QUALITY THROUGH COLLABORATION

THE FUTURE OF RURAL HEALTH

Committee on the Future of Rural Health Care

Board on Health Care Services

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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Quality Through Collaboration: The Future of Rural Health QUALITY THROUGH COLLABORATION THE FUTURE OF RURAL HEALTH Committee on the Future of Rural Health Care Board on Health Care Services INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Quality Through Collaboration: The Future of Rural Health THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 282-99-0045, T.O. #14 between the National Academy of Sciences and the Health Resources and Services Administration and the Agency for Healthcare and Research Quality. Support was also provided by Contract No. 03M00025301D from the Substance Abuse and Mental Health Services Agency and Contract No. P0105938 from the W. K. Kellogg Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data Quality through collaboration : the future of rural health / Committee on the Future of Rural Health Care, Board on Health Care Services. p. ; cm. Includes bibliographical references and index. ISBN 0-309-09439-9 (hardcover) 1. Rural health—United States. 2. Rural health services—United States. [DNLM: 1. Rural Health Services—trends—United States. 2. Delivery of Health Care, Integrated—trends—United States. 3. Health Policy—United States. 4. Quality of Health Care—trends—United States. ] I. Institute of Medicine (U.S.). Committee on the Future of Rural Health Care. RA771.5.Q34 2005 362.1′04257—dc22 2004028192 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2005 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museum in Berlin. Cover photos reprinted with permission: (1) Town of Clear Lake, Iowa, copyright 2002 Roger F. Bindl; (2) Aquilla Walker, PharmD, Manatee County Rural Health Services, Inc., copyright 2004 University of South Florida AHEC; (3) Tomah Memorial Hospital, copyright 2004 Tomah Memorial Hospital; (4) Home Health Care Nurse, copyright 2004 Jeff Joiner; (5) A Rural Ambulance Nissan 4WD near Bright, Victoria, copyright 2004 Driver Improvement Consultancy Pty Ltd.; (6) UCL Telemedicine Program, copyright 1999 University College London. Other photos available publicly: (1) Performing Breathing Test, Indian Health Service Photo Gallery, Image #206; (2) Small Farms, Agricultural Research Service, Image #K8502-1; (3) Child Being Examined by Physicians, National Institute of Allergy and Infectious Disease.

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Quality Through Collaboration: The Future of Rural Health “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Adviser to the Nation to Improve Health

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Quality Through Collaboration: The Future of Rural Health THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Quality Through Collaboration: The Future of Rural Health COMMITTEE ON THE FUTURE OF RURAL HEALTH CARE MARY WAKEFIELD (Chair), Director, Center for Rural Health, School of Medicine and Health Sciences, University of North Dakota CALVIN BEALE, Chief Demographer, Economic Research Service, U.S. Department of Agriculture ANDREW COBURN, Professor and Director, Institute for Health Policy, Muskie School of Public Service, University of Southern Maine DON E. DETMER, Professor of Medical Education, Department of Health Evaluation Sciences, University of Virginia, and Senior Associate, Judge Institute of Management, University of Cambridge JIM GRIGSBY, Associate Professor and Associate Director, Center for Health Services Research, University of Colorado Health Sciences Center DAVID HARTLEY, Director, Division of Rural Health, Muskie School of Public Service, University of Southern Maine SANDRAL HULLETT, Chief Executive Officer, Jefferson Health System, Cooper Green Hospital A. CLINTON MACKINNEY, Senior Consultant, Stroudwater Associates IRA MOSCOVICE, Professor and Director, Rural Health Research Center, Division of Health Services Research and Policy, University of Minnesota ROGER ROSENBLATT, Professor and Vice Chair, Department of Family Medicine, and Adjunct Professor, School of Public Health and Community Medicine, University of Washington TIM SIZE, Executive Director, Rural Wisconsin Health Cooperative LINDA WATSON, Associate Dean and Director, Claude Moore Health Sciences Library, University of Virginia

