Online training could help rural doctors offer better mental health care

More than half of all U.S. mental health care takes place at the primary-care level, and that percentage is even higher in rural areas, where mental-health doctors are often hundreds of miles away, reports Newswise, a research-reporting service. A new online training program could help rural primary-care doctors better treat patients with mental health issues, and that could be important in Kentucky.

The Behavioral Health Education Center of Nebraska, a part of the University of Nebraska Medical Center, designed the program. Educational Director Howard Liu said primary care doctors are overwhelmed by the amount of mental health care they must provide. Newswise reports "the goal is to help primary care providers get more comfortable as they prescribe medications and refer patients to psychiatrists and therapists." The adolescent version of the program was released last fall and is being used by doctors worldwide. The adult and geriatric version will be released this spring.

Primary care doctor Angie Brennan estimates 35 percent of all visits to her practice have been mental health related. She said there are specific rural challenges to treatment, including "reluctance to see a counselor and a lack of mental health insurance coverage – combined with an intensified fear that someone in the community will find out a patient has mental health issues." (Read more)

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Sept. 13 forum in Somerset will explore how rural communities can get healthier and get better care at lower cost

"In an era of tight budgets and strained resources, Kentucky and its rural communities can no longer afford 'business as usual' in the delivery of health care services," write Susan Zepeda and Amy Watts of the Foundation for a Healthy Kentucky. "As health care costs increase and health status declines, the question becomes: How can we ensure rural Kentuckians get better health care at lower costs?"

Zepeda, the foundation's president, and Watts, is senior program officer, see "promising opportunities" for rural communities to reshape health care, such as working with local health departments and civic leaders to "create communities that support healthy behaviors" and better integrate the health system, with special attention for the chronically ill.

These and other issues and ideas for rural health are on the agenda of the foundation's ninth annual Howard L. Bost Memorial Health Policy Forum, to be held Tuesday, Sept. 13 at the Center for Rural Development in Somerset. The forum will include state and national leaders. "Rather than wait for solutions from Washington, forum speakers will share strategies Kentucky’s civic leaders can put into place at the local, state and regional levels. Many will share ways that Kentucky is already doing this," Zepeda and Watts write in an op-ed article distributed to Kentucky newspapers.

The keynote speaker will be Dr. Len Nichols, who founded and directed Health CEOs for Health Reform, a group that helped policymakers see that reform of health insurance and health-care can be reformed together. Dr. Kavita Patel, a physician and former RAND Corp. researcher now at the Brookings Institution, will bring insights on how to achieve better care and better health at lower costs. Other experts from Kentucky, Virginia, Tennessee and North Carolina will share "practical policy strategies for positive health change in these challenging times," and smaller sessions will allow participants to engage with the speakers, Zepeda and Watts write, saying the forum's goal is to "provide accessible, safe and effective health care to nearly half of Kentucky’s citizens who call rural Kentucky home." More information is available on the foundation’s website, http://www.healthy-ky.org/.

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Patients in isolated rural areas have higher rates of death from chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease living in isolated rural areas "seem to be at greater risk" of death from COPD than those living in urban areas, even when "hospital rurality and volume" are taken into account, says a new study published in the latest issue of the Annals of Internal Medicine.

Researchers from Iowa City Veterans Affairs Medical Center collected data from COPD patients at 129 veterans' hospitals measuring first, 30-day mortality and then adusting for patient rurality, hospital volume, and hospital rurality. The results indicate "mortality was significantly elevated in patients living in isolated rural areas compared with those living in urban areas," regardless of patient and hospital characteristics, reports Doctors Lounge, an online medical resource for physicians, students and allied clinical professionals. (Read more)

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Defenders of small, rural hospitals take issue with study that found poor patient outcomes

A recent study that concluded small, rural "critical access hospitals" have poorer patient outcomes and lower quality of care is making waves in the medical community. A federally funded monitoring team from three universities issued a response noting certain weaknesses of the study, which was published in the Journal of the American Medical Association earlier this month.

It's not news that critical-access hospitals "have room for improvement," the team wrote. "What the JAMA authors fail to report is how much CAH scores on the process of care measures have improved over time," it writes. "Our most recent trend analysis, for example, shows that CAH scores on each of the pneumonia measures increased between 9 and 22 percentage points between 2005 and 2009."

The analysis in question was performed by researchers at the Harvard School of Public Health. It focused on nearly 1,300 critical access hospitals and looked at the outcomes of Medicare patients who have congestive heart failure, heart attacks and pneumonia. For all three conditions, CAHs performed at a lower standard. Patients at CAHs were more likely to die, and the facilities were behind in implementing electronic health records. It also found CAHs had a smaller number of specialists like cardiologists working at them than at non-CAHs. "That doesn't sound like news to us, either," said Al Cross, director of the Institiute for Rural Journalism and Community Issues.

