1
Introduction

A sense of distinction between rural and urban settings and communities is of long standing. The playwright Euripides is said to have offered the view in the 5th century BC that “The first prerequisite to happiness is that a man be born in a famous city.” And in the 3rd century BC, the writer of Ecclesiasticus, a book of the Apocrypha, asked the question “How can he get wisdom who holdeth the plow?” Yet in the formative age of our country, it was the virtues of agrarianism that were strongly asserted by Thomas Jefferson, who referred scathingly to the “mobs of great cities” and called farmers “the chosen people of God” (Beale and Cromartie, 2004, p. 1).

Rural communities are a vital, diverse component of the United States, representing nearly 20 percent of the nation’s population. The basic demographic feature of a rural area is that it is a place of low population density and small aggregate size. There is no one standard definition of rural in terms of population statistics. The most long-standing U.S. definition has been that of the Census Bureau, which defines rural as open country and settlements of less than 2,500 residents, exclusive of embedded suburbs of urbanized areas of 50,000 or more population. The Office of Management and Budget and the Economic Research Service have somewhat similar definitions (see Appendix B). Frontier areas are considered the most thinly settled counties, with population densities of fewer than 7 households per square mile.

Rural America reflects the multiethnicity of the nation as a whole. African American communities are numerous across the South’s lowland districts; Native Americans are clustered in the northern High Plains, the Four Corners region in the Southwest, and Alaska; and significant numbers of Hispanics live in the rural counties along the Rio Grande Valley.

There are, however, important differences between rural and urban areas that affect the delivery of health care services. Rural areas tend to have an older age structure than urban areas, as younger people migrate from rural areas and as retired people move in. This characteristic has implications for



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Quality Through Collaboration: The Future of Rural Health 1 Introduction A sense of distinction between rural and urban settings and communities is of long standing. The playwright Euripides is said to have offered the view in the 5th century BC that “The first prerequisite to happiness is that a man be born in a famous city.” And in the 3rd century BC, the writer of Ecclesiasticus, a book of the Apocrypha, asked the question “How can he get wisdom who holdeth the plow?” Yet in the formative age of our country, it was the virtues of agrarianism that were strongly asserted by Thomas Jefferson, who referred scathingly to the “mobs of great cities” and called farmers “the chosen people of God” (Beale and Cromartie, 2004, p. 1). Rural communities are a vital, diverse component of the United States, representing nearly 20 percent of the nation’s population. The basic demographic feature of a rural area is that it is a place of low population density and small aggregate size. There is no one standard definition of rural in terms of population statistics. The most long-standing U.S. definition has been that of the Census Bureau, which defines rural as open country and settlements of less than 2,500 residents, exclusive of embedded suburbs of urbanized areas of 50,000 or more population. The Office of Management and Budget and the Economic Research Service have somewhat similar definitions (see Appendix B). Frontier areas are considered the most thinly settled counties, with population densities of fewer than 7 households per square mile. Rural America reflects the multiethnicity of the nation as a whole. African American communities are numerous across the South’s lowland districts; Native Americans are clustered in the northern High Plains, the Four Corners region in the Southwest, and Alaska; and significant numbers of Hispanics live in the rural counties along the Rio Grande Valley. There are, however, important differences between rural and urban areas that affect the delivery of health care services. Rural areas tend to have an older age structure than urban areas, as younger people migrate from rural areas and as retired people move in. This characteristic has implications for

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Quality Through Collaboration: The Future of Rural Health the health care infrastructure: the elderly have a greater need for health care services, especially for chronic disease management and long-term care. Rural populations also exhibit poorer health behaviors (i.e., higher rates of smoking and obesity and lower rates of exercise). Compared with urban residents, rural populations tend to have lower levels of income and education and higher rates of unemployment. Further, uninsurance rates are higher in rural than in urban counties. Thus, in rural areas there is a greater need for health care safety net providers. Finally, distances to health care providers are longer in rural areas. Rural areas have a strong sense of community responsibility and propensity toward collaboration. As a result, they are adept at devising unique and creative ways to build social and physical infrastructures needed to provide the services that urban areas take for granted. Generally, there are fewer health care organizations and professionals of all kinds in rural areas, and the availability of health care services varies widely. Some rural communities adjacent to urban centers have access to the full range of health care services, while remote villages and isolated towns may have few if any medical resources. Those providers that are located in rural areas are characterized by less choice and competition, and some have broadened their scope of practice to accommodate the needs of the local community. For most rural communities, retaining workforce capacity and health care services—whether primary care, emergency, hospital care, long-term care, mental health and substance abuse, oral health, or public health—has been a continuing challenge. RURAL HEALTH POLICY Making correct decisions on rural health policy is contingent on understanding the unique characteristics of the communities and conditions in which health care is delivered. Rural communities are heterogeneous, differing in population density, remoteness from urban areas, and the cultural norms of the regions of which they are part. As a result, they vary in their demographic, environmental, economic, and social characteristics. These differences influence the magnitude and types of health problems communities face. National health policy has been increasingly responsive to rural health needs and problems. Over the years since 1983, Congress has created special categories of rural hospitals that receive either cost-based payment or elevated Medicare payments: rural referral centers, sole community hospi-