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Quality Through Collaboration: The Future of Rural Health Study Staff JANET CORRIGAN, Senior Board Director PHILIP ASPDEN, Senior Program Officer LYNNE PAGE SNYDER, Program Officer JULIE WOLCOTT, Program Officer GOOLOO WUNDERLICH,* Senior Program Officer BINA RUSSELL, Senior Project Assistant Editorial Consultants RONA BRIERE, Briere Associates, Inc. ALISA DECATUR, Briere Associates, Inc. Content Consultants DAVID A. KINDIG, Emeritus Professor of Population Health Sciences, University of Wisconsin Medical School *   Served until February 2003

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Quality Through Collaboration: The Future of Rural Health Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: KIM BATEMAN, HealthInsight LONNIE R. BRISTOW, Past-President, American Medical Association PATRICIA LASKY, School of Nursing, University of Wisconsin-Madison JAMES A. MERCHANT, College of Public Health, University of Iowa KEITH MUELLER, Center for Rural Health Policy Analysis, University of Nebraska Medical Center ELAINE POWER, National Quality Forum KAREN RHEUBAN, Office of Continuing Medical Education, University of Virginia SALLY K. RICHARDSON, West Virginia Institute for Health Policy Research, West Virginia University

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Quality Through Collaboration: The Future of Rural Health JOHN R. WHEAT, College of Community Health Sciences, University of Alabama Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Neal A. Vanselow, Chancellor Emeritus, Tulane University Health Sciences Center, and Charles E. Phelps, University of Rochester. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Quality Through Collaboration: The Future of Rural Health Preface In too many ways, rural communities have been at the margins of the health care quality movement. Most quality initiatives in the United States have been developed with urban health care features in mind and as a result have not always been directly applicable to rural health care settings. Before formulating a health care quality agenda in rural America, it will be necessary to determine the rural relevance of quality efforts broadly, while also developing new quality initiatives that directly recognize distinctive features of both the context in which care is given and care systems themselves in rural settings. For example, inpatient care in rural hospitals is often a smaller part of the total set of services than is the case in urban hospitals. Smaller case volumes and long-standing shortages of key health care services, such as those for mental health and substance abuse, draw a mix of providers different from the norm in urban settings. Historically, moreover, the financing of rural health care has been a particularly fragile endeavor. Along with the lack of established applicability of many quality efforts to rural settings, access and finance concerns have frequently hampered the ability of rural health care providers to fully address quality improvement. While acknowledging these challenges, the Institute of Medicine’s (IOM) Committee on the Future of Rural Health Care has charted an agenda for rural communities that fulfills the six aims set forth in the 2001 IOM report Crossing the Quality Chasm: A New Health System for the 21st Cen-

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Quality Through Collaboration: The Future of Rural Health tury of making health care safe, effective, patient-centered, timely, efficient, and equitable. This agenda also reflects the need to improve both the quality of personal health care and the health of the rural population as a whole, as well as to apply the newest tools available, such as information technology, to the work of delivering high-quality health care in rural settings. Specifically, the agenda addresses the need to modify existing quality indicators and processes to reflect the special characteristics of rural communities, to strengthen the human resources for health care networks in rural areas, and to implement a health care information infrastructure across rural communities. In the process, the committee also notes the importance of leveraging the unique strengths of rural communities. Implementation of the recommendations contained in this report, combined with the determination of rural communities to develop creative ways of improving their own health care systems, will set the stage for the consistent delivery of high-quality health care regardless of where one lives in the United States. Capitalizing on their unique strengths, rural communities and health care systems can meet the expectations associated with delivering the highest quality of care possible. Finally, this report represents the culmination of the dedicated efforts of many individuals. I would like to thank my fellow committee members, who worked long and diligently on this challenging study; the many experts who provided formal testimony to the committee and informal advice throughout the study; and the staff of the Health Care Services Board who managed the study and coordinated the writing of the final report. Mary Wakefield, Ph.D., R.N., F.A.A.N. Chair November 2004