"Issues such as the limited supply of primary care providers, home health and hospice services, rather than the supply of specialists, should be the focus of interventions to improve rural health quality," said the Flex Monitoring Team, named after its assignment, to evaluate the Medicare Rural Hospital Flexibility Grant Program. The team is made up of researchers from the University of Southern Maine, the University of Minnesota and the University of North Carolina-Chapel Hill. (Read more)

Writing for the Daily Yonder, Dr. Robert C. Bowman, family-medicine professor at the A.T. Still University School of Osteopathic Medicine in Arizona, also took issue with the study, in part because its findings ran counter to an article that was also published in JAMA last year. That article concluded that "greater proportions of underinsured, minority, and non-English-speaking patients were associated with lower quality rankings for primary-care physicians," Bowman quotes.

"Now JAMA has an article this year claiming lower quality of care in certain types of rural hospitals that are completely different in location, population, funding, and workforce," Bowman writes. "So what happened between last year, when patients made the difference in quality, and this year when it was location of the hospital? ... Why do sophisticated researchers, reviewers, and editors maximize the context of care sometimes (in 2010) and minimize it at other times (in 2011)?"

Bowman, founder of the Rural Medical Educators Group of the National Rural Health Association, took a jab at the researchers. "Do Harvard University researchers associated with hospitals with the most sources of income and the highest reimbursement rates even have the perspective to write about hospitals with the least lines of funding and the lowest reimbursement in each line?"

Though he takes issue with the article, Bowman said the topic "about high and lower quality critical access hospitals" is worthy of research. "Perhaps one of the problems with attempting such research is that there is little variation across rural hospitals. Perhaps that's because the system is designed to spend uniformly less on health care across rural America. . . . The end result is less care and less economic impact from health care in 30,000 zip codes with 65 percent of the U.S. population. And more care delivered in 3,400 zip codes in 4 percent of the land area." (Read more)

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Small, rural hospitals with 'critical access' designation have poorer patient outcomes and lower quality of care, study finds

A study has found that small, rural hospitals with the "critical access" designation have poorer patient outcomes and lower quality of care.

The analysis, performed by researchers at the Harvard School of Public Health, focused on nearly 1,300 critical access hospitals, a designation is given to facilities that have 25 or fewer acute-care beds and are more than 35 miles away from another hospital. In return for such concessions as limiting patient stays, CAHs get extra Medicare and Medicaid reimbursements. The Rural Assistance Center reports there are 30 CAHs in Kentucky.

The study looked at the outcomes of Medicare patients who have congestive heart failure, heart attacks and pneumonia. For all three conditions, CAHs performed at a lower standard. For patients treated for heart attacks, CAHs provided care in keeping with Hospital Quality Alliance standards 91 percent of the time, compared to 98 percent at other hospitals. The difference was even larger for patients with congestive heart failure patients (80.6 percent vs. 93.5 percent) and smaller "but still significant" for pneumonia (89.3 percent vs. 93.7 percent), the report says.

Patients at CAHs were also more likely to die. They had higher 30-day risk-adjusted mortality rates for all three conditions than patients admitted to other hospitals. The study also found CAHs behind in the implementation of electronic health records, 6.5 percent to nearly 14 percent.

"Despite more than a decade of concerted policy efforts to improve rural health care, our findings suggest that substantial challenges remain," the study authors write. "Although CAHs provide much-needed access to care for many of the nation's rural citizens, we found that these hospitals, with their fewer clinical and technological resources, less often provided care consistent with standard quality metrics and generally had worse outcomes than non-CAHs." (Read more)

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Rural emergency rooms frequented by the poor and uninsured

A new report from the federal Agency for Healthcare Research and Quality shows that low-income adults accounted for 56 percent of the 8 million rural emergency room visits in 2008. In nonrural hospitals, low-income adults accounted for only 30 percent of emergency room visits. According to the report, 44 percent of adult visits to rural emergency departments were paid for by Medicaid, were uncompensated, or billed to uninsured patients. Only 31 percent were paid for by private health plans. In nonrural hospitals, 37 percent of adult visits were paid for by private health plans, and 42 percent were paid for by Medicaid, uncompensated or billed to uninsured patients.

Emergency business is mainly just that for rural hospitals. Only 8.3 percent of rural emergency department visits resulted in a hospital admission, compared to 16 percent of non-rural emergency department visits.

The report also noted the lack of rural hospitals with trauma-level emergency departments. Nationally, only 2.4 of rural emergency departments held any level of trauma designation. Among non-rural emergency departments, 35.5 percent had a trauma designation. Read more here.