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Quality Through Collaboration: The Future of Rural Health tals, Medicare-dependent hospitals, and, in 1997, critical access hospitals. More recently, the Medicare Prescription Drug Improvement and Modernization Act of 2003 introduced a more favorable financial climate for rural hospitals. Partly in response to these changes, there has been a renaissance in rural health care in a number of rural communities. Some rural hospitals are replacing aging facilities (Gregg et al., 2002; Howe and Bavery, 1999; Rees, 2002). There are also examples of hospitals, physicians, and other health care providers building regional networks that are giving rural residents greater access to state-of-the art health care (Gregg and Moscovice, 2003; Minyard et al., 2003; Nebraska Office of Rural Health, 2002; Novack, 2003; Rosenthal et al., 1997; User Liaison Program, 1997). In addition, some rural health care providers and communities are embarking on significant quality improvement initiatives in response to the national quality movement (see Chapter 3). But these changes have not been enough. They are not widespread, and they are occurring too slowly. Many rural communities continue to struggle to sustain viable health care delivery systems (see Appendix C). In recent years, it has also become apparent that rural communities confront serious quality of care challenges as well. PURPOSE AND SCOPE OF THIS STUDY In the above context and given the increased interest in the quality of health care in rural America, the Health Resources and Services Administration (HRSA), the Agency for Healthcare Research and Quality (AHRQ), and the Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services (DHHS), together with the W. K. Kellogg Foundation, requested that the Institute of Medicine (IOM) undertake an independent, unbiased assessment of the condition of health and health care in rural America, and formulate an action plan for quality-focused rural community health systems. The charge to the committee included the following specific tasks: Assess the quality of health care in rural areas; Develop a conceptual framework for a core set of services and the essential infrastructure necessary to deliver those services to rural communities; Recommend priority objectives, and identify the changes in policies and programs needed to accomplish those objectives, including, but not

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Quality Through Collaboration: The Future of Rural Health limited to, payment policies and the necessary information and communications technology infrastructure; and Consider implications for federal programs and policy. In response to this request, the IOM appointed a committee of 12 members representing a range of expertise related to the scope of the study (see Appendix A for biographical sketches of committee members). The committee addressed its charge by reviewing the salient research literature, published and unpublished; government reports and data; empirical evidence; and additional materials provided by government officials and others. In addition, a workshop was held to augment the committee’s knowledge and expertise through more focused discussion of specific issues of concern, and to obtain input from a wide range of researchers, providers of health services, and interested members of the public. The committee also commissioned four background papers to avail itself of expert, detailed, and independent analysis of some of the key issues beyond the time and resources of its members (Beale and Cromartie, 2004; Gamm and Hutchison, 2004; Mueller and McBride, 2004; Nesbitt et al., 2004). The scope of the committee’s charge was very broad, covering the full range of health care services for people residing in different rural settings. The committee recognizes the growing importance of ensuring a broad range of quality health care services for rural America; however, resource and time constraints, as well as a lack of sufficient data, prevented the committee from fully addressing the issues surrounding all the services, settings, and population groups that might be considered relevant to its charge. For instance, a comprehensive consideration of the availability and quality of long-term care, coordinated care for chronic diseases and disability, and quality monitoring and reporting systems need to be addressed by separate studies. BUILDING ON IOM’S QUALITY CHASM SERIES The IOM has a long history of addressing quality of care issues. This IOM committee began its work by first reviewing the sizable body of knowledge that has accumulated through the efforts of many other IOM committees. Following is a brief summary of some of the key definitions, findings, and recommendations from other IOM reports that are of particular relevance to this committee’s work. Promulgated in 1990, the IOM’s definition of quality of care has stood the test of time—addressing both population- and individual-level health care needs and encompassing clinician and patient perspectives:

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Quality Through Collaboration: The Future of Rural Health Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM, 1990; p. 4). This definition encompasses both services that clinicians deliver to individuals (e.g., preventive, diagnostic, and treatment) and services available to defined populations (e.g., health education). Health services include a wide range of physical, dental, and mental health care—preventive, acute, and long-term care—provided in all settings. The above definition is consistent with the view that the health care system of the twenty-first century should balance and integrate the need for personal health care with broader communitywide initiatives that target the entire population and the environment (IOM, 2003a). Many factors influence the health of individuals and populations, including not only the environment, but also social behaviors and genetic predispositions (Kindig and Stoddart, 2003). With the release of Crossing the Quality Chasm: A New Health System for the 21st Century in 2001, the IOM embarked on what will likely be a decade-long journey to work with others toward reform of the health care system. The Quality Chasm report was a clarion call to improve the American health care delivery system as a whole along all of its quality dimensions. The report identifies six aims for quality improvement: health care should be safe, effective, patient-centered, timely, efficient, and equitable (see Table 1-1). These aims have now been endorsed by leading public- and private-sector organizations involved in health care reform. The Quality Chasm report stresses that a major overhaul of the health care delivery system is needed, and that changes will be needed at many levels. In 2003, the Quality Chasm series began focusing on the role of communities. In response to a request from the Secretary of DHHS, the IOM produced the report Fostering Rapid Advances in Health Care: Learning from System Demonstrations (IOM, 2003a), laying out a bottom-up strategy for health system reform that builds on the vision set forth in the Quality Chasm report. This strategy is based on the use of states or “market areas” as laboratories for the design, implementation, and testing of alternative strategies, leading ultimately to the creation of a set of model twenty-first-century community health systems over the coming years. To further galvanize efforts directed at rapid-cycle experimentation at the community level, the IOM held the 1st Annual Crossing the Quality Chasm Summit: A Focus on Communities in January 2004 (IOM, 2004). Fifteen communities and many national leaders participated in this summit, which focused on the development of action plans to produce significant

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Quality Through Collaboration: The Future of Rural Health TABLE 1-1 Six Aims for Quality Improvement Aim Definition Safety Avoiding injuries to patients from the care that is intended to help them Effectiveness Providing services based on scientific knowledge (evidence-based) to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively) Patient-centeredness Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions Timeliness Avoiding waits and sometimes harmful delays for both those who receive and those who give care Efficiency Avoiding waste, including waste of equipment, supplies, ideas, and energy Equity Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status SOURCE: IOM, 2001. improvements in five of the areas identified in the IOM report Priority Areas for National Action: Transforming Health Care Quality (IOM, 2003b): diabetes, asthma, heart disease, depression, and pain control in advanced cancer. The Fostering Rapid Advances report and the 1st Annual Crossing the Quality Chasm Summit report reflect a growing conviction on the part of many in the health care community that the health care system is too complex and geographically diverse to be reformed through national policy alone. This committee believes that rural communities afford a unique opportunity to experiment with various rapid-innovation strategies. At the same time, implementation of these health system reforms in rural “market areas” needs to reflect the important distinctions that exist between the rural health care delivery system and its urban and suburban counterparts. As discussed below, the situation in rural communities is different from that in urban and suburban areas; thus application of the quality reform agenda to rural areas will require a different assessment of services, resources, and connectivity.

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Quality Through Collaboration: The Future of Rural Health GUIDING PRINCIPLES FOR REFORMING RURAL HEALTH CARE In carrying out its work, the Committee on the Future of Rural Health Care confronted two challenges. The first was to determine how best to apply within a rural context the sizable body of work that has accumulated through the efforts of the IOM, as well as those of the many other public-and private-sector organizations engaged in the reform effort. The second was to contribute to the body of intellectual thought regarding health system reform in ways that will benefit all communities, both rural and urban. The committee was guided in its deliberations by the overriding principle that all rural Americans should have access to the full spectrum of high-quality, appropriate health care, regardless of where they live. Within the context of rural health, the committee interpreted the above overriding principle as follows: Rural communities should focus greater attention on improving population health in addition to meeting personal health care needs. Health care is only one of a number of determinants of the health of individuals, families, and communities. Traditional and expanded public health capacity focused on such issues as the environment, school-based health, and social support for the disadvantaged and handicapped can have a major impact on community health. A major theme of this report is that health care providers share with other groups (for example, consumers, employers, educators, government, and religious organizations) the responsibility to work together to achieve population health outcomes. Collaborative efforts are needed at the community level to create environments that minimize the likelihood of illness or disease (for example, through immunization campaigns), and to provide incentives for residents to pursue healthy lifestyles (for example, encouraging regular exercise). To have the greatest impact, the health care system must have well-defined processes for targeting limited resources in pursuit of both community-level and personal health care interventions. A core set of health care services (primary care, dental care, basic mental health care, and emergency medical services) should be available within rural communities. Health care has technical, cultural, social, and emotional dimensions. Patients are best served when they receive quality health care in their home environment from providers who are sensitive to local cultural norms and values, and know patients as members of families and communities. Requiring patients to travel long distances—the costs of which generally are not reimbursed by health insurance—to receive their health care not