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Quality Through Collaboration: The Future of Rural Health Foreword The Institute of Medicine (IOM) has had a long-standing focus on quality of care. In the first phase of the IOM quality initiative, the National Roundtable on Health Care Quality highlighted serious problems with the overall quality of care delivered in the United States. In the second phase, two reports, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, were released. Both reports called for a fundamental redesign of the health care delivery system. In the third and current phase, the IOM has sought to elaborate and to realize the vision of a future health system as set forth in the Quality Chasm report. The Quality Chasm report identified six aims for the delivery of health care: care should be safe, effective, patient-centered, timely, efficient, and equitable. Among the profound changes needed to achieve these aims are that information technology must play a central role in support of the delivery of care; that provider payment systems must reward the provision of quality care; and that the education and training of health professionals must encompass evidence-based skills and working in interdisciplinary teams. The study presented here marks another step in this third phase of the IOM’s quality initiative. Rural America, with about a fifth of the U.S. population, is a vibrant part of the nation. Its people are independent-minded, but with a strong sense of the need to work with others to provide services that many urban dwellers take for granted. Rural communities differ widely, both among themselves and from urban communities, in their economic

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Quality Through Collaboration: The Future of Rural Health and social characteristics. They also vary greatly in their population densities and their remoteness from urban areas. The set of health problems faced by rural communities differs from those faced by urban communities. Thus, realizing the vision and six aims set forth in the Quality Chasm report poses special challenges for rural areas that are not present in urban areas. The present report identifies ways to assure that rural America benefits from the many changes unfolding in the health care sector and especially from efforts to redesign health care to deliver the highest possible quality. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine November 2004

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Quality Through Collaboration: The Future of Rural Health Acknowledgments The Committee on the Future of Rural Health Care wishes to acknowledge the many people whose contributions and support made this report possible. The committee benefited from presentations by a number of experts on various issues addressed during its meetings over the past 14 months. The following individuals shared their research, experience, and perspectives with the committee: Michael Beachler, Pennsylvania State University; Marcia Brand, Health Resources and Services Administration (HRSA); Kathleen Buckwalter, University of Iowa; Helen Burstin, Agency for Healthcare Research and Quality (AHRQ); Carolyn Clancy, AHRQ; Elizabeth Duke, HRSA; Robert Galvin, General Electric Company; Larry Gamm, Texas A&M University; Stuart Guterman, Centers for Medicare and Medicaid Services; Brent James, InterMountain Health Care; David Kibbe, American Academy of Family Physicians; Ravi Nemana, The Health Technology Center; Richard Palagi, St. John’s Lutheran Hospital; Cathleen Pfaff, Cypress Healthcare, LLC; Steven Pierdon, Geisinger Health Systems; Howard Rabinowitz, Thomas Jefferson University; Regina Schofield, Office of the Secretary, Department of Health and Human Services (DHHS); Ulonda Shamwell, Substance Abuse and Mental Health Services Agency (SAMHSA); Glenn Steele, Geisinger Health Systems; Walter Stewart, Geisinger Health Systems; and Pamela Wirth, Susquehanna Health System.

