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| navigate: home: magazine: spring 2002: article | |
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Health care for rural residents: Responding to need By Crystal L. Hull | ||||||
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Improving access to basic health care in a region of the country identified as having the worst health status in the nation is no small undertaking. But two organizations, the Robert Wood Johnson Foundation, the nation’s largest philanthropy devoted to improving health and health care, and the Penn State College of Medicine, an organization known for its commitment to world-class care, have joined their resources to improve the health care of a population that has for too many years been underinvested in by both public policymakers and private philanthropies. The Southern Rural Access Program, a grant program administered by the Rural Health Policy Center at the College of Medicine in the Milton S. Hershey Medical Center, was initially given $14.5 million over a three-year period to improve health care in eight of the most rural, medically underserved states in the country. The program, reauthorized in January by the Robert Wood Johnson Foundation for another four years, received $22.5 million for Phase II initiatives. The Phase II allocation brings the total investment to $41.1 million for the administration, implementation and evaluation of the program for a period of more than eight years. Since its inception in 1998, the program has strived for improvements in access to care in the states it serves: Alabama, Arkansas, Georgia, Louisiana, Mississippi, South Carolina, (East) Texas and West Virginia. The health-care problems in these states are daunting — too few providers in rural areas, not enough students being properly prepared for careers in health care, too many uninsured people and not enough capital for infrastructure improvements. The program focuses on four key component areas: recruitment and retention of rural health-care providers, development of rural health leaders pipelines, development of rural health networks and creation of revolving loan funds. Robert Wood Johnson Foundation funds also support the 21st Century Challenge Fund, a matching grants program that provides money for small demonstration or analytical projects. “This program component allows Penn State to make grants that reflect the access-related priorities of local communities, even if they don’t fit into the core components of the Southern Rural Access Program,” explained Curtis E. Holloman, deputy director of the Southern Rural Access Program. “In the first phase, $2.5 million was allocated.” According to Michael Beachler, program and center director and Penn State alumnus, four factors influenced the Robert Wood Johnson Foundation’s decision to place the national program office within Penn State. “First, there was a positive track record established with the College of Medicine as a result of the Generalist Physician Initiative (a Robert Wood Johnson Foundation grant program) that has some commonality with the Southern Rural Access Program. Second, there was great admiration for both Mac Evarts (C. McCollister Evarts, retired dean of the College Medicine) and Jim Herman, who both played a key role in the administration of the Generalist Physician Initiative. “Third, at the time the decision was being made as to where to place the national program office, the merger between Penn State and the Geisinger Health System, which administered the largest rural HMO in the nation, was pending,” Beachler said. “The foundation felt it was a worthwhile experiment — bringing together a strong College of Medicine and a strong rural health delivery system. “And fourth, the plan for the rural access program originally included two target regions, one in the southern tier and one in the western/frontier tier,” he said. “To avoid showing favoritism, it was decided that the location of the national program office should not be in any of the grantee states. Even though the western region of the program wasn’t included in the final plan, the idea of placing the office in Hershey remained intact.” Dr. James M. Herman, MPH, associate dean, primary care, and professor and chair of the Department of Family and Community Medicine, concurs with Beachler’s assessment. “When the time came for the foundation to put the Southern Rural Access Program into motion, it was looking for a home with experience in leadership development, primary care infrastructure building and managed care. Hershey seemed to be a good place, because we had it all. We had been a past recipient of two Robert Wood Johnson Foundation grants and had worked diligently over a six-year period to improve the primary care environment within the College of Medicine.” “The College of Medicine has been given an opportunity and responsibility to provide leadership for the largest rural health grant program ever launched by a philanthropy in this country,” Beachler emphasized. “It’s been helpful to us to be part of a learning organization that can support our center administratively and organizationally and also use our lessons learned for a positive effect on the institution.” The Rural Health Policy Center has a multiplicity of roles as the national program office for the Southern Rural Access Program. “While a vast majority of the center’s efforts are aimed at administration and leadership of this very complex program, we are a catalyst at times to stimulate ideas and disseminate ideas across the states and, at other times, we are teachers and even cheerleaders,” Beachler explained. “We’re also program monitors and play an important role in the grant selection process. As the program matures, the office will play an even greater role in disseminating and translating lessons learned to the field.” Holloman added, “In many cases, if the Robert Wood Johnson Foundation and the College of Medicine had not been invited to come into these rural communities as partners, we would be seeing more people without health care — both preventive and early interventions — and health conditions would worsen. There would be devastating health consequences for residents of these communities if it weren’t for the types of interventions we are supporting. “We find that some rural folks often put off traveling great distances to see a provider and, in many cases, won’t go to a doctor until they are ‘dead sick.’ They often wait until they can’t get out of bed and someone makes them go to the doctor. We are addressing these types of problems through our efforts to recruit and retain providers in rural communities, as well as to provide support for programs that provide transportation services for patients to and from their medical visits,” he said. “Through our 21st Century Challenge Fund, kids in Alabama, Louisiana and West Virginia are receiving dental services for the first time,” Holloman said. “For some children, it may be the first time they have seen a dentist. Through our leadership efforts, outreach programs are being developed to recruit more dentists willing to serve Medicaid patients and increase the number of children accessing care.” One of the strengths of the Southern Rural Access Program has been the emphasis on listening to those who are closest to the problems and are able to change mindsets that have developed through generations. “The most rewarding and interesting role I have played has been as a facilitator and host of a series of dialogues about significant issues affecting access to care in the South,” Herman said. “We’ve been able to have deeper conversations than people usually have about the root causes of the problems as they relate