family Foundation analysis of 2016 plan selections by county released by ASPE for the 2016 enrollment period.
2016 ELECTIONS Rural voters turned out in a big way in the 2016 elections, and they voted overwhelmingly for the GOP. Donald Trump won rural America 3 to 1, and lower population red counties voted less Democratic in 2016 than 2012. Since Obama’s election in 2008, the trend of urban counties voting for Democrats and rural counties voting for Republicans has grown stronger.
ENROLLEES IN ACA MARKETPLACES IN 2016, BY CONGRESSIONAL DISTRICT
R Rep / <20K enrollees R Rep / 20K-30K enrollees R Rep / >30K enrollees D Rep / <20K enrollees D Rep / 20K-30K enrollees D Rep / >30K enrollees
Rural America and the ACA: From Promise to Delivery Schumann and others like him, who have found alternatives to the Affordable Care Act, represent only a fraction of rural Americans. Nearly 16 percent of the U.S. population, or 50 million people, live in rural areas, defined as those outside of Metropolitan Statistical Areas, or MSAs, according to the Kaiser Family Foundation. Rural Americans are more likely than their urban counterparts to be uninsured, and those that do have insurance are less likely to have it through their employers. There is also a higher percentage of rural Americans (18 versus 21 percent) on Medicaid. This scenario made the ACA seem promising. According to the Health and Human Services web page targeted at rural Americans, “The law will address inequities in the availability of health care services, increase access to quality, affordable health coverage, invest in prevention and wellness, and give individuals and families more control over their health care.” “Rural Americans experience higher rates of chronic disease, disability and mortality. But help is on the way,” it went on. The reality, for many rural Americans, played out differently. “Sadly, the private marketplace didn’t work in rural America,” said Maggie Elehwany, the vice-president of government affairs at the National Rural Health Association (NRHA). “The majority of rural counties
Sadly, the private marketplace didn’t work in rural America. The majority of rural counties had one or two options.There just wasn’t market competition.
WINTER 2017 | RHQ 25
had one or two options. There just wasn’t market competition.” Taking a simple analogy, Elehwany compares buying health insurance on the exchanges to buying airline tickets: the more ticket options, the more affordable tickets become. But in states like Wyoming, she said, there was only one provider. “It’s wonderful to give people an insurance card, but if they can’t afford to access healthcare, it means nothing,” Elehwany said. Schumann felt that pinch in Iowa. “The so-called affordable care did nothing for the guy paying the bills. It just jacked up the cost of insurance.” Some of the surge in premiums—expected to rise again 22 percent in 2017, according to HHS—was caused by insurers redistributing risk to pay for their sickest, and previously uninsured, new customers. These financial losses have caused many insurance companies to pull out of certain states, and the ACA altogether. That trend has hit rural America particularly hard. Seventy percent of the 650 counties with only one insurer on the exchange are in rural areas, according to the NHRA. Added to the dearth of insurers—and perhaps feeding into insurers’ flight—is that many of the rural states are also those that decided against Medicaid expansion. According to Kaiser, 65 percent of rural Americans live in one of the 24 states that did not expand Medicaid. Those places, particularly in the deep South and Appalachia, Elehwany adds, have populations that are sicker, with chronic diseases such as stroke and diabetes that can be expensive to treat—and even more expensive if left untreated. Molly Gamble, the editor in chief of Becker’s Hospital Review, says states ranked poorly for both the general health of their population and access to healthcare are a legitimate “cause for concern.” These states include Louisiana, Mississippi, Oklahoma, Georgia and Arkansas.
THE PLIGHT OF RURAL HOSPITALS Another by-product of the ACA in rural America has been the closure of rural hospitals, Elehwany said, citing the closure of eightyhospitals since 2010. “It has been devastating to rural hospitals. At this rate of closure, we’re going to lose a quarter of all rural hospitals in less than ten years if Congress doesn’t do anything. One in three are at risk of closing.” Of the eighty hospitals, Gamble adds, “The majority of these closures are in the South — Texas, Tennessee, Georgia, Alabama, Mississippi — each of these states had at least five closures. Texas had thirteen.” Becker and Elehwany both say the loss of a hospital is also economic. “When a hospital disappears, you lose 25 percent of the economy. Housing prices have even dropped in communities where hospitals have closed,” Elehwany says. While the reasons for the closures are complicated and many pre-date the ACA, the regulatory measures attached to the ACA have made it hard if not impossible for rural hospitals to stay afloat. Cuts to Medicare’s bad-debt program (whereby Medicare reimburses hospitals for debts their Medicare patients cannot pay), and sequestration, a two percent cut on Medicare payments, hit rural hospitals especially hard, she adds. “Bad debt stems from a lot of things,” Gamble says, including the ACA’s 35 percent cut in reimbursable bad debt for Critical Ac26 RHQ | ruralhealthquarterly.com
cess Hospitals—those with 25 or fewer beds, which are 35 miles or less from a tertiary institution. Furthermore, Gamble adds, in states that didn’t expand Medicaid, the uncompensated care costs for treating the uninsured drive bad debt; and patients with high deductible plans also run a risk to a hospital’s commercial debt. But the people who really suffer when a rural hospital closes are its patients. “A rural hospital closure isn’t so much a matter of convenience — it is a life or death affair,” Gamble said. “When someone experiences a heart attack or a complication with their pregnancy, the fact that the closest hospital is more than thirty miles away is a risk factor in itself.”
