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Spring 2018

Rural Health Quarterly

Diversity Rural care is changing because rural America is changing. Better keep up.

A Publication of the F. Marie Hall Institute for Rural and Community Health

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SPRING 2018 Might Midwives Help Fill Rural Maternity Care Gaps? 15

Forgotten America A mother’s 15 year struggle to get life saving care for her daughter.


Telehealth Along the Texas–Mexico Border 23

THE DIVERSITY ISSUE FROM THE PUBLISHER: Celebrating Diversity in Rural America

Veterans with PTSD, TBI may be Discharged for Misconduct 31

Teletherapy Fills Void for Vulnerable Population

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The Importance of Diversity in Research Minoritites continue to be underrepresented in the clinical trials that lead to the discovery of treatments and cures.



How one Montana tribe tackles health disparities with help from student researchers.

A Tale of Two Censuses


Reaction to the addition of a citizenship question among lawmakers and the general public has been deeply divided.

CHWs PLAY AN IMPORTANT Role in Cultural Sensitivity



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Volume 2, No. 2 Spring 2018

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



Section Editors Debra Flores—Health Education Travis Hanson—Health Technology Catherine Hudson—Rural Research Ronald N. Martin—Behavioral Health Cameron Onks—Public Policy Copy Editor Melanie Clevenger Research Associate Debra Curti



Web Developer Miguel Carrasco Contributors Jordana Barton O.M. Campbell Emily Forman Erica Hensley Cindy Uken


// HEALTH EDUCATION 34-39 Summer 2018

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Contacts and Permissions Email RHQ at RHQ@ttuhsc.edu. For more contact information, visit www.ruralhealthquarterly.com. Rural Health Quarterly is a free publication of the F. Marie Hall Institute for Rural and Community Health at the Texas Tech University Health Sciences Center.


SPRING 2018 | RHQ   3


Salad Matters: Celebrating Diversity in Rural America


ut on the South Plains of Texas where I work, most farmers will tell you not to plant until after Easter. That’s because the threat of a late freeze is negligible, the winds generally begin to die down, and most importantly, if we’re going to get rain, that’s the time it comes readily. These are all good things to have happen when planting a crop. BILLY U. PHILIPS, JR. That’s what everybody is thinking about in the agricultural world this time of year while the rest of us take it all EXECUTIVE DIRECTOR F. Marie Hall Institute for granted. Maybe the closest we get to that world is in the for Rural and Community produce section of our local supermarket or at our favorite Health at the Texas Tech home and garden center as we purchase hanging baskets University Health Sciences filled with geraniums, pansies, or tulips. We rarely think Center. about the people that provide all those pleasant things to eat and that bring delight to our eyes. Most people don’t know that non-Hispanic white people made up about 80% of the U.S. rural population in 2010 but accounted for only 25% of rural population growth in the previous decade. African Americans are still the largest rural minority population, but rural-living Hispanic populations increased about 45% to 3.8 million from 20002010. Other ethnic groups show similar trends, with rural Native Americans increasing by 8% and rural Asian populations increasing by 37%. What that means is the face of rural America is changing. Smarter people than I are writing and talking about the three “Ds” reshaping the demographics of rural counties in the U.S. – depopulation, deaths, and diversity. What they mean is that America is becoming more urbanized, rural areas in particular are becoming older, and the mix of the population is much more colorful and cultural. I have noticed the tone of that conversation is often political and often less than optimistic, regardless of party affiliation. I can understand that pessimism from my seat in the arena of health care. Hospital closures disproportionately affect rural communities and communities with a higher percentage of black and Hispanic residents. It’s like a double whammy of economic discrimination in the places and people that produce the food, fuel and fiber that are the stepping stones to economic vitality. There are two take-away messages in this changing face of rural America. First, there are fewer and fewer no-majority and no-minority counties in the US. We are definitely much more diverse. Second, rural poverty is as looming an issue as urban poverty, and poverty is an issue that can and must be eliminated. It’s like those old farmers tell us, it won’t be until those negative factors like poverty are past that we can expect a good harvest from our planting. I’d be shading the truth if I didn’t tell you that I am awaiting the good harvest. Out here it’s not long until we start seeing all the good things one could put in a salad – tomatoes, lettuces, radishes, squash, etc. I like that kind of diversity in my salad. But you have to have the mix of all of it to have it turn out tasty. Then, how you mix it up matters – one wants a good equity in the mix for the tastiest salad. Come to think about it, that’s probably why I’m optimistic about the changing face of rural America, but I also recognize the persistent threats that inequality, poverty and other forms of disparity pose. Working together, we must eliminate these disparities to ensure a healthy future for all rural Americans.


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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 2018—Texas Tech University Health Sciences Center. 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, associate dean for the School of Medicine Administration, TTUHSC Permian Basin Coleman Johnson, special assistant to the President, TTUHSC Retta Knox, RN, Hart School-Based Health Clinic, Hart, TX Susan McBride, Ph.D., RN, School of Nursing, TTUHSC Linda McMurray, executive director at TTUHSC Larry Combest Community Health and Wellness Center Will Rodriguez, senior managing director for CMHC, TTUHSC Ken Stewart, Ph.D., director of Community Development Initiatives, ASU, San Angelo, TX Dr. Julie St. John, assistant professor, TTUHSC Abilene Shari Wyatt, rural health specialist, State Office of Rural Health, Texas Department of Agriculture





U.S. Sen. Doug Jones says Alabama missed an opportunity by not expanding its Medicaid rolls in 2014. Jones has introduced a bill that would require a federal agency to provide annual summary data on how each state has been impacted by the decision to expand Medicaid or not.

A partnership between Eastern Arizona College and Arizona State University, the EAC-ASU Baccalaureate Nursing Program gives rural nursing students the opportunity to earn a bachelor’s degree in Thatcher, AZ, ensuring skilled quality care isn't lost to bigger cities.

whnt.com | 06.13.18

asunow.asu.edu | 05.10.18





Federal funding cuts to a program which subsidizes rural hospitals’ telecommunications costs could shutter Alaska's Cordova Community Medical Center. The center’s president said many of Cordova's systems – ranging from CT and X-ray scanning to telemedicine and payroll systems – rely on internet service they can no longer afford.

Arkansas became the first state in the nation to require its non-disabled adult Medicaid expansion population to work or volunteer 80 hours a month to maintain their health care benefits. Medicaid recipients must document their work hours through an online portal, even though many rural residents of the state don’t have interenet access.

The California Department of Public Health has issued a statewide standing order for naloxone, the emergency antidote that reverses the effects of an opioid overdose. The order enables all California organizations that work to reduce or manage drug addiction to distribute naloxone without a prescription from an individual doctor. In rural areas like the northern counties, treatment facilities often struggle to find a doctor who will write a standing order for naloxone.

www.governing.com | 05.15.18

arktimes.com | 06.05.18

sfchronicle.com | 06.15.18

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Pakistan According to WHO statistics, one in three adults in Pakistan is suffering from high blood pressure. Stress, poor eating habits and lack of exercise were identified as possible causes. Awareness about the disease in rural areas was also alarmingly low. tribune.com.pk | 06.02.18 6  RHQ | RuralHealthQuarterly.com


The courses will include more involvement of GPs in teaching and assessment and enhanced GP placements in deprived and rural settings.

Following a nine-day study, an expert from the World Health Organization has warned that the recent eruptions of Guatemala's Fuego Volcano will have short-, medium- and long-term health effects on its victims. The contamination of food and water from the metals contained in the volcano ash can cause gastrointestinal diseases and may also present in the respiratory system, skin and eyes. Approximately 3,623 victims were left destitute as a result of the Fuego eruption.

scotsman.com | 06.01.18

telesurtv.net | 06.21.18

The Scottish Government will fund 85 additional places at Scottish universities to help reach its aim of increasing the number of GPs by 800 over the next decade. Edinburgh University will offer 25 places to NHS healthcare professionals who want to retrain as doctors, which it said were hoped to address doctor shortages.

What’s news in your neck of the woods? Let us know: Email: Email your rural health news to RHQ at RHQ@ttuhsc.edu

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A bill to accelerate construction of high-speed broadband internet service in rural Colorado is now law. The law is designed to bridge the divide between urban and rural parts of Colorado, where fast internet is a lifeline for farmers, telemedicine, public schools and small businesses. $115 million will go to broadband grants between 2019 and 2023.

Hawaii Governor David Ige has signed a bill making the state the first in the U.S. to ban pesticides with chlorpyrifos. The bill also provides for a pesticide drift monitoring study and two full-time positions to educate and assist farmers.


agprofessional.com | 06.14.18

Florida International University has awarded $100,000 in grants to five FIU nurse practitioner graduate students to participate in a twoyear nursing education initiative to prepare advanced practice nurses to provide primary care in rural and underserved areas.

The small south Georgia town of Plains has no practicing physician. But that’s about to change, thanks in part to advocacy from the town’s most famous resident. Former President Jimmy Carter’s efforts have helped lead Mercer University School of Medicine to open a primary clinic in the town. Carter, 93, called the university’s president and talked about the need for health care in the town where he was born and still resides. The new clinic will have a physician and a nurse practitioner, and it will help train Mercer medical students.

dailynurse.com | 04.27.18

macon.com | 06.19.18

idahostatesman.com | 06.13.18



usnews.com | 04.02.18


IDAHO // Eight of the top 10 U.S. counties for non-medical vaccine exemption rates are in Idaho, according to a recent report. In Camas County in southern Idaho, nearly 27 percent of the kindergarten population opted out of childhood vaccinations in the 2016-2017 school year. With few exceptions, the counties with the highest exemption rates are located in rural areas.


Brazil As it struggles to control its second deadly yellow fever outbreak in consecutive years, Brazil’s government has said it will vaccinate everyone in the country who is not already protected – which means giving injections to 77 million people by the end of 2019. Although Brazil already recommends yellow fever vaccines in many areas of 23 of its 27 states, it has not been able to deliver on those recommendations, leaving many unprotected.

The Health Professions Council of South Africa has forced legendary French HIV expert Dr Francoise Louis to leave the country. The HPCSA has been heavily criticised for the move due to the shortage of skilled professionals in the public health sector.

A study of 2500 people in New South Wales found one third of those with moderate to high psychological distress did not associate their symptoms with a mental health problem. The rate of suicide is 66 percent higher in rural vs. urban areas of the country.

theguardian.com | 03.28.18

enca.com| 06.26.18

tendaily.com.au | 06.22.18 SPRING 2018 | RHQ   7

Rural Reports //



The Illinois Department of Healthcare & Family Services, announced the formation of a new 18-member state task force to develop a comprehensive telemedicine strategy for the Medicaid program to help improve access to health care for Illinois residents in rural areas.

Maryland’s rural areas don’t have enough doctors, according to a rural health plan recently released by state health officials. The state contracted with the Maryland Rural Health Association to develop the plan. About 25 percent of Marylanders live in rural areas.

bcrnews.com | 06.22.18

INDIANA // Indiana University's Center for Rural Engagement has announced plans to continue a pilot project, Sustaining Hoosier Communities, in Lawrence County. The program works in concert with IU's Grand Challenges program on addiction to develop strategies to foster and promote community wellness. news.iu.edu | 06.06.18

IOWA // Violent crime is surging in rural Iowa, fueled by the state's meth and mental health crises, law enforcement officials say. While Iowa's violent crime rate increased a slight 3 percent from 2006 to 2016, the rate among communities of fewer than 10,000 residents rose 50 percent during that same period.

KENTUCKY // Thanks to recently passed legislation going into effect July 1, 2019, Kentucky health providers will have more access to patients via telehealth. The new law will allow commercial insurance and Medicaid to pay for telehealth visits in the home as well as pay mid-level providers for telehealth visits. Previously, telehealth visits were limited to doctors and high-level practitioners, with patients required to be in a clinical setting for the visit. lexology.com | 06.21.18

baltimoresun.com | 03.02.18

MICHIGAN // An IT company is piloting a digital platform in a rural Michigan community that offers older adults a userfriendly high-tech connection to local organizations. Commun02 (Community Oxygen) taps into the power of IT to combat social isolation among older adults, as well as to support family caregivers. forbes.com | 06.03.18

LOUISIANA // Around 55 percent of the family medicine residency spots in Louisiana are now being filled by international medical school graduates, and 20 percent of active physicians in the state are international medical school graduates. Primary care shortages are most common in Louisiana's rural areas. theadvocate.com | 03.17.18


The Kansas Department of Health and Environment has declared the largest measels outbreak in 30 years over. Twenty-two people were affected.

Maine is ranked the worst state in the nation for Lyme disease, according to a new report. In 2016, Maine had nearly 90 cases of the disease for every 100,000 people, placing it first among a dozen states that have the largest number of cases in the country.

