The Rural Monitor, Volume 11, No. 2, Fall 2004
In this issue:
- Cover Story
Rural Life Not Always Idyllic for Retirees by Thomas D. Rowley
- Rethinking Human Services
Restructuring Human Services in
Rural Communities: Thinking
Outside the Box
by Tom Corbett, Ph.D.
- Look What's Coming
Picture a Health System...
by Wayne Myers, M.D.
- Around the Country
Funding and information resources:
Alzheimer’s Disease
Demonstration Grants Program;
Online Pesticide Poisoning
Diagnostic on the web;
Delta Rural Hospital Performance
Improvement Project
- Spotlight on Rural Research
Service Delivery for the Elderly
by Thomas D. Rowley
This issue is also available in PDF.
Rural Life Not Always Idyllic for Retirees
By Thomas D. Rowley
When Dawna Kanagy retired 16 years ago, the Rialto, California,
public school teacher packed up and headed north to be close to her
sister and live in the mountains. She opened a bookstore in tiny
Alturus in northeastern California. Her daughter followed soon after
and bought the local movie theater.
"It's a lovely town," Kanagy says. "There's
blue skies and fresh air. The people in the stores know you by name.
I love it here."
Kanagy affirms this even though at 73 she now has
osteoarthritis in her knees, is diabetic and is legally blind from
macular degeneration, all of which makes life in a remote rural area
challenging, to say the least.
Fortunately for Kanagy and other seniors in the region, five
years ago the county established a subsidized transportation
service to take them, and anyone else, wherever they need to
go—the doctor,
the store, even to the casino for a little fun.
Kanagy says that, overall, she has no regrets about
her move. Others who have retired to rural areas may have a different
perspective.
To be sure, retirement offers many the chance to
pack up and head for the country, its peace and quiet, low prices
and easy living. To others, however, the results of such a move
are less than idyllic. Medical care, social services, cultural
activities and transportation—things
they took for granted in the city—may be harder to
come by in some rural areas and completely unavailable in
others.
Lacking services, many rural people rely on friends,
families, churches and other organizations to provide care.
"Rural
people understand that the informal support network is really
what we depend on here," says Tom Briggs, Director
of the Delaware County Area Agency on Aging in the Catskills
of New York.
Newcomers to rural areas, however, must learn
to connect to that informal network. That can be challenging
for some. Those who don't
make the connection must look to more formal services for
help, if they exist. As a result, Briggs says, newcomers
are more likely to call 911.
Recognizing these problems,
experts advise would-be rural retirees to think about all
the services they need now, as well as the ones they might
need as they grow older and frailer, and see if those services
are in fact available. In short, they say, look before you
leap.
"It's the Boy Scout motto," says
Dennis Dudley, an Aging Services Program Specialist in the
San Francisco Office of the U.S. Department of Health and
Human Services' Administration
on Aging. "Be prepared. Ask the questions. Know what
you're
getting into."
Dudley, whose region includes several
western states, tells of retirees selling their homes in
San Francisco and moving to northern California for the natural
beauty and cheaper land, and then finding out that, sometimes,
the services they need simply aren't there. At the
most basic level, that can mean no one to shovel snow in
an area that, unlike the Bay, gets lots of it. At another
level, it can mean no way to get around—to shop, to
socialize, or worse, to get medical care. Once, he says,
a Greyhound bus driver called him on behalf of an elderly
woman who had just gotten off the bus in one of the small
towns on the route and was demanding to know where the (nonexistent)
local senior transportation system was.
Young people ask what
kind of schools an area has, Dudley says. Seniors need to
ask about health care and services, not just the price of
property. Sometimes, he adds, it is the adult children who
want mom and dad to move closer to them, without thinking
about what services their parents will need.
"There
are a lot of things you have to take into consideration," Dudley
says. "You're going to have fewer services."
In
the early years of retirement, fewer services may not be
a problem. Indeed, fewer services can be linked to fewer
taxes, which retirees may well find attractive. Besides,
the so-called "young old" tend
to have fewer medical conditions and fewer needs than older
seniors. But as people age, their needs increase. Planning
ahead is therefore critical.
"The young elderly don't
need services," says Pam
Matura, who directs an Area Agency on Aging in rural Ohio. "Problems
come at 75-plus with health conditions."
"People
don't ask the right questions when they're thinking
about retirement," says Audrey Flower, Executive Director of the
Madrone Hospice in Yreka, California. "They need to think about
services and the support systems. They need to realize that they're
not always going to be so independent [as they are when they retire and
move]."
