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| navigate: home: magazine: fall 2000: article | |
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Programs improve rural health in Pennsylvania By Mary B. Waltman | |||||||||||||||||
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Both residents and visitors enjoy traveling Pennsylvania’s back roads to take in the rugged, scenic beauty of the mountains and the rolling hills of contoured farmland. Although rural residents enjoy convenient access to these areas of natural beauty, finding access to adequate health care may not be as simple. The challenge to deliver quality health care services to rural areas involves issues unique to those communities. For instance, geographic isolation may be aesthetically appealing, but it might make it difficult to find conveniently located treatment centers, especially for special medical and emergency conditions. Because of professional isolation, lower salaries, insufficient technology, a shortage of trained personnel and longer hours, the recruitment and retention of physicians remain a challenge in rural communities. According to data compiled by the Pennsylvania Rural Health Association (PRHA), only 13 percent of the nearly 11,680 primary care physicians in the Commonwealth practice in rural areas. Related to the special challenges that exist is the fact that rural populations tend to be lower on the economic scale. According to U.S. Census Bureau data for the 1990s, the income gap between urban and rural areas increased, with only 40 percent of rural households earning $30,000 or more a year. By contrast, 60 percent of urban households earned $30,000 or more a year. In many rural areas where the largest employers are hospitals and schools, both economic stability and quality health care are dependent upon the continuing operation of the small community hospital. According to PRHA data, hospital closings result in a substantial profit loss that can affect the community’s ability to attract and retain businesses. Pennsylvania Office of Rural Health
The Pennsylvania Office of Rural Health (PORH) was established in 1991 to provide improved access to rural health care services. PORH is a joint effort of Penn State’s College of Health and Human Development and the College of Agricultural Sciences. It is funded by the U.S. Office of Rural Health Policy, Penn State and the Pennsylvania Department of Health.
Citing the great need for increased access to rural health services, PORH director Lisa A. Davis noted that of Pennsylvania’s 67 counties, 42 are classified as rural. In actual numbers, there are more people living in rural areas in Pennsylvania than there are in any other state. Two-thirds of Pennsylvania’s primary care providers, however, are located in urban areas. Because of the small percent of primary care physicians who practice in rural areas, a larger gap in the patient/physician ratio exists there than in urban areas. In 1996, rural Pennsylvanians had roughly one physician for every 655 residents, compared to one for every 325 residents in urban areas of the Commonwealth, according to data compiled by the Pennsylvania Rural Health Association.
To address these specific challenges, the Pennsylvania Office of Rural Health coordinates rural health programs and activities, assists in the recruitment and retention of primary care providers, creates a clearinghouse of information relating to rural health and offers technical assistance to rural community programs.
The strength of the Pennsylvania Office of Rural Health program lies in the recognition that each state has its own set of diverse problems and issues.
“It is not intended to be a cookie-cutter approach, where one size fits all for every state. Each state is unique,” Davis pointed out.
Since July 1999, PORH has been located in Beecher-Dock House on the University Park campus.
“We are an enigma,” Davis said. “Most offices are located in the State Department of Health. About five other offices are located on university campuses such as Penn State.”
Ann Cherry, PORH coordinator, pointed out that being associated with Penn State Cooperative Extension provides a “great conduit to rural areas.” Both women noted the importance of partnerships in achieving the success of increased access to quality health care for rural residents.
“The rural health alliance between the College of Agricultural Sciences and the College of Health and Human Development is truly a complementary partnership,” said Dr. Theodore R. Alter, associate vice president for outreach and director of Cooperative Extension and associate dean, College of Agricultural Sciences. “Together, we can pool the research and scholarship of our faculty members, the expertise of our Cooperative Extension field-based educators and our resources to improve the health and quality of life of Pennsylvanians, especially those living in rural communities.”
As part of the Office of Rural Health’s joint activity with Penn State Cooperative Extension, the Pennsylvania Office of Rural Health participates in a four-year Plan of Work (POW) for Penn State Cooperative Extension titled Healthy People, Healthy Communities. In this capacity, PORH works with Cooperative Extension agents to implement healthy community initiatives, provide technical assistance to county agents and develop in-service training sessions.
Another service PORH provides for Cooperative Extension agents is the collection of health and other community statistics to create a database of valuable information relating to rural health.
As part of the Pennsylvania Office of Rural Health’s outreach and education, and in collaboration with the Area Health Education Center for Pennsylvania (AHEC), the Office of Rural Health staff helps deliver continuing professional education seminars. Since 1997, 22 satellite programs by the Centers for Disease Control and Prevention have been downlinked at the University Park campus and other sites around the state. More satellite programs are planned. Rural Health Conference
One of the Pennsylvania Office of Rural Health’s largest projects, a statewide effort dealing exclusively with rural health issues, is the annual Rural Health Conference, which Cherry coordinates.