Created to address workforce shortages in rural Minnesota, the Assurance Scholarship program makes two years at Riverland community college tuition-free for graduates of local high schools who meet requirements. "There is such a demand in not just this region but the state of Minnesota for nurses, medical assisting, radiography,” said Laura Beasley, nursing program director at Riverland.

gardnernews.com | 06.12.18

newscentermaine.com| 06.14.18

kaaltv.com | 06.21.18

desmoinesregister.com | 05.06.18


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MISSISSIPPI // Head Start centers make up one-third of the center-based child care programs available in some of Mississippi’s most rural areas, providing access to health care and early intervention services that children may not otherwise get, according to a new report. Mississippi’s Head Start centers provide each child with health screening in five areas when they enroll, including vision, hearing and dental. hechingerreport.org | 04.24.18

MISSOURI // Some Missourians have turned to air ambulance memberships to shield themselves from charges their insurer may not cover after an emergency. In exchange for a fee, air ambulance memberships promise no additional out-of-pocket expenses after a patient is airlifted. The memberships are frequently advertised in rural areas, and the industry taps established organizations to help market them. ems1.com | 06.04.18



A recent report shined a light on problems with rural health care in Nebraska.The Medical Workforce Report shows that there are 13 rural communities in the state with no primary care available. Additionally, almost 20 percent of the state's doctors are more than 60 years old and could retire soon.

Every weekday, the ACCESS Allegany public bus system runs six routes featuring dozens of total stops, traversing the county and beyond to help people get to their doctor's appointments, jobs and social events. These ACCESS Allegany buses compose a public transportation system managed by a rural health development network, Ardent Solutions, in partnership with the local government.

3newsnow.com | 04.04.18

usnews.com | 03.30.18

NEVADA // A unique population health study in Nevada is combining genomic information from citizens with socioeconomic, environmental, and clinical data to develop insights into how lifestyle interacts with genetics. “Some of the region’s communities, especially the rural and underserved urban areas, are in crisis." says the website.

A North Carolina House effort to study the costs and benefits of expanding Medicaid was stripped from a bill focusing on rural health care needs in the state. Legislative leaders have repeatedly shot down efforts to expand Medicaid in North Carolina, citing potential future costs to the state. newsobserver.com | 06.14.18



A partnership of health care providers, addiction specialists and social workers has been formed to boost health care for addicted pregnant women in and around Billings, Montana.

40,000 individuals insured under True Health New Mexico and New Mexico Health Connections now have access to a free “virtual clinic” service enabled through a partnership with telehealth provider MDLIVE. The company expects most of the virtual clinic visits to revolve around symptoms related to issues like cold, flu, urinary tract infections, rashes and ear infections.

billingsgazette.com | 05.30.18

abqjournal.com | 06.14.18



As the need for psychiatrists in western North Dakota continues to rise, a residency program at the UND School of Medicine and Health Sciences is looking to fill the gap by using telemedicine to serve rural areas of the state where the services are most needed. grandforksherald.com | 06.10.18

OKLAHOMA // A summer camp aimed at getting students interested in the medical field, Operation Orange targets students in rural areas of Oklahoma where more health care workers are needed. kten.com | 06.05.18 SPRING 2018 | RHQ   9

Rural Reports //



Residents of some of the most rural parts of Eastern Oregon can now get easier access to colon cancer screenings. The Eastern Oregon Healthy Living Alliance is offering free screening kits to rural residents between the ages of 50 and 75. The Fecal Immunochemical Test kit allows people to take the test in the privacy of their own home, and then return the kit at a designated location.

Vermonters are dying by suicide at a rate more than 35 percent higher than the national average, continuing a years-long trend in spite of widespread prevention and education efforts. People in Vermont are more likely to take their own lives with a gun, for example, and the state’s suicide rates are higher than national averages in nearly every age group — especially between the ages of 70 and 74.

hermistonherald.com | 01.12.18

SOUTH CAROLINA // A South Carolina telepsychiatry program will be expanded to help relieve the psychiatrist shortage with new grants totaling $1.8 million from The Duke Endowment. Some $600,000 will be used to help add more advance practice registered nurses for the South Carolina Department of Mental Health’s telepsychiatry program, DMH announced. Another $1.2 million will help the department implement a countywide school telehealth initiative for children in Darlington County. greenvilleonline.com| 06.21.18

SOUTH DAKOTA // Sanford Health has expanded midwifery services to Dakota Dunes. "Many of our patients drive a significant distance from Northwest Iowa and other southern rural locations in South Dakota to see our nurse midwives. Many of our patients asked us to come (to Dakota Dunes)," said Terri L. Carlson, executive director of women's, family medicine and psychiatry and psychology for Sanford Health. siouxcityjournal.com | 06.07.18

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TENNESSEE // Nashville Metro Public Health Department officials reported 2 additional hepatitis A virus cases in early June, bringing the total number of confirmed cases to 16 since 2017. Cases of hepatitis A can occur in those who live in or visit rural areas or frequently eat or drink in settings of poor sanitation, says the CDC. In the USA, there are 3 FDA approved hepatitis A vaccines: Vaqta, Havrix, and Twinrix. precisionvaccinations.com | 06.08.18

vtdigger.org | 06.10.18

VIRGINIA // The University of Virginia's telestroke program is expanding services to patients across the state. “The whole point is to evaluate people in particularly rural community hospitals and get them to the right places so that they have a chance," said the program director. cavalierdaily.com | 06.11.18

TEXAS // Some residents around Lake Conroe face long commutes if they want to travel to the nearest full-service hospital. As a result, local hospitals have started filling the gaps in underserved areas by creating satellite primary care offices and partnering with urgent care clinics. communityimpact.com| 06.21.18

UTAH // Central Valley, Utah is finally getting the help it needs with an outdated water system and contamination. The state director for USDA Rural Development said the USDA was able to look at the current water infrastructure and address the health and safety issues for the residents. upr.org | 06.04.18

WEST VIRGINIA // The U.S. Department of Health and Human Services has awarded more than $24.7 million to health clinics across West Virginia in 12 different counties. The grants are awarded through HHS’s Health Center Cluster Program, which gives funds to community health centers serving rural, underserved communities. register-herald.com | 06.07.18

WYOMING // The Wyoming Department of Health recently rolled out a new mobile phone app intended to provide health tracking and management tools to families across Wyoming. wyomingpublicmedia.org | 02.12.18

Rural Research //

The Importance of Diversity in Clinical Trials and Research


lack lives matter.” “Blue lives matter.” “All lives matter.” These are slogans associated with recent events that speak to the value of life from differing vantage points. It’s unfortunate that these conversations still need to be had regarding systemic biases and inequalities that are pervasive throughout all Catherine Hudson segments of the human experience. What must be DIRECTOR FOR RURAL understood is that civil rights is more than a social HEALTH RESEARCH issue; it is all-inclusive, and health should not be F. Marie Hall Institute for left out of the equation. Rural and Community In spite of the advances in health care and Health increased awareness and understanding of diseases, health disparities are still experienced by many in this country. Minorities are affected by many chronic diseases at higher rates and experience disproportionately increased disease burdens from cancer, premature death and higher infant mortality when compared to the majority. Yet they continue to be underrepresented in the research that leads to the discovery of treatments and cures. Specifically, minority participation in clinical trials is essential and much improvement is needed. Clinical trials/research leads to medical products and treatments that will be ultimately used by the general population. Because people of different ages, races, and ethnicities may react differently to medical products, study participant diversity is important. Terry C. Davis, PhD, professor of medicine and pediatrics at Louisiana State University Health Sciences Center and Feist-Weiller Cancer Center, said during a press conference, “Despite all of this cutting edge, very exciting, wonderful research, [fewer] than 5% of cancer patients are currently enrolled in a clinical trial and [fewer] than 10% of these people are minorities. We must have diverse participation to identify how specific drugs and treatments are most useful for different people.” Diversity both for researchers and clinicians is also important. Only about 7% of all NIH R01 grants are awarded to African-American or Latino primary investigators. Among medical school graduates in 2014, 5% were Latino, 5.5% were African American, and less than 0.002% were American Indian. “This is a crisis,” Davis added, especially since minority physicians are typically willing to see more uninsured and Medicaid patients, and minority medical students have a greater commitment to work in underserved areas. The reasoning behind low minority participation in research is complex and many factors need to be addressed in order to increase inclusion of underrepresented populations in research. Lack of resources at the system and individual level as well as perceptions of distrust and implicit bias towards minority patients are barriers that still exist. Educating and informing clinicians, researchers and patients about the importance of clinical research and the availability of clinical trials is a good place to start.


Grant WATCH // RURAL COMMUNITIES OPIOID RESPONSE PROGRAM The Health Resources and Services Administration's (HRSA) Federal Office of Rural Health Policy (FORHP) has released the Notice of Funding Opportunity (NOFO) for the new Rural Communities Opioid Response (Planning) (RCORP) initiative for FY 18. HRSA plans to award approximately 75 grants to rural communities as part of this funding opportunity. All eligible high risk rural communities are encouraged to apply. You can review the funding opportunity at: https://www. grants.gov/web/grants/view-opportunity. html?oppId=305116 Successful awardees will receive up to $200,000 for one year to develop plans to implement opioid use disorder prevention, treatment, and recovery interventions designed to reduce opioid overdoses among rural populations. All domestic public and private entities, nonprofit and for-profitare eligible to apply and all services must be provided in high risk rural communities. The lead applicant must be part of a group including at least three other partners that have committed to forming a consortium or are part of an established consortium. This initiative is part of a multi-year Rural Communities Opioid Response initiative by HRSA aimed at supporting treatment for and prevention of substance use disorder. Please visit www.hrsa.gov and www. grants.gov to review the Notice of Funding Opportunity and apply. For more information please contact Federal Office of Rural Health Policy. DEADLINE: JULY 30, 2018 SOURCE: https://www.grants.gov/web/grants/ view-opportunity.html?oppId=305116

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ruralhealthinfo.org Online Library www.ruralhealthinfo.org/library RHIhub’s online library includes over 12,000 resources, updated daily. Find publications, research, organizations, maps, and websites. Search news and events to stay current on rural health issues. Looking for funding? Search for the latest federal, state, and foundation opportunities: www.ruralhealthinfo.org/funding

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A Tale of Two Censuses


n March 26, 2018, only three days before questions were officially submitted for use in the 2020 census, U.S. Department of Commerce Secretary Wilbur Ross announced that a question on citizenship would be included on the 2020 decennial census questionnaire. Since that announcement, reaction to the addition of a citizenship question among lawmakers and the general public has been deeply divided, even among members of the same party. So much so that the U.S. Cameron Onks House of RepATTORNEY resentatives F. Marie Hall Institute has scheduled for Rural and Community a public hearHealth ing to allow lawmakers from both sides of the aisle the opportunity to question officials from the U.S. Census Bureau and Department of Commerce on the propriety of adding the question. As a supplement to the ongoing discussions in the House of Representatives and elsewhere, this article will discuss the arguments that have been made on both sides (for and against including the citizenship question) and analyze how those positions affect various operations of government. This article is not an endorsement of one side over the other, rather, it is meant to explain both sides of the issue and let you, the reader, make your own determinations as to which is the proper course. The methods for conducting the census and the questions included on the census questionnaire have varied since the first census was conducted in 1790. Between 1820 and 1950, a period when large numbers of immigrants were settling

in the United States, a majority of decennial censuses included some form of a question on citizenship. Today, the citizenship question at the heart of the current debate is already asked on the American Community Survey, which is sent to approximately 2.6% of households. The question consists of five parts, four of which address United States citizens’ place of origin or naturalization year and one that allows respondents to indicate that they are not a citizen. The question does not inquire as to whether the respondent has legal status in the United States via a visa or related program. Those who favor the addition of the citizenship question argue that inquiring about citizenship status will generate more data that more accurately informs government and the private sector about the characteristics of the American populace, particularly with regard to how many citizens and non-citizens are in a given area. This information, they contend, will allow lawmakers and the DOJ to more accurately apportion federal funds and enforce existing laws. In an eight page memo released by the Department of Commerce, Secretary Ross cites the fulfillment of a December 12, 2017, DOJ request as justification for his decision, in which the DOJ asks that the question be added to provide census block level citizenship voting age population data in order to identify violations of Section 2 of the Voting Rights Act and protect minority voters; data that the DOJ says cannot be adequately obtained by the American Community Survey. Proponents also contend that an accurate count of citizens and non-citizens is an imperative prerequisite to an informed debate on immigration policy, citing international precedent for the addition. In the United Nations “Principles and Recommendations for Population and Housing Censuses”, the U.N. Department of Economic and Social

Affairs encourages nations to gather citizenship information in order to more precisely determine the flows and volume of international migrants and measure policy outcomes and impacts. Already a number of prominent countries, including major U.S. allies such as Australia, Canada, France, Germany, Indonesia, Ireland, Mexico, Spain, and the United Kingdom, all inquire about a respondent’s citizenship. However, opponents argue that the question has not been properly vetted and that adding the question at a time when immigrant and minority communities are increasingly concerned about privacy and U.S. Immigration and Customs Enforcement (“ICE”) deportations could reduce response rates and prompt inaccurate responses among citizens and non-citizens alike. In a 2015 Amicus Curiae brief submitted to the Supreme Court of the United States, four former Directors of the U.S. Census Bureau admit that the citizenship data provided by the American Community Survey are insufficient to enforce voting rights laws; however, they also counsel against the use of a citizenship question as part of the census count, saying “[n]or is it possible to accurately obtain a count of voting age citizens by inquiring about citizenship status as part of the census count. Recent experience demonstrates lowered participation in the census and increased suspicion of government collection of information in general.” They noted that “particular anxiety exists among non-citizens. There would be little incentive for non-citizens to offer to the government their actual status; the result would be a reduced rate of response overall and an increase in inaccurate responses. Both would frustrate the actual express obligation the Constitution imposes on the U.S. Census Bureau to obtain a count of the whole number of persons in order to apportion House of Representatives seats among the states.”

