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An Integrated Approach to Improving Health and Health Care in Rural Communities

SUMMARY

This chapter provides an integrated approach to addressing the personal health care and population health needs of rural communities. The six quality aims of the Institute of Medicine’s Crossing the Quality Chasm: A New Health System for the 21st Century are used to illustrate the broad range of actions that might be taken by rural communities at both the level of the personal health care system and the community level to improve health status. Many community-level actions extend beyond the traditional health care sector, thus necessitating greater collaboration between that sector and others, such as education, transportation, and social services. By making explicit the full range of options available to rural communities for improving health, the integrated framework set forth in this chapter is intended to lead closer to a more optimal allocation of scarce financial resources between personal health care and population health initiatives.

In 2001, the Institute of Medicine (IOM) released the report, Crossing the Quality Chasm: A New Health System for the 21st Century, calling for fundamental reform of the nation’s health care system. As the report makes clear, an extensive body of evidence substantiates the existence of a large quality gap—the care people actually receive falls far short of the care they should receive.



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Quality Through Collaboration: The Future of Rural Health 2 An Integrated Approach to Improving Health and Health Care in Rural Communities SUMMARY This chapter provides an integrated approach to addressing the personal health care and population health needs of rural communities. The six quality aims of the Institute of Medicine’s Crossing the Quality Chasm: A New Health System for the 21st Century are used to illustrate the broad range of actions that might be taken by rural communities at both the level of the personal health care system and the community level to improve health status. Many community-level actions extend beyond the traditional health care sector, thus necessitating greater collaboration between that sector and others, such as education, transportation, and social services. By making explicit the full range of options available to rural communities for improving health, the integrated framework set forth in this chapter is intended to lead closer to a more optimal allocation of scarce financial resources between personal health care and population health initiatives. In 2001, the Institute of Medicine (IOM) released the report, Crossing the Quality Chasm: A New Health System for the 21st Century, calling for fundamental reform of the nation’s health care system. As the report makes clear, an extensive body of evidence substantiates the existence of a large quality gap—the care people actually receive falls far short of the care they should receive.

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Quality Through Collaboration: The Future of Rural Health This IOM committee concurs with earlier IOM committees that fundamental change in the health care delivery system is needed to improve the quality of care and ultimately the health status of the population. But this will not be enough. Although access to high-quality personal health care services (e.g., preventive, acute, chronic, and end-of-life care) increases health and reduces pain and suffering, there are other determinants of health status in a community. Health outcomes are determined to a great extent by genetic predispositions, health behaviors, environmental exposures or threats, and social circumstances (e.g., educational levels, socioeconomic status) (LaLonde, 1975; McGinnis et al., 2002). Moreover, a growing body of research demonstrates the importance of considering these factors within a community context (Hillemeier et al., 2003). There is much variability across communities in terms of population health needs. Communities also have different strengths and resources to bring to bear in addressing population health needs. Lastly, addressing population health needs often requires strong local leadership and collaboration across different sectors and multiple stakeholders within a community. This chapter presents an integrated approach to addressing both personal health care and population health needs that builds on the six quality aims of the Quality Chasm report. The approach is intended to be most useful at the community level in facilitating prioritization of a community’s health needs and identification of the most promising interventions. The first section reviews the rather limited amount of literature that is available on the quality of rural health care. The second section addresses population health priorities in rural areas, with emphasis on the unique aspects of rural communities that should be considered in shaping a reform strategy. The third section proposes an integrated framework for addressing both personal health care and population health needs in rural communities, providing examples of interventions at both the community and individual levels that might contribute to improved population health. The fourth and final section summarizes the IOM committee’s conclusions and recommendations for moving forward. QUALITY OF CARE IN RURAL COMMUNITIES As noted above, there is a large body of evidence documenting serious shortcomings in the American health care system for each of the six quality aims identified in the Quality Chasm report. In 2000, the IOM published the report To Err Is Human: Building a Safer Health System, calling national

