Integrated Approaches to Improving Rural Health Equity and Access

Rural communities face a unique set of health inequities that are not as common in urban areas. Two main contributors to this disparity are structural urbanism, the idea that current models of health care funding are biased in favor of large populations, and the mental health and recovery services workforce shortage which disproportionately affects rural health service delivery.

Social determinants of health are amplified by structural urbanism and contribute to barriers in accessing health care, such as limited transportation options, long distances to the closest health organization, limited internet access and health insurance coverage, low rates of health literacy and workforce shortages. The on-going COVID-19 pandemic has also worsened rural health disparities as rural communities have faced disproportionate numbers of COVID-19 cases, increases in unemployment and negative mental health impacts and other heightened disparities.

Black, Indigenous and People of Color (BIPOC) Populations in Rural Communities

Although rural health equity challenges impact all residents in rural communities, communities of color and other marginalized communities experience disproportionately higher rates of poverty as well as negative physical health, mental health and substance use treatment outcomes. Native Americans in rural communities in particular have faced high levels of historical injustice and report experiencing serious psychological distress 2.5 times more than the general population.

Several studies indicate that immigrant and migrant agricultural workers in rural communities experience significantly high levels of stress, depression and substance use. Among individuals who identify as LGBTQ+ in rural communities, health care barriers can include culturally insensitive health care practices, low levels of provider knowledge of LGBTQ+ specific health issues and, in some cases, anti-LGBTQ+ stigma that contribute to overall negative mental health and substance use outcomes.

Potential Solutions to Improving Rural Health Equity

Despite detrimental social determinants of health and provider shortages, there are several potential solutions to advance health equity in rural communities, especially through integrated health care strategies, as outlined in the National Council’s recent Rural Health webinar series below.

In the webinar series, Carolyn Rekerdres, M.D., and Marisa Giggie, M.D., MPAFF, presented key upstream strategies to advance rural health equity, including:

• Increasing equitable funding strategies through Certified Community Behavioral Health Clinics (CCBHCs). CCBHCs are a source of equitable funding to increase health care access and sustainability in rural communities, as they are required to provide services to individuals regardless of their ability to pay, including lack of insurance. Regarding long-term sustainability, Medicaid expansion in additional states would cover individuals who lack health insurance, allowing a payer source for the people who currently have no funding for care. Funding provided through the American Rescue Plan will allow for expanded mental health and recovery services in schools for Oklahoma students and across the state in Colorado.
• Improving equity infrastructure by increasing internet and cell phone access among rural individuals and households. Funding provided through the American Rescue Plan will likely be used to increase cell phone accessibility and internet service in rural areas.
• Broadly advancing telehealth in rural communities to provide several health care services, including mental health and substance use recovery services. Since 2016, 19% of rural School Based Health Centers (SBHCs) have used telehealth to provide integrated health services. Furthermore, school-based telehealth has become more pertinent to cover service gaps among youth populations during the COVID-19 pandemic. Telehealth has proven effective in other settings as well; in a recent study on telepsychiatry in a rural inpatient psychiatric facility, providers found it was effective, flexible and contributed to continuity of care among patients. Telehealth is also a promising solution to bridge care gaps in rural long-term residential facilities.

Several practice-oriented strategies may be considered as well such as:

• Use of the Collaborative Care Model, a team-based model led by a primary care physician who works together with mental health and substance use care managers, psychiatrists and other mental health providers to provide a measurement-guided care plan and focuses on principles of chronic care delivery.
• Increasing telemedicine opportunities at the individual clinic level to provide more flexible services for rural providers and clients.
• Expanding the role of nurse practitioners and physician assistants, specifically related to telehealth practices.

To address the overall workforce shortage, organizations are exploring options and designing innovative approaches. A few more tangible strategies that have been successful for rural health organizations include:

• Innovative Provider Recruitment Strategies. One suggestion described in more detail during the CoE’s recent webinar is to emphasize the benefits and strengths of being a rural health provider, such as career satisfaction, opportunities to innovate and serve as a community leader, quality of life and lower costs of living. Another recruitment strategy is to increase financial incentives for being a rural provider through things like loan repayment benefits, tax credit programs and scholarships.

Innovation Highlight: Dr. Marisa Giggie, associate professor of Psychiatry and Behavioral Medicine at the University of Alabama, prioritized an integrated health recruitment strategy through founding a Behavioral Health Fellowship in Primary Care, a one-year, clinical training program for family physicians upon graduation from program residency. This program increases knowledge of common psychiatric disorders and training in evaluation and treatment of these challenges among family medicine physicians. Hear more about this fellowship in our recent webinar.

• Advance Professional Development and Education of Existing Workforce. To strengthen the existing rural health workforce and newly recruited providers, it is important to also consider ways to advance professional development and education through collaborative learning and training. Project ECHO (Extension for Community Healthcare Outcomes), an innovative approach to virtual medical education and care delivery focused on brief didactic presentations and case-based learning on key health care issues, may serve as a bridge to strengthening the workforce and enhancing access to care in rural settings. The CoE provides several opportunities related to ECHO and is launching a rural health focused ECHO in fall 2021. Additionally, education on advancing health equity internally and externally within health organizations, as well as education around cultural humility related to health care considerations specific to marginalized rural populations, are essential to advancing rural health equity.

Although rural health equity challenges are extensive, in recent years, integrated health strategies have emerged in rural areas, some out of necessity due to COVID-19, and will continue to make tremendous impacts in rural communities across the nation. The strength and resilience of rural communities must be acknowledged and leveraged to improve the health and mental wellbeing of rural residents. Innovative organizations across the country are actively working in their communities to address these challenges, and collective discussion learning must continue.

Helpful Resources

• Healthcare Access in Rural Communities Overview – Rural Health Information Hub
• Rural Mental Health Overview – Rural Health Information Hub
• Mental Health and Rural America: Challenges and Opportunities – National Institute of Mental Health
• Structural Urbanism Contributes to Poorer Health and Outcomes for Rural America – Health Affairs
• Long-term Trends in Deaths of Despair – United States Joint Economic Committee