The Sage Stage
Modoc County sits in the northeast corner of California. Its 9,500
residents are spread over a territory the size of Connecticut,
giving it just two people per square mile. With natural wonders
and lots of public land, Pamela Couch, Director of the Modoc Transportation
Agency, describes it as "gorgeous with no tax base." Not
surprisingly, transportation is a real issue.
Since 1999,
the agency has run the Non-emergency Medical Transport
Project, also known as the Sage Stage, a low-cost bus service
that helps seniors (and others) go where they need to go and get
the services they need to get. Using funds from federal, state and
local governments (fare revenues cover only 10 percent of the actual
costs), the Stage takes residents to destinations around town as
well as cities far away—Klamath Falls, Oregon
(100 miles), Redding, California (143 miles), and Reno,
Nevada (190 miles).
The Stage, says, Couch, is the region's
only transit option. Greyhound abandoned its routes through
the county in the late 1980s and there are no taxis.
"There's
no way out," she says.
For newcomers to the area, that fact
can be quite troubling. A lot of people, Couch says, moved
to the area for the rural lifestyle without thinking about
the distance to specialized medical care. Many are too elderly or
too infirm to drive.
"We're the link between them and
services," Couch
adds.
The Stage is actually a fleet of six buses. And while
many riders use the Stage to get to medical care, the service
is not acute transport. Rather, it takes riders to doctors' appointments,
regular treatments for chronic conditions and even to visit
family members in the hospital. Nor is it solely for medical
destinations; the Stage also travels to airports, shopping, and
entertainment destinations—all at low-cost, subsidized rates.
"We
pretty much take folks literally where they need to go
in those terminus cities," she says. "Once you've
gone a hundred miles, it's not much difference to take them
on to the doctor or even their sister's."
After dropping
people off, the bus lays over to give riders time to get
treatment, have lunch and perhaps do a bit of shopping
before heading back.
Finally, although 80 to 90 percent of riders
are elderly or disabled (service is curb to curb for the
elderly and door to door for the disabled), others use
it too.
"I myself use the bus," says Couch. "My
family's
in Southern California."
Other regular riders include a 91-year-old
woman who goes to dialysis three times a week in Reno,
for $18 roundtrip, and another just over 80, who just gets on the
bus to ride around and socialize.
After a stroke kept him from driving,
Jack Shepherd used the service to get everywhere, including
therapy in Klamath Falls.
"It made all the difference in the
world to me," Shepherd
says. "There are no real buses, no trains, a very, very small
private airport. And other than that there is no transportation
in Alturas. The service does a real good job, especially
for people who are older."
Dawna Kanagy, a 73-year-old artist
and retired teacher, loves the Sage Stage. She says she
couldn't
get the kind of service provided by the Stage in the big
city. Before the Stage, Kanagy was homebound for three years.
She now relies on it to take her everywhere—on Mondays
to the casino and then the grocery store, on Fridays to the library,
Denny's
for coffee and then the senior center for bingo.
"Hurray for
Sage Stage," she says. "It's
given me life again. Sage Stage is the best thing that's happened
to me." |
Three Big Challenges
While conditions around the country vary, experts from all corners
agree that the three biggest challenges facing rural seniors—newcomers and old timers
alike—are housing, access to care and transportation. They also agree that
the three are interrelated.
Housing
In many rural areas, housing is relatively cheap compared
with urban areas. But the purchase price by itself can be misleading.
Seniors often need more than just a house. They need help with maintenance
(snow shoveling, lawn care and the like) if they are to stay
there. Because of the out-migration of working-age people in many
rural areas, such maintenance services are often hard to find.
On
top of that, many elders will ultimately need assisted living facilities
and/or skilled nursing facilities (aka nursing homes) for when they
can no longer live independently.
Matura knows that from experience since Ohio ranks near
the bottom in offering assisted living to low-income people, which
limits options for aging in place.
Giving seniors the opportunity to
avoid being placed in nursing homes is supported by the elderly and
elderly advocates, but it requires resources that may not always
be available in rural communities.
In its 2004 report to the Secretary of Health and
Human Services, the National Advisory Committee on Rural Health
and Human Services (NACRHHS) finds that rural areas as a whole
have more nursing home beds per 1,000 people than do urban
areas (66.7 versus 51.9). However, the supply of rural nursing beds
is due, in part, because rural areas have fewer home- and community-based
services that help keep seniors out of nursing homes. In addition,
the overall average aside, some rural areas have no nursing
homes.