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Quality Through Collaboration: The Future of Rural Health attention to the tens of thousands of Americans who die each year as a result of medical errors. A year later, the IOM released the Quality Chasm report, calling for fundamental reform of the nation’s health care system. Both reports include literature reviews. An appendix to the Quality Chasm report provides a literature review conducted by researchers at the RAND Corporation based on 73 publications from peer-reviewed journals. These literature reviews substantiate the existence of a large quality gap: the care people actually receive falls far short of the care they should receive. Since the release of these reports, numerous other publications have documented the serious nature of the quality challenge. Studies continue to reveal disturbing rates of medical errors in virtually all health care settings—hospital, nursing home, and ambulatory (Gurwitz et al., 2000, 2003). In addition to studies focusing on safety, recent evidence raises concerns about the effectiveness of health care. Of particular note, a large research study conducted by RAND found that, on average, patients receive only about 55 percent of those services from which they would likely benefit (McGlynn et al., 2003). Much of this research on quality of care has been conducted in urban settings. Some of the large analyses have included rural providers in their study samples, but have not reported rural-specific results (see, for example, Thomas et al., 1999). There is no reason to believe that the overall results (i.e., that quality is highly variable) of this large body of literature would not apply to rural America, as the factors believed to contribute to these quality shortcomings (e.g., poorly designed systems, siloed delivery systems, inadequate use of information technology) exist to varying degrees in both rural and urban areas. But there may well be rural and urban differences in the prevalence of particular types of quality problems, not to mention the specific approaches that would be most effective in improving quality. As the overall literature on the state of quality has been examined in previous IOM reports, it is not reviewed in this report. However, a small number of studies exist comparing quality in rural and urban areas, and these are reviewed in this section. Also discussed are studies that point to the need for different types of interventions in rural versus urban settings to address concerns regarding quality of health care. The discussion is organized according to the six quality aims set forth in Chapter 2 of the Quality Chasm report. Safety Patient safety is the prevention of harm to patients (IOM, 2004). In a recent comparison of rural and urban hospitals using 19 safety measures,

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Quality Through Collaboration: The Future of Rural Health Romano and colleagues found that rural hospitals had lower risk-adjusted rates of potential safety-related events for 14 of the 19 indicators (e.g., decubitus ulcer, infection due to medical care, postoperative respiratory failure), and higher rates for 5 indicators (anesthesia reactions and complications, accidental puncture and laceration, postoperative hip fracture, abdominopelvic wound dehiscence, and birth trauma) (Jolliffe, 2003; Romano et al., 2003). An earlier study of New York state hospitals found that rural hospitals had significantly lower adverse event rates than New York City and urban upstate hospitals after controlling for age and severity of illness (Whitener and McGranahan, 2003). Another study examined rural hospitals by bed size and found that, compared with large rural hospitals (100+ beds), both medium-sized (50–99 beds) and small (<50 beds) rural hospitals had significantly lower rates of postoperative hip fracture, hemorrhage, and hematoma; the medium-sized hospitals had lower rates of postoperative respiratory failure, while the small hospitals had lower rates of iatrogenic pneumothorax infection (Cromartie, 2002). On the other hand, a study of rural health clinics documented a wide range of medication errors, including errors in dosage, errors in agent selection, and failure to recognize potential drug interactions and contraindications (Williamson et al., 1991). Patient safety practices are processes or structures whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures (Shojania et al., 2002). Since the publication of the IOM reports To Err Is Human (IOM, 2000) and Crossing the Quality Chasm (IOM, 2001), key organizations involved in patient safety activities have augmented their programs. For example, the National Quality Forum (NQF) has endorsed standards to improve patient safety, the Agency for Healthcare Research and Quality (AHRQ) has published evidence-based studies on specific actions that can increase patient safety, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has expanded initiatives and resources to enhance patient safety in the organizations it accredits (NQF, 2003; AHRQ, 2004; JCAHO, 2004). In addition, health care purchasers, notably represented by the Leapfrog Group, have developed several targeted standards for delivering care to increase safety. Nonetheless, there is a general absence of studies examining patient safety issues in rural provider settings. Of the few research studies that do exist (Coburn et al., forthcoming; Romano et al., 2003), there has been no evaluation of how the characteristics of rural practice, such as smaller-sized facilities and low volume, may impact patient safety. In addition, rural pro-