In Kentucky, approximately 75 of the state's 130 hospitals are in rural areas, according to the Kentucky Hospital Association. The state has been working to improve its trauma system and will soon begin designating level IV trauma centers in some of the state's smallest hospitals, said Dick Bartlett, emergency preparedness and trauma coordinator for the Kentucky Hospital Association. Already, Marcum & Wallace in Irvine and Livingston Hospital in have met requirements for the designation and will be certified, once the state approves the new level IV designation. (The national report focused on levels I-III; in Kentucky, level I-III are certified by the American College of Surgeons.)

The new designation is part of an effort by Kentucky to improve trauma care statewide. Having a level IV trauma center means better trauma care for Kentuckians injured in rural areas, Bartlett said. "It improves your potential for survival," he said. These hospitals have committed to providing certain levels of staffing, including a board-certified emergency room physician, and to following protocols to quickly decide whether a patient can be treated at their facility or if a patient should be transported to another, higher-level facility.

A map showing Kentucky's current trauma hospitals and those hospitals seeking trauma certification is available here.

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Rural Training Track programs get more health professionals to rural areas, but live 'on the edge' of funding and personnel

By Tara Kaprowy
Kentucky Health News

With the Obama administration offering more funding to improve rural health care, Rural Training Track programs to steer medical students to rural areas are hoping to expand, a move that would benefit underserved areas of Kentucky.

"Over 62 million Americans live in rural America and there is a significant crisis in terms of having access to care for these people," said Amy Elizondo, vice president of program services at the National Rural Health Association. "There is a very uneven distribution of health care professionals and an acute shortage of primary care physicians in rural areas. If we can recruit and retain physicians to serve rural areas, we improve access for rural America." (University of Washington map; click for larger version)

RTT programs aim to educate family physician residents in rural environments with the hope they will continue to practice there, Candi Helseth reports in a deailed article for the Rural Assistance Center. "These residency programs are a proven model for addressing rural family physician workforce shortages, with more than 70 percent of graduates praticing in rural areas," Helseth reports. The first such program started in Colville, Wash., in 1985. There are 25 RTTs in 17 states, including one in Morehead by the University of Kentucky and St. Claire Regional Medical Center. Eight physicians have graduated from the program there since it was established in 2000, five of whom are practicing in Kentucky. Of those five, three have joined the SCR medical staff.

There are similar success stories across the country. In Caldwell, Idaho, 95 percent of graduates have chosen to practice in rural areas over the past 16 years. "We heavily recruit residents who are rural-oriented," said Dr. Samantha Portenier, a practicing physician and director of the Caldwell RTT. "We've had some who were not and we converted them. Part of it was that they really saw where the training we give them and the skills they learn are so needed in rural areas. I emphasize that in rural areas you can specialize in areas that particularly interest you."

Despite the success, 10 RTT programs have closed in the past 10 years. "Every RTT lives on the edge in terms of funding," said Dr. Randall Longenecker, who is project director of Rural Training Track Assistance Demonstration Project. "In general RTTs are small, have limited faculty and are vulnerable to personnel changes, a bad year for recruiting, loss of funding and many other factors beyond their control."

Morehead's RTT is funded by St. Claire. Residents spend their first year at the UK College of Medicine in Lexington and their second and third years at St. Claire, which is accredited by the Accreditation Council for Graduate Education. Carla Terry, St. Claire's graduate medical education coordinator, acknowledged the difficulty in maintaining an RTT program. "The reason why the RTTs are in jeopardy is that all the faculty that teach them are voluntary," she told Kentucky Health News. "They are not paid to teach, they still have to keep their patient load. If it were a university program, all the faculty would be paid."

But St. Claire physicians believe strongly in rural-based education and also see how they can benefit from their investment. "We actually had a physician that when he came here he was interested in starting a residency because he wanted to use that as future recruitment," she said. "We look at it as training future partners."

Now, RTTs are under a federal microscope. The health care reform law created the Rural Training Track Assistance Demonstration Project, a three-year pilot program that plans to "collect comprehensive information to better understand the collective forces challenging RTT models and develop solutions that will strengthen existing RTTs and encourage development of new RTTs," Helseth reports.

The time is ripe, given that more medical students are choosing to be family medicine physicians, up by 11 percent last year and 8 percent the year before. "We have a real opportunity here to redefine the importance of primary care being foundational in rural workforces," Dr. Ted Epperly, past president and past board chairman of the American Academy of Family Physicians, told Helseth. "Right now, only 9 percent of physicians are choosing to practice in rural areas while 20 percent of the population lives there. RTTs offer a way to give family physicians a broad scope of practice, which they need practicing in a rural area, and to get them to stay in those rural areas." (Read more)

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