Access to care
As with most things in rural America, sparse population
and long distances increase the per-unit cost of many medical and
social services to the elderly. Relatively more people who are poor
(12.4 percent of rural seniors live in poverty compared with 9.1 percent
of urban seniors) and people who have no health insurance compound
the problem by reducing the revenues for service. Therefore,
private providers are less inclined to locate in rural areas.
As for
public providers, short and declining funds stand in the way of their
offering services.
And for both public and private
sectors, qualified service professionals are difficult to get
and keep. According to the NACRHHS, the health and human service
infrastructures in rural areas are much worse than those in urban.
That makes recruitment and retention of personnel much more difficult.
As a result, shortages of medical and social services plague
many rural seniors, reducing their quality of life and limiting
their ability to remain in their own homes.
With no oncologist
and no cardiologist in Yreka, for example, Flower says cancer and
heart patients must travel an hour north to Medford, Oregon or an hour
and a half south to Redding, California. In addition to the time required,
the travel involves high mountain passes and, at times, extreme weather.
Likewise,
seniors in Matura's rural Ohio district travel 185
miles roundtrip for dialysis. "It's nothing," she
says, "to drive 200 miles for care."
Transportation
According to the NACRHHS report, 40 percent of rural
residents live in areas with no public transportation system, 80
percent of rural counties have no public bus service, and, though the
automobile is the only mode of transportation, 57 percent of rural
residents do not own a car. Taxis? Not in most rural areas. Consequently,
the rural elderly depend on family, friends and neighbors to
get them where they need to go.
As a result, the Committee concluded
that lack of adequate transportation is the single most pressing
issue facing rural elders. Many rural seniors simply have no good way
to reach the services they need. What's more, recent cutbacks
of commercial intercity bus services mean the challenge will only get
worse.
Across the board, rural aging experts bemoaned how difficult
it is to get people to services and appointments.
"In rural
areas, we are transportation disadvantaged," Matura
says.
Tom Briggs tells the story of an elderly woman who moved
to his area last year and bought an idyllic little house up in
one of the hollows four miles from the main road and ten miles
from the nearest community. The woman does not drive nor own
a car. The realtor had assured her—incorrectly—there
would be public transportation. As a result, the woman
would have to walk 10 miles to get to town for groceries and
any services she might need.
"In the middle of winter,
that's life threatening," Briggs
says. "We ended up driving our bus out to pick her
up. That costs us money. It slows the system down. It forces
us to have to rethink how we provide services to people."
And,
he says, "This is not that unusual."
Too Soon,
Too Late
The specific results of the lack of housing, care and
transportation services may vary from place to place and person to
person, but the overall toll it takes on rural seniors does not.
For some, it means moving to an assisted-living or skilled nursing
facility too soon; for others it means moving too late. For
all, it can mean a decrease in quality of life.
In the Catskills,
Briggs sees people who are frail choosing to live in assisted living
(if available) or nursing homes earlier than their conditions warrant,
because the services to keep them at home simply are not there.
"They
kind of jump over the next transition," says Briggs. "It's
premature institutional placements."
In Nevada,
the opposite is true, according to Carol Sala, Administrator
of the Nevada Division for Aging Services.
"Nevada
kind of has a frontier attitude," she says. "People
stay in their homes longer than they need to."
Reinforcing
that mentality is a lack of services brought on, in
part, by low tax rates.
"We do not have a lot
of services out in the rural areas," Sala
says. "One of the reasons people move here is
because of low taxes. That means less service."
In
either case, rural seniors often are not getting
care appropriate to their individual needs.
Addressing the
Problems
To help ensure that rural seniors have what they
need, Briggs recommends three approaches.
Wellness promotion
One low cost way of meeting service needs is to promote wellness
among seniors.
"We almost have to create a culture of wellness in this country," Briggs
says. "It can't be just the most educated and well-to-do
that exercise and eat right. It has to be almost a patriotic duty that
we take care of ourselves."
Education of potential
immigrants
The experts agree that all immigrants to rural areas, especially
those like the elderly who may need special services, need to educate
themselves on what is and is not available in the country. Dennis
Dudley thinks communities need to help provide that education.
He sums up the hard choice faced by communities attracting retirees:
make sure the services are available or warn seniors that they
are not.