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Quality Through Collaboration: The Future of Rural Health viders may face different safety risks. For example, given the more limited services available in rural areas, patients are more likely to be referred or transferred for diagnosis and treatment. The interfaces between personnel at different facilities, the application of standardized protocols, and the transfer of complete and relevant information all require significant attention to minimize the potential for error and ensure seamless transfers. Effectiveness Effectiveness refers to care that is evidence-based (IOM, 2001). Evidence-based practice is the integration of the best research evidence with clinical expertise and patient values (Sackett et al., 1996). Such care avoids both overuse, or the provision of services that expose the patient to more potential harm than good, and underuse, or the failure to provide services from which the patient would likely have benefited (Wisconsin Medical Society, 2002). The evidence pertaining to rural and urban differences in effectiveness is mixed. One study found that rural areas scored higher than urban on the appropriate provision of preventive services related to breast examinations/ family history for breast cancer, influenza immunization, and cholesterol screening; no differences were found in provision of preventive services for blood pressure, tobacco use screening and counseling, and mammography and pap smears (Pol et al., 2001). On the other hand, rural populations tend to be diagnosed at a more advanced stage of cancer, to be less likely to have their cancer staged at the time of diagnosis, and to have less access to state-of-the-art technology (Gamm et al., 2002). A study of elderly diabetic patients found that patients in large remote rural communities (i.e., ones that could support both generalist and specialist physicians) were significantly more likely to receive those services than their urban counterparts, while patients in smaller rural communities were less likely to receive those services than urban patients (Rosenblatt et al., 2001). One study of interventions for acute myocardial infarction (AMI) found that patients admitted to rural hospitals were less likely to receive aspirin, heparin, intravenous (IV) nitroglycerin, and IV fluids (Baldwin et al., 2004). In another study, Medicare beneficiaries hospitalized for AMI in rural hospitals were found to be less likely than those hospitalized in urban hospitals to receive several recommended interventions (e.g., aspirin, heparin, IV nitroglycerin), and risk-adjusted rates of death within 30 days of an admission for an AMI increased with “rurality” or degree of remoteness of the hospital

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Quality Through Collaboration: The Future of Rural Health (Baldwin et al., 2004). An analysis of outcomes of coronary angioplasty procedures performed in rural and urban hospitals found that in-hospital mortality after angioplasty for AMI was worse in low- and medium-volume rural hospitals, but overall outcomes in rural and urban hospitals were similar for patients without infarction (Maynard et al., 2000). Patient-Centeredness Care that is patient-centered reflects the qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient (IOM, 2001). Patient-centeredness is a multifaceted concept that incorporates such elements as the following: Patient satisfaction with care Provision of information, education, and other supports to assist patients in self-management of chronic conditions (Lorig et al., 1999; Wagner, 1998) Efforts to promote patient health literacy (Detmer et al., 2003) Shared decision making between patients and clinicians Few studies have assessed differences in patient perceptions of these qualities in rural and urban areas. One study did find that rural providers generally score higher on compassion and accessibility than their urban counterparts, but many believe that rural physicians are less qualified (Reiber et al., 1996). Timeliness Timeliness in access to care is a critical factor influencing the quality of rural health care. While timeliness in the urban sense tends to denote long waits at doctors’ offices or emergency rooms or waiting on gurneys in hallways for procedures, in the rural context, timeliness often reflects the response times of emergency medical personnel and the overall distance a patient must travel to receive services. Timely access to emergency care is a major issue for rural residents. Response times by emergency medical personnel and transport times via ambulance to the hospital are notably greater than in urban areas. A study of five counties in Washington State found the mean response time for rural incidents was 13.6 minutes (median = 12 minutes), versus 7 minutes (me-

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Quality Through Collaboration: The Future of Rural Health dian = 6 minutes) for urban incidents (Grossman et al., 1997). Mean transport times were also significantly longer for rural incidents (17.2 minutes in rural areas versus 8.2 minutes for urban), and death risk was seven times higher if the response time was greater than 30 minutes. Another study of 12 counties near Augusta, Georgia, found more modest differences with rural and urban emergency response times of 7.9 and 5.1 minutes, respectively (Morrisey et al., 1995). Handoffs between clinicians at each point along the response continuum have a significant impact on the outcome of rural patients because of the overall fragmentation of emergency medical services and the rural health system in general, and the greater geographic distances that must be traveled to reach the local emergency room or nearby trauma center. Timeliness also relates to the long distances patients must travel to receive health care services because of the scarcity of human and technological resources in the local community. When local resources are inadequate to provide core health care services to the population, the quality of health care suffers. One study of 16 rural areas with high outflow of patients to urban centers found that poor local access to providers of obstetric care was associated with a significantly greater risk of having an abnormal neonate for both Medicaid and privately insured rural patients (Nesbitt et al., 2004). Another study of rural adults with HIV infection found that nearly 75 percent sought care in urban areas and that more than 25 percent had delayed obtaining care in the past 6 months because of travel considerations (Ormond et al., 2000). Efficiency Efficient health systems optimize resources and minimize waste to obtain the best value for investments in health care services and administration. Efficient systems ensure that the appropriate clinical services are available to meet the health needs of the local community while balancing cost of care and avoiding underuse, overuse, and misuse of services (IOM, 2001). Comparisons of efficiency between rural and urban health systems can be misleading. Efficiency is a measure of inputs over desired outputs, and if one of the outputs is care close to home, comparisons of efficiency need to have a rural-to-rural rather than rural-to-urban focus. The committee realizes it is not feasible to provide all health care services close to home, but this should be the goal for the core services (i.e., primary care in the community, emergency medical services, primary- and secondary-level hospital care,

