Transforming rural communities through population health
 Alana Knudson  Tracy Morton  Brock Slabach |
Supporting a healthy population starts with having a safety net of resources to help people thrive and improve their lives. However, essential components of health such as clean water, healthy food, early childhood education, and senior centers are missing in many communities, particularly in rural America.
“Instead of solving issues that contribute to poor health, our current system addresses problems when it’s already too late — and we’re paying the price,” says Brock Slabach, MPH, FACHE, NRHA senior vice president of member services. “We have one of the most expensive health care systems in the world, but the U.S. still doesn’t perform well in outcomes compared to other industrialized countries.”
One side effect of a dysfunctional system is the large burden that falls on rural health care providers, who have to compensate for gaps in social services. “People show up in the ER because it’s the only resource they have for intervention, or they come to the doctor’s office with years of accumulated problems,” Slabach says.
As health care professionals and community leaders search for solutions, exploring the role of population health is key. Social determinants of health have a direct influence on the delivery of health services in rural communities.
Alana Knudson, PhD, Walsh Center for Rural Health Analysis co-director, is involved in research and evaluation of public health systems, payment models, and insurance coverage. “I believe all things stem from looking at population health and the many different contributions that add up to health and well-being. Population health is where we begin to create vibrant and vital communities, particularly in rural communities,” Knudson says.
Tracy Morton, MPH, National Rural Health Resource Center director of population health, was originally inspired to work in population health because she saw the potential to affect people’s lives on a larger scale. “Social determinants of health are the areas that we’re born into, where we live, and where we work. A rural community that supports health is a place where people choose to stay and live the life they want,” Morton says.
Looking through a different lens
“Population health involves looking at what’s going to influence a healthy population. It’s economic stability, safety, housing, food, and security — all of the things you need before you can do anything else in your life,” Knudson says.
“Population health is about making life better for people no matter where they live,” Slabach adds. “Your ZIP code should not determine your life expectancy and your quality of life.”
The Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute identify the following as four key social determinants of health:
Clinical care is a key component of health, but as health care providers know, many health-related problems can’t be resolved in a single office visit. “What happens within the walls of our facilities only affects about 20 percent of health outcomes,” Morton says.
For some rural populations, simply getting through the door to receive health services can be a challenge, whether due to a shortage of providers, long distances to travel, inadequate health insurance coverage, or other issues. “Many of our rural communities have no access to public health,” Knudson explains. “The health care delivery system has been decimated by low funding over the past decade, and this has had the greatest impact on rural communities. Access to behavioral health and oral health services are often limited or nonexistent in rural communities.”
Health behaviors are the everyday choices that drive health outcomes, including diet, exercise, smoking, using alcohol or drugs, getting enough sleep, managing stress, etc. Making healthier choices can move the dial on health status — and empowering people to take control of their health is a major public health goal. While everyone has choices, certain barriers make it harder for some people to access healthy food, exercise regularly, and focus on their health.
“Many health behaviors are also driven by cultural or family norms, especially tobacco and alcohol use. We need to encourage everyone to be brave in talking about substance abuse, mental health, and other pressing issues,” Morton says.
Social and economic factors influence whether people have opportunities to be healthy. Ensuring economic stability starts with education — early childhood education, quality schools, high school graduation rates, higher education, and health literacy.
“We need jobs with livable wages and benefits such as health insurance, so people aren’t living in fear of becoming bankrupt from one catastrophic illness or injury,” Knudson says. When people are worried about providing basic needs for their family, taking care of their own health becomes a lower priority, and that’s when health problems can spiral out of control.
Social interactions and relationships are also important for mental health and well-being. “The WHO identifies social isolation as No. 1 health issue facing our world,” Knudson says. “We can never underestimate the impact the social component has on people’s health and longevity.”
Environmental conditions such as clean air and water, safe homes, and transportation are vital to good health. Some towns rely heavily on industries where workers may be exposed to pollution or chemicals that may have long-term health risks.
“We work with some rural communities where they turn on the faucet and see brown water,” Knudson says. “There are also a lot of food deserts in rural areas, sometimes with no access to affordable fruits and vegetables.” Lack of transportation options can also lead to health inequities, especially for older and vulnerable populations.
Working toward solutions
“We’re seeing some fantastic things happening with the Medicare Shared Savings Program or MSSP,” Morton says. These accountable care organizations allow providers to share in the savings they achieve through programs and services that might help with chronic disease management.
Working with community organizations helps address some of the social determinants of health with a more holistic approach. “Health care facilities are also taking steps to address the needs of the whole person, not just the emergent issue that brought someone into the doctor’s office or hospital,” Morton says. “This includes making referrals for mental health, social services, housing assistance, food shelf, or other resources.”
“We have some really great bright spots out there,” Knudson adds. “We’re working alongside those forward-thinking rural communities to identify successes so other communities can emulate what they’re doing to create a culture of health.”
These incremental steps continue to generate momentum, but it’s challenging to make meaningful progress without a significant change in the fee-for-service systems that dominate current payment structures. “Innovation in this area is promising for the future of rural health, and we’re seeing programs take shape at the state level,” Slabach says. “One of the payment systems we’re noting with great optimism is the Pennsylvania Rural Health Model, a Centers for Medicare & Medicaid Services Innovation project. This program transforms the incentive system for eight rural hospitals to begin the transformation to population health. The savings accrued stay in the community so they can be reinvested in other services that will improve the population.”
Prioritizing population health
“We need to step back and look closely at social determinants and make a case for greater investment in areas such as education and economic opportunity,” Knudson says. “We also need to look higher upstream to promote prevention. We spend the bulk of our money addressing health problems when it’s already too late, but what we really need to do is look at ways we can create improvements that support people to live and be healthy.”
In a speech to providers on Nov. 14, HHS Secretary Alex Azar said hospitals may soon be allowed to pay for certain services that cover the “whole person,” moving upstream into social determinants of health like housing and food that go beyond traditional medical care.
“As rural providers of care contemplate moving more intently into population health, flexibility and empowerment are helpful in expanding their work into areas such as housing and food insecurity,” Slabach says. “However, Medicaid reimbursement for most rural providers is often much less than the cost of providing care, which doesn’t provide the financial means by which these strategies can be implemented.”
The role of community organizers is another key to elevating population health. “Health happens outside of the four walls of our clinics and hospitals,” Knudson explains. “It happens where we work and where we play, where we go to church and gather. Recognizing the opportunities in rural and helping to pay it forward can help us continue to create resilient, vibrant rural communities.”
Working with other community members is critical, and Slabach believes there’s an opportunity to better prepare health care leaders for the importance of teamwork. “The future hospital administrator is not going to be an institutional manager,” Slabach says. “They are going to be a community organizer — someone who makes connections, builds consensus, and brings various organizations together under a common goal.”
Image © us.fotolia.com/Christian Hinkle