Why are rural communities at greater risk for poor health outcomes? A simple Google search will return a staggering number of statistics and factors contributing to the numerous health disparities that impact the almost one-fifth of Americans living in rural areas. Amongst the many contributing factors, access to healthcare consistently presents itself as a challenge for individuals and families living in rural areas across the country.

Unite Us is committed to supporting rural communities across the 42 states we currently work in. Our local community engagement teams have the pleasure of partnering with organizations and coalitions to do innovative work in rural communities. Some of the most common rural inequities we encounter continue to be access to behavioral health services, lack of availability of broadband internet, and access to transportation resources.

Network responses and best practices to address common rural health challenges

Access to mental and behavioral health

The ADK Wellness Connections network, powered by Unite Us, covers a wide rural region in upstate New York and has seen a massive increase in mental and behavioral health needs since the start of the pandemic. Simply put, there are not enough service providers available to meet the community’s needs. As a result, a network partner, Cornerstone Mobile Counseling, launched an innovative mobile counseling response to address this gap. Through this service, mental health providers across 24 counties can travel to client’s homes. Providing at-home services enables clients to have their needs met without having to travel or find an office with availability.

Lack of availability of broadband internet

Although healthcare providers have increased their ability to offer telemedicine to support the increasing need for mental and behavioral health services, telemedicine is only accessible to those who have in-home broadband internet. The need for broadband access is a growing challenge as we continue the shift to digital communication. Many aging and remote populations lack access to high-speed internet.

According to the Federal Communications Commission’s Eighth Broadband Progress Report, “Nearly one-fourth of the population—14.5 million people—lack access to this service. In tribal areas, nearly one-third of the population lacks access. Even in areas where broadband is available, approximately 100 million Americans still do not subscribe.”

The lack of accessible traditional provider options for rural America, coupled with the opportunity to get treatment online, suggests that broadband access is a health equity issue. The bottom line is that we need broadband to expand health care access. Unite Us is actively supporting partners in their CHART application process, which can enhance digital technology.

In the interim, the most rudimentary solution to access barriers is transportation. Clients need to be able to get to their health and social care providers, if nothing else.

Access to transportation resources

As a social determinant of health, access to affordable transportation is fundamental to mental, physical, and emotional well-being. In rural and urban settings, transportation impacts the use of health-related services because individuals without reliable transportation are more likely to delay or forgo necessary appointments, preventive care, and health maintenance activities.

New York’s largest rural county, St. Lawrence county, is not served by any interstate highway system section. Due to insufficient road access and high poverty rates, nearly 20 percent for the adult population, 30 percent for the child population, and the autonomous Mohawk settlements struggle to access necessary resources, including education, employment, health, and social care.

Recognizing these barriers, our network partner, Adirondack Health Institute, awarded the St. Lawrence Health System a $154,000 access-to-care grant for low-income St. Lawrence residents. The Volunteer Transportation Center, an Adirondack Wellness Connections network partner, now accepts assistance requests from community members and electronic referrals through the Unite Us Platform.

The rides are made accessible in many different ways: fuel gift cards, mileage reimbursements, free bus rides, and a program created wherein volunteer drivers provided car rides to people from their homes to the bus stop. In this community, in just one year, nearly 1,100 rides have been coordinated through the Unite Us Platform, ensuring underserved clients got everywhere from dental check-ups to cancer treatments.

Enhancing your rural health equity strategy

Partner with Unite Us today to coordinate multiple services, track data and outcomes, and identify and address trends and gaps in your community. Our local teams bring together community-based organizations to seamlessly address health disparities using Unite Us as a common tool. As we expand and grow our networks, prioritizing rural communities and ensuring a broad range of community-based organizations’ participation in these networks is a priority.