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Quality Through Collaboration: The Future of Rural Health long-term care, mental health and substance abuse services, oral health care, and public health services). It is also important to recognize that rural and urban health care delivery systems have different advantages and disadvantages when delivering care. Rural systems are generally less complex than urban, so certain types of inefficiencies, such as the ordering of redundant laboratory tests because the results of earlier tests cannot be located, may occur less frequently. Conversely, larger urban providers likely benefit from volume discounts when purchasing supplies, material, and other resources. Equity The aim of equity is to ensure that the availability of care and quality of services are based on an individual’s health care needs and not on personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status (IOM, 2001). Differences in the availability of health care resources (see Chapter 4) between rural and urban areas are one form of inequity noted throughout this report. Rural areas, like urban, also confront equity issues related to the sizable numbers of residents who do not have health insurance or have insurance that provides very limited coverage. There is a sizable body of evidence indicating that people who lack health insurance receive too little health care, and often the services they do receive are not timely (IOM, 2002). These studies are not specific to rural areas, however, so it is not possible to determine whether rural areas differ from urban in terms of this equity challenge. The federal government did recently establish the Community Access Program to provide grants to rural and urban communities to expand and coordinate safety net services for uninsured and underinsured Americans (HRSA, 2004). It is too early to assess the impact of this program, but grant awards in fiscal years 2000 to 2002 totaled about $255 million. In 2002, this program was replaced by the new Healthy Communities Access Program, to which Congress appropriated $105 million for fiscal year 2003. The IOM report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (IOM, 2003a) documents the pervasive nature of another form of inequity: disparities in the care that is received within a health system depending upon an individual’s race or ethnicity. On the whole, racial and ethnic minorities tend to receive a lower quality of health care than nonminorities across a range of illnesses and health care services, even when socioeconomic factors are controlled. As discussed in Appendix

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Quality Through Collaboration: The Future of Rural Health B, some minorities, such as Native Americans, Hispanics, and African Americans, are more concentrated in rural and frontier areas and have lower health status than other residents of these communities. Information is not available to indicate whether these within-system inequities are greater or lesser in rural than in urban health systems. Summary The evidence base pertaining to differences in quality between rural and urban health care is highly inadequate, and more research on this issue is clearly needed. In the case of safety and effectiveness, there are so few studies that it is not possible to determine whether there are differences between rural and urban areas. Timeliness is the only aim for which the results are clear and not surprising: access to critical services, such as emergency care, is impeded by geography and scarcity of providers. As for the other aims—patient-centeredness, efficiency, and equity—the evidence is anecdotal at best. HEALTH BEHAVIORS AND HEALTH THREATS IN RURAL COMMUNITIES A comprehensive review of the Quality Chasm six aims is beyond the scope of this report; however, this section highlights some of the more salient differences between rural and urban communities in terms of health behaviors and environmental threats—the two areas most amenable to intervention in the short run. Appendix B speaks to differences in the racial and ethnic compositions of rural and urban communities (which influence genetic predispositions to a great extent) and many other socioeconomic factors that influence health. Although the evidence base pertaining to the quality of health care is lean, there is a good deal of evidence pointing to differences in the health behaviors of rural and urban populations. A recently published document, Health, United States, 2001 with Urban and Rural Chartbook (NCHS, 2001) highlights some of the key differences: Adolescents and adults living in rural counties are more likely to smoke than those in urban areas. In the most remote rural areas, about 19 percent of adolescents smoke, as compared with 11 percent of adolescents in metropolitan central areas. Adults living in the most rural counties are the most likely to smoke (27 percent of women and 31 percent of men), and