Economic development
With older people moving in and young people moving
out in search of jobs, education and other opportunities, many rural
areas face an imbalance in those demanding services and those providing
them.
On top of that, dwindling revenues and tax bases crimp rural
communities' abilities
to pay for services. What's needed in many rural areas
is an economic shot in the arm.
Ironically, many rural areas
around the country—particularly
those closer to metropolitan areas and those with amenities like
good climate and beautiful scenery—are recruiting retirees
as an economic development strategy, and succeeding. Indeed,
in Briggs' area,
he says retirees are "the only show in town."
Immigration
is not all bad, says Briggs, noting that most of the retirees
to his area are wealthier and younger.
"For the most part,
we're benefiting from this immigration," he
says. "They enrich the economy."
Still, Briggs points
out, even rural communities that benefit from the influx of retirees
would do well to plan how they will meet these seniors' ever-increasing
need for services as they grow older.
Rethinking Human Services
by Tom Corbett, Ph.D.
Restructuring Human Services in Rural Communities: Thinking Outside the
Box
In the last issue, I suggested that disadvantaged citizens in rural
areas are further penalized by what Richard Nathan has called the "silo-ization
of human services." As programs and service systems multiplied over
the years, needy families increasingly were faced with an almost
unfathomable fragmentation of strategies designed to help them.
Why might
this be important? For one thing, there is widespread evidence
that many in need simply do not access the help they need. Estimates suggest
that 20 percent of eligible low-income workers do not receive a refundable
credit under the Earned Income Tax Credit program. Participation rates
of impoverished families in other programs are much worse. Almost half
of eligible adults miss out on Medicaid; close to 60 percent miss out on
Food Stamps, and only a fraction of low-income workers struggling in the
secondary labor market take advantage of federal training programs.
Low participation by those who really need help is only half the problem.
Rebecca Blank, director of the National Poverty Center at the University
of Michigan, in remarks prepared for a conference on The Importance
of Place in Poverty Research and Policy suggested that the "…reasons
people are poor in rural areas are many and intertwined, and as such,
policies and programs to address rural poverty should focus on multiple,
and complementary, strategies."
Many rural families need more than
one form of assistance at the same time. Just think about the service
needs required by rural families facing economic and social dislocation
as their traditional agriculture-dominated economy collapses. Yet, trying
to successfully navigate through a labyrinth of separate programs places
an undue burden on these rural service consumers.
Many argue that the obvious solution is service integration,
the blending together of services in ways that blur the programmatic
and policy distinctions among different systems. Service integration
is often characterized as the "Holy Grail" of public policy—ever
sought but never quite realized. This lure of service integration
is seductive because it promises better outcomes through more effective
services delivered in a more efficient manner.
Oddly enough, this widely accepted promise of
better human services is, in reality, difficult to define. We are
not sure what it is. Mark Ragan, after visiting a number of one-stop service
centers and other integrated service models for the Annie E. Casey Foundation
concluded that service integration can mean many things:
There is no single answer. Based
on observations at the sites visited for this study, service
integration is a combination of strategies that simplifies and facilitates
clients' access
to benefits and services. Each site has implemented a distinctive
mix of strategies, processes, and partner agencies.
Given this diversity of program models, how should
we begin to think about service integration? As a starting point,
we might profitably consider the following as attributes of a fully
integrated system:
- Families would have easier access to a broader
range of services and assistance than are available under existing
service delivery methods.
- Families would have access to individualized
service plans that accommodate the diverse and complex circumstances
that motivated them to seek help in the first place.
- Service plans
would be able to accommodate multiple issues simultaneously.
- Service
plans would respond to changing circumstances and could be
modified as progress is made or new issues arise.
- Families would at least
have the potential of engaging the service system at different
levels of intensity, from self-initiated and self-directed forms
of help to intensive interactions with multiple programs.
- The focus of both
the clients and the system would be on achieving individual
and family goals rather than participating in a particular program.
- The
community would come to see the system as a strategy for resolving
individual, family, and community challenges rather than as an
agency where specific programs are located.
Clarity of concept is an important
element of good policy making and a better and more universally
accepted understanding of service integration is one key to advancing it.
We need to develop a common vocabulary and conceptual framework so that
communicating with one another about service integration is possible.
Apparently, there are many ways to put integrated
service models together. But what ultimately defines such initiatives
is how they affect individuals and families as they seek help. If a new
way of organizing services does not change the consumer's experience
in a positive way, by delivering accessible services, more effectively
and efficiently, there is little reason to introduce the changes. After
all, every policymaker and practitioner I have met to date makes it clear
that service integration is very hard work.