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The Center for Medicare and Medicaid Services (CMS) Community Health Access and Rural Transformation (CHART) model is an important opportunity to advance community-based health transformation in rural areas and provide federal funding for health system reform. Unite Us can support care coordination across the continuum of care through our infrastructure, facilitate early and proactive care through screening for the social determinants of health, bring together trusted and local community providers, and empower communities with data and outcomes tracking that can identify resource gaps and disparities.

Unique social determinants in rural areas

While people with complex clinical and social needs who live in rural areas encounter similar challenges to people living in urban areas–such as poverty, food insecurity, homelessness, and lack of transportation–these challenges are exacerbated by limited infrastructure and resources.

A good example in rural America is transportation. Nearly two million rural residents are without access to a car, and public transportation services are often severely limited and underfunded. Even with access to transportation, individuals may have to travel far greater distances than in urban areas to reach hospitals, doctors’ offices, and emergency and social services. The result is an increased likelihood of delaying or forgoing necessary appointments, preventive care, and health maintenance activities.

These social determinants contribute to worsened health outcomes; a study from the CDC reveals that the 46 million individuals living in rural areas are at greater risk of dying from five leading causes – heart disease, cancer, unintentional injuries, chronic lower-respiratory disease, and stroke – than their urban counterparts. Though health leaders agree hospitals are often best positioned to address social determinants in communities, they are limited by the lack of direct reimbursement for these services needed for upfront investment.

Even more, racial and ethnic minorities living in rural areas encounter several systemic inequities that impact use of health services and overall well-being – currently, 1 in 5 rural residents identify as Black, Hispanic, American Indian/Alaska Native and Asian American/Pacific Islander. Though racial and ethnic disparities may be invisible in the rural context, minority populations face real inequities in areas such as access to education and broadband, insurance status, and income levels.

A proven solution for rural communities

Unite Us believes that some of the most promising opportunities and approaches to improve care delivery in rural areas leverage the fact that these communities have a unique social fabric, with community members relying on each other, and trusted local leaders, for support. Our rural engagement strategy is tailored to meet the needs of the community through: in-person community sessions and meetings, distribution of paper flyers rather than inaccessible digital materials, and forging relationships with community champions (such as United Ways).

Our team is dedicated to improve our technology and adapt our engagement strategy to make health and social care more accessible, equitable, and outcomes-focused.

• Our statewide network in North Carolina covers a geographic area that is 80% rural. In the eight-county area surrounding Chowan, which has a population of less than 150,000 people, our team adjusted our engagement strategy to understand the community’s distinct needs and brought together 50+ organizations connecting residents to resources.
• Our Unite West Virginia network includes rural counties in the Appalachian Mountains and the Eastern Panhandle, with one county having a total population of 8,505. To reach the most rural individuals, we teamed up with Family Resource Networks, a local and trusted non-profit, and onboarded community-based providers.

“The very first time [one of our team members] made a referral in the Unite Us Platform to another organization, she sent a joyful email saying ‘I just made my first referral to another organization. It was a woman who also needed help with housing and was afraid she would be evicted. I sent her to this other organization, all within the platform!’ She was so thrilled… it made all of us realize: wow, there’s something here.”

– Glenn Wise, Program Director, Manna Food Bank, North Carolina

Rural health system transformation is underway

At Unite Us, we encourage the continued adoption of new policies and programs that build a sustainable foundation for care delivery in rural communities. First, our team encourages investments in building a local workforce to help solve doctor and nurse shortages, a critical issue in many rural communities. This means not only investing early in the recruitment of students from rural areas into health profession programs, but also supporting reimbursement flexibility for alternative providers such as nurse practitioners, physician assistants, and community health workers which can fill vital primary care roles in their communities. Telehealth is also an increasingly powerful tool that can supplement local workforce limitations and support rural patients and providers. Telehealth services connect patients with specialists located elsewhere and can provide needed peer support to rural health professionals who often work in isolated environments. Health systems and policy makers should continue to expand reimbursement for telehealth, and invest heavily in rural broadband infrastructure to ensure rural communities stay connected.