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Quality Through Collaboration: The Future of Rural Health only raises the cost and complexity of care, but also may impair outcomes by increasing the patient’s physical and emotional stress, reducing the likelihood of seeking follow-up care, and limiting proximate family support. Yet not all services can be delivered locally. Rural communities may not generate a large enough volume of services for certain specialty providers to support their practices financially and to maintain adequate levels of skill and technological support to deliver safe and effective care. When care cannot be delivered locally, links should be established to services in other locales. Rural communities should have established relationships with health care providers and institutions in urban settings to provide their residents with seamless access to a full range of well-coordinated services. The spectrum of services available in rural communities should be based on the population health needs of the local community. Rural areas are heterogeneous in size, density, the demographic and socioeconomic composition of the population, and the cultural norms and values of families and the community. Whether services are provided locally or at a distance depends on a host of factors associated with the specific rural community. Each community should have a mechanism for determining the appropriate spectrum of services to maintain locally for its population, guided by the imperative that any service provided locally must be of high quality and economically feasible. The provision of rural health care services should be shaped and guided by local community and rural organizations and institutions. Although not all health care services can be provided in rural areas, rural communities can be instrumental in helping shape the health care systems on which they depend. Solutions to rural health care issues should be shaped by the structured input of rural residents. Both locally operated health systems and those that are part of networks spanning urban and rural communities should incorporate rural perspectives and local residents in their governing structures. Health literacy must be fostered in ways that acknowledge the culture of the rural population. Rural health care requires a team of well-trained health care clinicians, managers, and leaders working together. These teams must provide continuous services, maintain adequate coverage, and establish and foster seamless linkages with other elements of the health care system both locally and at a distance—a major challenge for rural health care systems. Health professions educational institutions, particularly those in states with large proportions of rural populations, have the responsibility to select, train, and sup-

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Quality Through Collaboration: The Future of Rural Health port health professionals for rural practice. Health professions schools, including those for dentists and mental health professionals, have a public trust. They are supported by public funds and have an obligation to incorporate the needs of the public into their clinical and educational mission. Furthermore, they must realize that their responsibility does not end when students graduate; rather, they must work to support rural-based providers by extending continuing education opportunities and providing links to the academic environment. Health care financing should explicitly address the special circumstances of rural areas. One of the major problems facing the American health care system is the number of people who are uninsured, a problem that is complicated in rural areas by the small numbers of large employers, who traditionally offer most of the health insurance in the United States. To create the future rural health care system, mechanisms must be designed for making health insurance available for all residents, whether rural or urban. Mechanisms must also be designed for providing capital and financial support for rural health care institutions, such as hospitals and nursing homes; for rural infrastructures, such as emergency medical services and health care applications of information and communications technology; and for community-based initiatives. Major sources of public financing, such as Medicare and Medicaid, must consider the special needs of rural beneficiaries in the design and application of new policies and procedures. For example, the introduction of pay-for-performance programs must reflect the special circumstances of rural health care—the smaller scale and differing case mix as compared with urban health care. Efforts to develop local and national health information technology infrastructures should focus specific attention on rural communities. All communities stand to derive sizable benefits from the National Health Information Infrastructure, but these benefits may be even more substantial in rural communities. The development of an information and communications technology infrastructure offers much potential to provide rural residents and their local providers with virtual access to specialists in outside areas, and to enhance the access of all providers to complete patient data and information in a timely fashion. Given their limited financial resources and the small scale of rural provider organizations, most rural health care systems will need financial and technical assistance to establish electronic health records and secure platforms for data exchange.