BENEFITS OF THE ACA IN RURAL AMERICA Despite the shortcomings of the ACA in rural areas, many experts say that it did provide some positive change in the dim healthcare landscape of rural America. Robert Annas, the senior managing director of SOLIC Capital in New York City, a restructuring and investment banking firm that specializes in healthcare, says that for starters, the ACA added 20 million people to the insurance rolls throughout the U.S. Annas pinpoints at least one area where the ACA helped rural America directly: allowing access to preventative care, namely through physicals. “When you don’t have an active engagement with care you often have patients present in the emergency room, [which is] the most expensive form of care.” Sarah O’Leary, the founder of Exhale Health, a consumer health care advocacy, said the ACA provided three main benefits: mental healthcare; free contraception; and screening tests for breast and cervical cancer; as well as diabetes, cholesterol and high blood pressure—all “things that would make for a healthy America,” O’Leary says, “rather than dealing with things once they get into an acute circumstance.” That’s particularly true in rural America, where chronic conditions are pervasive and uninsured people have traditionally resorted to the ER in the absence of regular checkups. Scrapping all these benefits with the potential repeal of the ACA is daunting, O’Leary said. “What people don’t realize about the ACA is that it wasn’t a marketplace. It was a 2,000-page document. It put in the prevention/protective element so that people would in theory be guaranteed access to affordable care,” O’Leary said, citing the inability of insurance companies to deny coverage based on preexisting conditions and coverage of adult children under their parents’ plans as two main protective elements. Notably, however, rural America voted for Trump—three to one. And many of the votes came from places where people conceivably fell through the cracks of the ACA. According to Gallup poll data, six of the eight counties with increased premiums voted for Trump—namely in Pennsylvania, Wisconsin, Michigan, Florida and Pennsylvania: the states that sealed Trump’s victory. Also, 19 percent of Trump voters in three of the demographic groups that Trump won—the African-American South, Evangelical hubs, and working class country—said there were times that they did not have money for necessary healthcare and medicine. This scenario begs the question of whether people voted for Trump because they felt left out of the ACA. “The confusion in what these people just did to themselves is mind-boggling,” O’Leary said, adding that Trump won states with the largest increases in ACA enrollment.
CRITICAL ACCESS HOSPITALS 1,330 critical access hospitals (CAHs) provide essential medical care to rural communities. Each CAH maintains 25 or fewer beds and contributes more than 200 jobs to the local economy. Annual services provided include:
patients treated in CAH emergency departments
outpatient visits to CAHs
patients admitted to CAHs
babies delivered in CAHs
Source: National Rural Health Association
Whether or not rural Americans voting for Trump were enrolled in the ACA or not, she continues, “the biggest fallacy is that the government makes money from the ACA. They don’t. It is not Obama, or the administration’s fault that premiums went up. It’s Congress’ inability to reign in insurance companies. They are the ones taking our checks.” O’Leary, who recently moved to Texas, says that someone she met blamed Obama for the 46 percent rise in her premiums. “I told her, ‘Listen, please don’t take this the wrong way, but the administration doesn’t get your check. Blue Cross/Blue Shield gets it,’” O’Leary said. “’Secondly, without the ACA, you’d be paying $55,000 a month for that drug rehab program.’” Insurance companies are instead driving health expenses. “Insurance companies are wildly profitable, and health care is the largest lobbying group in D.C. It’s bigger than the NRA (National Rifle Association) and defense. They spend hundreds of millions to bribe politicians to get them to do what they want them to do.” Meanwhile, health consumer abuses are ubiquitous, O’Leary adds, citing billing fraud at 56 percent. In her consultancy, she advises people to be proactive and vigilant about their care and what it costs them. “Question bills,” she said. “Wait until you get an EOB (explanation of benefits.) Wait to see what insurance will pay. Don’t say, ‘How will I pay it?’ Say, ‘Do I owe it?’”
REPEALING THE ACA IN RURAL AMERICA Most experts say the repeal of the ACA under the Trump administration will take two or more years—so nothing is likely to happen overnight. Still, the air is thick with long-range speculation. “What might happen,” O’Leary said, “Is that the quality of care that we have access to could go down. We might lose access to preventative screenings and affordable medications.” “Losing those preventative measures is the danger,” she added, citing the loss of the free annual wellness exam as especially worrisome because it will mean people will return to using the
ER as their one-stop health visit. “We’re talking about hundreds of thousands of people potentially dismissed, falling through the cracks again,” said Robin Lewy, director of programming at the Rural Women’s Health Project based in Gainesville, Florida. As for the hospitals, “The repeal of the ACA in the plainest terms would be a detrimental event for rural hospitals and would place great emphasis and need on an adequate replacement,” Gamble said. If Medicaid expansion were dismantled, states would be snapped back to pre-ACA baseline for uncompensated care, which would drive bad debt, she added. Annas anticipates that the rate of rural hospital closure will increase—unless those institutions engage in creative solutions to keep going. Two possibilities are merger acquisition affiliation with larger hospitals; and using telemedicine to provide care remotely, he said. Whatever the case, Annas added, in the next 18 to 24 months “we’ll be waiting with baited breath to see exactly what replacement means.” In early January, Trump advisor Kellyanne Conway said no one would lose health coverage after the ACA is repealed. Trump has mentioned possibly holding onto certain features of the ACA, like the provision for adult children to stay on their parents’ coverage plans, as well as barring insurance companies from declining insurance to people with pre-existing conditions. He’s also mentioned moving Medicaid to a block grant system, in which a lump sum from the federal government would be given to states, and the states would decide how to distribute it. The measure is designed to reduce federal spending on Medicaid in the long run. “That reduction in federal spending on Medicaid means states would likely take on a greater portion of the cost of the program, which may result in states putting forth more of their own funding dollars or imposing greater restrictions on Medicaid eligibility and benefits or curbing payments to providers,” Gamble said. “They may do a combination of these things, none of which are positive developments for rural hospitals.” Annas added that the block grant program would become “a political football.” Another repeal initiative that Trump has mentioned is provider price transparency. “In the long run, price transparency is the right thing for patients and our economy. We need that clarity,” Gamble said. “In the short-term, it’s going to be painful for healthcare organizations, especially those that already face staffing and financial challenges. It will fall on those rural providers to do the gritty, time-consuming and painstaking work of first figuring out their costs.” Annas says one of the travesties of repeal is that the ACA has simply not had enough time to play out. The ACA was implemented only a few years ago. By comparison, Annas said, “Medicare started in the mid-sixties, and it took years for it to flesh out.” Whatever the case, he said, “rural health care is going to be at the forefront of the conversation.” Elehwany says the NRHA takes a non-partisan view. “We feel it’s imperative to explain to both Democrats and Republicans that a lot of concepts of the ACA fell short in rural America,” she says. “Our big push is not necessarily support or repeal of ACA. Just to say: Get rural America right.”