In the next article, we will discuss some
basic approaches to integrating services.
Tom Corbett has emeritus status at the University of Wisconsin-Madison
and is an active affiliate with the Institute for Research on Poverty
where he served as Associate Director. He has worked on welfare
reform issues at all levels of government and continues to work with a
number of states on issues of program and systems integration.
Look What's Coming
by Wayne Myers, M.D.
Picture a Health System . . .
In previous columns I've argued that our current approaches
to health care are failing because they are too expensive and too
dangerous. Health expenses are going up at over 12 percent per year,
while the non-health part of the economy is growing at a rate of
less than two percent. Employers are using various exit strategies
regarding health insurance but they are getting out. More people
die every year from hospital mistakes than die of car wrecks or influenza.
Cost
experts say one reason our care is so expensive is that it is fragmented
into hundreds of thousands of small independent units. The overhead
costs of each one of these managing themselves and their billing
are enormous, probably a third of our total health care outlay.
This fragmentation is also a big part of the safety problem for two
reasons. First, people do make mistakes; even doctors and nurses.
If the consequences of these mistakes are to be avoided, systems
need to be in place to detect and fix the errors before they hurt
people. It is hard for small units to develop the information systems
that can catch these errors. Second, many of the errors creep in
when patients and information move between organizations as they
must for any serious episode of care. If we can pull some of the
fragments of health care together into systems of care we have a
chance to cut costs and hurt fewer people.
If system development has
implications for controlling medical errors, shouldn't we be
hearing about it in the medical liability controversy? One strategy
for reducing liability costs is to reduce mistakes! In a commercial
airline flight the lives of some hundreds of people depend on the
decisions of the pilot. Why are we not hearing about pilots quitting
in droves because their liability insurance costs too much? There
are two reasons. Information and hardware systems in air travel prevent
or detect most human errors so they very rarely kill people. In the
rare event of an accident, society looks for a system failure, not
just a scapegoat. You can't put the wrong
fuel in a plane. The hardware won't let you. But you can certainly
put the wrong I.V. in a patient.
Rural communities seem more likely
than large cities to be able to pull together model systems of
care simply because they are smaller and less complex. Think of your
own community. If you were going to outline a consolidated health
care system for your region what would it look like? Who would "own" the
system? Who should hire and fire the managers? Under what incentives
should system managers work?
At this point one's philosophy of social organization
comes to the fore. Some will no doubt argue that commercial free
enterprise is the way to go. Private business supposedly does everything
better and cheaper. If you believe that you might be trying to have
the doctors form a corporation to acquire the hospital, drug stores,
nursing home and assorted agencies. That model was more common in
past simpler days but examples are still to be found. I don't
know of situations where local investors have taken the lead but
there may be some. In general the private sector has gone for buying
up lots of hospitals, or pharmacies or nursing homes rather than
building integrated systems of care. I suspect this is because not
many managers are good at managing different kinds of business. The
private model also needs competition to keep it honest. Few urban
and fewer rural models can afford redundant competing systems.
My
bias is toward consumer-controlled health care. My favorite models
at the moment are the Regional Health Corporations of rural Alaska.
They are comparable to Native American Tribal organizations. Each
is governed by a Board made up of representatives of each community
served. The Corporation owns the regional hospital as well as a
clinic in each subscribing community, the mental health and substance
abuse treatment agencies, EMS and, in some regions, a long term care
facility. The corporation pools revenue from all sources—Indian Health,
Medicare, Medicaid, private insurance, state program funds—to
meet regional needs.
We need, and lack, comparative performance information
on different models of care. In its absence you should begin thinking
about organizational possibilities for your community. It is a
matter of life, death, money and power; all the biggies.
Wayne Myers, a pediatrician, founded the University of Kentucky
Center for Rural Health and served as its director. He also served
as director of the Office of Rural Health Policy in the Department
of Health and Human Services' Health Resources and Services Administration.
He is a past president of the National Rural Health Association and
currently serves on its Board of Trustees.
Around the Country
Rural Alzheimer's Patients Get Help
A Boy Scout merit badge in West Virginia and support
for caregivers in Maine are just two of the programs currently
funded by the Alzheimer's
Disease Demonstration Grants Program. The federal program helps
state agencies find flexible and innovative ways to serve families
of Alzheimer's patients and those with related dementia.