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The trouble does not end with reduced response rates. Distrust in government, reduced response rates, and poor data integrity all translate into higher follow up costs, as the Bureau will be forced to increase staff and cross reference census results with administrative records to accurately interpret the data. Field costs associated with address canvassing and nonresponse follow up operations comprise the most expensive aspects of the 2020 census. As of October 2017, the Census Bureau estimates that it can conduct the 2020 Census for approximately $15.6 billion dollars, nearly $2 billion more than the 2010 census. The 2020 Census Life-cycle Cost Estimate cites distrust in government as a potential driver of costs, stating that “[i]f a substantial segment of the public is not convinced that the Census Bureau can safeguard their response data against data breaches and unauthorized use, then response rates may be lower than projected, leading to an increase in cases for follow-up and costs.” These concerns are epitomized by South Carolina Congressman Trey Gowdy’s statements to Secretary Ross in a congressional hearing in late 2017, where he explained that “cost matters . . . if you were somehow able to convince our fellow citizens that they will get an A+ product, they aren’t happy about the higher costs, but they can swallow that. Its when you get higher costs and a substandard product, it feeds the disconnect [with government].” The importance of quality census data and the impacts of an undercount cannot be overstated. The Supreme Court of the United States describes the decennial census as “the linchpin of the federal statistical system . . . collecting data on characteristics of individuals, households, and housing units throughout the country.” Data collected by the decennial census is used to determine not only the number of representatives for a given area, but also

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to apportion approximately $800 billion in federal funds each year. If states with high immigrant populations, such as Texas, Florida, and California, were undercounted, it would result not only in underrepresentation, but also fewer federal dollars. According to the George Washington Institute for Public Policy, about 300 financial assistance programs created by Congress rely on data derived from the decennial census to distribute federal funds to states and local areas. Most notably, five major programs, Medicaid, the Children’s Health Insurance Program, Title IV-E Foster Care, Title IV-E Adoption Assistance, and the Child Care and Development Fund, all use the Federal Medical Assistance Percentage (“FMAP”) to determine reimbursements to and payments from each state government (totaling $286.1 billion in Fiscal Year 2015; 48.1% of all federal grants to states and 13.0% of all state budgets). A state’s FMAP determines the relative federal and state spending proportions allowable under each program. A state’s FMAP is itself determined in part by its per capita income. Since a state’s income is independent of the decennial census count, as a state’s population count in the census changes, its per capital income, and thus its FMAP, also changes. In FY2015, thirty-seven states lost funding as a result of their FMAP scores due to persons missed in the 2010 census count. The exact loss per uncounted-person varied from state to state, with an average of $1,091 lost per person across the country. Texas is already at risk of a potential undercount, regardless of the citizenship question. High numbers of low-income residents, high rates of rurality, and the scattering effects of hurricane Harvey all combine to make Texas a difficult state to accurately count in 2020. Add to that the potential for reduced response rates as a result of the citizenship question and Texas faces an even greater

probability of an undercount. And Texas is not alone. States with the fastest growing immigrant populations (North Dakota, South Dakota, Indiana, West Virginia, Wyoming, Nebraska, Pennsylvania, Alaska, Minnesota, and Delaware) could also be affected. Whether you support or oppose inclusion of the citizenship question will largely depend on how likely you feel it is to impact response rates and data integrity, as well as your perspective on what data the census should produce and how much it should cost. If you believe it will not materially affect response rates, then adding a question on citizenship would be of great public benefit, providing much needed data to lawmakers and the private sector. However, if opponents to the question are correct and it results in an undercount of the total population residing in the United States, the effects would be significant, particularly for rural Americans. Although both sides are able to make anecdotal arguments, it is important to point out that there is little empirical evidence for the impact a citizenship question might have on the census count. As Secretary Ross himself admitted in his March 26th memo, “it is possible this belief is true, there is no information available to determine the number of people who would in fact not respond due to a citizenship question being added, and no one has identified any mechanism for making such a determination.” Nonetheless, there is an argument to be made that had the question been introduced earlier and included in the 2018 Census Test Questionnaire, which is currently ongoing, the true impacts could have been measured and a more informed determination made. For now, the question remains included and is set to be sent to every household in America come 2020. As to whether Congress will intervene after more information comes to light, we will have to wait and see.



Might Midwives Help Fill Rural Maternity Care Gaps?

non-rural ones.



aternity care in rural America is disappearing fast. Between 2004 and 2014, 9 percent of rural counties lost hospital obstetric services. Now, more than half of our nation’s rural counties lack such services. Despite 15 percent of the nation’s population living in rural areas, only 6.4 percent of OB/GYNs work there. Maternal and infant mortality— both tied to lack of adequate prenatal, delivery, and postpartum care—are shockingly high in the U.S., and the rates are highest in rural areas. Despite the increased risk of complications, the number of planned C-sections is often higher in rural areas because many women fear they might not make it to the hospital in time for the birth if they go into labor naturally. Most shocking are the racial disparities in pregnancy and birth outcomes, as maternal and infant mortality are two to four times higher among black women compared to white women. Predominately black rural counties are more likely to lack or lose obstetrical care. When a patient calls a hospital in labor, “you have ER doctors rolling the dice: do we get her on the ambulance or not? Will she make it to the hospital?” said Dr. John Waits, a family physician and obstetrician in rural Bibb County, Alabama. In west and southwest Alabama, Waits says travel time for maternity care can be upwards of two hours. “Now, times that by a factor of 15 to 40 prenatal visits. And if you develop diabetes or hypertension—which are epidemics in rural areas—now you need two visits a week,” said Waits. “Twenty percent of our county are no-car families. Much of the rest are one-car families. Prenatal care suffers horrendously.”

A recent study using the Midwives Alliance of North America Statistics Project 2.0 dataset found no increased risks for midwife-attended rural births when compared with nonrural ones.

Of Alabama’s 54 rural counties, 45 had hospitals offering obstetrical services in 1980; today only 16 do. It has the fewest maternity-care providers per capita and one of the highest infant mortality rates in the nation. Here, the infant mortality rate actually increased in 2016. The rates of infant and maternal mortality are about three times higher for black women than they are for white women. Waits says what’s really dangerous about these rural maternity-care deserts is how much institutional knowledge evaporates when a labor and delivery unit is shuttered. “In a hospital with a labor and delivery unit, ER doctors are accustomed to seeing pregnant women come through the doors; they are comfortable with dealing with them,” Waits said. “When a labor and delivery unit closes, the doctors leave, the nurses leave. Then it’s up to the ambulance personnel to take care of women and children. Without a labor and delivery unit, they aren’t going to the hospital except in crisis. You lose the institutional memory of how to care for that population.” So what’s the solution to this growing crisis? Enter midwives, who for low-risk patients, can deliver lower-cost maternity care with just as good or better outcomes and consistently higher satisfaction rates. A recent study found no increased risks for midwife-attended rural births when compared with

In countries with similarly unavailable hospital-based maternity care, midwives are seen as a life-saving solution. In the U.S., a decades-long campaign sewing skepticism about the safety of midwifery means nearly 90 percent of births are attended by physicians. “Midwives have been shut out,” says Jennie Joseph, a British-trained midwife whose pioneering model for “easy access prenatal clinics” has improved birth outcomes in Florida. “We should be able to provide prenatal care at the very least, if not delivery.” Joseph says if patients receive prenatal care with a midwife—care they wouldn’t have otherwise gotten because of cost, lack of an obstetrician, or distance/transportation issues— “that in and of itself will save lives. Midwifery could really make a difference in rural areas.” In the first report of its kind, a panel of maternity care experts mapped the integration of midwives into regional U.S. health systems. They found higher levels of midwife integration were associated with better health outcomes: significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean (VBAC), and breastfeeding, as well as much lower rates of obstetric intervention, cesarean, preterm birth, low birth weight, and infant death. Unfortunately, the data also showed even in the state with the highest rate of midwife integration—Washington,

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which scored 61 out of a possible 100 points—there is still a long way to go. The problem? For starters, the term “midwife” has no standard definition. Multiple types of midwives exist in here: Certified Nurse Midwives (CNMs), Certified Midwives (CMs), Certified Professional Midwife (CPMs), and licensed midwives (LMs). CNMs and CMs have masters degrees in midwifery and are certified through the American Midwifery Certification Board. CNMs are registered nurses and are licensed to practice in all 50 states, while CMs are only licensed in four states. Nationally, nurse midwives attend 8.3 percent of births. The vast majority of births occur in hospitals; only 3 percent of CNM/ CM-attended births occur in birthing centers, another 3 percent in homes. Many states require these midwives to practice under an obstetrician. CPMs and LMs, on the other hand, are largely viewed as outside the medical establishment. They are often referred to as lay midwives, they attend births in birthing centers or homes. They may have only have a high school diploma, but should have completed training and an apprenticeship with a certified midwife. While LMs must only meet the state licensure requirements, CPMs are certified through North American Registry of Midwives (NARM). To achieve certification, midwives must observe 10 births, deliver 20 babies under supervision, and conduct 40 postpartum exams, 20 newborn exams and 75 prenatal exams. While NARM certification is the standard for lay midwives in the U.S., not everyone believes it requires enough training. In a 2015 statement, the American College of Obstetricians and Gynecologists (ACOG) instead endorsed the International Confederation of Midwives (ICM) education and training standards. While all CNMs and CMs meet these standards, as many as two-thirds of lay midwives don’t. ACOG asserts universal implementation of ICM standards would help ensure safe, high-quality care.

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Laws governing lay midwifery vary widely by state. Thirty-three states recognize lay midwives via licensure, but there are big variations in what’s required for licensure and what midwives are allowed to do. These differences mean some states enjoy cooperation among physicians and midwives, while in others, hostility reigns. Interprofessional cooperation is connected to better health outcomes. “Especially in rural areas, I definitely think they could help fill gaps in care,” says Karen Brock, who’s spent her life as a midwife in rural Cullman County, Alabama, just like her grandmother before her. “Travel time is less of a concern since midwives often travel to families.” She estimates she’s delivered around 1,500 babies since 1983. With a score of 18 out of 100, Alabama ranked next-to-last in midwifery integration. (North Carolina was last with a 17.) In 2017, Alabama became the most recent state to offer lay midwives licensure. The practice had been illegal there since 1976. In states without licensure regulations, professional midwives risk prosecution. Practicing medicine without a license is often punishable as a felony and carries steep fines. Previously, many Alabama midwives traveled to Tennessee to tend to their patients or attempted to practice under the radar. “I’ve had women travel three hours to me to get the kind of care they wanted,” Brock said. Over the past 14 years, she says she’s taken an average of 50 moms a year across state lines to receive midwifery care in Tennessee where she is licensed. Brock says most Alabama midwives quit practicing when it became illegal; others left the state to set up their practice where it was legal. Historically, midwives delivered most babies in America. Even by 1900, midwives still attended half of births. Since most midwives were black women or immigrants, the stigmatization of midwifery throughout the 20th century made a particular impact on women of color. In the 1920s, there were over 42,000 midwives practicing in the U.S. Most were black women

serving black communities. By the mid-’30s, 60 percent of births to black women in the south were still midwifeattended; 90 percent of white women birthed under physicians. Segregated healthcare meant black women often received lower-quality care than their white peers, so they were likely better off with a midwife. The push to discredit and restrict the practice of midwifery was purportedly about safety, but the data didn't bear that out. In truth, the smear campaign was actually a case of sexism, xenophobia, and racism. Midwives were labeled as witches or witch doctors; ignorant, superstitious, and dirty. This hit rural southern states hardest. Alabama began requiring midwives to attend state-run training, no matter how long they had been practicing. When the state outlawed practicing midwifery over age 65, all 150 black "granny midwives" were suddenly unable to earn a living. Unfortunately, the recent resurgence in midwives has largely been among wealthy white women. And structural racism continues to impact healthcare quality for black Americans. Joseph says the question we need to be asking is: “Why isn’t every woman getting the same quality of care?” In 1998, she founded the nonprofit Commonsense Childbirth with the hope of improving maternity care for people of color. “They typically blame the women, to educate them—‘these women are so bad, they’re so naughty; these women should eat better’—but you can’t do that when it’s across the socioeconomic strata,” Joseph said. “For women of color, it’s not just about income, education, insurance; it’s not that they are not trying hard enough. Racism, classism, discrimination is built into the healthcare system. We have to face it, otherwise I don’t think we can fix it.” According to the midwife integration assessment, states where more black babies are born had significantly lower access to midwives. The researchers concluded that more midwives would lead to “long-term health benefits for black mothers.”