WINTER 2017 | RHQ 27
Health Technology // By now, you are probably thinking that this sounds like a Tricorder from Star Trek. Well, you’re not far off...
DISRUPTIVE TECHNOLOGY AND ITS IMPACT ON RURAL AREAS What happens when advancing technology so shakes up the status quo that it creates a completely new culture, industry or set of practices?
ecently, I gave a capstone speech for the 4th World Congress on Ultrasound. It was one of the most interesting conferences that I have attended in a very long time. For most people, ultrasound is another of the miracle technologies of medicine that are mysterious and not widely understood. Most people BILLY U. PHILIPS, JR. about to have their first child have seen those images that confirm there’s a baby on the way EXECUTIVE DIRECTOR and maybe even give clues as to the sex of that F. Marie Hall Institute child. Most people don’t know that ultrasound for Rural and Community Health was actually discovered a dozen years before the x-ray in 1883, but it has just recently found a place as a promising application in medicine.
POINT OF CARE ULTRASOUND (POCUS) Ultrasound scanning, also called sonography, is a non-invasive diagnostic imaging tool that works by transmitting high-frequency sound waves into the body. It produces images of internal organs such as the uterus, ovaries, liver, kidneys, thyroid gland, scrotum, pancreas, gallbladder, bladder, lungs and heart. It can detect abnormal structures like stones, cysts and tumors, or it can show blockages in blood flow and other fluids. It can be done in real time or stored and viewed later in 2D, 3D and in dynamic motion. It can be used to guide invasive procedures such as needle biopsy or aspiration. It is a relatively simple way to examine symptoms of swelling, pain or
28 RHQ | ruralhealthquarterly.com
HANDHELD SONOGRAPHY Portable ultrasound monitors that fit in the palm of your hand have become increasingly affordable and will soon be widely available at multiple price points.
Top Left: Girl gets ultrasound of her thyroid. Right: Ultrasound scan of a thyroid gland.
WINTER 2017 | RHQ â€ƒ 29
infection and harmless, unlike x-rays, CT scans and MRIs that involve the use of radiation. By now, you are probably thinking that this sounds like a Tricorder from “Star Trek.” Well, you’re not far off. It’s pretty similar in concept and applications. Ultrasound has become extremely portable, and handheld machines are commonly used in teaching medical and other professionals and will soon be as common in practice as the stethoscope. When I first saw an ultrasound machine, it was the size of a large filing cabinet and had its own motorized cart to propel it to patient rooms in the hospital. It cost several thousands of dollars. Today, that same machine — well actually a better version with color-flow Doppler and voice-recording for patient information — weighs less than a pound and is about the size of an iPhone. It’s cost is around $2,500, and for a bit more one can purchase a “smart version” that perfects and verifies the location and quality of the image.
DISRUPTIVE TECHNOLOGIES ARE COMMON IN THE MARKET So what we have in ultrasound is a disruptive technology. A disruptive technology is one that displaces an established technology or so shakes Slice : 32.9 the status quo of medicine that it completely creates a new culture, industry or set of practices. We all know Slice : 32.9 of disruptive technologies that impact our lives daily. Things like personal computers that displaced the typewriter, cell phones that have radically altered the telecom industry or email that has transformed communications and the postal industry. Handheld ultrasound will do the same in medicine, but I think it will go further. To understand what I mean, let me use an example from the hotel industry. In business there are four fundamental questions that underlie every successful business. These are: How is value created? How is value consumed? How is quality controlled for the value created? How does value 30 RHQ | ruralhealthquarterly.com
scale? Consider AirBNB and how it forced a restructuring of the value chain and operating model for the hotel industry. AirBNB allows anyone with a spare mattress or room to run their own “bed and breakfast” by giving them access and tools to market them to a potentially global clientele. AirBNB also changed consumption behavior. It wasn’t common for travelers to stay in a stranger’s place until the demand for a “good deal” room rate became a factor and changed the very design of a traditional trip. Since hotel chains are known and branded for their service quality and the reliability of the customer experience, AirBNB changed the quality paradigm by relying on a peer-curation system that ensured consumers had information from fellow travelers on the quality and reliability of the property they were considering. Traditional hotels would scale their product by adding more rooms by either buying or building new sites. But AirBNB scales by improving its ability to match travelers, by leveraging better data. Of course,
other disruptive technology have led to similar changes in other industries. Ever heard of Uber? Let’s explore how ultrasound might disrupt an area of medicine. Consider prenatal uses of handheld ultrasound. This is an arena of life that has in most places in the world not been a domain of medicine but rather of the doula or midwife. Considering that US home births increased by 29 percent from 2004 to 2009, a trend that continues and now stands at about one percent of all births, a technology such as handheld ultrasound could revolutionize the birth industry. The fastest growing segment of homebirthers, about 1 in every 90 births, is non-Hispanic white women, mostly affluent. These are women who can afford the ever falling price of handheld ultrasounds and who have the means to share their experience with that innovation throughout social circles, especially in this age of social media. I could imagine that initially someone with a handheld ultrasound might learn to do only a few things but Slice : 4 do them very well. As .7 the machines
Slice : 4 .7
Slice : 19.
CERTIFIED NURSE MIDWIVES 32.9%
Slice : 19.
OTHER MIDWIVES 32.9%
U.S. home births (2004-2009)
Slice : 4 2.9
get smarter, that set of things could easily expand. What if that someone were a well-known doula or midwife, or a nurse practitioner? Isn’t it reasonable to expect the word to spread in that community and well beyond? With the price of the technology falling and with patients curating with their own sense of quality control and reliability, as in the AirBNB example, the birth market would be changed rapidly. Even if more traditional healthcare providers become proficient in the use of ultrasound, that too would scale the technology by making it easily accessible for application across every applicable dimension of health service.
