Rural and Migrant Health

Rural Populations The largest rural population in history of United States is now. 75% of counties are classified as rural; they contain only 20% of the U.S. population Number/size of rural counties are highest … in the South (35%) in the Midwest and West (23%) in the Northeast (19%) Census data 20% of nation’s children under 18 15% of nation’s elderly More than 50% of nation’s poor Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 2
Rural Populations (Cont.) Economic base is shifting Agriculture is the “food and fiber system” All aspects of agriculture (core materials to wholesale and retail and food service sectors) are included Poverty in rural areas greater than in urban areas Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 3
Rural Populations (Cont.) Poverty continues to be greater in rural America than in urban areas. Aging-in-place, out-migration of young adults, and immigration of older persons from metro areas. Greater diversity among residents: a country of immigrants historically and today. Health disparities exist—rural population more likely to be older, less educated, live in poverty, lack health insurance, and experience a lack of available health care providers and access to health care Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 4
Health Disparities Among Rural Americans Only 10% of U.S. physicians practice in rural areas Ratio of physicians in rural population is 36:100,000 (nearly double in urban settings) More often assess their health as fair or poor More disability days resulting from acute conditions More negative health behaviors (untreated mental illness, obesity, alcohol, tobacco, and drug use) that contribute to excess deaths and chronic disease and disability rates Higher number of unintentional injuries Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 5
Defining Rural Populations Population size Rural = towns with population of less than 2500 or in open country [farm/nonfarm] Density Rural = fewer than 45 persons per square mile Frontier = less than 6 people per square mile Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 6
Defining Rural Populations (Cont.) The Rural-Urban Continuum uses population and adjacency to metropolitan areas Core Based Statistical Areas (CBSAs) Metropolitan areas = county with at least one urbanized area of 50,000 or more people Micropolitan area = area contains a cluster of 10,000 to 50,000 persons Outside CBSAs = noncare areas Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 7
Describing Rural Health and Populations Differ in complex geographical, social, and economic areas Disparities include key indicators of health: Employment Income Education Health insurance Mortality Morbidity Access to care Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 8
Rural Health Disparities: Context and Composition Context: characteristics of places of residence Geography, environment, political, social, and economic institutions Composition: collective health effects that result from a concentration of persons with certain characteristics Age, education, income, ethnicity, and health behaviors – Braveman (2010) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 9
Context: Health Disparities Related to Place A downward spiral may exist: people leave ? services are lost ? tax base becomes insufficient ? fewer services are provided ? long distances to get health care ? jobs become scarce and more people leave ? the cycle continues Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 10
Context: Health Disparities Related to Place (Cont.) Access to health care (#1 priority) Fewer primary care physicians General health services lacking Health insurance coverage … Varies according to race and ethnicity; age and residence (rural or urban) Influences health patterns May create financial barriers to health care Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 11
Composition: Health Disparities Related to Persons Income and Poverty One of the most important indicators of the health and well-being of all Americans, regardless of where they live. Regional differences—highest in the South Racial and ethnic minorities—rates among rural racial minorities two to three times higher than for rural whites Family composition—female-headed families have highest rates Children—among the poorest citizens in rural America Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 12
Composition: Health Disparities Related to Persons (Cont.) Health risk, injury, and death Higher rates of obesity, smoking, sedentary lifestyles, alcohol use, firearms usage, suicide, vehicular accidents; lower rates of seat belt use Risk factors Age, education, gender, race, ethnicity, language, and culture Education and employment Occupational health risks Perceptions of health (gender, race, ethnicity) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 13
Agricultural Workers Accidents and injuries caused by: Environmental conditions Geographic isolation and working alone Use of agricultural machinery Delayed access to emergency or trauma care Acute and chronic illnesses: Musculoskeletal discomfort, acute and chronic respiratory conditions, hearing loss, hypertension Chemical exposure (pesticides, herbicides, etc.) Secondary conditions related to demanding farm work Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 14
Migrant and Seasonal Farm Workers (MSFW) Health Disparities Poorest health and the least access Low income and migratory status Cultural, linguistic, economic, and mobility barriers Minimal or no preventive care Mobile clinic sites form a central link to health services Migrant Health Program (MHP) bases services on enumeration of MSFW Migrant and Seasonal Farm Worker Enumeration Profile Study (MSFWEPS) (2000) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 15
“Thinking Upstream” Concepts applied to Rural Health Attack community-based problems at their roots Emphasize the “doing” aspects of health Maximize the use of informal networks Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 16
Rural Health Care Delivery System Health care provider shortages Rural shortages likely to become worse Need to “grow their own” Telemedicine Cost-effective alternative to face-to-face care Telehealth includes telephones, fax machines, email, and remote monitoring Telemedicine permits two-way, real-time, interactive communication between patient and provider Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 17
Rural Health Care Delivery System (Cont.) Managed care in the rural environment Possible benefits: Potential to lower primary care costs Improve the quality of care Help stabilize the local rural health care system Risks Probable high start-up and administrative costs Volatile effect of large, urban-based, for-profit managed care companies Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 18
Community-Based Care A myriad of services provided outside the walls of an institution Home health and hospice care, occupation health programs, community mental health programs, ambulatory care services, school health programs, faith-based care, elder services (adult day care) Community participation in decisions about health care services Focus on all three levels of prevention An understanding that the hospital is no longer the exclusive health care provider Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 19