Since 1992, the program, which is operated by the U.S. Department
of Health and Human Services' Administration on Aging (AoA),
has given three-year grants to states for the purposes of providing
direct service, administration, outreach and education. The grants
require an escalating match—25 percent in year one, 35 percent
in year two and 45 percent in year three. In addition, half of
the grant and match must go to direct service. The maximum grant
amount is $350,000 per state per year.
According to AoA Aging Services
Program Specialist Lori Stalbaum, the beauty of the grants is
their flexibility, allowing states to determine where and how to
target and utilize the funds within six broad categories of direct
service: home health, personal, day, companion, short term care
and respite care.
As a result of
that flexibility, innovative efforts come about. West Virginia
is working with Boy Scouts to develop a merit badge for caring
for Alzheimer's patients, which will teach youngsters
what the disease is like and help them understand what the patients
need.
Other states have used the money to help assemble care teams—groups
of volunteers who provide specialized services such as hair dressing,
lawn mowing and the like.
"The flexibility allows states to tweak and fine tune things
as they go," Stalbaum says. "It's a learning
process."
Because it is a learning process, states may apply
more than once for the grants. However, they must do something
different with the money each time, even if the new effort builds
upon previous ones.
In fiscal year 2004, AoA awarded 38 demonstration grants.
One of those grantees is Maine, in its third go round. One of
the most rural states, Maine is using the grant to focus on family
member caregivers through a Caregiver Companion Program.
"They're
really the backbone of the home care system," says
Romaine Turyn, the state's program director. "If something happens
to them, the whole care plan for that person could be in jeopardy."
Unfortunately,
and not surprisingly, those caregivers are burning out, Turyn says. The Maine
Caregiver program seeks to reduce caregiver stress, burden and depression—to
keep them from burning out.
To achieve that, the program sends
Alzheimer specialists to visit caregivers at home to give them information
about the disease, including what to expect throughout its progression,
and tips on dealing with the difficult behaviors that often accompany
it. Specialists will also look at the house and suggest ways to
make it a more accommodating environment. Finally, caregivers who
are depressed will be able to receive mental health care.
Rural Maine, like many other
rural areas, has a shortage of providers trained in dementia care, so specialists
in the program are not necessarily highly trained individuals but people who
have been caregivers themselves and know what it is like.
Family caregivers are very isolated geographically, Turyn says.
They tend not to want to leave home even to shop. Some of these
caregivers haven't
been out of the house with the person with dementia in a very long time. Sometimes
they just need a break, she says.
For
information on the program, see http://www.aoa.gov/alz.
Pesticide Poisoning
Help Online
In many agricultural areas, pesticide poisoning
is a real concern. Yet many clinicians have little training in dealing with
it. Now, the Online Pesticide Poisoning Diagnostic is helping health
care professionals and others recognize, diagnose and report pesticide-related
illnesses.
The project is a joint effort between
the Pesticide Action Network North America (PANNA) and the Northwest Regional
Primary Care Association (NWRPCA). PANNA—one
of five PAN Regional Centers worldwide—strives to replace pesticide use
with ecologically sound and socially just alternatives by linking local and international
consumer, labor, health, environment and agriculture groups into an international
citizens' action network. NWRPCA works to ensure equal access to high quality,
primary health care for all residents living in Washington, Oregon, Idaho and
Alaska by providing tools and services that support community health centers.
The
online tool provides symptom, first aid and treatment-related information for
some 1,900 pesticides. It allows users to search for possible pesticide poisoning
agents by entering observed symptoms, pesticide active ingredients, product
name, pesticide use type, crop or application site and/or geographic
location.
In addition,
the web site provides a wealth of information on pesticides and a helpful tutorial.
Information on the site comes from the U.S. Environmental Protection Agency
(EPA), U.S. National Toxicology Program, and International Chemical
Safety Cards. Funding for the project came from the EPA, the Northwest
Regional Primary Care Association (through a grant from HRSA) and
the David B. Gold Foundation.
According to NWRPCA's Anne Powell, clinicians at community
and migrant health centers see a lot of migrant seasonal farmworkers exposed
to pesticides. They don't always recognize the problem for what it is,
because the symptoms can be minimal and may be common to other illnesses. This
tool helps them accurately diagnose and treat the condition.
Powell also notes the value of the tool's
reporting mechanism, which walks users through the process for reporting pesticide
poisoning. "That's
important," she says, "because there's a lack of reporting.
This will help improve policies and regulations."