TRIPLE AIM OF HEALTH REFORM Health care has always been about quality and, more recently, about access to care, especially for rural areas. With the advent of the Patient Protection and Affordable Care Act of 2010 (Obamacare), it has been about those two aims and another, which is the costs of care. The picture above
shows these triple aims, how they are interrelated, and highlights how they are going to lead to four disruptive innovations. Those disruptions are improved quality, greater value, more technology, and a greater focus on population health initiatives. Consider this proposition: When society values something it defines it, and when it defines it then it scales it, and when it scales it then it measures it, and when it measures it then it improves it. The corollary is true as well; namely, when something is shown to be improved it is more easily monetized and payment systems will reflect that. In fact, under Obamacare, the idea is to ensure that all citizens have access to care through health insurance. The notion is that payment mechanisms will reward better outcomes which will put in place the value proposition that will lead to smarter spending. I wonder how many of us would agree that health care would be more accessible if it were obtainable anywhere, at any time, by anyone. It would likely be better if we could
add that consultation with another trained mind would probably make it better, thus adding a quality dimension. Many readers are probably thinking that type of health transaction would be much less expensive, more affordable and, if time is money, convenience would be a key. This may seem a bit disturbing to some readers. Change is uncomfortable, and with all new technologies there are hazards like misuse. In places like rural West Texas, we face a triple threat of another kind that will be fertile ground for the growth of disruptive technologies like POCUS.
THE RURAL TRIPLE THREAT The triple threat in rural West Texas is distance, health workforce shortages, and an aging population with comorbidities. What is it that the Affordable Care Act can do to ensure people have access to care? When you sign up for the exchanges – what do you get? You purchase insurance. And if you live in an urban area of the country, access to care is often
WINTER 2017 | RHQ 31
determined by whether or not you have an insurance card because the infrastructure of health providers is much denser in urban centers. However, if you live in rural America, if you live in most places in West Texas, you can have 100 insurance cards and still not have access to health care. The fact is that 85 percent of the US population lives in an urban or suburban area. Care is focused on the 85 percent of the folks that live in urban areas. As I write this, the first day of open enrollment in the ACA plans has started and the news is that most rural Americans will face much higher premiums and many fewer insurance plan options. That has been more the norm in rural areas since the inception and passage of the ACA.
HEALTH CARE AND THE ECONOMY There must be innovations that provide new ways to take care of the folks that live in rural regions. The reasons are simple. The 15% of the population that lives in rural America provides food, fiber, and fuel for the nation. When healthcare is not readily available to rural residents, the impact on the local economy can be dramatic. Take the case of Bowie, Texas where the Critical Access Hospital closed about a year ago. Within weeks, the largest employer in town closed its operation and moved to a town less than an hour away that kept its hospital afloat. The impact is felt in Bowie as depressed employment opportunities and a lost tax base for schools and the hospital. If the pattern holds, within 10 years what was a viable downtown business district will be boarded up, restaurants will give way to fast food sold in a gas station, and all that will remain are those who could not make a new start, mainly the elderly and poorer residents. If the school continues — not likely as busing is already used in rural regions — it will have many fewer teachers, counselors, and related services. 32 RHQ | ruralhealthquarterly.com
TELEMEDICINE Many in rural areas will find that one promising option for continued care will be telemedicine, used to provide routine primary care, behavioral health and counseling, and for managing acute and chronic conditions by employing remote monitoring equipment that regularly and reliably sends information on biomedical parameters (e.g., heart rate, blood pressure, glucose, weight, etc.) to caregivers who will manage medications and other aspects of care using virtual technologies. For those of us who live in places like West Texas, distance is a fact of life as are shortages in nearly every type of healthcare provider. In our region, most of it is classified as a Frontier area with ten or fewer residents per square mile. We definitely live with health disparities in such areas. Rural residents tend to be poorer. On average, per capita income is $7,417 lower than in urban areas and rural Americans are more likely to live below the poverty level. The disparity in income is even greater for minorities living in rural areas. Nearly 24 percent of rural children live in poverty. Rural residents also tend to be older and have more health issues than their urban counterparts. We can’t forget that health professions shortages extend to mental health professionals in a time when the mental health issues in society are obvious. Consider some of the key reasons – large numbers of returning veterans with PTSD, children from poor and single parent homes, and older people isolated by dementia, distance and disease. Telemedicine is a technology we are using to make things better on all these fronts.
PIONEERS AND THEIR ABIDING SPIRIT M. C. Overton was born in Morganfield, KY in 1878, the fifth of six children. He left high school after two years to work various odd jobs, including four years with the Bell Telephone Company, before resigning to enter medical school. While interning in Kentucky, a classmate informed him of a shortage of
physicians in the Plains area, so he entertained the idea of setting up practice in Texas. Dr. Overton visited Lubbock in 1901. On the second day he weathered a violent sandstorm, but it didn’t deter his determination to set up practice here upon completion of his internship. From 1902 – 1906 he was the only licensed physician in the area. His practice encompassed 23 counties, 21,477 square miles, and a population of 16,342. Dr. Overton made house calls by horse and buggy until 1908 when he bought the first privately-owned automobile. Despite the vast amount of acreage to encompass, Dr. Overton managed to stay in touch with his office. He carried a phone receiver with him that had a long wire attached to it. When he came across an overhead phone line, he would throw the wire across it, and contact an operator to check in with his office. This enabled him to reduce the number of miles between patients. Telemedicine has advanced from Dr. Overton’s time. Today, a telemedicine visit is very much like a traditional office visit, simply with technology involved. There is still patient-clinician interaction, communication of the patient’s need to the clinician, and steps taken towards resolution by the clinician. This disruptive innovation, telemedicine technology, does not supplant patient-clinician interaction. It is changed by that technology and the future will tell whether it has been more influenced by market forces or healthcare forces. I know my hope is that whichever prevails we optimize success and do not harm. Real and lasting innovation with new technologies like point-of-care ultrasound and telemedicine come when those technologies roll out into use and add value to healthcare encounters, while maintaining safety and security. It is our obligation in the F. Marie Hall Institute to create a competency based standard of education around new technologies if we want to lead in creating a standard of competency in care delivery with those technologies. For us, it’s the pragmatism that accompanied the pioneering that made it all happen, and that’s the stuff we’re all about.
Learn telemedicine clinical presenting procedures, technology, and business!