So now that midwifery is legal again in Alabama, patients will soon have more options when it comes to maternity care, right? Maybe. Brock says because of all the restrictions in the new state licensure bill, “a non-established midwife is going to have a very hard time; they’re going to go to Tennessee where it’s easier to practice.” The largest burden is having to carry medical malpractice insurance. Florida and Indiana are the only other states that require lay midwives to carry malpractice insurance. Premiums can range from $5,000 to upwards of $30,000 a year. In addition, the Alabama bill stipulates lay midwives are not allowed to care for twins, breech, or VBACs. “These restrictions aren’t evidencebased,” Brock insists. “We’re having to compromise a lot to get licensure.” Until recently, Alabama was also one of the roughly half-dozen states where nurse midwives are required to work under a physician’s supervision. When nurse midwives are granted independence from doctors, they tend to practice in rural settings. In Alabama, nurse midwives attend two percent of births, but their use is growing. Brock says after a health department survey showed Alabama was the worst state to be a nurse midwife, it “made hospitals realize that women wanted this kind of care, so they began hiring more.” In 2016, one Birmingham clinic hired its first nurse midwife in 20 years. “One was just hired here in Cullman,” Brock said. Waits believes midwives can be “a great physician extender, but in the face of full institutional closure, they’re not gonna move the needle” on these gaps in rural maternity care. “Midwives can be a part of the team, but they shouldn’t be put in a position where there’s no local capacity to deal with prematurity, emergency operative obstetrics,” Waits said. “They’re good at helping in specific contexts, but have a very limited usefulness. Licensed professional midwives, if they were in out community, they would be fine for term, uncomplicated deliveries and prenatal care. Dangerous home births are not the problem here. Many patients

need a C-section, need a NICU.” So what other options exist for filling maternity care gaps? Well, there are programs offering financial incentives to work in rural areas, and plenty of medical residencies offering rural healthcare tracks, but clearly these haven’t been enough. It’s not that medical students aren’t interested in obstetrics or in working in rural areas, Waits says. It’s that when they’re offered job contracts at the end of their education, these positions literally don’t exist.

“Women aren’t choosing a midwife because of money— Medicaid will pick up their hospital tab—they’re trying to limit interventions and have a good, natural birth.” “You’re not going to do it with one recruit. It’s not about encouraging more med students to go into obstetrics, it’s that they would have to want to move somewhere and grow a labor and delivery unit from the ground up,” said Waits. That’s what he did. Before 2015, Bibb County had been without a labor and delivery unit for 20 years. It was no small feat, as he and his team spent five years getting the unit ready to receive patients. “This isn’t about people not willing or able to do this work, it’s about infrastructure. We need to look at the way we reimburse hospitals for labor and delivery care,” Waits said. Costs are of course at the root of many hospital closures. Research shows hospital closures spiked in states that chose not to expand Medicaid. Alabama is one such state. It’s especially expensive to keep a labor and delivery unit open, due to the high cost of obstetric intervention and the low patient-to-medical professional ratios. In addition, medical malpractice premiums skyrocketed in the 1980s, especially for OB/GYNs. From 1985 to 2000, the number of hospitals offering obstetrics fell 23 percent. “You have to deliver 50 to 100 babies

a year to clear your medical malpractice premium payment,” Waits said, explaining that when he and his team surveyed all of the labor and delivery units that had closed in recent years, the premium costs were one of the top reasons for closure. In Alabama, roughly 55 percent of patients are on Medicaid. Long waits for Medicaid approval mean pregnant women on Medicaid often don’t receive any prenatal care until well into their second trimester in Alabama. The Affordable Care Act requires Medicaid to cover nurse midwifery services, but not all states require private insurance to cover it. In eleven states, Medicaid also covers professional midwives. Without insurance coverage, only women who can afford to pay for a midwife out-of-pocket can utilize their services. “Women aren’t choosing a midwife because of money—Medicaid will pick up their hospital tab—they’re trying to limit interventions and have a good, natural birth,” Brock said. Many lowrisk patients who might have otherwise chosen a midwife may ultimately end up costing Medicaid more money for an obstetrician and hospital birth because that’s what their insurance dictated. It’s often those Medicaid-covered OB tabs that are straining hospital budgets. Waits says rural hospitals should invest in family doctors with OB/GYN certification because when they don’t get the volume of pregnant patients required to meet insurance premiums, a family doctor can treat plenty of other types of patients. But he cautions they will still need institutional support in the form of a team of nurses and physician assistants who know how to care for pregnant women and newborns. Given the severity of the maternitycare crisis, rural doctors may have to start accepting midwives into their regional care networks. “I really hope, my desire is that midwives will be in a position of some respect again, that medical professionals would look on us as a valuable profession,” Brock said. “I’d like to think it’s changing; things take longer in Alabama.”


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Making it easier for healthcare providers to help patients live tobacco-free.


Let our team partner with yours to create clinical workkows and community outreach that addresses the leading cause of preventable death. Refer patients to the Texas Quitline with a new button in your electronic medical records or

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Help To Quit

Use mobile devices available in the Google Play and Apple app stores

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Talk to our team about how these tools can help improve your healthcare system’s performance on the measures that matter The Tobacco Research and Evaluation Team and the Texas Quitline are funded by the Texas Department of State Health Services


FORGOTTEN AMERICA A Mother’s 15 Year Struggle To Get Life Saving Care For Her Daughter BY EMILY FORMAN

amitria Jernigan takes her daughter Tashea to the Peyton Manning Children’s Hospital at St. Vincent’s in Indianapolis every three weeks for a blood transfusion. Tashea has a blood disorder known as sickle cell disease, and it caused her to have a stroke when she was two years old. The regular blood transfusions prevent her from having another one. The trouble is when Tashea had the stroke, she was in Indiana’s Lake County, a place where few medical providers know how to handle sickle cell disease. A doctor from Indianapolis now visits the region a few times a year to fill the gaps, but that care came too late for Jernigan and her daughter. These days just leaving the house is a heroic feat because Tashea is wheelchair bound. Jernigan has to lift Tashea out of her bed into her wheelchair and from the wheelchair to the car. Tashea is only 42 pounds, but it still takes a toll on Jernigan’s arthritic knees. They moved to Indianapolis from Lake County in 2017 for Tashea’s health. Jernigan followed her oldest daughter who recently started college at Purdue University in Indianapolis. But the move meant leaving behind two teenage daughters because of a custody battle. She still hopes to bring them to Indianapolis one day, but she couldn’t risk Tashea’s health any longer. Tashea almost died twice because she wasn’t getting proper care in Lake County. “And once we got here doctors appointments was just was falling in our lap,” said Jernigan. Although she was homesick, Jernigan said she was happy to be in Indianapolis, “because she (Tashea) was being neglected for so so so many years on her health.” Jernigan said she gave up on Lake County hospitals after they didn’t have blood ready for one of Tashea’s scheduled transfusions. Jernigan said her daughter can’t afford to miss a transfusion and risk another stroke because she might not survive. For years, Jernigan took Tashea to Illinois for sickle cell treatment. A lot of families in Lake County do this

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because the care is better. But Tashea needed more than sickle cell care. She needed specialists to help her breathe, to help her gain weight and to make sure her medications didn’t damage her organs. Jernigan said there was a cap on how much of Tashea’s medical care her Indiana insurance would cover out-of-state. Finally her doctor in Illinois told her she needed to move either to Illinois or Indianapolis. Jernigan chose Indianapolis to be close to her oldest daughter. Jernigan said she has already seen results “she has not been hospitalized not once in eight months we’ve been here.” She said she posted the good news on her Facebook page, “because she was going to the hospital every month when we was up in Lake.” Jernigan cobbled together Tashea’s care for nearly 15 years. She said she had no idea there were specialists that could help her daughter two hours south in Indianapolis, and the Lake County doctors never mentioned it. The out-of-state doctors made the referral. “She never had a neurologist, a pulmonologist. She never had none of this,” said Jernigan. Tashea can’t talk. She can’t move. It’s because of the stroke she had when she was two years old. Jernigan remembers taking her daughter to the ER because she couldn’t breathe. She got worse and the doctors sent Tashea to an Illinois hospital. Jernigan said goodbye to her daughter before she went home to get some rest. “She’s like bye mom,” Jernigan said those were her daughter’s last words. The next day Tamitria learned Tashea had had a stroke. Jernigan said the doctors told her, “she had the mentality of a newborn,” and that she’d never be the same. Doctor Emily Meier is Tashea’s hematologist in Indianapolis now. “It’s a sad case because we don’t see very many kids like that anymore.” She said Tashea’s case used to be the norm with children who have

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Tashea Jernigan gets blood transfusions every three weeks because she has sickle cell disease and it prevents her from having another stroke. EMILY FORMAN / SIDE EFFECTS PUBLIC MEDIA

sickle cell disease. But treatment has improved over time. Now doctors start kids on a medication to prevent stroke earlier. Jernigan knows things are different, but she said she still beats herself up. “I tell the doctors I wish I had of came here before now,” she said, remembering her daredevil daughter at two, pre-stroke. She used to ride her toy bike down the stairs, gobble pancakes and listen to her favorite song Get Low by Lil Jon and The East Side Boyz. Meanwhile, Jernigan will soon

find out if surgery can help straighten her daughter’s spine. After 15 years of just dealing with Tashea’s health issues, Jernigan has discovered an entire world of new medical options for her daughter and a new life for herself. In fact she’s started to date after a nine year hiatus, and she’s on the search for a Bruce Willis type. “That is my future husband,” she laughed.


This story was produced by Side Effects Public Media, a news collaborative covering public health.



Telehealth Along the Texas-Mexico Border



ealth is fundamental to individuals, families and the economy. As Julio Frenk wrote in Harvard International Review, "Good health reduces poverty, protects family assets, improves educational performance, increases labor productivity, enhances the investment climate and, through all of these things, stimulates economic growth."1 One of the greatest challenges in health care today is improving access to care for rural, underserved urban and uninsured populations. Increasingly, health care systems are expected to deliver cost-effective quality care to more people. To meet this demand, health care systems often rely on digital health information and tools to enhance continuity of care and increase efficiency, timeliness and reach.2 One promising tool, telehealth, is an alternative-care model that can be deployed to address access-to-care issues for hard-to-reach populations, such as the residents of the Texas–Mexico border. The Texas border region is a mix of urban and rural geographies and is one of four persistent poverty areas of the country.3 Approximately 48 percent of people on the Texas–Mexico border live at or near the poverty line. An even larger percentage of residents in the periurban and rural colonias, 62 percent, live at or near poverty.4 Research by the Robert Wood Johnson Foundation found that a person’s zip code is more of a predictor of health outcomes and how long a person will live than their genetic code.