The tool is available free of charge at http://www.pesticideinfo.org.
For information, contact Anne Powell of the Northwest Regional
Primary Care Association at mreeves@panna.org or (415) 981-1771.
Delta RHPI Project Helps Small Hospitals
Two years after participating in the
Delta Rural Hospital Performance Improvement (RHPI) Project, a small hospital
in Arkansas has been named the 2004 Top Leadership Team in the small hospital
category by HealthLeaders, a media company that supplies business information
to healthcare executives and professionals.
Since receiving
comprehensive and targeted consultations through the RHPI Project, Lawrence
Memorial Hospital, a 25-bed critical access hospital in Walnut
Ridge, has turned a minus 15 percent margin into a positive 3.5
percent margin, cut receivable days from 124 to 49 and reduced
turnover from 40 percent to 16 percent. According to the HealthLeaders
web site, the hospital's metamorphosis was
the product of improved teamwork that led to data sharing, new service lines
and incentive programs. (Earlier efforts had gotten a one percent county-wide
sales tax dedicated to the emergency department and critical access hospital
designation.)
The hospital also opened an auto shop where the hospital's
300 employees can get their cars repaired at reduced rates, which saves them
time, boosts morale and generates revenue for the hospital. Other added services
include a catering service to the community, a cardiac rehabilitation unit and
a sleep lab.
Through
staff meetings, retreats, and sharing of performance data, hospital leaders
were able to correct long-standing problems in communication among
the various departments. Those corrections helped people see how,
for example, staff shortages in nursing and radiology hampered
clinical care departments and prompted the use of expensive temporary
personnel.
According to Ernest Briner, vice president
of support services at Lawrence Memorial, the hospital put performance measurements
into place and publicized them so everyone could see how well a department
was or was not doing.
"We had nothing to
hide," he says. The hospital showed residents
that its quality was equal to that of larger facilities.
As a result of all these
efforts, Briner says, "our numbers started to
come back up. Things are looking really good."
So good, in fact, that the
hospital is undertaking a $1.4 million expansion of its emergency department.
"It was a team effort. It took everybody to make
this thing turn around," he
says. "It was a great honor to receive this award. It did a lot for the
esteem of the hospital. It did a lot for the community."
The Delta RHPI
Project, a demonstration program administered by the Office of Rural Health
Policy in the Health Resources and Services Administration, provides
on-site technical assistance to hospitals in the Delta region to
help them improve their financial, clinical and operational performance.
The Project also collects and disseminates business tools, information
and databases and works with state and regional agencies to help
build capacity to provide technical assistance to rural hospitals
in the Delta.
For more information on Lawrence Memorial Hospital,
see http://www.lawrencehealth.net.
For more information on the Delta RHPI Project, see: http://deltarhpi.ruralhealth.hrsa.gov
Spotlight on Rural Research
by Thomas D. Rowley
Service Delivery for the Elderly
As the elderly population grows in the United States, programs that
offer services to the aging will need to evolve and expand to meet
their changing needs. Two new reports look at service delivery to
rural (and other) elderly. Another report focuses on elders in Appalachia.
Ham, Goins and Brown (ed.) Best Practices
in Service Delivery to the Rural Elderly. West Virginia University Center on Aging, 2003.
This
report, prepared for the U.S. Department of Health and Human Services' Administration
on Aging, covers the waterfront of issues in rural elder services.
The list of authors is a who's
who of experts in rural health and human services from around the
country.
The rationale for the report lies in the fact that the rural
elderly face obstacles in staying healthy and staying at home over
and above those faced by their urban and suburban counterparts.
According to the report, "their care and wellbeing, and indeed their
quality of life, is frequently impaired by such issues as lack of
nearby younger family members (or lack of any younger individuals
to help—paid
or unpaid), poor access to transportation, non-availability of many
services generally regarded as "standard" care for the
urban/suburban population, lack of education, including both illiteracy
and other educational disadvantages, as well as a lack of knowledge
of the potential for interventions, medical care and support services,
and, underlying all, the poverty that so often accompanies rural
living."
While each of the report's 13 chapters offers
rich analysis, the final chapter provides a concise summary of best
practice principles and a set of policy recommendations, or a "Plan
of Action on Rural Aging." These principles and recommendations
are based on demonstration projects, contributions of national experts
on rural aging programs and policy, and national studies of best
practices.
As
for best practices, the chapter highlights four major features
found in successful programs:
- New and innovative programs are developed
to serve clear, unmet needs.