Frontiers in Telemedicine Certificate Course This program focuses on competency-based learning and is designed for licensed healthcare professionals, including mental health professionals, nurses, nurse practitioners, physician assistants, residents, and medical doctors who desire to learn about telemedicine.
Online Learning and Resources
Live Lectures and Equipment Demonstration
Hands on Practice with Patients and Equipment
At the end of this course, the student should be able to demonstrate: basic knowledge of Telemedicine/Telehealth and define those who could benefit from this technology knowledge of the Originating/Distant site, as well as the clinician/staff roles at each one ability to operate certain telemedicine technologies knowledge of the procedures for a telemedicine encounter utilization of knowledge required to present and manage the patient through telemedicine application of communication skills in patient and medical team communication
D E L E V A R T S S E L D A O R A
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34 RHQ | ruralhealthquarterly.com
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r ve t o ly s ju st of : mo hand k n o g e or i lat orkin o tak rd w u w op ha et ce a p hard t lik heir cti a s r t o a p n are te th ily p.m. nor ha ere ey do espi m t i a 5 f h a le . to or m ric live rs. Th ces. D g e n si a.m old s ur in. ke Am ho al s w wor reso ty th ate a m 8 on c riou r u e e r r o r i t m d in amil lfiel thei pre s ope ay fr com like s n i f o rid he ith ead rse ff” ow e a t e. Th , and al w spr w nu gh F as t stu ns. e in opl hers frug are a fe rou uch “big itio h s e d s ag Im 00 p , ranc y are urce and day t ents e the con t l c o 0 s i e n , n d r h res sta Mo ailm an ron 5 me , i dt h far s an ality n Ass pen treat not d ch t o g n a an u n u i s s a ’ r o n f ysic . It ca ey c eds, a i d n c m i an A Ph tow tea r, th t ne hys ural t e p n is f o in r ic i ligen owev ecial t n i e n i l n c s d s. H , sp e o ce i per ractic t that n Th ture ncies 0 c c 1 p o a fra erge out erica the f pulati b a em m ite . po ly
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WINTER 2017 | RHQ 35
of rural counties have no public transportation
of children in families with incomes less than $50K/year miss essential medical appointments due to lack of transportation
of respondents at a large, urban hospital had previously missed an appointment or arrived late due to transportation difficulties
of rural patients could not get to a pharmacy due to transportation barriers 36 RHQ | ruralhealthquarterly.com
This small town sits in an 896-squaremile county with only two ambulances for the entire county. The five crewmembers that drive them do so on a volunteer basis. Emergencies are triaged by severity, and the drivers are pulled away from their full-time jobs when a trip is needed. Mrs. Smith, aged 67, lives in this town. She is a widow and diabetic. She stopped being able to drive a few years ago. She is retired and lives on Social Security, which does not quite make ends meet. Meals on Wheels drops off a bag of food for her once a week. Her only son has a full time job on an oilrig 170 miles away, almost a three-hour drive. When Mrs. Smith needs to go to her annual diabetic retinopathy visit, her options are slim. Her son must take three days off from work to get home, take her to and from the hospital where her specialist works, and travel back to the rig. Most of the time, patients like Mrs. Smith simply put off the care that they need. When this happens, their condition often deteriorates over time until it reaches a critical level. In Mrs. Smith’s case, that could mean eye pain, hemorrhage, and even blood vessel damage to the point of total blindness.
MOBILE TECH TO THE RESCUE Liberty Mobility Now hopes to help people like Mrs. Smith. The ambitious tech start-up provides advanced smart phone technology designed to work in rural areas for individuals to request trips as well a call center for those who want to visit with a live person to set up an account or book a trip. As with Uber and other ride sharing services, Liberty drivers are independent contractors who get paid per mile by accepting trips requests. Drivers earn between $0.76 – $0.80 per mile in most states, and all payment is handled electronically so no cash is changing hands. We asked President and CEO Valerie Lefler to tell us more about her company: How did you get started in this business? What made you choose this? We got started after working with rural public transit providers in Nebraska and recognized a major gap for night and weekend transportation in counties that had public transportation and that there were many counties that did not have any transportation options. I chose this because we saw the need and hear story upon story of pain,
suffering, institutionalization, etc. from folks who just simply needed a ride. What is unique about your business that sets you apart from a company like Uber? A couple different things separate us from Uber. First, we offer a call center for those who do not have access to smart phones or cell service. Second, our drivers are background checked and finger printed, trained a full 8 hours, and drug tested. Our drivers meet the same regulations as taxi drivers in most states. This allows us to meet all the regulations for federal funds. How do you market or advertise your business? We use the standard email, social media, radio, but we also focus our marketing locally with the schools, community colleges, churches, etc. We aim to put every dollar back into the local economy as much as possible and see the most benefit when working with schools which are the heart and soul of the community. Do you have any plans to expand your business into other cities/regions? Absolutely, we have several locations planned nationwide. There is western Nebraska up first, then we plan to expand into Corpus Christi, Texas and the coastal bend region. There are five additional locations we’re considering and discussing for 2017 as well. For folks who are interested, they can subscribe to our email list at thisisliberty.com. Agencies and organization who are interested in working with us to launch in a community near them can email firstname.lastname@example.org Is there anything else that you would like our readers to know? We are looking for angel investors. We need to grow our business so quickly to meet all the demand in the rural communities and we cannot do that without angel investment. If anyone is interested in investing in this wonderful company doing great work, my email is email@example.com. Liberty is planning deployment in seven states by the end of 2017. By 2020, Liberty plans to be available nationwide in the US and operating in several countries around the world.