Their study of life expectancy across the United States found that “geographic disparities in life expectancy in our nation . . . can be explained in large part by differences in race/ethnicity and socioeconomic factors such as income…” The study demonstrates that lower-income zip codes have significantly lower life expectancy than higher-income zip codes.5 THE TELEHEALTH TOOL Telehealth is a useful model poised to make a significant impact on health challenges on the border.6 Telecommunication technologies are used in combination with other health services to deliver integrative health care to more patients regardless of geographic location. Greater efficiencies may be reached in telehealth by using more mid-level providers such as nurse practitioners and physician assistants for direct patient care in consultation with a physician through videoconferencing. Furthermore, primary care physicians can broaden their offerings by incorporating videoconferencing with specialists during appointments with patients.7 Some people who hear the terms “telehealth” or “telemedicine” express concerns that it means there is less in-person contact with a health care provider. Patients want a health care provider who is present, can interact personally with them and can perform a physical exam if necessary. However, telemedicine is not an either/or binary

where the only options are to either meet with the doctor on a computer screen or meet in person at the doctor’s office. Most telemedicine programs, such as those highlighted in this publication, include a qualified health care provider who is physically present but also has the ability to videoconference with a supervising physician or specialist. The University of Texas Medical Branch reported, “The integration of telehealth into the American health care system can offer unparalleled access to high-quality care to every citizen no matter where they live. The combination of sophisticated videoconferencing, electronic medical records, proven disease management protocols and telemonitoring can revolutionize medical care.”8 Telehealth has proven to be effective for improving access to specialists, increasing patient satisfaction with care, improving clinical outcomes, reducing emergency room utilization and increasing cost savings.9 Thus, telehealth is increasingly seen as an effective means for serving patients who are limited by poverty, geography, lack of insurance and debilitating health challenges. Many of these challenges are evident in the health disparities found on the Texas-Mexico border. HEALTH DISPARITIES ON THE BORDER The University of Texas Health Science Center at Houston School of Public

Health defines health disparity as “diseases, disorders and conditions that are unique to, more serious, or more prevalent in subpopulations in socioeconomically disadvantaged and medically underserved, rural and urban communities.”10 The Texas– Mexico border has a high prevalence of diabetes and related conditions such as obesity, tuberculosis, depression and anxiety. The region also experiences disparities related to access to care, such as a lack of access to health care facilities, a high uninsured population and a shortage of health care providers. Prevalent Diseases. The general population of the border region is about 90 percent Hispanic, and the periurban and rural colonias are 96 percent Hispanic.11 The Cameron County Hispanic Cohort study, which is considered to be the most comprehensive study of diabetes on the Texas-Mexico border to

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date, evaluated a group of over 2,000 randomly selected Mexican American adults and found that 30.7 percent had diabetes.12 In contrast, the rate of diabetes nationally is 11.3 percent. For Mexican–Americans across the U.S., the diabetes rate is 13.4 percent—substantially less than rates found in the Cameron County Hispanic Cohort study.13 The Cameron County Hispanic Cohort study noted that nearly half of those with diabetes are undiagnosed, and over 55 percent are untreated. Untreated diabetes is common among patients admitted to the hospital for serious health issues such as cardiovascular disease and sepsis. In addition, the Rio Grande Valley—the four-county region along the southern border which includes Cameron, Hidalgo, Willacy and Starr counties—has the highest rates of diabetes-related amputations. Moreover, poor mental health has been linked to diabetes, obesity

and limited physical activity.14 The Regional Health Plan for Region 5, which includes the four Rio Grande Valley counties, reported 28.6 percent of adults experience a measurable level of depression, while 30 percent of adults have measurable levels of anxiety, rates that are well above what we see in the broader population.15 Among the Cameron County Hispanic Cohort, nearly 49 percent of the study participants were obese. Overall, approximately 90 percent were overweight, obese or extremely obese. This high instance of unhealthy body mass index translates to a population at high risk of developing diabetes and associated illnesses and infectious diseases. For example, people with diabetes have an increased susceptibility to infectious diseases such as tuberculosis. The border region continues to have the highest rates of tuberculosis in the nation with Maverick and Cameron counties exceeding

15 cases per 100,000 people. Tuberculosis in Texas averages 4.7 cases per 100,000 people.16 Limited Access to Health Care. The Dallas Fed’s “Las Colonias in the 21st Century” report documented the issue of limited access to health care in the border region. The report cites county-level data; thus, it is relevant beyond the colonias to the wider border region. Three key challenges were noted. First, low-income border residents rely primarily on community clinics in or near urban areas for medical care. The clinics are often overbooked and do not have many choices for referring patients to public hospitals for acute care. And, those residents who live in deep rural areas do not have health care facilities nearby; thus, they are required to travel long distances for care.17 Second, the region has a high uninsured population. Preventive health care often depends on patients having insurance. Between 30 and 40 percent of adults under age 65 in the border region are uninsured, compared with 26.8 percent in Texas. Uninsured residents may delay receiving care until their conditions are more acute, often requiring costly emergency room visits.18 19 Third, there is a shortage of health care providers. The health care challenge is magnified in South Texas by the lower ratio of health care professionals in comparison with the rest of the state. These include physicians, dentists, physician assistants and nurse practitioners.20 For example, the entire border region is designated a mental health professional shortage area.21 With an increasing need for support and services for mental health issues associated with prevalent diseases along the southern border, the shortage of professionals to provide required care creates a particular challenge for the region.

DIGITAL DIVIDE LIMITS USE OF TELEHEALTH The Texas–Mexico border region has some of the greatest health disparities and one of the greatest digital divides in the country.22 The digital divide is the gap between people who have access to broadband services and know how to use the internet and those who do not have such access or knowledge.23 Broadband is a high-speed internet service that is always on and has sufficient speeds for uninterrupted transmission of data. The Federal Communication Commission’s (FCC) defines broadband as a download speed of 25 Mbps (megabits per second) and 3 Mbps for uploads.24 Limited broadband infrastructure prevents the region from using telehealth widely to improve health outcomes. While there is an opportunity with technological advancements in health care to reach underserved areas more effectively, if the digital divide is not bridged, the benefits of innovation will bypass those areas because of an outdated or nonexistent digital infrastructure. Both medical innovation and digital infrastructure need to work in tandem. According to Pete Otholt, senior IT&S manager for Methodist Healthcare Ministries of South Texas Inc. and member of the Digital Inclusion Alliance San Antonio, “While telehealth offers a proven solution to the gap in access to care, it is necessary to recognize that limited broadband infrastructure and access in underserved and rural areas limits the application of telehealth for regions most in need.”25 Moreover, as technology advances, the digital divide could also constrain the economic productivity of the health care industry. This is especially significant since in the last quarter of 2017, “for the first time in history, health care . . . surpassed manufacturing and retail . . . to become the largest source of jobs in the U.S.”26 In the state of Texas, health services is one of the top three fastest-growing industry clusters.27

Indeed, in the El Paso metro area, the health services industry cluster ranks as the second-fastest in employment growth. In the McAllen–Edinburg–Mission metro area, on the lower Rio Grande Valley border, health services ranks among the top three industry clusters.28 Although health services is a large and growing industry, access to care challenges noted in the previous section continue to inhibit improved health outcomes for residents. The University of Texas Rio Grande Valley School of Medicine, which admitted its first class in 2016, has been heralded as a beacon of hope for the future of health care in South Texas. Francisco Fernandez, M.D., a faculty member at the school, noted, “In order to mobilize our students and faculty to address our community’s serious health disparities, such as diabetes, we will need broadband infrastructure and connectivity that will allow service in remote areas through telehealth.”29 Harnessing the promise of telehealth requires communities to first determine broadband availability—recognizing that sufficient and reliable broadband speeds are required to accommodate the use of secure videoconferencing and transmission of high-definition images commonly used in telehealth. It is also important for health care institutions to partner with local governments as they develop their digital inclusion plans to ensure broadband capacity and speed will support telehealth.30 31 A comprehensive guide to closing the digital divide is provided in “Closing the Digital Divide: A Framework for Meeting CRA Obligations.”32 The publication also describes an effort underway to expand broadband access and digital inclusion on the border in the section, "Digital Opportunity for the Rio Grande Valley, South Texas." One of the key goals of the project is to create a robust fiber-optic network that will enable the use of telehealth throughout the border region. Another important reason to close

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the digital divide is to provide the capacity to use telehealth for emergency response. In 2017, telemedicine was deployed to address health needs during major hurricanes.33 34 TELEHEALTH INITIATIVES IN TEXAS AND LOUISIANA The digital divide presents a barrier to the use of telehealth in the border region. However, four accounts from various locations in the Eleventh Federal Reserve District demonstrate the opportunity for telehealth to address the specific health challenges that exist along the border. The initiatives described below are from both urban and rural geographies and represent efforts to use telehealth to reach the underserved.

(HoW) is a telehealth program administered by LUPE in partnership with Methodist Healthcare Ministries of South Texas Inc., the Valley Baptist Legacy Foundation and Doctors Hospital at Renaissance to broaden access to health care in low-resource communities. The HoW program offers a holistic approach to health through its outreach efforts. These include:

Bringing Telehealth to the Colonias

Mobile health clinics Community health workshops focused on preventive care led by University of Texas Rio Grande Valley medical school residents and other health advocates Leadership training for certified promotoras (community health educators) through the Texas A&M Colonias Program.35

The colonias, the lowest-income communities of the border, have been a public health focus of government agencies, community advocates, elected officials and residents for over three decades due to the lack of basic infrastructure and substandard housing—and the impact of those conditions on health outcomes. An organization serving the colonias, La Union del Pueblo Entero (LUPE), is partnering with a regional hospital system to use telehealth to improve access to care. “We are the connectors,” explained Tania Chavez, systems strategist and development manager for LUPE. “We’re the middlemen between the community and the health system,” she said. LUPE is a community-based organization located in San Juan, Texas, in Hidalgo County. Its focus is to build stronger, healthier communities where residents use the power of civic engagement for social change. LUPE’s grassroots connection with the communities it serves has helped create access to valuable programs and services that have improved the quality of life in the border region. Health on Wheels

The mobile clinics operate out of a motor home retrofitted with high-definition videoconferencing equipment and state-of-the-art medical devices to offer general medical services, vision and specialty care. Services include low-cost vision exams and eyeglasses, diabetes prevention and care, women’s health and mental health care. Certified promotoras are a vital asset to the program as they successfully engage with the community to schedule appointments for the mobile unit, encourage attendance at health workshops and recruit future promotoras. Prior to partnering with LUPE, Doctors Hospital at Renaissance was unable to attract patients to its mobile clinic. However, once the hospital partnered with LUPE, its mobile unit became an effective way for border residents to receive health care. The HoW program plays a critical role in the community by identifying unmet health needs and serving the uninsured. Indeed, 91 percent of patients served through the program lack any form of health insurance, and the mobile clinic is the only place medical care is received by 13

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• •

percent of its patients. The mobile clinics also serve as an important entry point into the health system—34 percent of mobile clinic patients have been referred to other community clinics for follow-up care.36 Transforming Diabetes Care Methodist Healthcare Ministries of South Texas Inc. serves low-income patients who typically do not have health insurance, often struggle to find reliable transportation and sometimes live in rural areas with limited access to basic health care and specialists. Pete Otholt, with Methodist Healthcare Ministries of South Texas Inc., emphasizes “the importance of telemedicine as a means of providing integrated, responsive and cost-effective health care services to underserved populations. For diabetes patients, real-time support is especially important as many factors contribute to managing the disease.”37 As part of an initiative to provide integrated health care in real time, Methodist Healthcare Ministries of South Texas Inc. and Medtronic developed the Turning Point pilot program for diabetic patients with uncontrolled HbA1c (A1C) levels—a measure of a person’s average level of blood glucose, or blood sugar, over three months. The six-month pilot program used a smartphone digital app to monitor diabetes progress and offer real-time support, without which, many patients fail to manage the disease effectively. For example, Philip Fisher, a San Antonio chef who plans and prepares meals for Outcry in the Barrio Ministry, was diagnosed with diabetes in 2014. Like many diabetes patients, Fisher was overwhelmed with managing the disease on his own, so he ignored it. When his doctor suggested he participate in the Turning Point program, Fisher had an A1C level of 10.9 percent. His A1C level was well above the 7 percent target A1C for people with diabetes set by the American Diabetes Association.38

HoW Program Mobile Clinic, Hidalgo County, Texas, 2017. Photo credit: La Union del Pueblo Entero

The Medtronic app helped Fisher keep track of his blood glucose levels, blood pressure, sleep patterns and weight. As with each patient in the program, he was assigned to a Medtronic care coordinator who: 1) completed his enrollment; 2) helped with equipment troubleshooting; 3) maintained open communication through in-person or phone checkins; 4) tracked Fisher’s progress through the app; 5) timely communicated health information to his physician to avoid further health complications; and 6) offered diet counseling. Fisher experienced significant improvement. He brought his AIC level down 5 points to 5.9 percent, which is below the diabetic range. These results inspired Fisher to begin preparing healthier meals

for the men he serves in his ministry.39 Overall, the program was successful at improving patients’ A1C numbers by an average of 2.0 points. Fisher and other patients lost weight, benefited from increased energy and became role models for others in their families and community. Positive health outcomes and patient satisfaction led to continuation of the program.40 Improving Health Care Access for Rural Veterans The Rural Veterans Coordination Pilot Program (RVCP), operated by Volunteers of America North Louisiana in partnership with the Overton Brooks VA Medical Center

in Shreveport, Louisiana, was originally a two-year program extended to three years that provided psychiatric services to veterans in underserved areas by using telemedicine to complement services offered at the VA medical center. The $2 million project, sponsored by the Department of Veterans Affairs (VA), outfitted a cargo van that served as a state-of-the art mobile clinic using satellite technology. At the mobile clinic, telemedicine appointments were facilitated by an on-site nurse or social worker and were videoconferenced from Overton Brooks VA Medical Center. Bryan Byrd, executive vice president of innovation and new business development for Volunteers of America North Louisiana asserts,