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Quality Through Collaboration: The Future of Rural Health those living in large metropolitan areas are the least likely (20 percent of women and 24–25 percent of men). Remote rural areas have the highest rates of self-reported obesity among women of all geographic areas. About 23 percent of female residents in rural counties are obese as compared with 16 percent of those living in metropolitan fringe areas (i.e., suburban) and 20 percent of those in metropolitan central areas. Residents of very rural areas (no city with a population of 10,000 or greater) are the most likely to be inactive during leisure time, followed by central city residents of large metropolitan areas. Lack of regular physical exercise is particularly high in nonmetropolitan counties of the South, where 56 percent of women and 53 percent of men report that they do not engage in exercise, sports, or physically active hobbies during leisure time. These rates are very high compared with national rates for metropolitan fringe areas (28 percent for men and 34 percent for women). There are also differences in the threats to health that are present in rural and urban communities. For example, deaths from unintentional injuries (e.g., motor vehicle injuries, falls, poisoning, and suffocation) increase as counties become less urban (NCHS, 2001). In 1996–1998, the age-adjusted death rate for unintentional injury for males was 86 percent higher in most rural counties than in the fringe counties of large metropolitan areas. For females, this rate was about 80 percent higher in the most rural counties than in large metropolitan (central and fringe) counties. In summary, important health behaviors and health threats can and should be addressed at the community level to achieve an optimal impact on health status. There are sizable differences between rural and urban areas in both of these regards, and these differences need to be better understood. Moreover, important differences are likely to exist within rural communities in terms of priorities for action, necessitating community- or state-based action plans. IMPROVING POPULATION HEALTH AND PERSONAL HEALTH CARE Rural America has struggled for many decades with shortages of health professionals; constrained access to specialty services; and financial, geographic, and other barriers to health care access (see Appendix C). Although addressing the problems of the availability of and access to health care ser-

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Quality Through Collaboration: The Future of Rural Health vices has been the cornerstone of rural health policy, an underresourced health care delivery infrastructure persists in many rural areas. The committee believes more must be done to strengthen the rural health care delivery infrastructure to achieve and sustain high-quality care, and subsequent chapters of this report provide guidance on enhancing quality improvement processes (Chapter 3), enhancing the health professions workforce (Chapter 4), providing more stable financing (Chapter 5), and building a stronger information and communications technology (ICT) infrastructure (Chapter 6). Achieving consistent, high-quality care is predicated on addressing each of these key areas. Bolstering the personal health care delivery system is important, but the committee also believes a better balance must be struck between investments in personal health care and community health improvement strategies. As pointed out in the IOM report Fostering Rapid Advances in Health Care: Learning from System Demonstrations: The health care system of the 21st century should maximize the health and functioning of both individual patients and communities. To accomplish this goal, the system should balance and integrate needs for personal health care with broader communitywide initiatives that target the entire population. The health care system must have well-defined processes for making the best use of limited resources (IOM, 2003b, p. 19). The committee believes rural communities must build a population health focus into decision making within the health care sector, as well as in other key areas (e.g., religious institutions, agricultural extensions, rural cooperatives, education, community and environmental planning) that influence population health. Most important, rural communities must reorient their quality improvement strategies from an exclusively patient- and provider-centric approach to one that also addresses the problems and needs of rural communities and populations. The committee encourages rural health communities to focus greater attention and resources on improving population health. Programs focused on population health often involve collaboration, which may include providers within the health care sector. For example, the providers in a community might pool resources to sponsor a communitywide educational program aimed at the prevention and early diagnosis and treatment of diabetes. In other instances, the collaboration might involve health care providers and stakeholders outside the traditional health care sector in efforts to improve population health. For example, initiatives to reduce obesity in children

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Quality Through Collaboration: The Future of Rural Health TABLE 2-5 Personal Health Care System and Community-Level Interventions: Illustrative Examples for Efficiency Definition Measures Interventions Personal Health Focus Population Health Focus Personal Health Care System Community Level Personal Health Care System Community Level Avoid waste, including waste of equipment, supplies, ideas, and energy, in the delivery of personal health care services Avoid waste, including waste of equipment, supplies, ideas, and energy, in the delivery of personal health services Seek efficient allocation of community resources and assets to personal and population health services to maximize health impact for the community Measures of clinical efficiency (e.g., rates of use of evidencebased practices) Measures of production efficiency (e.g., average annual health care costs for care of a patient with diabetes) Measures of clinician time spent on paperwork Measures of service duplication (e.g., ordering of redundant tests) Tobacco cessation rates associated with per capita expenditures on communitywide smoking cessation programs Measures of average days lost from work or school due to preventable illness per resident Dissemination of best practices regarding outpatient and inpatient workflow efficiency Financial incentives to providers to reward adherence to protocols and coordination of care Finance strategies that allow for more flexible integration of services (e.g., behavioral health, long- term care) Investment in electronic health records Public reporting of population-based measures of health care use Development of public policy that encourages (through financial and other incentives) a balance between personal health care and community health improvement programs