BEHAVIORAL HEALTH //
TEENAGE ANGST INTERVENTION CAN BE AS SIMPLE AS LISTENING TO A TEEN’S CONCERNS
I was one of those kids raised in a large school. My graduating class was more than 600 students. Nobody knew me and I did not have any close friends. School was a place that I went to at 8 am and left at 3 pm. Although it was a large school, with a lot of students, I found myself isolated. The popular kids were the football players and the cheerleaders. I could not RONALD N. tell you the name of one person from my high school MARTIN, LPC and there were over twenty five hundred. I was not THE TWITR PROJECT connected to my school or my fellow students. F. Marie Hall Institute Fast forward a few decades and I have observed for Rural and Community the school connection within the rural community. Health The rural community is a place where everyone knows you by your name or your family. There have been songs written about people in the town square, the church, local festivals, the local cafe, and in some cases the barbershop. However, it is remarkable that the central focus in the community is the school. Small community schools provide a social connection for residents. They come together for sporting events, band concerts, school festivals, and special events. The school gym may be the largest indoor area for social gatherings in town. These activities offer opportunities for people to connect socially to the group. At the end of the school year, the high school graduation is the central focus of a community. The graduating class may have fifteen to thirty students. The ceremony is supported by the community and is very personable. Some graduating ceremonies have a photo slideshow of each student from birth to the events of the senior year. They each have a connection to the other. Adults that grew up rural in these schools have life connections as they grow older. The members in the community watch each other grow up, get married, have children, experience life troubles and blessings together. They are connected and their lives intertwine. However, some of the adolescents never feel connected to the group and find themselves isolated for various reasons. As they struggle to find their place in the group, the feelings of loneliness, hopelessness and isolation become part of their belief system. They believe they are worthless and irrational thoughts begin to infiltrate their thinking. They have not developed or have not been taught appropriate coping skills. Adolescents are impulsive, and without coping skills they may resort to behaviors that are detrimental to their safety and the safety of those around them. These dynamics have been identified as factors in school violence studies. It is important to recognize students that are struggling with these feelings and intervene. Intervention can be as simple as listening to the students concerns, encouraging interaction with fellow students and a referral to a mental health professional.
AG MATTERS CONTINUED FROM PAGE 23
disposal grants are available to federally recognized tribal lands, communities along the U.S.-Mexico border and rural towns. The funds are used to install proper waste disposal systems and, in some cases, outfit homes with new plumbing.
Health Education For decades, the USDA has been involved in efforts to educate Americans of all ages how to keep off excess weight and lead a healthy lifestyle. Since 1969, the Expanded Food and Nutrition Education Program has worked with low-income families to develop healthy diet and exercise habits and educate them about food safety. The program uses peer educators from the participants’ communities and operates in all 50 states, the District of Columbia and six territories. In 2015 alone, the program reached nearly half a million Americans. Agriculture also plays a hand in developing the nation’s nutritional guidelines. In partnership with the Department of Health and Human Services, the department issued the 2015-2020 Dietary Guidelines for Americans. The report outlines five key strategies to develop healthier eating patterns.
Preventing Foodborne Illness Nationally and in Your Home The USDA helps protect the food supply through the Food Safety and Inspection Service. The office monitors the importation of meat, poultry and egg products by issuing safety certifications to some foods from other countries and auditing their food inspection systems. Domestically, the same agency monitors food processing and distribution through microbiological testing. It also maintains a system that tracks and alerts potentially dangerous foods. For consumers, the office maintains a USDA Meat and Poultry Hotline to answer individual questions about food preparation.
WINTER 2017 2017 || RHQ RHQ 37 37 WINTER
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THE UNSUNG POWER OF RURAL...
School Connectedness “Since true happiness is inseparable from the feeling of giving, it is clear that a social person is much closer to happiness than the isolated person striving for superiority.” — Alfred Adler, “Individual Psychology,” 1926.
MORE INFORMATION //
If I’m being honest, I didn’t always hold a high opinion of “rural americans.” I was raised in the city, proud and privileged. // AMANDA I thought most FREEMAN, LPC rural folks were, THE TWITR PROJECT well, backward. F. Marie Hall Institute Over time, my for Rural and Community feelings have Health changed. I would now characterize them as kind, wise, hardworking and community oriented. Why the shift in thinking? Education and work experience helped, but my understanding really changed when I immersed myself in the Ralls Independent School District. Located on U.S. Highway 62/82 with a population around 1,915, Ralls, TX fits the rural community
description to a T. Like other rural schools, Ralls ISD has the same needs and struggles as their urban and suburban counterparts. However, according to the Center on Innovation and Improvement, rural schools fair far better in achievement. This is certainly true in Ralls. Our city schools are plagued with drugs, violence, high dropout rates and lonely and withdrawn students who fall through the cracks and may end up in our criminal justice system. Ralls ISD has a population of around 585 students, and 81.5 percent of these students are economically disadvantaged. This number is 15.6 percent higher than that of an urban school district not too far away. Over half of Ralls ISD students are statistically at risk for dropping out. However, more than 96 percent of those students graduated in 2013.
The Telemedicine Wellness Intervention Triage and Referral (TWITR) Project leverages telemedicine services to intervene with junior high through high school students who are at risk for injury or harm to themselves or others in school settings. The project was created following a grant from the Office of the Governor for the State of Texas to create a model for identifying students at risk for committing school violence and to intervene before acts of violence occur. The TWITR model uses Licensed Professional Counselors to go into schools, to assess students identified by school staff as having behavioral problems possibly leading to violence, and to refer students in need of mental health care to counseling or telemedicine psychiatric services. For more information on The TWITR Project, visit www.twitrproject.org or call 806.743.1338. WINTER 2017 | RHQ 39
In that same nearby urban school district, 42.6 percent of students are at risk for dropping out, with a graduation rate of 87.5 in 2013. Ralls dropout rate in 2013 was only 1.4 percent. Since then, they have had a 100 percent graduation rate. As the Center on Innovation and Improvement says, “Taking district socioeconomic status (SES) and perstudent expenditures into account, the smaller the district, the higher the achievement.” Lower volume places greater responsibility on a school to engender improvements. Rural schools rely on their available resources and are innovative. Strong relationships among staff, a team-oriented approach to planning, and disciplined work contribute to the high achievement of rural schools. Typically, teachers in rural school districts exhibit high concern for their students beyond the classroom and they also take an invested interest in their needs. In addition, faculty relationships with families are strongly associated with achievement in rural schools. The school ties the community together in rural counties, and students perform better when they have a sense of belonging.