Home Care and Hospice Nurse case management and development of local resources Often hospital based in rural areas Use county extension services as a bridge for outreach services Improve home care for these patients and provide support for their families A partnership between the public health nurse and county extension service could provide support, as well as information groups and caregiving classes, for the important informal provider network. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 20
Faith Communities and Parish Nursing A strong sense of community, family life, and religious faith Integrating nursing expertise and faith-based knowledge to provide holistic care to members of congregations Involved in case management and coordination of services Collaboration with other organizations to extend limited rural community health resources Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 21
Informal Care Systems Evolve from self-reliance and self-help traits of rural residents Include people who have assumed the role of caregiver based on their individual qualities, life situations, or social roles Provide direct help, advice, or information Need to identify and combine informal services with formal systems Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 22
Rural Public Health Departments Public health nurses are often the core providers of public health services in rural areas. Collaboration of services is key—need to develop partnerships with other heath provider agencies. Environmental health, maternal and child health, and communicable disease control are the three highest-priority programs. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 23
Rural Mental Health Care Lack of specialized mental health providers in rural areas. Most services provided by primary care providers without adequate preparation or support. Perceived stigma prevents individuals from seeking mental health services. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 24
Emergency Services Getting patients from the place of injury to the trauma center within the “golden hour” is frequently not possible because of distance, terrain, climatic conditions, and communication methods. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 25
Emergency Services (Cont.) Challenges faced by rural EMS systems Shortage of volunteers and lower levels of training Training curricula that often do not reflect rural hazards (e.g., farm equipment trauma) Lack of guidance from physicians Lack of physician training and orientation to EMS Also contributing to difficult public access for emergency care: Low population density Large, isolated, or inaccessible areas Sever weather Poor roads Lower density of telephone/communication methods Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 26
Emergency Preparedness in Rural Communities Challenges in rural areas: Resource limitation Human, financial, and social capital Separation and remoteness Longer response times Low population density Impacts funding Communication Warning systems often absent or neglected in remote areas; burden on individuals Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 27
Legislation and Programs Affecting Rural Public Health Programs that augment health care facilities and services Community Health Centers (CHC) program Migrant Health Clinic (MHC) program and the Migrant Health Program (MHP) Medicare’s Rural Hospital Flexibility (RHF) grant program Primary care cooperative agreements Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 28
Rural Community Health Nursing “CH nursing along the rural continuum” Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 29 Nonmetropolitan Areas Metropolitan Areas
Rural Nursing … … is the practice of professional nursing within the physical and sociocultural context of sparsely populated communities. It involves the continual interaction of the rural environment, the nurse, and his or her practice. Rural nursing is the diagnosis and treatment of a diversified population of people of all ages and a variety of human responses to actual (or potential) occupational hazards or actual or potential health problems existent in maternity, pediatric, medical/surgical and emergency nursing in a given rural area. –– Bigbee (1993), Lee & Winters (2004), Rosentahl (2005), Williams et al. (2012) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 30
Characteristics of Rural Nursing Should rural nursing practice be designated as a specialty or subspecialty area because of factors such as isolation, scarce resources, and the need for a wide range of practice skills that must be adapted to social and economic structures? Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 31
Characteristics of Rural Nursing (Cont.) Positive aspects Ability to provide holistic care Know everyone well Develop close relationships with the community and with coworkers Enjoy rural lifestyle Autonomy and professional status Being valued by the agency and community Negative aspects Professional isolation Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 32
The newcomer practices nursing in a rural setting, unlike the more experienced nurse, who practices rural nursing. Somewhere between these extremes lies the transitional period of events and conditions through which each nurse passes at her or his own pace. It is within this time zone that nurses experience rural reality and move toward becoming professionals who understand that having gone rural, they are not less than they were, but rather, they are more than they expected to be. Some may be conscious of the transition, and others may not, but in the end, a few will say, "I am a rural nurse.” – Scharff (1998, p. 38) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 33
Rural Health Research Research agendas must address: The capacity of rural public health to manage improvements in health Information technology capacity in rural communities Developing and monitoring performance standards in rural public health Developing leadership and public health workforce capacity within rural public health Interaction and integration of community health systems, managed care, and public health in rural America – Berkowitz, Ivory, & Morris (2002) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 34
Capacity of Rural Public Health to Manage Improvements in Health Healthy People 2020 objectives and intervention strategies Information Technology in Rural Communities EHR and reimbursement Preparedness strengthens infrastructure Continuing education and advanced education Telehealth impact on public health Skills via distance learning? Costs and infrastructure of IT? Gaps in epidemiology and surveillance capacity? Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 35
Performance Standards in Rural Public Health National Public Health Performance Standards Program (NPHPSP) describe an optimal level of performance by public health systems regardless of location. Used to improve collaborations among key public health partners, educate participants about public health, strengthen the network of public health partners, identify strengths and weaknesses, and provide benchmarks for public health practice improvements Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 36
Leadership and Workforce Capacity for Rural Public Health IOM report (2003)—preparing public health workforce for 21st century CDC Public Health Improvement Initiative (2012)—accreditation support Medicaid impact on interaction and integration of community health systems, managed care, and public health New models of health care delivery for rural and frontier areas being tested


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