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Quality Through Collaboration: The Future of Rural Health TABLE 2-6 Personal Health Care System and Community-Level Interventions: Illustrative Examples for Equity Definition Measures Interventions Personal Health Focus Population Health Focus Personal Health Care System Community Level Personal Health Care System Community Level Provide care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status Provide rural community residents with access to high-quality care that meets population-based health needs Provide all community residents with an environment that promotes health (e.g., smoke- free public establishments) Patient perceptions of the acceptability of services, stratified by race, ethnicity, religion, and other relevant subgroups Measures of differences in the appropriateness of services provided to patients of different racial and ethnic backgrounds Measures of health care access and use across subpopulations and geographic areas Rates of exposure to environmental hazards (e.g., lead poisoning) by race, ethnicity, and zip code Sponsoring of cultural competency training for health care professionals Development of public policy that encourages (through financial and other incentives) a geographic balance of health care providers Cultivation of strong leadership and public–private partnerships (between the health care sector and other community stakeholders) to raise awareness of environmental forces that have a disproportionate impact on the health of minorities

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Quality Through Collaboration: The Future of Rural Health and communitywide planning to locate providers in nearby underserved areas, and public programs to address environmental hazards that have a disproportionate impact on minorities. Leadership and Collaboration In light of the fundamental changes under way in health care, there is a critical need for strong leadership in rural communities. A great deal of attention has been focused on external forces that shape a community’s health care system, such as public and private purchasers’ payment policies, state practice regulations, and government programs and policies in support of health professions education. These external forces are important, but community-based efforts and solutions must play a role as well (Amundson, 1993). Strong leadership will be needed within health care institutions (e.g., hospital CEOs and board members) and the professional community to redesign the care delivery system to achieve the six aims set forth in the Quality Chasm report (IOM, 2001) (see Chapter 1). Addressing safety and quality concerns in hospital, ambulatory, and other settings requires developing a new culture and making changes in organizational management and care processes. The development of models of care delivery that better meet the needs of a chronically ill population will necessitate fostering stronger collaborative relationships among (1) the various health professionals that constitute the care team, (2) the various institutions and provider settings within a rural community that make up the delivery system, and (3) the providers within a rural community and other essential providers outside the community (e.g., tertiary care centers, telemedicine specialty providers). Strong leadership will also be needed to engage the broader rural community in health and health care issues. Efforts to strengthen what are often fragile delivery systems in rural areas will be more successful to the extent that they engage key stakeholders in a community (e.g., employers, schools, local government) (Amundson, 1993). Addressing population health needs and providing ongoing support for those with chronic illnesses will also necessitate collaboration with social services and faith-based organizations. Health care institutions will need to partner with schools, local media, libraries, and other organizations in their efforts to raise population health literacy. Lastly, fundamental reform of the personal and population health systems will necessitate developing innovative approaches to the financing and delivery of health services. Every rural community needs its own health care leadership to participate in strategic planning, oversee the management of services delivered lo-

