Total immersion: Rethinking the future of rural health and well-being

By: Eric Meade and Emily Oehler | 12/06/17

Eric Meade is a futurist and organizational strategist at the Whole Mind Strategy Group.

Emily Oehler is a director in Grant Thornton LLP’s public sector strategy practice with a focus on health care.

Rural communities vary a great deal in terms of population, infrastructure, remoteness and culture. But in general, they are fundamentally different from cities along all of those same dimensions. It stands to reason, then, that the health care system that works well in rural America would be qualitatively different from the health care system that works well in cities.

While that probably sounds obvious to most, the habits and assumptions with which federal agencies pursue rural health improvement do not always reflect this understanding. Federal programs tend to focus on expanding rural residents’ access to the type of health care that works in cities, for example, by incentivizing physicians to practice in rural areas rather than strengthening a form of health care that fits the rural context.

Keith Mueller from the Rural Policy Research Institute notes, “Right now we’re still dealing with the legacy of thinking that we need a physician everywhere, and we’re defining shortage areas on that basis and setting ourselves up for failure because we can’t hit those targets.”

So what kind of thinking would set us up for success? In a popular TED talk, tech investor Tim Ferriss describes how he overcame his fear of swimming by learning Total Immersion Swimming.¹ Terry Laughlin developed this approach to swimming by going back to the fundamental principles governing the biomechanics of the human body in water.

The technique is surprisingly different from how most of us learned to swim. The swimmer does not kick, since kicking converts only 3 percent of the expended energy into forward movement. Also, the swimmer submerges 95 percent of his body under the water (for better hydrodynamics) rather than swimming on the surface. As it turns out, most of the energy many of us expend in swimming is actually wasted. It keeps us on the surface but it does not move us forward.

Similarly, many federal efforts to improve rural health resist total immersion in the rural context and instead focus on keeping rural residents on the surface — that is, keeping them connected to the kind of health care that works well in cities. But what is the alternative? What would total immersion in the rural context look like? We propose four mental shifts that are critical to the immersion process.

From parity to equity

Federal efforts to achieve parity between urban and rural health care may be unfeasible — and even counterproductive. For example, the difficulties that rural obstetrics and gynecology (OB-GYN) providers have in obtaining malpractice insurance — because they cannot assure an emergency cesarean section within a prescribed period of time (or at all) — end up reducing rural access to OB-GYN services in some areas.

What if federal efforts shifted their goal from parity to equity? While parity denotes sameness or equality, equity (in health) refers, according to a seminal article by Braveman and Gruskin, to “the absence of systematic disparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/disadvantage — that is, different positions in a social hierarchy.”

Equity implies that a rural resident’s health care could be better or worse than that of her urban counterpart depending on the situation. For example, what services can a rural OB-GYN provider safely offer, and how could such a provider be credentialed and insured? The key is to ensure each person gets what they need, to the extent possible, so that they can achieve their greatest health potential.

While parity is easy to understand, equity raises important questions for rural health. For example, is rurality fundamentally a source of disadvantage? Braveman and Gruskin cite geography as a source of disadvantage, but they also note that “not all health disparities are unfair” in that “we expect young adults to be healthier than the elderly population.” Would we not expect urban populations to have more proximate access to health care than rural populations?

And if, as Braveman and Gruskin suggest, the standard should be that all people in a society can attain the health status enjoyed by the most socially advantaged group, then who should be designated as most advantaged? Is it the white, male, affluent, educated professional teleworking from a rural area, or is it that same person when he lived in the city? Is some part of rurality a social disadvantage and another part simply a chosen location and lifestyle? What is the equitable response to each?

From external funding to local assets

Paul Mackie of the National Association for Rural Mental Health notes, “Rural spaces are not devoid of everything. The basic infrastructure is there somewhere.” Rural areas may not have the large, college-educated workforce to be found in cities, but they may have patients who could serve as peer advisors as well as high school graduates eager for low-level or mid-level clinical training. They may not have research hospitals, universities or large corporations, but they may have community colleges, rural broadband providers, local businesses, agricultural extension offices, Future Farmers of America chapters and other networks that could be leveraged to improve health.

Some organizations are already leveraging these assets, such as:

• NTCA, the Rural Broadband Association, has funded a pilot program through which the local broadband provider will convert a room in a public library into a simulated living room where veterans can receive telehealth services.
• The Colorado Department of Agriculture has launched a crisis line for farmers facing emotional stress related to their financial struggles.
• Several U.S. universities offer fully accredited online clinical education programs that allow rural residents to build skills and credentials without having to leave their community for several years of training.

From implementing programs to convening process

Outside the federal government, many funders of rural health improvement have shifted from implementing programs developed in urban environments to convening and empowering local groups of rural residents to identify and address health challenges on their own. For example, the Colorado Trust — a health conversion foundation headquartered in Denver — shifted much of its philanthropic model from grant making to convening residents of communities across the state as they identify their own needs and plan their own activities.

This approach produced activities that might not immediately come to mind for urban donors, such as creating public spaces to foster greater interaction among residents and a stronger sense of social belonging. One community focused on keeping their community center open in the evenings, while another created a “pop-up community center” that offers Zumba, African dance, English language and other classes.

The shift has required the Colorado Trust to learn new ways of engaging with communities. As the Trust’s Courtney Ricci notes, “It’s really a coaching relationship. There’s a dance of knowing when to answer the question and when to throw it back at them.” The result is greater community ownership of the strategies and actions, which would be less likely if the ideas came from outside the community.

From rescuing to coaching

Of course, there is still a role for the urban health care system to support rural communities. Using the Total Immersion Swimming metaphor, this is more likely to take the form of coaching to help rural communities move forward than rescuing them by pulling them out of the water they are in.

There are several opportunities to provide this coaching. The most prominent is telehealth, which offers great promise not only for direct care delivery (once the considerable obstacles to widespread adoption have been overcome) but also for consultation among clinicians across long distances.

Other examples include platforms like Project ECHO (Extension for Community Healthcare Outcomes), which links specialists and generalist community providers in interactive, case-based learning networks focused on complex diseases, conditions and health problems, and remote (e.g., video) monitoring of rural health care facilities, as in a telehealth hub run by Avera Health, to direct local providers to the patients with the greatest or most urgent needs.

Shifting from rescuing to coaching may be the most difficult step, since it requires accepting rural health care systems not as equal to urban health care, but rather as a valid vehicle in their own right for health care delivery in the rural context. This is the essence of meeting the members of a community where they are — of immersing oneself in their world and working with them to find the best next version of themselves.

As Tom Morris from the U.S. Department of Health and Human Services’ Health Resources and Services Administration notes, “Rural America has always been a place where innovation has taken place, from community health workers to community paramedicine to telehealth and beyond.” For these reasons, innovation in health and well-being from a perspective of “total immersion” may be the most effective way to move rural communities forward.

1 See https://www.ted.com/talks/tim_ferriss_smash_fear_learn_anything.

Eric Meade (Eric@WholeMindStrategy.com) is a futurist and organizational strategist at the Whole Mind Strategy Group. Emily Oehler (Emily.Oehler@us.gt.com) is a director in Grant Thornton LLP’s public sector strategy practice. This article is the result of interviews with 13 rural health leaders from across government, academia, and the nonprofit sector, as well as a review of case studies in rural health innovation.

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