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“The program improved the quality of life for veterans and their families. The RVCP has demonstrated savings of thousands of miles not traveled. The average mileage traveled by rural veterans to the Overton Brooks VA Medical Center is 145 miles per visit, with the program’s average annual travel savings exceeding $1,800 per veteran.”41 While the individual cost savings to veterans is significant, the program also improved outcomes for the VA medical center with a 59 percent reduction in inbed days of care and a 35 percent reduction in hospital readmissions. Furthermore, the program reduced the number of missed appointments, improved veteran access to preventive care and reduced higher-cost emergency room use. The nonprofit applied for continued support from the VA, and it is looking to diversify funding by applying for grants from other sources. This will enable the organization to expand telemedicine services from a focus on psychiatry to include additional services such as dermatology, diabetes management, long-term care and post-acute care.42 In an article detailing the work of the RVCP, Jen Fifield of the Pew Charitable Trusts notes, “While long drives and limited access to health care are familiar burdens for many rural residents, the problem is particularly acute for veterans in those areas. They are far older than other rural residents and far more likely to be disabled, meaning more of them are in need of medical care. And, there are a lot of them—one in four veterans lives in rural areas, as compared to one in five adults in the general population, according to 2015 census data.”43 Diverting Unnecessary High-Cost Emergency Room Visits In 2014, the Houston Fire Department began a partnership with the Houston Department of Health and Human Services along with 13 other community organizations to intro-

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duce the Emergency Telehealth and Navigation Project (ETHAN) to ease emergency department overcrowding and overuse. The goal of ETHAN is to reduce the stress on emergency response resources by diverting nonemergency patients to other less cost-intensive resources.44 Paramedics connect patients with minor injuries or illnesses by video to an emergency physician using a tablet device powered by wireless technology. The physician determines whether the patient needs to go to the emergency room, what mode of transportation is best suited to the patient’s level of acuity or whether the patient should see a primary care doctor instead. In cases where an emergency room visit is not necessary, appointment arrangements and transportation are coordinated for the patient. In cases where ETHAN was used, 80 percent of unnecessary ambulance and emergency room visits were averted.45

nomic factors, health care access and health behaviors.46 While the digital divide can be a barrier to positive health outcomes, the reverse is also true. Closing the gap can transform the provision of health care on the border and achieve positive health outcomes for its residents. NOTES 1. 2.


CONCLUSION This publication documents the positive role telehealth can play in serving populations most in need of quality and appropriate health care. LUPE’s HoW program, mentioned earlier, illustrates an important lesson: Technological innovations can be coupled with innovative community development approaches to reach low- and moderate-income populations. Furthermore, to unleash the full potential of telehealth, underserved urban and rural communities will need to address the digital divide. The significant role of broadband access to the provision of health services has led Mignon Clyburn, a commissioner of the Federal Communications Commission, to call broadband access one of the social determinants of health. Clyburn recognizes that broadband is critically important to health outcomes and must be addressed along with the other social determinants of health: physical environment, socioeco-






“Health and the Economy,” by Julio Frenk, Harvard International Review, June 14, 2014 “Benefits of Telemedicine in Remote Communities and Use of Mobile and Wireless Platforms in Healthcare,” by Alexander Vo, G. Byron Brooks, Ralph Farr and Ben Raimer, University of Texas Medical Branch, 2011, https:// telehealth.utmb.edu/presentations/benefits_of_telemedicine.pdf. United States Department of Agriculture, Economic Research Service. Persistent-poverty counties had poverty rates of at least 20 percent in each U.S. census, 1980, 1990 and 2000, and American Community Survey five-year estimates, 2007–11. Persistent poverty regions include: Central Appalachia, the Mississippi Delta, First Nation Communities (in New Mexico, Arizona and the Dakotas) and the Texas border region. “Las Colonias in the 21st Century: Progress Along the Texas–Mexico Border,” by Jordana Barton, Emily Ryder Perlmeter, et al, Federal Reserve Bank of Dallas, 2015, www.texascolonias.org. Robert Wood Johnson Foundation Commission to Build a Healthier America, www.rwjf.org/en/about-rwjf/ newsroom/features-and-articles/Commission/resources/city-maps.html. This publication includes health data from seven counties along the Texas– Mexico Border: Cameron, Hidalgo, Starr, Webb, Maverick, El Paso and Willacy, Regional Health Plan for Region 5 Community Needs Assessment, Professional Research Consultants, Aug. 31, 2012. Also, “What’s Next? Practical Suggestions for Rural Communities Facing a Hospital Closure,” Texas A&M University Rural & Community Health Institute (RCHI), 2017, recommends telemedicine as one of the viable solutions to the health care access challenge in rural areas, www.rchitexas.org/newsrelease/rural-hospital.html. “A Guide to Understanding Mental Health Systems and Services in Texas,” 3rd Edition, Hogg Foundation for Mental Health, 2016. “Benefits of Telemedicine in Remote Communities & Use of Mobile and Wireless Platforms in Healthcare,” by Alexander Vo, G. Byron Brooks, Ralph





13. 14.


16. 17.

18. 19.


Farr and Ben Raimer, University of Texas Medical Branch, 2011, https:// telehealth.utmb.edu/presentations/Benefits_Of_Telemedicine.pdf. “The Telehealth Promise: Better Health Care and Cost Savings for the 21st Century,” by Alexander H. Vo, AT&T Center for Telehealth Research and Policy, Electronic Health Network, University of Texas Medical Branch, May 2008, https://telehealth.utmb.edu/ presentations/The%20Telehealth%20 Promise-Better%20Health%20Care%20 and%20Cost%20Savings%20for%20 the%2021st%20Century.pdf. Lisa Mitchell-Bennett, “EvidenceBased Strategies to Change Behavior and Promote Health” (presentation delivered at the Rio Grande Valley Regional Convening at the University of Texas Rio Grande Valley, Sept. 14, 2017). “Las Colonias in the 21st Century: Progress Along the Texas–Mexico Border,” by Jordana Barton, Emily Ryder Perlmeter, et al, Federal Reserve Bank of Dallas, 2015, www.texascolonias.org. Joseph B. McCormick, M.D., “Population Health in Cameron County: An Update from the Cameron County Hispanic Cohort Study” (presentation delivered at the Rio Grande Valley Regional Convening at the University of Texas Rio Grande Valley, Sept. 14, 2017). Regional Health Plan for Region 5 Community Needs Assessment, Professional Research Consultants, Aug. 31, 2012. Lisa Mitchell-Bennett, “Evidence-Based Strategies to Change Behavior and Promote Health” (presentation delivered at the Rio Grande Valley Regional Convening at the University of Texas Rio Grande Valley, Sept. 14, 2017). Regional Health Plan for Region 5 Community Needs Assessment, Professional Research Consultants, Aug. 31, 2012. Texas Department of State Health Services, 2014, www.dshs.texas.gov/. “Las Colonias in the 21st Century: Progress Along the Texas–Mexico Border,” by Jordana Barton, Emily Ryder Perlmeter, et al, Federal Reserve Bank of Dallas, 2015, www.texascolonias.org. Texas Department of State Health Services, 2014, www.dshs.texas.gov/. A discussion of the impact of the uninsured population relying on emergency room visits for primary care can be found in “Las Colonias in the 21st Century: Progress Along the Texas–Mexico Border,” by Jordana Barton, Emily Ryder Perlmeter, et al, Federal Reserve Bank of Dallas, 2015, www.texascolonias.org. “Las Colonias in the 21st Century: Progress Along the Texas–Mexico Border,” by Jordana Barton, Emily Ryder Perlmeter, et al, Federal Reserve Bank

of Dallas, 2015, www.texascolonias.org. 21. “A Guide to Understanding Mental Health Systems and Services in Texas,” 3rd Edition, Hogg Foundation for Mental Health, 2016. 22. “Closing the Digital Divide: A Framework for Meeting CRA Obligations,” by Jordana Barton, Federal Reserve Bank of Dallas, 2016, www.dallasfed.org/cd/ pubs/digitaldivide.aspx. 23. The Next Generation Network Connectivity Handbook: A Guide for Community Leaders Seeking Affordable, Abundant Bandwidth, by Blair Levin and Denise Linn, Benton Foundation, vol.1.0, July 2015, http://www.gig-u. org/cms/assets/uploads/2015/07/ValNexGen_design_7.9_v2.pdf. 24. “2016 Broadband Progress Report,” Federal Communications Commission, Jan. 29, 2016, www.fcc.gov/reportsresearch/reports/broadband-progressreports/2016-broadband-progressreport. 25. Pete Otholt (senior IT&S manager for Methodist Healthcare Ministries of South Texas Inc.), in discussion with the author, Sept. 20, 2017. 26. “Health Care Just Became the U.S.’s Largest Employer,” by Derek Thompson, The Atlantic, Jan. 9, 2018. 27. “At the Heart of Texas: Cities’ Industry Clusters Drive Growth,” by Pia Orrenius, Laila Assanie, et al, Federal Reserve Bank of Dallas, 2016, www. dallasfed.org/research/heart. 28. “At the Heart of Texas: Cities’ Industry Clusters Drive Growth,” by Pia Orrenius, Laila Assanie, et al, Federal Reserve Bank of Dallas, 2016, www. dallasfed.org/research/heart. 29. Francisco Fernandez, M.D. (professor, Department of Psychiatry, Neurology and Neurosciences, University of Texas Rio Grande Valley School of Medicine), in discussion with the author, May 22, 2017. 30. Closing the Digital Divide: A Framework for Meeting CRA Obligations,” by Jordana Barton, Federal Reserve Bank of Dallas, 2016, www.dallasfed.org/cd/ pubs/digitaldivide.aspx. 31. “What Speed Do you Need” Infographic, National Telecommunications & Information Administration, Broadband USA, www.ntia.doc.gov 32. “Closing the Digital Divide: A Framework for Meeting CRA Obligations,” by Jordana Barton, Federal Reserve Bank of Dallas, 2016, www.dallasfed.org/cd/ pubs/digitaldivide.aspx. 33. “In Mega-shelter for Harvey Evacuees, Telemedicine Plans to Help Doctors Keep Up” by Leah Samuel, STAT (Boston Globe Media), Aug. 31, 2017, www.statnews.com/2017/08/31/harveyshelter-telemedicine/. 34. “New York–Presbyterian Specialists Use Telemedicine to Treat Stranded Puerto Ricans” by Bill Siwicki, Healthcare IT News, Nov. 9, 2017, www.healthcareit-




38. 39.








news.com/news/newyork-presbyterianspecialists-use-telemedicine-treatstranded-puerto-ricans. The Texas Department of State Health Services defines promotoras as community health care workers who inform residents about health-related issues and who teach families health care literacy, Texas Community Health Worker Program, March 2014, www. dshs.texas.gov/mch/chw/CommunityHealth-Workers_Program.aspx. Tania Chavez, “La Union del Pueblo Entero Health on Wheels” (presentation delivered at the Rio Grande Valley Regional Convening at the University of Texas Rio Grande Valley, Sept. 14, 2017). “Interrupting the Cycle of Diabetes,” https://medium.com/@ibmcognitivebusiness/interrupting-the-cycle-ofdiabetes-600380ddfd02. American Diabetes Association, www. diabetes.org. “A Chef Takes a Fresh Approach to Diabetes,” https://medium.com/ cognitivebusiness/a-chef-takes-a-freshapproach-to-diabetes-4235fad1f222. “A Chef Takes a Fresh Approach to Diabetes,” https://medium.com/ cognitivebusiness/a-chef-takes-a-freshapproach-to-diabetes-4235fad1f222. Bryan Byrd (executive vice president of innovation and new business development for Volunteers of America North Louisiana), in discussion with the author, Oct. 9, 2017. Bryan Byrd (executive vice president of innovation and new business development for Volunteers of America North Louisiana), in discussion with the author, Oct. 9, 2017. “For Rural Veterans, New Approaches to Health Care,” by Jen Fifield, the Pew Charitable Trusts, Aug. 3, 2017, www.pewtrusts.org/en/research-andanalysis/blogs/stateline/2017/08/03/ for-rural-veterans-new-approaches-tohealth-care. “Healthcare Council Features Project ETHAN (Emergency TeleHealth and Navigation),” Greater Houston Partnership, 2015, www.houston.org/assets/ pdf/news/July-Healthcare-CouncilRecap.pdf. “Project ETHAN Telehealth Program Cuts Number of Emergency Department Transports in Houston,” by Karen Appold, ACEPNow, July 15, 2015, www. acepnow.com/article/project-ethantelehealth-program-cuts-number-ofemergency-department-transports-inhouston/. Remarks of Commissioner Mignon L. Clyburn of the Federal Communications Commission at the Launch of the Mapping Broadband Health in America Platform, Microsoft Innovation and Policy Center, Aug. 2, 2016, https:// apps.fcc.gov/edocs_public/attachmatch/ DOC-340590A1.pdf.