It is critical, too, that new value-based payment models are adapted to the unique characteristics of rural areas like small population size and high hospital operating costs. For example, down-side models, where providers refund payers if costs exceed a benchmark, are particularly threatening for rural hospitals operating on thin margins. The CHART payment model, however, provides much needed flexibility for rural hospitals and is a great example of tailoring funding policies for the rural context.

At Unite Us, we are eager to team up with health systems, non-profits, state and local governments and other stakeholders to develop and implement systems of community-based and integrated care in rural communities. Please reach out if your organization is interested in partnering with Unite Us on your CHART application.

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Advocating for rural communities has always been a passion of mine. Splitting my formative years between Ramseur, NC (population: 1,692) and Morehead City, NC (population: 8,661), I was shaped by playing hide-and-seek in cow pastures during the day and flounder-gigging at night. Growing up in a small town, I quickly realized the things that came easily to my relatives in bigger cities were harder to come by for my family. Some of these conveniences were minor and related to material things (i.e. the nearest Target was 45 minutes away), however, some were more serious and could be the difference between life or death. When someone you know has a heart attack and the closest cardiovascular surgeon is 30 minutes away, distance matters.

Rural North Carolina by the Numbers

The term rural can have many definitions, but according to the NC Rural Center, rural counties have average population densities of 250 people per square mile or less.¹With this definition applied, 80 of North Carolina’s 100 counties are considered rural. In 2017, North Carolina had total population of 10,273,419, with 2,210,611 people residing in rural counties.²

Access to Care in Rural Counties

Access to quality care is vital to good health, yet in rural communities, there can be various barriers to this access.⁴In these areas, residents may have trouble accessing primary care, emergency services, public health services, dental care, and/or appropriate mental health services. According to Healthy People 2020,⁵regular and reliable access to healthcare can:

• Prevent disease.
• Detect and treat illnesses.
• Improve quality of life.
• Decrease chance of early death.

Factors impacting access to care in rural North Carolina include health insurance coverage, workforce shortages, distance and transportation, social stigma and privacy issues, and poor health literacy.

One example of workforce shortages concerns the delivery of primary care. When it comes to access to healthcare professionals, rural communities often show disparities. In fact, metropolitan counties in the state have 26.6 physicians per 10,000 residents compared to the most rural counties having only 10 physicians per 10,000 residents.³For the people in these communities, this could mean traveling farther for care, or for those without transportation, foregoing care completely.

Social Determinants of Health for Rural Residents

According to the World Health Organization, social determinants of health (SDOH) are “circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness.”⁶Rural communities often experience many disproportions in SDOH compared to more urban areas. In North Carolina, the average income in 2016 was $42,244, but in rural areas the average was $34,847. Along the same lines, the poverty rate in rural North Carolina was 18.3%, compared to a poverty rate in urban areas of 13.7%.⁴

Rural residents may also face barriers related to access to housing, transportation, and affordable, healthy food. These barriers may be particularly impactful for residents who are already financially insecure.

For more information on specific SDOH affecting each county in North Carolina, use this interactive map available through the State Center for Health Statistics: https://schs.dph.ncdhhs.gov/data/hsa/

Looking Forward

It’s often said that there is no silver bullet to solve problems within healthcare. Each community within our state is unique – with different barriers and various solutions. Addressing the problems in rural North Carolina will require community collaborations, not only at an organizational level but also with those that know the community the best: the people who live there. I’m so proud to be from rural North Carolina and if there are three lessons I have learned,they are the following:

• A small-town community can be the best support system in the worst times.
• Not everyone knows what a lightning bug is.
• The word y’all has many meanings.