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Quality Through Collaboration: The Future of Rural Health ORGANIZATION OF THE REPORT This report addresses the current status of health care quality in rural America and proposes ways to build quality, focused rural community health systems. Chapter 2 presents an integrated approach to addressing both population health and personal health care needs. Chapter 3 addresses quality measurement and improvement initiatives in rural areas. Chapter 4 identifies strategies for strengthening the human resources available to rural communities to improve health and health care, focusing on the availability and preparedness of health care professionals, as well as broad-based mobilization of a community’s residents and key stakeholders. Chapter 5 addresses the implementation of pay-for-performance initiatives within the rural context; it also examines the financial viability of rural health care delivery systems and recent steps taken to improve rural health care financing. Finally, Chapter 6 considers ways to foster the deployment of the National Health Information Infrastructure required for the delivery of quality care, homeland security, and public health applications. The committee hopes that this report will contribute to the development of policies leading to high-quality, efficient, and cost-effective health care systems for rural America. The report is intended to provide guidance to a wide audience, including those in rural communities working to improve health and health care, individuals responsible for national and state health policy, and those in the research community working on rural health issues. Finally, the committee believes that broader health reform efforts focusing on both urban and rural communities would benefit from implementation of the health reform strategies proposed in this report for rural communities. Rural communities represent excellent sites to pilot innovative ways of improving population health and personal health care delivery, given the smaller scale of rural health care and the strong sense of community in rural areas. Although these pilot projects would be tailored to the rural context, many of the lessons learned would have broad applicability to other communities. REFERENCES Beale C, Cromartie J. 2004 (February). Profile of the Rural Population. Commissioned Paper for the IOM Committee on the Future of Rural Health Care. Washington, DC. Gamm L, Hutchison L. 2004 (February). Mental Health and Substance Abuse Services: Prospects for Rural Communities. Commissioned Paper for the IOM Committee on the Future of Rural Health Care. Washington, DC.

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Quality Through Collaboration: The Future of Rural Health Gregg W, Moscovice I. 2003. The evolution of rural health networks: Implications for health care managers. Health Care Management Review 28(2):161–177. Gregg W, Knott A, Moscovice I. 2002. Rural Hospital Access to Capital: Issues and Recommendations. Minneapolis, MN: Rural Health Research Center, University of Minnesota. Howe P, Bavery G. 1999. Funding for renovation: A rural hospital’s experience. Seminars in Perioperative Nursing 8(4):229–232. IOM (Institute of Medicine). 1990. Medicare: A Strategy for Quality Assurance, Volume I. Washington, DC: National Academy Press. P. 4. IOM. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. IOM. 2003a. Fostering Rapid Advances in Health Care: Learning from System Demonstrations. Washington, DC: The National Academies Press. IOM. 2003b. Priority Areas for National Action: Transforming Health Care Quality. Washington, DC: The National Academies Press. IOM. 2004. 1st Annual Crossing the Quality Chasm Summit: A Focus on Communities. Washington, DC: The National Academies Press. Kindig D, Stoddart GL. 2003. What is population health? American Journal of Public Health 93(3):380–383. Minyard KJ, Lineberry IC, Smith TA, Byrd-Roubides T. 2003. Transforming the delivery of rural health care in Georgia: State partnership strategy for developing rural health networks. Journal of Rural Health 19(Supplement):361–371. Mueller KJ, McBride, TD. 2004 (February). Financing the Rural Health Care Delivery System. Commissioned Paper for the IOM Committee on the Future of Rural Health Care. Washington, DC. Nebraska Office of Rural Health. 2002. Nebraska’s Story: A Collection of Nine Critical Access Hospital Community Stories and Two Network Stories. Lincoln, NE: Nebraska Department of Health and Human Services, Office of Rural Health. Nesbitt TS, Yellowlees PM, Hogarth M, Hilty DM. 2004 (March). Rural Health Care in the Digital Age: The Role of Information and Telecommunications Technologies in the Future of Rural Health. Commissioned Paper for the IOM Committee on the Future of Rural Health Care. Washington, DC. Novack, NL. 2003 (September). Bridging the Gap in Rural Healthcare. The Main Street Economist: Commentary on the Rural Economy. [Online]. Available: http://www.kc.frb.org/RuralCenter/mainstreet/MSE_0903.pdf [accessed July 2004]. Rees T. 2002. North Carolina hospital redefines itself as a critical-access facility. Bertie Memorial called a national model. Profiles in Healthcare Marketing 18(1):34–39. Rosenthal TC, James P, Fox C, Wysong J, FitzPatrick PG. 1997. Rural physicians, rural networks, and free market health care in the 1990s. Archives of Family Medicine 6(4):319–323. User Liaison Program. 1997 (November 19–21). Strengthening the Rural Health Infrastructure: Network Development and Managed Care Strategies—Workshop Summary. [Online]. Available: http://www.ahrq.gov/new/ulp/ulpstren.htm [accessed August 2004].