SPRING 2018 | RHQ   29

Making a Healthy Difference for Rural Texans

SERVING THE TEXAS RURAL HEALTH COMMUNITY The obstacles faced by health care providers and patients in rural areas are vastly different than those in urban areas. The Texas Rural Health Association (TRHA) is a nonprofit organization whose primary goal is to improve the health of rural Texans. Since 1984, individuals and organizations of TRHA have been dedicated to providing leadership on rural health care issues through advocacy, communication, and education.

THE TRHA MISSION  Promote rural health as a distinct concern in Texas.  Serve as a strong and unifying voice for concerned citizens,

community leaders, public officials, and health care providers and organizations working to improve rural health in Texas.  Advocate for rural health and promote an enhanced status

and improved health system for rural Texans.  Provide a forum for exchange and distribution of

information and ideas related to improvement of rural health.  Encourage the development of appropriate health resources

to all rural areas of Texas.

WWW.TRHA.ORG | 512-368-9860 | PO BOX 201363 AUSTIN, TX 78720


Veterans with PTSD, TBI may be Discharged for Misconduct


lmost 3 million U.S. military veterans live in rural communities and rely on the Veterans Administration for health care. In fact, the VA allocates 32 percent of its health Ron Martin care budget Licensed Professional to rural Counselor veteran care. Texas Tech University These are Health Sciences Center, well known The TWITR Project facts. Less well known are the facts surrounding service members discharged for misconduct, many of whom return or retire to rural America without the benefits available to veterans who were honorably discharged. According to the Government Office of Accountability (GAO), 13,283 or 23% of service members discharged for misconduct between 2011 and 2015 were diagnosed with

Post-Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI) or another mental health condition, and some members of the Navy were separated in lieu of a court martial in direct violation of Pentagon policy which requires a medical exam. Navy policy does not require a medical exam for this type of discharge. If you are familiar with the movie Pirates of the Caribbean: Curse of the Black Pearl, there is a scene in which Barbossa, an 18th century pirate, discusses ship policy. Barbossa tells his unwilling guest Miss Turner, “First, your return to shore was not part of our negotiations nor our agreement, so I must do nothing. And secondly, you must be a pirate for the pirate’s code to apply, and you’re not. And thirdly, the code is more what you’d call “guidelines” than actual rules.” Some things never change, it seems. In a document that was published in May 2017 (DOD Health: Actions Needed to Ensure PostTraumatic Stress Disorder and Traumatic Brain Injury Are Considered in Misconduct Separations), the Government Office of Accountability (GAO) expresses concern about the lack of consistency in the policies between each

branch of the military. The GAO is an auditory and investigative office with very little ability to enforce changes in government organizations, but they have made several recommendations to the DOD. One of the recommendations was to address inconsistencies in discharge training policies. The GAO found that “two of the four military services have TBI training policies that are inconsistent with DOD policy.” The DOD declined to address the inconsistencies, however. Another area of concern for the GAO is the lack of data or the inadequate use of the data to monitor adherence to policies related to PTSD and TBI services that are provided. Failure to monitor the adherence to these policies may result in service members being inappropriately separated for misconduct, the GAO noted. To date, the Department of Defense has failed to provide consistent guidance in addressing TBI, PTSD, and other mental health disorders that may lead to misconduct discharges. The Pentagon must develop a consistent training program and a single policy that is required for all branches of the military to use, monitor, and enforce to protect service members that are subject to other than honorable discharges.


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Teletherapy Fills Void for Vulnerable Population BY ERICA HENSLEY


hen Laurie* moved to rural western Colorado, she thought she had found a tranquil oasis to rest and die. The then-32-year-old was sober and living with HIV, but her health was waning and the mid-1990’s HIV medications were taking a toll on her body. “I moved to this area at a time in my life when I was dying, and wanted to move to an area that wasn’t busy or fast-paced, and a lot slower than what I was used to,” she said. She couldn’t find a nearby doctor willing to take an HIV case, so she photographed spots on her body and sent them to her old specialist at Johns Hopkins University. He diagnosed her symptoms remotely via dial-up Internet. But, Laurie survived. She found an HIV doctor 250 miles away and while her physical health began to improve through the trips across the state, her mental health spiraled. She was far from home and her new sparsely populated community was devoid of the support groups she had come to rely upon on the East Coast. There were no affordable mental health resources, she struggled to find addiction recovery support, and her tenuous Internet connection didn’t accommodate online social networking with other people living with HIV. She felt hopeless, questioned the point of all the HIV activism she had championed through the decade and began to self-medicate with alcohol, after seven years sober. “I was the girl who put ashes on the White House lawn and chanted in front of the FDA,” she said. As

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much as the move was complimentary to living longer, she lamented being removed from a supportive community. “When I moved here, it was completely different,” she said. “Politically, socially and medically it was 15 years in the rear.” That’s where Project Alliance, as it came to be known, came in. A team of researchers set out to identify and test barriers to mental health care among people living with HIV in rural areas. A team of psychotherapists wanted to bridge those barriers—limited resources, transportation and connectivity issues—with telephone-based interpersonal therapy. Depression is the most common psychiatry disorder associated with people living with HIV, and those in rural areas are 1.3 times more likely to be depressed than their urban counterparts and less likely to access regular mental health care, according to Timothy Heckman, lead author of the group’s latest project. Their most recent work out of University of Georgia’s College of Public Health builds upon years of research, and found that teletherapy effectively reduces depression for people living with HIV in rural areas, over the long term.

“In people living with HIV, having a greater number of depressive symptoms is associated with more impaired daily functioning, poor engagement and retention in care, greater rates of risky sex, poorer adherence to antiretroviral therapy, and more comorbid health conditions,” Heckman said. “Obviously, all of these are important reasons to reduce depression in [this group] but, equally important, we just want to provide them with a chance to lead happier and healthier lives.” The study was relatively small, with 147 participants from rural areas across 28 states, but found that after nine hour-long weekly sessions acute depressive symptoms were reduced, and that reduction persisted after four and eight-month follow-ups. Using a randomized control group that received standard in-person therapy, the teletherapy recipients were also less likely to use crisis hotlines and had fewer overall health care visits for emotional or substance-use support, according to the study. Though the study showed statistically significant depression reduction in this unique population, it was also the first

controlled study to show long-term teletherapy efficacy in any clinical population, signaling to researchers that more needs to be done in this area. For Laurie, the phone-administered nature of the therapy was an important aspect. Not only did it mean she could enjoy the view from her deck during the session and not have to worry about driving to the next town to access services, it also gave her a veil of anonymity that she had never experienced in her community, where she often feels stigmatized and discriminated against. “It allowed me to talk about things that I wasn’t willing to talk about with other therapists and I looked forward to talking to someone who was understanding of my experiences, or at least willing to listen,” Laurie said. “I grieved that relationship ending, but it was for a study and I knew I’d have to tell my story all over again to someone else.” Though HIV cases still cluster in urban areas, it’s mostly rural states that are driving the epidemic. While the South is home to 38 percent of the nation’s population, it comprises more than half of new HIV cases, according to the Centers for Disease Control and Prevention. This stretch of mostlyrural areas also sees higher rates of poor and uninsured people, but most of the region’s states did not expand Medicaid through the Affordable Care Act. Of the 37,600 new national cases in 2014, southern states have the highest proportion in rural or suburban areas, at 23 percent. The most recent data from the CDC pinpoint Georgia as the hub of new HIV diagnoses. Just edging out Louisiana, Georgia had almost 32 new diagnoses per 100,000 people in 2016, and 1.5 more cases overall than the national average. Though rates have gone down in recent years, Black Americans are disproportionately diagnosed

with HIV across the nation, especially in the rural south. In the U.S. overall, Black Americans account for 44 percent of new diagnoses, but only 12 percent of the population. Black Georgians account for 69 percent of new diagnoses, out of 32 percent of the population. After metro Atlanta, the southern rural half of the state sees the next highest rates of cases.

Depression is the most common psychiatry disorder associated with people living with HIV, and those in rural areas are 1.3 times more likely to be depressed than their urban counterparts. To address the unique challenges of HIV in rural Georgia—including a network of 159 counties and swaths of remote land without paved roads or hospital access—the state health department has been expanding its telemedicine infrastructure for both behavioral and specialist care over the last decade. Almost all of the state’s health districts offer telemedicine hubs, and every county has a HIPPAsecure endpoint unit to connect patients remotely to the hub. Districts are big—covering up to 14 often-rural counties and over 6,000 square miles—and patients have to be seen in-person for at least the first visit to access remote sessions from their county unit afterward. Twelve counties have HIVspecific telemedicine units, which spreads out to about one per district outside of metro Atlanta. As of 2016, 45 behavioral health providers offered state-sponsored mental telehealth services. Dr. Gregory Felzien previously led the HIV program in the southeast part of the state, and found

himself spending upwards of 70 percent of his time traveling just to get to patients. Now as director of the Department of Public Health’s entire HIV program, he says HIVspecific telemedicine has changed the way he gives and patients receive care. “Telemedicine has expanded the capability of specialists in touching a greater number of lives throughout rural communities,” Dr. Felzien said. After using telemedicine for almost a decade now, remote sessions allow more visits with reduced doctor and patient travel times, but better yet, he says, keep patients at their medical home where they are comfortable and have built relationships. Dr. Felzien is concerned, though, about maintaining a sufficient workforce that can care for people living with HIV as they age into an older cohort. “In meeting the needs of this population, we must focus on provider recruitment, increase training and HIV awareness, retain providers within the HIV workforce and focus on strengthening wrap-around services for patients through greater community collaboration,” he said. Laurie, now 53 and with an undetectable viral load, worries too—both for herself, as she sees political forces threatening to chop the health benefits she relies on, and for her fellow HIV-positive Coloradans. She tried to start a local support group to no avail, and not because the disease isn’t there. It’s just invisible, she says. “For long term survivors … our wellness is fragile and it’s a scary time,” She said. “It’s not like I have a support group for people with HIV… but I do believe telemedicine has the mission of healing—it’s sad that it’s not developed more than it is, especially for rural places.”


*Last name and town removed to protect medical privacy.

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In the frontier state of Montana, where kids are taught from a young age to “cowboy up,” suicide has a stranglehold on its people. Residents, many of whom live in isolation, are killing themselves at a rate faster than almost any other place in the nation. Mental health, public health and even government 34  RHQ | RuralHealthQuarterly.c officials are scrambling to find a way to halt what has been deemed a crisis.

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FIRST NATION Montana Tribe Tackles Health Disparities with Help from Student Researchers




Summer 2017 | RHQ   35

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efusing to accept the trauma, alcoholism, diabetes and mental illness that has hindered generations of Native Americans before them, students at Blackfeet Community College in Montana are searching for answers in the vials of blood, sweat and saliva they have stockpiled in their biomarker lab. The samples, collected on the Blackfeet Indian Reservation, are part of a research project spearheaded by Neha John-Anderson, Ph.D., who works in the Department of Psychology at Montana State University (MSU). Her co-researcher, Agnieszka Rynda-Apple, Ph.D., is also a professor at MSU. The team, flanked by students, is particularly interested in understanding how positive experiences and relationships may grant protection from the negative consequences of trauma or adversity on health. “While it’s impossible to change the past, there’s always the possibility to make changes in the current environment to bring about positive outcomes,” John-Henderson said.