“We highly stress collaboration, networking and cooperation,” Cherry said. “It’s nice to know there is that kind of partnership and commitment. We all have the same goal.”
The conference is the only one in Pennsylvania devoted exclusively to rural health issues. It brings together physicians, nurses, educators, administrators, center directors and students.
“We run the gamut,” Cherry said, adding that there are always a wide array of interests represented and many beneficial interactions. In the past, participants have come from as far away as Florida and Australia to gather information for their rural health projects.
In addition to fostering partnerships among providers, educators and consumers, the Rural Health Conference strives to update and enhance knowledge and skills relating to health care education and technology. Featured speakers at the 2000 conference, held in June, included Pennsylvania Atty. Gen. Mike Fisher and Pennsylvania Secretary of Health Robert Zimmerman.
Some of the wide-ranging topics covered at the conference on Rural Health: Building Partnerships for the Future focused on agromedicine, community health, nursing, race and class issues in healthcare and telemedicine. Speakers addressed barriers to accessing health care services in rural areas, pesticides and farm safety, distance education in health care, developing rural health networks and maximizing physical abilities for farmers who want to remain in agriculture following an injury or health condition.
At the conference, Dr. Kathleen Fisher, assistant professor in Penn State’s School of Nursing, discussed the safety of Amish farm children. Fisher led a team of Penn State nurse researchers, in collaboration with the Clinic for Special Children and the Lancaster Safe Kids Coalition, to teach Amish children about farm safety the fun way.
The team developed an interactive game called “Amos and Sadie’s Farm — A Pathway to Safety,” featuring a board game of questions and answers. The project was funded by the Children’s Miracle Network and the Center for Rural Pennsylvania.
“The educational game, which is illustrated by an Amish artist, will be distributed to schools in the Amish communities. We plan to distribute games to hospitals and health centers located near Amish communities throughout the state,” Fisher said. AgrAbility
Several Penn State faculty members are involved in rural programs with supportive connections to the Pennsylvania Office of Rural Health. One program, called AgrAbility, is funded by the U.S. Department of Agriculture and operated by Penn State’s Department of Agricultural and Extension Education, in collaboration with the Easter Seal Society of Central Pennsylvania. AgrAbility assists farmers who are disabled or afflicted with medical problems to continue to produce crops and care for livestock. The program helps farmers who are disabled, such as by the loss of a limb, by offering them equipment and home modifications.
According to Dr. Connie Baggett, principal investigator for the project and associate professor of agricultural science and extension education at Penn State, modifications may come in the form of a complicated mechanical lift to assist a farmer without a leg to get up on his tractor. Another form of modification might be a simple door handle instead of a doorknob for a hand or arm injury.
Baggett explained that this “assistive technology” program is available to farmers, farm workers and their families involved in growing food or fiber products. To assess farming situations for modifications, he and an assistant conduct on-site visits to evaluate buildings and equipment. They make about 15 to 20 assessments each year.
“We are very safety-minded,” Baggett said. He has worked cooperatively with PORH for three years and said one of the greatest benefits has been to make it possible for older farmers to remain involved in their occupation. “It’s important to keep them in place until there are younger farmers to take over.”
Two other rural health programs are based in the College of Medicine’s Office of Primary Care in the Department of Family and Community Medicine: the Area Health Education Center of Pennsylvania (AHEC) and the Pennsylvania Agromedicine Program. Area Health Education Center
The Department of Health Resources and Services Administration and the Pennsylvania Department of Health fund the Pennsylvania Area Health Education Center.
According to Linda Kanzleiter, program manager for the Pennsylvania Area Health Education Center, strategic directives of the program aim to increase access to primary health care services in medically underserved communities through a network of community-based clinical training. AHEC has developed unique partnerships between academia and community that support a statewide medical education and training infrastructure for the primary care health professions. Through linkages between medical schools, health science institutions and community, AHEC enables the recruitment and retention of a qualified health professions workforce, especially in medically underserved communities, for the Commonwealth.
Pennsylvania AHEC also introduces primary and secondary school students to careers in the health professions by establishing programs such as shadowing health professionals, math and science camps, Health Explorers, as well as participating in the Governor’s School for Excellence in the health careers.
Community and public health programs are another way AHEC helps promote health in medically underserved communities. Working with partners from around the state, the Pennsylvania AHEC promotes community health education on diabetes, smoking cessation, teen pregnancy, asthma and other public health initiatives.
Areas in Pennsylvania identified as having a shortage of health care providers have been designated by the federal government as Health Professions Shortage Areas or Medically Underserved Areas.
