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.