THE ADLERIAN APPROACH Alfred W. Adler (1870-1937) was an Austrian medical doctor, psychotherapist and founder of the school of Individual Psychology, a theory of personality. Adler focused his pioneering work on community life, prevention, and population health. Adlerian psychology stressed the importance of nurturing feelings of belonging, and he stressed the importance of community. I’m an Adlerian counselor, and I use his theory as a way to understand and guide my clients. Collaborating and cooperating with one another can benefit society as a whole, instilling social interest and personal wellbeing. Adler once said, “The goal of the human soul is conquest, perfection, 40 RHQ | ruralhealthquarterly.com
security, superiority. Every child is faced with so many obstacles in life that no child grows up without striving for some form of significance”. The Centers for Disease Control and Prevention says, “School Connectedness” is an important factor in both health and learning. School Connectedness is, in essence, the belief held by students that teachers, parents, and peers all care about their success, and more importantly about them as individuals. School Connectedness is a holistic approach to health and learning much like the ideas Alfred Adler espoused in the early 1900s. As a Licensed Professional Counselor for The TWITR Project, I have had the opportunity to visit many different school districts throughout West Texas. Ralls ISD has been one of our TWITR school districts for the past three years. When I was asked to write a feature article, I immediately thought of Ralls. They are extremely invested in their students. There is always need in our rural communities, yes, but this is a rural community that has something to offer us, to teach us. The “Wingspread Declaration on School Connectedness” describes three critical things a student must experience to feel connected: 1. High academic expectations and rigor coupled with support for learning 2. Positive adult /student relationships 3. Physical and emotional safety What does all that look like in real life? I think it looks a lot like Ralls ISD.
THE HALLS OF RALLS It’s not easy to describe the passion that the Ralls High School principal, Miguel Salazar, has for his students and teachers. Mr. Salazar is a terrific storyteller, and he graciously spent hours with me sharing the history of his district. He helped me under-
stand what School Connectedness really is: it was already written all over the walls of the school in black and white photographs. Mr. Salazar celebrates his students and teachers by placing framed photos all over the school. He wrote a grant and was awarded funds to produce his picture project. If I can share what they know about school connectedness, then maybe we can contribute to the health of other students. So this is how they do it: Like a living yearbook, the halls of Ralls High School are covered with black and white photos of students and staff. (Photos courtesy of Ralls High School)
GREAT EXPECTATIONS At Ralls ISD, expectations and support for learning begins with the administration. Principal Salazar stresses the use of technology in teaching his students. Each student is provided with a Chromebook to enhance learning opportunities. He also stresses the importance of having a relationship with students and says being able to build a rapport with them is a major factor in his hiring. Shay Bolm, the school counselor, says Salazar really goes the extra mile in his concern for both students and faculty. She described encountering a suicidal student her first week at Ralls, and due to transportation issues, she personally drove the student to an inpatient facility to receive the necessary care. But the trip turned out to be longer than she had anticipated. In West Texas there are few residential treatment facilities for children, and the nearest major city to Ralls has none. She was worried, however, that there was no one available to pick up her own children. But Mr. Salazar picked her children up, took them home with him, and fed them. She says he is like this with everyone. “He goes above and beyond,” Bolm said. “He is brilliant and sets high expectations for himself and others around him. He makes me want to be a better person. He makes our students want to be better. We have a lot of respect for him.” Jeremy Griffith, the Ralls Middle School principal, has been with Ralls ISD for 13 years, and his wife also teaches at Ralls Elementary. In 2008, Mr. Griffith’s daughter Reese was born with a rare heart condition, Williams Syndrome. For several weeks, he stayed up at the hospital with his daughter. During this time, Mr. Griffith was the head football coach. He said his fellow coaches would bring video of the games up to the hospital so he could watch and help develop a plan for them. He says he will never forget all the love and
support the people of Ralls provided his family. I learned a lot about Reese while visiting Mr. Griffith and others in Ralls. Reese never met a stranger. She was a beautiful, empathetic little girl who cared deeply for others. And she loved to play softball. The Ralls ISD baseball field was named in honor of her. She was four years old when she passed. Of course, Ralls is equally dedicated to academic achievement. Chelsey Campbell, the principal at Ralls Elementary School understands that in order for students to excel, parents must buy in. For the past three years, Mrs. Campbell has worked diligently on bulding strong connections with “her” parents. In addition to hosting an elaborate Fall Festival, countless music recitals, and a popular recycling program, each year the school hosts a book fair. The fair has become a huge community event, and parents do a lot of their Christmas shopping there because it allows families who struggle with transporation to shop for gifts without leaving town. The book fair also provides a way for the school to get books into more students’ homes, encouraging literacy and learning at an early age. Ralls also has a great after-school
program. The Edge Mentoring Program is designed to keep children off the streets and encourage academics and creative learning. A bus picks students up and transports them to the program where they are given help with homework and offered classes in the arts, cooking and baking, candy making(!), and most recently archery. The program is designed to offer the enrichment learning a student may not get in his or her home. The Edge Mentoring Program also gives parents extra time to get off work without leaving their children unattended.
POSITIVE STUDENT RELATIONSHIPS One of the coolest stories shared with me about the students in Ralls was about a boy named Geronimo. He was a high school student with an enlarged heart that prevented him from playing sports. He loved his school and everyone loved him. He also loved NBA star Lebron James, so the Children’s Miracle Network sent Geronimo to watch Lebron play. During the unveiling, students performed a flash mob, dancing to the song “Geronimo.” He and his parents were
Ralls ISD provides opportunities for students, parents and staff to get to know one another in order to provide students with a sense of community and belonging.. WINTER 2017 | RHQ 41
unaware that the Children’s Miracle Network was about to give him such a great gift. Two days prior to the event, the entire school practiced the routine. The cheerleaders taught them the dance. It’s this sense of community and connection that makes opportunities like this possible. Last year, for example, the Ralls Student Council decided to help other students in need. Student Council Representative Virginia Meza suggested a dodgeball tournament to help raise money to purchase winter coats for any student who needed one. With students helping to spread the word, the project was a success. Around 50 coats were provided to kids in the district.
