putting the family perspective into rural health care farm foundation national public policy...
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Putting the Family Perspective into Rural Health Care
Farm Foundation National Public Policy Education
Conference
Sept 20, 2004Roberta Riportella, PhD
University of Wisconsin-MadisonUniversity of Wisconsin Extension
Objectives To understand a family perspective
on creating health for families To consider how rural families may
be uniquely affected by changing demographics and health policy
To consider how a family perspective might lead to different solutions for creating health
Methods Consider what we know about
creating health Consider who rural families are Put those rural families into a model
explaining families’ role in health Consider what kind of system is in
place to address risks and poor health outcomes for rural families
Direct and Contributing Factors to Health
Direct Lifestyle Factors (50%)
Cigarette Smoking Alcohol & Drug Consumption Nutrition Stress/Mental Well-Being Body Fitness
Environment (20%) Biological
Predisposition (20%) Health System (10%)
Contributing Education, Income
(SES) Self-Esteem Social Support Community
Norms, Beliefs, & Expectations
Family
Household in which we grow up, household which we create as adults
Legal and non-legal attachments, mom,dad,kids,grandparents,extended family, guardians
Family Health and Illness Cycle
I llness appraisal
Health promotion
Vulnerability
Acute response
Adaptation
FAMILY
Doherty, William J. (2002). A family-focused approach to health care.
Illness Appraisal Disease is not merely a biological
phenomenon
Disease: the sickness/diagnosis itself, bodily processes
Illness: the manifestation of disease in and through the individual experience of disease
Health Status Health status of the adult rural
population was more frequently described as fair/poor. (28% vs. 21%).
Chronic conditions in the adult population as diagnosed by physicians were also more prevalent in rural areas. (47% vs. 39%)
http://www.nal.usda.gov/ric/index.html
Southeast Asian refugees
poorer health status accepting perception of well-
being beliefs about cause of disease beliefs lead to type of healer
Health Promotion and Risk Reduction Socialization extends to the variety of
habits, attitudes, behaviors, actions toward health, as well as attitudes toward using the formal health care system
What do we learn? Who needs to be part of the “treatment?” Are choices individual/family/societal
responsibilities?
Complications to making positive choices Food shopping limited, healthy foods
expensive No health clubs/indoor shopping malls
for walking Social life around taverns
Alcohol and smoking culture Liquor stores Good information (often confusing
messages, internet-based)
Vulnerability and Disease Onset Social support in the family
Social ties Stress in family life
Acute Response The immediate aftermath of illness
for the family
Adaptation to Illness and Recovery The family as the setting for care
of the recovering or chronically ill member.
Implications Delivery system: Differently trained health
care providers Teaching so providers can assess the influence of
family factors on health and thereby Understand individual as whole person and as member
of larger units of family and social/cultural environment Treat family members as partners in health care
Financing and organization of health care Ability to pay/be insured
Coverage of all family members Availability of providers
Geographic: Supply of ProvidersHealth Care Personnel
The supply of health care personnel represents one of the greatest contrasts between rural and urban areas in the United States.
While the rural population makes up 1/5 U.S. citizens, only 1/10 physicians practice in rural areas.
Specialists are concentrated in urban areas. Generalists are far more likely to practice in rural. One reason is rural physicians earn less money.
http://www.nal.usda.gov/ric/richs/stats.htm#demographicshttp://www.nal.usda.gov/ric/richs/stats.htm#demographics
Geographic: Supply of ProvidersHealth Care Facilities
Rural hospitals 2226/5134 in rural areas Most fewer than 100 beds, mainly
private nonprofits but also include those owned by state and local governments and for-profit hospitals.