The populations in these areas often have difficulty accessing quality health care and may be underinsured or uninsured. One way Pennsylvania AHEC strives to increase the number of health professionals in those areas is by developing education and training programs. In order to nurture student interest in the health sciences, the Pennsylvania AHEC has initiated programs to teach prospective medical students the important role that health care providers play in people’s lives. Helping sponsor job fairs, which attempt to match professionals with areas that desperately need their help, is one way AHEC achieves this goal.
Maintaining a quality-learning environment for health professionals is an important goal of the Pennsylvania AHEC, Kanzleiter stressed. Retention of health professionals is promoted by collegial support and continuing health professions education that allows them to remain current and enhances knowledge and clinical skills. Last year, AHEC offered continuing education programs statewide and to each AHEC region. More than 5,000 health professionals participated in programs, such as cancer updates, domestic violence, practice management, pediatric HIV and other public health and clinical topics.
By using state-of-the-art technologies, such as satellite broadcasting, the Internet and desktop conferencing, AHEC can help health care providers stay in touch with advanced procedures.
As reported in last year’s outcome measures, the Pennsylvania AHEC facilitated recruitment of four physicians, three physician assistants, one dentist, five nurse practitioners and one psychiatrist. Pennsylvania Agromedicine Program
The Pennsylvania Agromedicine Program is supported by the Pennsylvania Department of Agriculture. This outreach and education program operates in collaboration with the Pennsylvania Office of Rural Health, the Pennsylvania Department of Health, the Penn State College of Agricultural Sciences, Penn State Cooperative Extension and the Penn State College of Health and Human Development.
The Agromedicine Program is a partnership of health and agricultural professionals that promotes the health and safety of agricultural providers and workers, their families and consumers of agricultural products through a combination of the sciences of agriculture and medicine. Agromedicine topics include agricultural chemicals (safety, toxicity, oncology, teratology, etc.), noise-induced hearing loss, skin cancer, farm stress, insect-transmitted diseases and other areas of preventive, occupational and environmental medicine, rural health and primary care.
The Pennsylvania Agromedicine Program also is a key partner for the annual Rural Health Conference, offering workshops and educational sessions on agriculture and farm worker health issues for physicians, nurses, emergency medical personnel, migrant health workers and others.
Dr. Rugh Henderson, director of the Agromedicine Program at Penn State and a family and preventive medicine physician, sees the program as “integrating the medical science with the agricultural sciences of the land-grant university.”
One of agromedicine’s projects included the video production of a training guide for farmers, farm workers and applicators in the handling of pesticides and chemicals, as part of the Environmental Protection Agency Worker Protection Standard.
“We work closely with the University’s agricultural programs and the Pennsylvania Office of Rural Health,” Henderson said. The Pennsylvania Agromedicine Program collaborated with AHEC to launch a statewide training program for emergency medical personnel dealing with farm emergencies. He noted that the emergency could be anything from a fire involving pesticides to a tractor rollover. Currently, the Pennsylvania Department of Health is collaborating on workshops to prepare school nurses to deal with pesticide use in schools and Integrated Pest Management.
“The greatest benefit of agromedicine is the direct input by medical personnel to agricultural science programs and vice-versa,” Henderson said. “We used to exist independently, but now we are communicating and integrating information and activities. Better programs result because of the input of the expertise of the various agricultural and health care professionals.”
Henderson said he believes the link between the agricultural sciences and medicine is important.
“There is a need for current reliable information and advice for Pennsylvania citizens,” he said. “Many rural and environmental health issues generate a broad spectrum of opinions and ideas. The Pennsylvania Agromedicine Program seeks to be a source of sound information that is scientifically based.” Pesticide applicators training and certification
The Swimming Pool Pesticide Applicators Training and Certification Program is another outreach program conducted in partnership with the Pesticide Education Program of the College of Agricultural Sciences and the Penn State Aquatics program. The Pennsylvania Office of Rural Health staff serve as coordinators and facilitators for the training and certification of individuals who apply chemicals to public swimming pools. Certification is required under the Pennsylvania Pesticide Law.
The applicators program, which began four years ago, uses interactive compressed video technology to deliver the programs to five campuses: Penn State Harrisburg, Penn State New Kensington, Penn State Wilkes–Barre, Penn State Great Valley and University Park campus.
Davis reported that in the past two years, 631 applicants received certification and 637 received recertification. Since 1996, 1,910 participants have attended 13 training sessions. She noted that the format for the program originated with a project to certify health officers and became so successful that they were asked to use it for swimming pool applicators. The Pesticide Education Program offered by the College of Agricultural Sciences provides the core staff for the training sessions. Medicare Rural Hospital Flexibility Program
To help struggling rural hospitals remain financially viable, Davis said the Medicare Rural Hospital Flexibility Program/Critical Access Hospital Program, or FLEX, was established by the Balanced Budget Act of 1997. The Pennsylvania Office of Rural Health collaborates with the Pennsylvania Department of Health and the Governor’s Policy Office on the statewide implementation of the project. The program helps preserve access to primary care and emergency services, as well as improve reimbursement of services.