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Quality Through Collaboration: The Future of Rural Health cally, and ensure accountability to local needs (Calico et al., 2003). Committed leadership of senior clinicians and administrators is key to the institutional and environment changes necessary to achieve improved quality of care and patient safety—a task that may at the same time be more difficult in rural areas because of personal connections that amplify feelings of blame for errors and easier because of the fewer layers of bureaucracy in rural health care delivery (Wakefield, 2002). The W. K. Kellogg Foundation’s Leadership for Community Change program offers an example of how community-based rural leaders can be cultivated. Begun in 2003, this program will work closely with local organizations at six rural and urban sites around the country to recruit a cohort of fellows (25 per site) who will participate in a mix of classroom training, mentoring, and networking at the national level over a period of 2 years (W. K. Kellogg Foundation, 2004). The program emphasizes the training of leaders already in place in their communities, rather than the identification and grooming of potential leaders from outside of the community, thus strengthening existing local resources. Future leaders of rural health systems might also be cultivated through formal educational programs that broaden young health professionals’ skills and knowledge of leadership competencies, health care organization and management, community planning and collaboration, epidemiology, and social and environmental services (Wheat et al., 2001). One approach that should be considered is the development of combined degree programs in public health and one of the clinical professions (e.g., medicine, pharmacy, nursing) that incorporate experiential learning opportunities in rural communities. Recognizing the need for stronger leadership throughout the health care system, the National Center for Healthcare Leadership (NCHL) was established in 2001 (NCHL, 2003). With support from The Robert Wood Johnson Foundation and the W. K. Kellogg Foundation, NCHL’s transformational leadership project has identified core competencies for health care management to ensure that management leadership is available to meet the needs of the health care sector, and has established an Advanced Learning Institute. Consideration should be given to establishing a learning collaborative for rural communities that could apply and build upon the work of NCHL and others. CONCLUSIONS AND RECOMMENDATIONS Rural communities, like much of America, face significant challenges in closing the quality gaps in both health care and population health status. In

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Quality Through Collaboration: The Future of Rural Health rural areas in particular, critical precursors to providing quality care are often in short supply. Many rural communities have long had difficulty attracting and retaining clinicians because of concerns about isolation, limited health facilities, or limited employment and education opportunities for their families. Health care systems in rural areas tend to be financially fragile (see Chapter 5), with some services, such as mental health and substance abuse, being critically underfunded. The human and technological infrastructures of rural health care are generally inadequate to support the quality improvement ambitions of rural communities and health care systems (see Chapters 4 and 6, respectively). Rural America faces sizable challenges in improving population health behaviors. Obesity, for example, is a major health issue for many rural communities, as is the case in many urban communities. Unless actions are taken now to improve health behaviors, the future burden of chronic disease in many rural communities will be enormous. In agricultural and mining communities, unintentional work-related injuries are a serious concern. It is critical, therefore, that existing and new resources aimed at improving rural health and health care be deployed strategically to maximize the cost-effectiveness of those investments, recognizing both the need to improve the quality of individual-level care and the desire to improve the health of rural communities and populations. In many respects, rural communities and areas have been on the margins of national health care quality discussions. Given the characteristics of rural environments, there is a need for critical analysis of the relevance of urban-derived quality efforts. This analysis should include reassessing, refining, and adapting some applications while also identifying new approaches tailored to rural communities. A roadmap for applying the quality agenda evolving at a national level to sparsely populated areas is needed. The goals of making care safe, effective, patient-centered, timely, efficient, and equitable for rural and frontier communities necessitate designing systems that build on the human and capital resources available in rural America. The committee has proposed using a decision-making framework that (1) links decisions within the personal health care delivery system more closely to the achievement of population health priorities, and (2) involves explicitly considering both personal and population-level interventions when making investment decisions. This framework is intended to provide a guide for health system reform and action in rural areas, and perhaps urban areas as well. Although this chapter has provided illustrative examples of how the framework can be applied, much work remains to be done in determining

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Quality Through Collaboration: The Future of Rural Health strategic health priorities in rural America and in identifying and evaluating alternative interventions at the personal health care and population levels. Key Finding 1. A wide range of interventions are available to improve health and health care in rural America, but priorities for implementation are not yet clear. The Health Resources and Services Administration is the obvious agency to take the lead in setting priorities, in collaboration with other federal agencies, such as the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention, as well as with rural stakeholders. This would entail systematically cataloguing and evaluating the potential of interventions to improve health care quality and population health in rural communities. As discussed in Chapter 1, the IOM report Fostering Rapid Advances in Health Care: Learning from System Demonstrations (IOM, 2003b) suggests a set of bottom-up strategies for health system reform that would enable states and/or communities (or “market areas”) to mount demonstrations to test alternative strategies for creating a twenty-first century health care system. Not surprisingly, most innovations in health care, including those in quality improvement and safety, emerge from and are designed for urban-based, usually academically based, health centers. Yet application of these strategies in rural environments can be difficult if not impossible. These strategies and approaches need to be modified to fit the realities of the rural health care environment, and rural-derived quality innovation needs to be strengthened and supported. The committee believes not only that rural communities must participate in such demonstrations, but also that, because of their smaller scale, more cohesive community structures, and other unique characteristics, rural areas and health systems offer an excellent opportunity to undertake and evaluate significant health system reform initiatives. The committee recognizes the challenges of attempting to develop communitywide programs that encompass and integrate population and personal health services (Kindig and Stoddart, 2003). But unless one assumes unlimited future investments in health care, prioritizing investments in the rural health care system will be critical. Recommendation 1. Congress should provide the appropriate authority and resources to the Department of Health and Human Services to support comprehensive health system reform demonstrations in five rural communities. These demonstrations should evaluate alter-