PHYSICAL AND EMOTIONAL SAFETY In each of the principals’ offices, on their computer screens, is a live view
of their campus. I was visiting with Mr. Salazar, clarifying a few stories, and I swear that man has eyes in the back of his head. We were not even looking at the computer when he jumped up and said, “Where is that student going?” He rushed out of the office to find out why the student left the building. School security is another big point of emphasis in Ralls ISD. “Ralls ISD looked at several factors when we implemented access control on all buildings as well as the policy allowing certain employees to carry a firearm,” said Salazar. “Student and staff safety is a top priority at Ralls ISD. Based on the increasing number of shootings in gun free zones and recognizing the delay in response from emergency first responders, including law enforcement, in an emergency situation may have devastating consequences, the School Board adopted the policy allowing specific school employees to carry firearms.”
Ralls ISD also takes extra precautions when it comes to the mental and emotional well-being of their students. They know there are times a student needs extra help despite the best efforts of the school. Ralls asks for help and welcomes outside counselors and telemedicine. As one staff member noted, “We are not perfect, and we don’t claim to be.” They are however, a team of caring educators who understand the struggles their students face because they know each of them personally. Visiting Ralls ISD has been a humbling experience. Rural America has something to teach us all when it comes to education. They are connected, and it runs deep. Many of the students I spoke to said they appreciate the small classes and individual attention they receive in Ralls, but I think one student in particular summed it up best: “Our teachers tell us they care.”
FLASH MOB FOR GERONIMO For two days, students in Ralls High School practiced a synchronized song and dance in order to deliver the surprise announcement that the Children’s Miracle Network had granted an ill student’s wish to see NBA star Lebron James play. 42 RHQ | ruralhealthquarterly.com
Rural Health Research Gateway The Rural Health Research Gateway is an online library of research and expertise. It’s free to use, searchable, and provides access to the work of all ten federally-funded Rural Health Research Centers and Policy Analysis Initiatives. The Rural Health Research Center (RHRC) is the only Federal program that is dedicated entirely to producing policy-relevant research on health care in rural areas. The Federal Office of Rural Health Policy funds seven RHRCs and three rural health policy analysis initiatives. The Centers study critical issues facing rural communities in their quest to secure adequate, affordable, high-quality health services for their residents.
This online resource of research connects you to: • Research and Policy Centers • Research Projects • Experts • E-mail Alerts • Fact Sheets • Policy Briefs • Reports • Communication Toolkit
How can we help? • email@example.com • www.facebook.com/RHRGateway • twitter.com/rhrgateway
ruralhealthresearch.org This project was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under grant # U1JRH26218. The information, conclusions, and opinions expressed in this toolkit are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.
RHQ CONFERENCE CALENDAR
hether you’re a health worker, a researcher, an educator or a student, professional conferences are a way to catch up of the lastest trends in your field or to make connections that can last a lifetime. Check out our list of upcoming rural health conferences below, and please let us know if you’re hosting one later in the year so we can help you spread the word. You can email all the details to RHQ@ttuhsc.edu. 30th Annual Rural Health Leadership Conference Feb 5-8, 2017 Phoenix, AZ www.healthforum-edu.com NHRA Rural Health Policy Institute Feb 7-9 2017 Washington DC www.ruralhealthweb.org Small and Rural Hospital Conference Feb 15-17, 2017 Newry, ME www.themha.org
Annual National Association of Rural Health Clinics Spring Institute Mar 20-22, 2017 San Antonio, TX narhc.org
American Telemedicine Association Annual International Meeting and Exposition Orlando, Florida May 22-25, 2017 www.americantelemed.org
California State Rural Health Association 32nd Annual Rural Health Care Symposium Feb 22-24, 2017 Sacramento, CA www.calhospital.org
18th Annual Rural Health Conference March 30-31 2017 Tuscaloosa, Alabama rhc.ua.edu
Rural Health Association of Oklahoma Rural Health Conference May 25-26, 2017 Norman, OK www.rhao.org
Western Forum for Migrant and Community Health Feb 22-24, 2017 San Francisco, CA www.nwrpca.org Rural Hospital and RHC Workshop Feb 24, 2017 Madison, MS mrha34.wildapricot.org
National Rural EMS Conference April 26-27 2017 Fargo, ND nosorh.org Critical Access Care Hospital and Rural Health Clinic May 2-4 2017 Reno, NV wipfli.com
Critical Access Hospital Conference June 6-7 2017 Minneapolis, MN www.eidebailly.com Annual Rural Health Conference Jun 13-14, 2017 French Lick, IN www.indianaruralhealth.org
2017 Rural Medical Education Conference May 9, 2017 San Diego, CA www.ruralhealthweb.org
Dakota Conference on Rural and Public Health June 13- 15 2017 Minot, ND ruralhealth.und.edu
22nd NRHA Health Equity Conference May 9, 2017 San Diego, Ca www.ruralhealthweb.org
Annual Minnesota Rural Health Conference June 19-20 2017 Duluth, MN minnesotaruralhealthconference.org
40th Annual Colorado Hospital Association Rural Health and Hospital Conference Mar 8-10, 2017 Golden, CO cha.ps.membersuite.com
NHRA Rural Hospital Innovation Summit May 9-12, 2017 San Diego, CA www.ruralhealthweb.org
Rural Health at the Crossroads June 21-23 Amarillo, TX crossroadsconference.us
Rural Hospital & Rural Health Clinic Workshop Mar 10, 2017 Tupelo, MS mrha34.wildapricot.org
40th Annual NRHA Rural Health Conference May 9-13 2017 San Diego, CA www.ruralhealthweb.org
Wisconsin Rural Health Conference June 21-23 2017 Glacier Canyon Lodge, Glacier Dells www.wha.org
NW Rural Health Conference Feb 27- Mar 1 2017 washington.edu 23rd Annual Rural Health Educational Summit Feb 28-Mar 1, 2017 Jacksonville, FL floridaruralhealth.org
44 RHQ | ruralhealthquarterly.com
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Repeal and Replace: What does Trumpcare mean for Rural America? • Fact or Fiction?: Self-Diagnosis in the Digital Age • Quality of Life: A Y...
Published on Jan 25, 2017
Repeal and Replace: What does Trumpcare mean for Rural America? • Fact or Fiction?: Self-Diagnosis in the Digital Age • Quality of Life: A Y...