To qualify as a Critical Access Hospital, the applicant must be a Medicare program participant, have a maximum of 15 acute care beds (or a maximum of 25 if participating in a “swing bed” program for long-term services) and have an average annual length of stay of 96 hours. The facility must also be located in a rural area at least 35 miles from another hospital (or 15 miles in mountainous terrain or areas with only secondary roads) or be identified by the state as a necessary provider. To be eligible for designation as a Critical Access Hospital, the facility must be located in a state that has a rural health plan. Rural dental care program
Providing dental care poses another challenge for rural health facilitators. Dr. Deborah Bray Preston, associate professor in the School of Nursing, College of Health and Human Development at Penn State, sought to improve dental health care in rural Pennsylvania. Through the Area Health Education Center and the Pennsylvania Office of Rural Health, Preston was able to obtain assistance and funding for dental programs in Juniata and Mifflin counties, where her research uncovered a dire need for dental care.
“There is nothing available for low-income groups,” she noted. “The health care of these populations is so unbelievable. We hope to hire a part-time dentist, first to serve the children and later, with increased funding, the adults.”
In her pursuit to acquire better health care for this rural group, Preston used the statistical database maintained by the Pennsylvania Office of Rural Health to support a grant proposal to fund the project.
In explaining the need for the collaboration of several different groups, she said, “There are many different fingers in the pie. Even as a researcher, I find that rural is generalistic.”
Funding for the dental grant is being provided through the Penn State College of Health and Human Development and the Northeast Regional Center for Rural Development.
The Pennsylvania Office of Rural Health (PORH) also collaborates with the Bureau of Health Planning of the Pennsylvania Department of Health in its efforts to improve the quantity and distribution of primary care practitioners, especially in rural underserved areas. The Bureau of Health Planning has developed a continuum of programs targeted at improving access to health care in rural communities, ranging from interdisciplinary student educational experiences, medical school education and curriculum, practice supports such as the Loan Repayment Program and Area Health Education Center and site development through the Community Challenge Grant Program. Representatives of PORH collaborate with the Bureau of Health Planning in many of these programs by participating in the Loan Repayment Program Application Review Committee, the State Health Improvement Plan and its associated committees and taskforces and by assisting in the evaluation of applications for Community Challenge Grants and being a source of data and information on rural health status as the Bureau of Health Planning develops and evaluates its primary care initiatives.
As part of their outreach activities in this area, the Pennsylvania Office of Rural Health staff, in conjunction with other rural health advocates, coordinated a one-day workshop in Harrisburg last year on federal grant programs and grant-writing techniques. Ten proposals were submitted, and according to Davis, the outcome resulted in several contacts expressing preliminary interest. PORH hopes to plan more of these regional workshops in the future.
Davis and Cherry said collaboration among the various groups is necessary in meeting their goals to provide quality health care to rural areas.
“We couldn’t exist on our own,” noted Cherry, who has been with PORH for three years. “We’re just one piece of the pie. It takes all of the pieces to make it work.”
Cherry said she would like to see businesses join with local communities to improve health care because then “everyone benefits.”
Davis, who previously was outreach coordinator for the Department of Health Policy and Administration at Penn State, added, “We’d like to expand our outreach and connections to the College of Health and Human Development, the Department of Health Policy Administration and Penn State Cooperative Extension to become more integrated into what the college is doing.”
Because of the cooperation among various academic groups and health organizations, Davis remains optimistic about meeting the goals of rural health care in the future. In the fall 1999 issue of the Pennsylvania Rural Health newsletter, she wrote that the transition of the office to its new administrative location has brought increased resources, including increased access to health services researchers and enhanced outreach activities to health care professionals in Pennsylvania. “We are fortunate, as well, to have our ties with Penn State Cooperative Extension strengthened and formalized.”
Collaborations and partnerships are helping the Pennsylvania Office of Rural Health make a difference in people’s lives.
In the future, Davis said she would also like to “increase the efforts for additional continuing education and outreach programs.” Finding the funding for these programs is a large part of the plan, as well as finding additional partners in state and civic organizations. “The new push is to create community partnerships. Each entity is dependent upon the other — business, education, health services, financial institutions and civic organizations — and all need to work together for the common goal,” Davis added.
An outreach program of the College of Agricultural Sciences, Penn State Cooperative Extension and the College of Health and Human Development | ||||||||||||||||
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© 2002 Outreach Communications, Outreach & Cooperative Extension, The Pennsylvania State University phone: (814) 865-8108, fax: (814) 863-2765, e-mail: outreachnews@outreach.psu.edu |
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