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Quality Through Collaboration: The Future of Rural Health native models for achieving greater integration of personal and population health services and innovative approaches to the financing and delivery of health services, with the goal of meeting the six quality aims of the Quality Chasm report. The Agency for Healthcare Research and Quality, working collaboratively with the Health Resources and Services Administration, should ensure that the lessons learned from these demonstrations are disseminated to other communities, both urban and rural. These demonstration projects would involve the establishment of collaborative structures, community-based prioritization of potential investments in health, and the development of communitywide population health programs. As discussed in Chapter 3, there will be a need for communitywide quality measurement and monitoring systems that include measures of both population health and the quality of care provided through the health care delivery system. Some of these demonstrations may well involve the implementation of new payment models, for example, a capitation payment approach administered at the community level, encompassing financing for both population and personal health. Additional work is needed to identify alternative payment models that are consistent with the committee’s integrated approach, and to describe how such models might be tested through demonstrations in rural communities. Residents of rural America are diverse, but one thing they generally do have in common is a strong sense of attachment to their community. This community orientation, combined with the smaller scale of rural health, human services, and community systems, may afford rural communities an opportunity to demonstrate more rapidly the vision of balancing and integrating the needs of personal health care with broader communitywide initiatives that target the entire population (IOM, 2003b). Efforts should also be made to build stronger rural communities that mobilize all types of institutions (e.g., health care, educational, social, and faith-based) to both augment and support the contributions of health professionals. As discussed above, to achieve the greatest improvement across all six quality aims, rural communities will need to focus greater attention and resources on improving population health. Doing so will necessitate building coalitions. Some coalitions will involve stakeholders from within the health care sector; for example, the providers in a community might pool resources to sponsor a communitywide education program aimed at the prevention and early diagnosis and treatment of diabetes. Other coalitions will engage stakeholders outside the traditional health care sector in

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Quality Through Collaboration: The Future of Rural Health efforts to improve population health; for example, efforts to reduce obesity in children might include outreach to school leaders to encourage the provision of more nutritious lunches and snacks. For the most part, the leadership for both types of efforts will need to come from the health sector. Too often today, practicing health professionals do not feel they have the skills or interests to offer sustained leadership in these domains. Key Finding 2. Rural communities engaged in health system redesign would likely benefit from leadership training programs. Such training programs could be provided by the Agency for Healthcare Research and Quality and the Office of Rural Health Policy working collaboratively with private- and public-sector organizations involved in leadership development, such as the National Council for Healthcare Leadership and the W. K. Kellogg Foundation’s Leadership for Community Change Program. AHRQ and the Office of Rural Health Policy should work together to sponsor leadership training programs in rural areas. Consideration should also be given to collaborating with private-sector groups engaged in leadership development, such as the National Council for Healthcare Leadership and the W. K. Kellogg Foundation’s Leadership for Community Change Program. REFERENCES AHRQ (Agency for Healthcare Research and Quality). 2004. Medical Errors and Patient Safety. [Online]. Available: http://www.ahrq.gov/qual/errorsix.htm [accessed September 29, 2004]. Amundson B. 1993. Myth and reality in the rural health service crisis: Facing up to community responsibilities. Journal of Rural Health 9(3):176–187. Anderson GF, Hussey PS. 2001. Comparing health system performance in OECD countries. Health Affairs 20(3):219–232. Baldwin LM, MacLehose RF, Hart G, Beaver SK, Every N, Chan L. 2004. Quality of care for acute myocardial infarction in rural and urban U.S. hospitals. Journal of Rural Health 20(2):99–108. Calico F, Dillard C, Moscovice I, Wakefield M. 2003. A framework and action agenda for quality improvement in rural health care. Journal of Rural Health 19(3):226–232. Coburn A, Wakefield M, Casey M, Moscovice I, Payne S, Loux S. Forthcoming. Assuring rural hospital patient safety: What should the priorities be? Journal of Rural Health 20(4):314–326. Cromartie J. 2002. Nonmetro migration continues downward trend. Rural America 17(4):70–73.

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