to social-economic inequalities, race, gender and barriers to health care that have developed for generations within families. Through these dialogues, participants learn that trust is a necessary prerequisite for effective access and also how trust can be built as people heal and undo generations of pain.” The Rural Health Policy Center also has learned some key lessons and gained invaluable experience that can be applied to rural health initiatives in both Pennsylvania and in rural communities all across America. “While they have a long way to go, there are issues being addressed at the policy level more effectively than many other states, including Pennsylvania,” Beachler said. “Many of our grantees use the resources of university-based health policy centers either as project lead agencies or as analytical resources,” he said. “Pennsylvania health-care policy could be improved through state government/university partnerships like those that exist between state health agencies and the university-based Arkansas Center for Health Improvement and Georgia State University’s Health Policy Center and the state’s Department of Health. New models can be developed from the ground we broke in the Southern Rural Access Program, as different ways have been found to do things that weren’t successfully being done before.” Examples include South Carolina’s statewide system of providing a locum tenens service that could have broad applicability to Pennsylvania and other areas. Its name translated into English is “local tenant” and, in this situation, the visiting physician who assumes the role of the local medical provider for the community in the absence of the area’s established provider is the local tenen. This win-win situation helps to meet the needs of rural providers who often do not have a support system in place to relieve them of their duties when they need a vacation or want to pursue continuing education. Locum tenens services benefit family practice faculty and residents, as well, by providing real-world training experiences. Regionally organized, the South Carolina service marries the needs of the rural and academic communities. Herman thinks Pennsylvania can learn from this effort and others. “We’re learning a lot together, and this helps us work on new programs,” Herman said. “For example, we are actively looking at incorporating how we could bring together a series of partnerships to make a locum tenens program work in Pennsylvania. We’ve also learned quite a bit about policy initiatives that work and are giving serious thought to how we can influence policy at the local, state and national level.” There has also been increased recognition of the importance of nonprofit Area Health Education Centers (AHEC) in the delivery of health care through flexible, neutral approaches of bringing people together to manage a wide variety of roles within different states. “We can learn a lot about innovative AHEC programs from several of our states,” Beachler noted. “Whether it’s Pennsylvania, North Carolina or any of our eight grantees, relationships have to be developed with the academic medical institutions and the offices of rural health, AHECs, rural health associations and state departments of health,” said Holloman, a former public health director and community health center administrator from North Carolina. Herman is a strong advocate for bringing academic health centers into the loop. “I encourage linkages between premedical school activities and activities in academic health centers,” Herman said. “Our Generalist Physician Initiative and Area Health Education Center program experiences have been invaluable in guiding the grantees on issues such as how you recruit a provider and what role the community has in it.” Another program success related to recruitment and retention is the revolving loan funds that provide much needed access to capital. The loan funds have found new ways to secure capital resources from private banks, federal and state capital funding streams and philanthropic resources. The loan funds are increasingly starting to receive national attention, especially in Arkansas and Mississippi, where nonprofit organizations with a traditional emphasis on economic development have expanded their portfolios to include health-care providers in their efforts to strengthen the economic viability of rural communities. The grantees have been very fortunate. Creative and interesting collaborative partnerships have been formed involving health-care system players, private philanthropies and federal programs. There has been an unusually high degree of leveraging of resources. Sustaining the levels of these partnerships will be challenged once the Robert Wood Johnson Foundation resources are no longer available, but there are early success stories. For example, the Arkansas River Valley Rural Health Cooperative has developed partnerships with local tax resources, state government, the foundation, two federal government resources and philanthropic sources. It has used these resources to launch insurance coverage, disease management and pharmaceutical discount pilots for medically indigent adults in a four-county area. Much of the program’s success rests on two main factors — its design and the people and resources chosen within the states. “The program’s design has been a real key to its success,” Holloman said. “It’s not a cookie-cutter approach. The program was designed to allow for flexibility by the grantees in developing solutions that fit their needs. It also was designed as a competitive process whereby the grantees were challenged to design interventions that would have the greatest impact and chance for success. We challenged the grantees to be strategic, innovative and creative and try new approaches. “From the initial grantee application workshop to the submission of their Phase II application, we let the states decide who should be the lead agency and with whom they needed to partner to make lasting changes,” Holloman added. “For some states, it was the first time that many of the players had ever come together for a common cause. Since the program is about system building, we challenged the grantees to invest in people and resources that will build and sustain systems.” Phase II of the program will demand just as much, and maybe even more, partnership building than the first phase. The foundation has challenged the grantees to cluster their interventions in a specific geographic region of the state to continue to emphasize the “community development” orientation that each of the states embraced over the past three years. States will need to find more partners willing to provide resources and funding to sustain some of the program interventions beyond the Robert Wood Johnson Foundation’s funding and College of Medicine’s staffing support. “The next four-year authorization is certainly an example of the foundation and Penn State continuing their commitment to partner with others to improve access to care in this underserved area of the country,” Holloman said. “Dean (Darrell) Kirch has talked about taking Penn State outside the traditional institution and into the community. This program is a prime example of that goal being realized.” “Reauthorization will provide an opportunity in each state to continue the progress made in providing lasting change for real people in need,” Beachler added. “Our future beyond the next four years is uncertain. However, we will make these four years as productive as possible and will look for new opportunities to make a difference in the rural health field.” An outreach program of the Rural Health Policy Center at the College of Medicine | |||||
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