Learn more abouthow we’reconnecting providers across sectors to combat barriers to care:

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References:

1.NC Rural Center

2.USDA Economic Research Service: State Fact Sheets

3.The Sufficiency of Health Care Professional Supply in Rural North Carolina

4.Rural Health Information Hub

5.Healthy People 2020

6.World Health Organization

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The state of health across the country is undergoing great transformation as communities collectively work together to address the disproportionate spending and poor health outcomes. Much of the conversation has been centered around urban communities and reasonably so, the urban/suburban population in the US accounts for about 81% of the total population, but that doesn’t mean that we can forget about our rural communities. Today, 46 million americans live in rural America and this population experiences high rates of chronic disease, higher mortality rates, and lower life expectancy than their urban counterparts. The health disparities that exists in our rural communities are growing, and the solution for addressing these disparities is a different one than what we are seeing in the rest of the country.

A report published by The National Advisors Committee on Rural Health and Human Services, defined 4 key social determinants that significantly impact rural populations more than urban ones. The 4 social determinants identified are: geography; wealth, income, and poverty; education and labor markets; and transportation. Not only do rural communities experience a lack of clinical resources as well as challenges in accessing those resources, but the social factors that impact one’s life are increasingly prohibitive for this specific population.

Dig a little deeper into the key challenges for each of the core social determinants that affect rural communities and it is clear that public, private, and nonprofit agencies need to be innovative and flexible when it comes to building programs to solve this issue in rural America.

Geography – The mortality rate in rural counties is 13 percent higher than in metro counties and residents of metro counties lived two years longer on average than residents of rural counties. Urban communities are geographically isolated which leads to a lack of basic health and human services. In addition to simply accessing services, studies are starting to show that depending on where people live there are already challenges that exist with regards to accruing wealth and amenities to access physical activity.

Wealth, income, and poverty – From 2000- 2010 urban counties saw an increase of residents living in poverty from 4% to 15% whereas rural counties saw an increase from 17% to 32%. The lack of economic opportunity and mobility in rural communities has often led to an increase in risky behaviors leading to unintentional accidents through motor-vehicles or overdoses.

Education and labor markets – Rural communities on average experience lower college completion rates in addition to a lag in rural employment growth. A large factor in the lag in employment growth is attributed to the increasing age of the population as well as a less educated workforce.

Transportation – If individuals do not have access to personal means of transportation it can be incredibly difficult to access the most basic necessities. Just 32% of rural counties have full access to public transportation services with another 28 percent having only partial access.

The breakdown above is just a glimpse into the unique challenges that rural communities face particularly when it comes to accessing basic health and human services in their communities. That being said, there are solutions and programs that are working to address these specific challenges and the results are promising.The University of New Mexico launched the Health Extension Rural Offices (HEROs) program, which assigns HERO agents throughout the state to serve as community liaisons with the UNM Health Sciences center. Additionally, the center launched the “Beyond Flexner” movement, a national effort to change how academic health centers address social determinants that play a pivotal role in health risks and outcomes. At Kalispell Regional Health they launched a non-profit called ASSIST Neighbors Helping Neighbors, an organization powered by volunteers that serves as the hub to address the vulnerable patients needs once they are discharged from the hospital. Hospitals, clinics and doctor’s offices refer patients to ASSIST who have been identified as potentially needing assistance. From there ASSIST reaches out to the patients and ensures they provide ways to solve their additional needs.

The two examples above are a small fraction of the innovative programs designed to support our rural communities access whole person care. It is undeniable that community leaders are working together to bridge the gap to deliver whole person care but each community is different, thus programs and support will vary. Nonetheless, there is an approach that can be replicated across all communities, one that views clinical and social services along one continuum. Where community nonprofits, hospitals, and government agencies are all working together to improve health outcomes for the populations they are dedicated to serving. Unite Us provides the social infrastructure to support this type of approach. Our software supports collaboration among community partners and provides the shared visibility and outcomes data to inform care interventions and programs. Resulting in community partners working together and having an even greater impact on health outcomes in rural communities.

For more information on how we support rural communities address the health and social needs of vulnerable populations fill out your information here and a member of our team will reach out shortly!

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