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“That potential is what drives my research.” At the heart of this project are the 17,321 members of the Blackfeet Nation, one of 10 largest tribes in the United States. Located in northwest Montana, it was one of the first tribes in the nation to take control of its health programs after The Indian Health Care Improvement Act, a rider on the Affordable Care Act, permanently authorized the IHS Tribal Self-Governance Program. It allows tribes to take over Indian Health Service operations like diabetes management or ambulance service. Exposure to adversity and trauma can begin early in life among the American Indian population and persist into adulthood, John-Henderson said. These exposures have important implications for mental and physical health. Little is known about how positive factors in the social environment may affect the degree to which early life adversity negatively impacts health. In other racial/ethnic groups it has been shown that positive factors such

as maternal warmth are capable of reducing the negative impact that early life trauma or adversity has on health. More broadly, an example of a positive factor would be a warm family environment or the availability of social support. Based on their discussions with community members, it seemed plausible that connections to the Community could act in a similar way for the Blackfeet community. The project is aimed at Native Americans taking charge of their health and charting a new path for future generations, one that isn’t plagued by stress, depression and substance abuse. Their ultimate goal is to identify what is causing disease and illness and intervene. The research project is one way in which Montana tribes are leveraging resources and sovereignty to improve the health of their communities and chart their own destinies, John-Henderson said. “This is a big, big deal,” said Matt Kuntz, executive director of National Alliance on Mental Illness Montana. “Our native communities

have been wracked by trauma for generations. In order to truly learn and recover, it’s important they do their own research instead of relying on somebody else to point the way. Biomarkers are where the diagnosis of mental health is heading. That’s the direction of brain diagnostics. The important thing is that they are doing this. We can’t wait until somebody comes up with the magic potion. This gives me a lot hope for the tools, techniques and insights that they are uncovering.” Kuntz has testified in Congress on more than one occasion on behalf of Indian Health Services and rural health care services. Waiting for Congress to reform the Indian Health Service is not an option as lives are at stake. American Indians live almost two decades less than other Montanans, according to the most recent State of the State’s Health report that was compiled by the Department of Public Health and Human Services. White men in Montana lived 19 years longer than American Indian men, and white women lived 20 years longer than American Indian women. White women lived seven years longer than White men, and American Indian women lived six years longer than American Indian men. “This is my first time working with Native communities,” JohnHenderson said. “This work is all new for me. Before here, I was working inner city, predominantly African-American, individuals in Pittsburgh. The theme that’s gone through most of my work is resilience. So, when I first came here in fall of 2016, I had the opportunity to go off with some colleagues to Blackfeet Nation and meet with students at Blackfeet Community College. I was just really taken aback by resilience and the stories that they all tell and the tremendous adversities that they face, and in spite of that they have this unrelenting commitment to keep moving forward.”

Student Researcher Megan Gordon, Blackfeet Community College.

Students at Blackfeet Community College were particularly interested in the connection, very broadly, between stress and health. They wanted to pick John-Henderson’s brain about the ways that stress can be measured and look at health outcomes. Jerry Racine, a student researcher, said, “I have enjoyed having the opportunity to work on research that I believe can really make a difference in Indian country. I have learned about different biomarkers of the immune system and how they relate to stress levels. These biomarkers provide a physiological measure of stress levels in our community. We collect salivary and blood samples and do the analysis ourselves. Over the past few years, we have collected data and the findings have the potential to make a

difference in our community and for Indian country. We hope that our work will be published so that we can help address the stress and health problems our community faces. This will open many other doors for Blackfeet Community College to make a direct impact on the Blackfeet Nation. Megan Gordon initially signed on for the research project because she said she needed a job. But after working on it for almost a year it’s become much more, she said. “It’s helped shape my future education and career goals when before I wasn’t always sure what I wanted to do. (While) doing this research on stress levels and resiliency in our community, I have seen a correlation between a higher sense of belonging to the community and a lower stress level. I want to see this work

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continue and make a difference for the people. It would be amazing to see this research bring about more facilities in town for kids and adults to reduce stress and have something to do with their free time that also contributes to their physical health.” They have a lab where students have been trained to do all of their own biological analyses, looking at markers that connect to physical health. They were generally asking about stress, but they wanted to have a more developed questionnaire, so John-Henderson and her colleagues developed a survey with the students to examine in-depth measures of stress and how a sense of belonging to the community mattered. In their initial findings, it was the combination of early life trauma and a weak sense of belonging to the community that predicted negative health outcomes. On the other hand, individuals who had a high number of adverse childhood experiences who felt a strong connection to their community had a physiological profile that associates with reduced risk for diseases. These findings suggest that maintaining a strong connection to the culture and community may be protective with regards to physical health, particularly for individuals who have experienced high levels of trauma in their childhood. Moving forward, Henderson said, we need to understand a few things. First, what are the ways in which connection to community is fostered? For example, is it about speaking the language, or is it most important to participate in tribal practices and community events? Secondly, how does a sense of belonging impact health behaviors in ways that could be protective? Do individuals who feel a strong connection to their community have more positive social interactions? Do they feel less lonely? Do they sleep better? Are their eating habits more consistent with the traditional diet? “That’s what I’m working on right now,” John-Henderson said. “I’m

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working with the community advisory board, trying to develop a project where we can really measure all these things and really try to understand better what’s going on.” Specifically, tribal members who experienced high levels of childhood adversity but who also report high levels of sense of belonging to their community have significantly lower levels of an immune inflammatory marker of cardiovascular disease risk compared to individuals who similarly experienced high levels of childhood adversity but who report low levels of belonging to their community.

"[Blackfeet Nation] was

one of the first tribes in the nation to take control of its health programs after The Indian Health Care Improvement Act..." “If we can understand these relationships better, then we can design interventions,” John-Henderson said. Betty Henderson-Matthews is the project leader of the student-led project titled, “Correlation of stress levels and disease susceptibility in the Blackfeet Community.” “This research is important as it gives the students and community members the opportunity to be involved in research that could directly impact their health,” Matthews said. “The work is done by the community in efforts to advance community health.” This project will support ongoing secondary data analyses of the existing stress and health dataset and will develop a second phase of the study, which will further explore the predictors of a sense of belonging to the tribal community and how a sense of belonging associates with the biomarkers of disease risk. Specifically, the project pursues three related aims: •

To work with Blackfeet Community College on analyses of

the existing stress and health dataset, focusing on relationships between early life experiences, belonging to the tribal community, and health-relevant biomarkers, and to work collaboratively toward presentation and publication of these findings. To expand on the findings from the first phase of the study through development of a second phase of the project in partnership with the BCC students. This project will further investigate both predictors of and outcomes associated with a sense of belonging to the Blackfeet tribal community. To formulate a Community Advisory Board to develop a proposal for an intervention that would promote positive health outcomes by fostering an increased sense of belonging to the Blackfeet tribal community.

“One of the things that we’re learning is that even from one generation to the next, the narrative changes and the concerns change and the way that they connect with their people changes,” John-Henderson said. “I think what’s gained is that they feel empowered from their initial findings. They feel motivated to move forward and keep designing their own research questions with our guidance. Right now, for example, they’re writing up their first paper for peer review publication, so they feel like they’re partaking in science in a way that they feel like can really give back to their community because from the very first stages and all the way through, it has been driven by the community needs.” Funding for the research was provided by the Center for American Indian and Rural Health Equity at Montana State University in Bozeman, Mont., the IDeA Networks of Biomedical Research Excellence, a program of the National Institutes of Health, and the American Indian/Alaska Native Clinical and Translational Research Program.


CHWs Play Important Role in Cultural Sensitivity


he community health worker role has evolved within the last fifteen years. The conceptualized job functions of community health workers, also known as promotoras, has consisted mostly of community outreach and education. The effectiveness of community Debra Flores health workers Director in the comWest Texas AHEC, F. Marie munity became Hall Institute for Rural and apparent by Community Health the success of the entities and programs that included community health workers in their implementation plans. Early on, the well-intended researchers in their ivory towers riding into the community on their white horses determined to rescue a community from their perils were met with a wall of mistrust and other barriers such as lack of health literacy and monolingual obstacles. The lack of cultural knowledge and sensitivity on behalf of the programs intended to promote health

and prevent disparities were failing and it wasn’t clear why. Fortunately through research projects along the border with difficult to reach populations, the community health worker/promotora concept was being utilized as far back as the 1970s. When someone asks me what the key is to the effectiveness of community health workers, I always respond that there are many, but the primary one is that community health workers must possess a cultural awareness about, and a love for, the communities they serve. In my experience developing, implementing and working with community health workers for the last 20 years, cultural and linguistic sensitivity continues to be the reason community health workers are effective. It is not usually effective to drop a community health worker into a community that they are not familiar with, which is why it is important to recruit community health workers from the community that the program/ project intends to serve. Cultural congruence is vital to reaching the members of those communities. If a trust and acceptance already exists between the community and community health workers, the barriers fall away. Although the role of community health workers can be multifunctional, cultural sensitivity is at the

heart of the work CHWs do within the communities they serve. This attribute is pertinent to addressing lifestyle factors that affect difficult to reach populations. Without cultural sensitivity, it can be difficult to, say, visit a marginalized neighborhood in the evening to do an initial home visit. And without trust from that community, it may not be a good idea to do so. Community health workers who have built relationships in these neighborhoods, often where they grew up or currently reside, are able to avoid the cultural differences. Cultural sensitivity also includes understanding and being able to address the unique needs of individuals that reside in those neighborhoods. Fortunately, current community health workers encapsulate many cultures and backgrounds. Increased recruitment and training intended to include rural communities has been particularly positive and fruitful. The exponential growth of certified community health workers in Texas has made it possible to have a cadre available for recruitment and employment in the many facets of health care. Bridging the cultural sensitivity gap has been beneficial for both the institutions hiring community health workers and the communities benefiting from the services delivered by community health workers.


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heck out our list of rural health conferences, and let us know if you’re hosting one so we can help spread the word. Email us the details at RHQ@ttuhsc.edu.

Wisconsin Rural Health Conference June 27-29, 2018 Osthoff Resort 101 Osthoff Avenue Elkhart Lake, WI www.wha.org Misssissippi Rural Health Association Rural Health Clinic Workshop: Practice Management Training July 1, 2018 Riley Workforce Development 1524 Hwy 19 N Meridian, MS msrha.org NRHA SRHA Leadership Conference July 17-18, 2018 Omni Shoreham Hotel 2500 Calvert Street NW Washington, D.C. www.ruralhealthweb.org NRHA Rural Quality and Clinical Conference July 18-20, 2018 Omni Shoreham Hotel 2500 Calvert Street NW Washington, D.C. www.ruralhealthweb.org National Institute for Social Workers and Human Services in Rural Areas Conference July 18-20, 2018 Murray State University 240 Alexander Hall Murray, KY www.ruralsocialwork.org Bi-annual International Rural Nursing Conference 40  RHQ | RuralHealthQuarterly.com

July 23-26, 2018 Nashville Airport Marriot 600 Marriott Dr Nashville, TN training.ua.edu/irnc Arizona Rural Health Conference July 26-27, 2018 High Country Conference Center, 201 W. Butler Ave Flagstaff, AZ crh.arizona.edu Rural Data Summit July 31-August 2, 2018 La Fonda on the Plaza 100 E San Francisco Street Santa Fe, NM www.worh.org Illinois Rural Health Association Educational Conference August 8-9, 2018 Hilton Garden Inn Champaign, 1501 S Neill St Champaign, IL www.ilruralhealth.org Missouri Rural Health Conference August 21-23, 2018 The Lodge at Old Kinderhook 678 Old Kinderhook Dr.

Camdenton, MO www.morha.org Rural Health Clinic Conference September 25-26, 2018 Sheraton Kansas City Hotel at Crown Center, 2345 McGee Street Kansas City, MO www.ruralhealthweb.org Critical Access Hospital Conference September 27-29, 2018 Sheraton Kansas City Hotel at Crown Center, 2345 McGee Street Kansas City, MO www.ruralhealthweb.org 35th Annual Oregon Rural Health Conference October 3-5, 2018 The Riverhouse 3075 N. Business 97 Bend, OR www.ohsu.edu National Association of Rural Health Clinics Fall 2018 Institute October 23-25, 2018 Hyatt Regency Lake Tahoe 111 Country Club Drive Incline Village, NV narhc.org




Go to http://goo.gl/oR2QWF Click “REGISTRATION” Fill in the registration form. Submit payment.

www.westtexasahec.org CHWBridge@ttuhsc.edu Phone: 806-743-3644

CHW Workforce Development Bridge to Excellence •

Available to students nationwide

For Texas residents, this program is certified by the Texas Department of State Health Services (DSHS) and provides 160 contact hours towards certification

Certificate of completion for non-Texas residents

CHWs will acquire skills in outreach, patient navigation, follow-up services, community health education, informal counseling, social support, advocacy, and participation in clinical research.

Who can become a CHW?

Registration Fee

- Anyone with computer knowledge - Anyone at least 18 years old - Per Participant: $500.00 - Payment options: Full $500 or 5 months at $100 - Discounts to employers training 2 or more employees

HQ Plaza, 5307 West Loop 289, Suite 301 Lubbock, TX 79414

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Profile for Rural Health Quarterly (RHQ)

Rural Health Quarterly 2.2 - Spring 2018  

Celebrating Diversity in Rural America • The Importance of Diversity in Research • A Tale of Two Censuses • Telehealth Along the Texas–Mexic...

Rural Health Quarterly 2.2 - Spring 2018  

Celebrating Diversity in Rural America • The Importance of Diversity in Research • A Tale of Two Censuses • Telehealth Along the Texas–Mexic...