In Pennsylvania, rural elderly are the fastest growing segment of the population and are projected to increase by 30 percent over the next 20 years. According to experts, there is a severe shortage of nurses and physicians ready to take care of these older adults, with the greatest scarcity in rural areas. The new online Graduate Certificate in Geriatric Nursing Education—a program of the John A. Hartford Center of Geriatric Nursing Excellence at Penn State and Penn State's School of Nursing, delivered through Penn State World Campus—aims to address this challenge. The certificate will give nurse educators a background in geriatric nursing that they, in turn, can use in teaching RNs and nursing students—in areas with the most need—the information and skills to work with elderly patients. "There is a hunger for this type of knowledge," said Dr. Ann Kolanowski, director of the Hartford Center, explaining that the center often hears from area nurses seeking the latest research on elder care. "They really want to know how to care for frail, older adults."

Other efforts include:

• The School of Nursing is able to prepare nurse practitioners all over the state by offering a master's—level program with a rural focus, through video conferencing at every Penn State campus.
• The Bachelor of Science in Nursing (RN to B.S.), offered by the School of Nursing through World Campus since 2004, allows RNs to earn a bachelor's degree, which in turn lets them pursue a graduate degree and the opportunity to teach. There have been more than 400 participants in the program to date.

Photo: Gretchen Graham

To urban types, a place like Greene County seems lost in time—with residents isolated by its mountainous terrain, harsh winters and lack of public transportation. Steeped in Appalachian culture, residents are suspicious of intervention and have learned to rely on themselves, their families and their neighbors for support.

"It's like another world here," said Dr. Mona Counts, Elouise Ross Eberly Professor of Nursing at Penn State. "You don't see it exist in other places. Because it's so different, others tend to look down on it. But the people are wonderful. I'm very protective of them."

Counts is a fixture here in Greene County, where the population is the poorest in the state. For 15 years she has been the director of the Primary Care Center of Mount Morris—which offers preventive and primary care services for the county's geographically and culturally isolated, underserved families, regardless of their ability to pay. Now, as an extension of that facility, a mobile health clinic has taken to the roads throughout the county.

For up to four days a week, in different routes publicized in the "Green Saver" and through word of mouth, the mobile clinic sets up at churches, granges, food banks and other convenient places throughout the county, offering the same health services as the Primary Care Center.

"We call ourselves the ‘circuit riders,'" said Counts.

Barriers to Health Care

The mountainous terrain discourages Greene County residents from seeking care at facilities outside of their community. Services available 20 to 30 miles away may take residents as long as an hour to travel the distance along the narrow, winding roads. Bad weather is known to double the travel time. Plus, there are a high number of older adults in Greene County living alone who are not comfortable with driving.

Even those willing to travel might not have health insurance or be able to afford the gas to get to a facility. Greene County—where coal mining is the primary industry—is one of the two counties in Pennsylvania identified by the Appalachian Regional Commission as a distressed Appalachian county. According to census data, household income here is more than $10,000 below the state average, and many employers can't afford to buy into health care plans.

Appalachian culture is another barrier to seeking out care. "They tend to utilize self-care practices," said Counts. "For example, they will use tea and hot toddies to treat colds and not consult a health care professional until they develop pneumonia. They show little interest in how their actions may impact their future." Counts cites as an example a patient who received a diagnosis of lung cancer. "He places the blame on the ‘fact' that he is just cancer-prone, not his years of smoking history."

Nurses More Approachable

Residents are also hesitant to seek out health care services from individuals who don't understand their way of life or who they perceive are talking down to them, said Counts. Counts has found through her research—interviews with hundreds of residents—that the people of Greene County are more likely to seek professional services provided by nurse practitioners than by doctors. "Nurses are perceived as more approachable, understanding and part of the community," said Counts. "They are not perceived as ‘highfalutin'—a typical Appalachian statement."

Gov. Ed Rendell sees facilities led by nurse practitioners—registered nurses who have completed advanced nursing education, including a master's degree and possibly a doctorate—as a vital way to increase access to health care.

Rendell and University of Miami President Donna Shalala recently called nurse-managed health care centers—particularly for low-income and vulnerable populations—a "solution in plain sight." This has been the case for patients at the Primary Care Center of Mount Morris, which provides services to the more than 5,000 individuals in the area who can travel there. The center is staffed with nurse practitioners who are schooled in Appalachian culture and who educate patients on prevention and the connection of behaviors with illnesses.

For example, one man who came in after cutting his hand on ice told Pam Armstrong, a nurse practitioner at the center, that he hadn't been to a doctor in 15 years. He was overweight, so Armstrong checked his blood sugar. It was high, at 500. "We got him on medication and talked about the benefits of fruits and vegetables. Six months later he lost 40 pounds, and his diabetes is under control," said Armstrong, adding, "Mona and the center have a wonderful reputation."

On the Road

Armstrong herself grew up in southern Appalachia and came to the center as a nursing student. She was asked to stay on after she graduated, and she helped work on the initial grant to get the center's mobile health clinic moving. It has been on the road for about a year now. The mobile unit's staff includes a nurse practitioner, medical assistant and a social worker, offering the same services as the center. Recently, dental services were added to the mix.

"Now people can drive a few minutes instead of a half-hour to get to a clinic. They can save that gas money for food or medicine," said Armstrong. Armstrong sees the benefits. For example, an elderly woman who used an oxygen tank found it difficult to get out and go far. She had been consulting a doctor in her town, but he left the area.

"She was able to come to us when our mobile clinic was near her home," said Armstrong. "She had diabetes and had been put on a complex regimen of insulin. She was having trouble reading her syringes because of her failing eyesight. We were able to educate her and get her on a simpler regimen. Since then, she's been feeling better."

Diabetes and other chronic diseases such as hypertension are common in Appalachia, because of lifestyle and genetics.

Robert Mt. Joy of Cornerstone Care, which manages both the center and the mobile unit, said that early indications show that the mobile unit is doing everything he'd hoped. "It has taken hold quickly," he said, adding that he expects the unit to reduce inappropriate use of emergency rooms.

The unit will soon make stops in neighboring Fayette County as well.

While medical mobile units are used regularly around the world to accommodate hard-to-reach populations, Counts likes to view the mobile health project of the Mount Morris Primary Care Center as unusual, because of its interaction with a large research university.

"It shows that Penn State is fulfilling its mission as a land-grant university, by addressing the need for access to health care and improving quality of life," said Counts, who teaches a full workload in addition to working at the center. "The School of Nursing has been phenomenal."