- Programs bring together new fiscal packages and funding
streams integrated to support the programs.
- New agency coalitions and partnerships emerge, which
did not work together before, to shape the service delivery system of the
program.
- Program evaluation
outcome measures are developed to assess the impact of the program on clients
receiving services and benefits.
As for policy recommendations,
the report emphasizes three cross-cutting issues that must be considered in
order to form a relevant and coherent structure to rural aging policy:
- An economic development policy in rural areas to provide
the workforce and revenue base upon which to build elder services;
- A standardized definition
of "rural" acceptable for targeting
programs; and
- An integration of the many fragmented federal and state agencies
and programs that comprise the rural service delivery puzzle.
The report is available
at: http://www.hsc.wvu.edu/coa/publications/best_practices/best-practices2003.asp.
Haaga, J. The Aging of Appalachia, Population Reference Bureau,
April 2004.
Noting that the U.S. population is aging less rapidly
than that of other rich countries because of higher immigration
and fertility rates, this report points out that Appalachia is, in
fact, graying at a faster pace and the proportion of its people over
age 65 is higher than the rest of the nation (14.3 percent compared
with 12.4 percent). It then asks the question: Does it matter much
for the region to be ahead of the curve, to be older than the nation
as a whole?
To address that question, the report uses Census 2000 data
to show how and why the age structure of Appalachia differs from
the national average and discusses implications of that age structure.
It also argues that the implications are not all negative. "The
changing age structure will be an important fact of life for decision
makers in both the public and private sectors in Appalachia in coming
years—but
not a dire threat to standards of living.
In arriving at that conclusion,
the report asserts that discussions of the graying population generally
focus on national-level fiscal effects—particularly on Medicare
and Social Security. "This
perspective overlooks the state and local effects and contributes
to the general perception of older residents as an economic problem
to be solved. But even in a narrow economic focus, the older population
has to be seen as a resource, not just consumers of public services." Indeed,
the report states that some areas try to recruit elderly residents,
essentially trying to achieve what Appalachia already has.
That said,
the report allows that poverty and disability among the elderly
represent problems for Appalachia that can strain local government
finances. And notes that governments everywhere must prepare for
the revenue and expenditure effects that the baby-boom retirement
will bring. "The
Appalachian region will hardly be alone in dealing with these challenges," writes
Haaga. "But the
stresses will be most visible in Appalachia, with its markedly older
population."
Report is available at http://www.prb.org/rfdcenter/.
Government Accountability Office. Transportation-Disadvantaged
Seniors: Efforts to Enhance Senior Mobility Could Benefit from
Additional Guidance and Information. August 2004. (GAO-04-971)
In this report,
GAO identifies (1) federal programs that address the mobility issues
of transportation-disadvantaged seniors, (2) the extent to which
these programs meet their mobility needs, (3) program practices
that enhance their mobility and the cost-effectiveness of service
delivery, and (4) obstacles to addressing their mobility needs and
strategies for overcoming those obstacles.
Noting that five
federal departments administer 15 programs that are key to addressing
the mobility issues of transportation-disadvantaged seniors, the
report finds that some needs are still not being met, including
those for trips to multiple destinations or for purposes that involve
carrying packages; trips to life-enhancing activities, such as cultural
events; and trips in rural and suburban areas.
The
extent of the unmet needs, however, is not ascertainable given
limited data. The report finds that the U.S. Department of Health
and Human Services' Administration on Aging (AoA), which is
required by law to provide guidance to states on how to assess seniors' need
for services, has not done so. Consequently, local agencies on aging
interviewed for the report used inconsistent methods to assess seniors' mobility
needs.
The report also finds that local transportation service providers
have implemented a variety of practices that enhance mobility and
the cost-effective delivery of services. Still, several service
providers interviewed said implementation of such practices was impeded
by limited federal guidance and information on successful practices.
Finally,
experts and stakeholders identified several obstacles to addressing
transportation-disadvantaged seniors' mobility needs,
potential strategies to better meet these needs, and trade-offs associated
with the strategies. And GAO recommends that AoA take action to improve
guidance on assessing mobility needs of transportation-disadvantaged
seniors and publicize information on alternative transportation services
and practices that service providers can implement to enhance senior
mobility.
Report is available at: http://www.gao.gov/new.items/d04971.pdf
Call for Input
Something newsworthy going on in your part of rural America? Send a one-paragraph summary to the editor at: editor@raconline.org.
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