Heavily dependent on Medicare 1991-1995 363 rural hospital closures 1999 only 24 closures
http://www.nal.usda.gov/ric/richs/stats.htm#demographicshttp://www.nal.usda.gov/ric/richs/stats.htm#demographics
Community Activation of Family Health Care: An emerging model
Patients and families as partners with professionals Families as producers of health promotion,
not just consumers of health care Learning, coping, and healing occur
best within communities Identify and activate potential
communities Community asset building perspective
Key Findings NACRHHS Report Benefits to integrating behavioral health
and primary care in rural settings Access to oral health services in rural
communities very limited Rural elderly face significant challenges
in accessing needed services Not necessarily family-centered report
Behavioral health (BH) and primary care in rural settings
Primary care practitioners have major responsibilities for diagnosing and treating common mental illnesses (depression)
BH services are highly fragmented due to staff shortages
Separate facilities for mental and physical health care
Autonomous BH and primary care providers practice with informal referral relationships
Primary care and BH providers do not share joint responsibility for managing patients
Behavioral health (BH) and primary care in rural settings: Barriers
Higher percentage un- and under-insured for both physical and mental health
Medicare rules set standard. Higher copays Only certain professionals reimbursed (not
marriage and family therapists) Rural areas have less reimbursable
providers to work under Higher copays + less choice + cost sensitive
consumers => less access
Behavioral health (BH) and primary care in rural settings: Strategies
Diagnosis and treatment by a fully integrated clinical team
Co-location of providers Dual certification of providers Unknown efficacy of these approaches Use of Rural Health Centers (3500)
authorized to provide mental health but few do (only recover 50% cost; paid less than FQHC)
Factors limited oral health Lack of fluoridated community
water supplies Older populations (lifetime of risks,
old habits) Increased poverty
Less food choice (soda bottle babies) Limited access to oral health care
Rural oral health status Untreated dental caries
31.7% rural, 25.2% urban Lost all teeth
16.3% rural, 8.8% urban (45-64 yr olds)
37% rural, 27% urban (65+)
Access to Oral Health Care Factors limiting access
Geographic isolation/lack of adequate transportation Lack of dentists participating in publicly financed
programs (~16% nationwide) Low public financing (<2/3 prevailing rate) Population thought to miss appts, not comply with advice Administrative burden
Uneven distribution of practitioners Poor coordination between dental and medical care Lack of dental insurance Cultural attitudes toward dental care Professional competition issues
Health challenges for rural older adults 40% of all older adults report good health
Rural older adults report fair to poor health 1½ more than urban older adults
Continuous poverty Difficulty accessing transportation Distance to care Lack of knowledge of available services
Lack of nearby younger family caretakers Shortage of qualified workers
Rural elderly face significant challenges in accessing needed services
1.6 million older adults in nursing homes
Fewer home and community based services makes nursing home use greater in rural 66.7/1000 beds rural 51.9/1000 beds urban
Medicaid 10.1% rural, 8.2% urban
Emerging Issues Obesity and wellness
Higher rates of chronic disease and limitations on activities of daily living
Higher rates of obesity Regular physical activity reduces risk yet inactive leisure
time more common among rural residents. Strategies
Steps to a Healthier US community grant program (CDC) for diabetes, obesity and asthma prevention
Targets prevention efforts: physical inactivity, poor nutrition, tobacco use
$13.7 million, $4.4 to small cities and rural communities At-risk populations (ethnic, low-income, disabled, youth,
senior citizens, uninsured, underinsured=rural) Small city/rural communities component (Washington, NY,
Arizona, Colorado)
Emerging Issues: cont’d. Access to specialized services (terminal
illness) Travel far for diagnosis and treatment Lack of hospice care
Health system changes Vulnerability of rural providers to rapid
increase in insurance plans that intend to have consumers avoid providers with higher prices
Consumers may travel greater distances, further jeopardizing infrastructure of providers for those who cannot travel
Families need to be supported in their roles as creators/maintainers of health Knowledge
What works, what doesn’t Resources
Income Insurance Formal support (health care system)
References Doherty, William J. (2002). A family-
focused approach to health care. In K. Bogenschneider (ed). Taking family policy seriously: How policymaking affects families and how professional can affect policymaking. Mahway, NJ: Lawrence Erlbaum Associates.
The 2004 Report to the Secretary: Rural Health and Human Service Issues. The National Advisory Committee on Rural Health and Human Services. ftp://ftp.hrsa.gov/ruralhealth/NAC04web.pdf
References: cont’d. Rural Health Policy Institute, U of Nebraska,
http://www.rupri.org/HealthPolicy/
http://www.rupri.org/ruralHealth/presentations/mueller111202.pdf
http://www.ers.usda.gov/emphases/rural/gallery/
Trends in the Health of Americans Chartbook:http://www.cdc.gov/nchs/products/pubs/pubd/hus/metro.htm
References: cont’d.http://www.shepscenter.unc.edu/research_programs/Rural_Program/mapbook2003/totalpopulation.pdf
Map book http://factfinder.census.gov/servlet/Basi
cFactsServlet Geographic Comparison Table Census
2000 http://factfinder.census.gov/servlet/GCTTable?_bm=y&-geo_id=01000US&-_box_head_nbr=GCT-P1&-ds_name=DEC_2000_SF1_U&-_lang=en&-format=US-1&-_sse=on
References: cont’d. Uba, Laura. Cultural barriers to
health care for Southeast Asian Refugees. Public Health Reports, 107, 5, Sept-Oct 1992: 544-548.
Fadiman, Anne. The Spirit Catches You and You Fall Down. New York, The Noonday Press, 1997.