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Quality Through Collaboration: The Future of Rural Health A number of experts were important sources of information, generously contributing their time and knowledge to further the committee’s aims. Sunga Kay Carter, Research Coordinator at the Emergency Medical Services for Children National Resource Center, provided useful unpublished research data on workforce strength in emergency medical services. The committee also thanks David E. Cockley, Assistant Professor, Department of Health Sciences, James Madison University; Jeptha W. Dalston, President and CEO, Accrediting Commission on Education for Health Services Administration; Peter Keller, Professor and Chairperson, Department of Psychology, Mansfield University; and Liane Pinero Kluge, Association of University Programs in Health Administration. The committee commissioned four papers that provided important background information and insights for the report. Calvin Beale, in association with John Cromartie, U.S. Department of Agriculture, authored a paper describing and analyzing data needed to understand rural population trends, the changes and diversity in the rural population, and the issues associated with defining “rural.” Larry Gamm, in collaboration with Linnae Hutchinson, Texas A&M University, produced a paper describing and analyzing prevalence and rural disparities in mental health conditions and substance abuse behaviors, along with barriers to accessing professionals and services in these areas. Keith Mueller, in association with Timothy D. McBride, University of Nebraska Medical Center, authored a paper describing and analyzing reimbursement, financing, and payment policies for rural health care. Thomas Nesbitt, working with Peter Yellowlees, University of California-Davis Health System, wrote a paper on information technology for the rural health care context. The committee also benefited from the work of other committees and staff of the Institute of Medicine that conducted studies relevant to this report. The committee benefited particularly from the work of the Committee on the Quality of Health Care in America and the Committee on Identifying Priority Areas for Quality Improvement. The committee on the Quality of Health Care in America produced the 2000 report To Err Is Human: Building a Safer Health System and the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century. The committee on Identifying Priority Areas for Quality Improvement produced the 2003 report Priority Areas for National Action: Transforming Health Care Quality. The committee recognizes the hard work of staff at the Institute of Medicine. Maria Hewitt of the National Cancer Policy Board, Institute of Medicine, was very gracious in lending copies of a study on rural health and rural

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Quality Through Collaboration: The Future of Rural Health emergency medical services, conducted from 1989 to 1990 during her tenure at the Office of Technology Assessment. Finally, funding for this project came from HRSA, AHRQ, SAMHSA, and the W. K. Kellogg Foundation. The committee extends special thanks to HRSA, AHRQ, SAMHSA, and Kellogg for providing this support.

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Quality Through Collaboration: The Future of Rural Health Contents     EXECUTIVE SUMMARY   1      The Health Care Quality Challenge,   2      Addressing the Quality Challenge in a Rural Context,   2      Addressing Personal and Population Health Needs,   4      Establishing a Quality Improvement Support Structure,   6      Strengthening Human Resources,   7      Providing Adequate and Targeted Financial Resources,   11      Utilizing Information and Communications Technology,   13      Summary,   17      References,   18 1   INTRODUCTION   19      Rural Health Policy,   20      Purpose and Scope of This Study,   21      Building on IOM’s Quality Chasm Series,   22      Guiding Principles for Reforming Rural Health Care,   25      Organization of the Report,   28      References,   28

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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   30      Summary,   30      Quality of Care in Rural Communities,   31      Health Behaviors and Health Threats in Rural Communities,   38      Improving Population Health and Personal Health Care,   39      Conclusions and Recommendations,   52      References,   56 3   QUALITY IMPROVEMENT ACTIVITIES IN RURAL AREAS   60      Summary,   60      Key Components of a Comprehensive Quality Improvement Program,   61      Current State of Quality Improvement Efforts in Rural Areas,   66      Conclusions and Recommendations,   73      References,   75 4   HUMAN RESOURCES   78      Summary,   78      Fundamental Reforms to Improve Quality,   80      Enhancing the Rural Health Professions Workforce,   89      Options for Mobilizing Community Resources,   106      Conclusions and Recommendations,   109      References,   113 5   FINANCE   119      Summary,   119      Pay-for-Performance,   120      The Funding of Rural Health Care,   126      The Funding of Rural Mental Health and Substance Abuse Services,   139      Conclusions and Recommendations,   140      References,   142 6   RURAL HEALTH CARE IN THE DIGITAL AGE   147      Summary,   147      ICT Applications in Rural Settings,   150

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Quality Through Collaboration: The Future of Rural Health      Current Status of ICT in Health Care,   159      Accelerating the Adoption of ICT in Rural Settings,   165      Conclusions and Recommendations,   168      References,   181     APPENDIXES         A   Biographies of Committee Members   193     B   Characteristics of Rural Populations   200     C   The Rural Health Care Delivery System   220     INDEX   249

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