Putting the Family Perspective into Rural Health Care

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Putting the Family Perspective into Rural Health Care. Farm Foundation National Public Policy Education Conference Sept 20, 2004 Roberta Riportella, PhD University of Wisconsin-Madison University of Wisconsin Extension. Objectives. - PowerPoint PPT Presentation


  • Putting the Family Perspective into Rural Health CareFarm Foundation National Public Policy Education Conference

    Sept 20, 2004Roberta Riportella, PhDUniversity of Wisconsin-MadisonUniversity of Wisconsin Extension

  • ObjectivesTo understand a family perspective on creating health for familiesTo consider how rural families may be uniquely affected by changing demographics and health policyTo consider how a family perspective might lead to different solutions for creating health

  • MethodsConsider what we know about creating healthConsider who rural families arePut those rural families into a model explaining families role in healthConsider what kind of system is in place to address risks and poor health outcomes for rural families

  • Direct and Contributing Factors to HealthDirectLifestyle Factors (50%)Cigarette SmokingAlcohol & Drug ConsumptionNutritionStress/Mental Well-BeingBody FitnessEnvironment (20%)Biological Predisposition (20%)Health System (10%)ContributingEducation, Income (SES)Self-EsteemSocial SupportCommunity Norms, Beliefs, & Expectations

  • Family

    Household in which we grow up, household which we create as adultsLegal and non-legal attachments, mom,dad,kids,grandparents,extended family, guardians

  • Doherty, William J. (2002). A family-focused approach to health care.

  • Illness AppraisalDisease 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 statusaccepting perception of well-being beliefs about cause of disease beliefs lead to type of healer

  • Health Promotion and Risk ReductionSocialization extends to the variety of habits, attitudes, behaviors, actions toward health, as well as attitudes toward using the formal health care systemWhat do we learn?Who needs to be part of the treatment?Are choices individual/family/societal responsibilities?

  • Complications to making positive choicesFood shopping limited, healthy foods expensiveNo health clubs/indoor shopping malls for walkingSocial life around tavernsAlcohol and smoking cultureLiquor storesGood information (often confusing messages, internet-based)

  • Vulnerability and Disease OnsetSocial support in the familySocial tiesStress in family life

  • Acute ResponseThe immediate aftermath of illness for the family

  • Adaptation to Illness and RecoveryThe family as the setting for care of the recovering or chronically ill member.

  • ImplicationsDelivery system: Differently trained health care providersTeaching so providers can assess the influence of family factors on health and therebyUnderstand individual as whole person and as member of larger units of family and social/cultural environmentTreat family members as partners in health careFinancing and organization of health careAbility to pay/be insuredCoverage of all family membersAvailability of providers

  • Geographic: Supply of ProvidersHealth Care PersonnelThe 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#demographics

  • Geographic: Supply of ProvidersHealth Care FacilitiesRural hospitals2226/5134 in rural areasMost fewer than 100 beds, mainly private nonprofits but also include those owned by state and local governments and for-profit hospitals. Heavily dependent on Medicare1991-1995 363 rural hospital closures1999 only 24 closureshttp://www.nal.usda.gov/ric/richs/stats.htm#demographics

  • Community Activation of Family Health Care: An emerging modelPatients and families as partners with professionalsFamilies as producers of health promotion, not just consumers of health careLearning, coping, and healing occur best within communitiesIdentify and activate potential communitiesCommunity asset building perspective

  • Key Findings NACRHHS ReportBenefits to integrating behavioral health and primary care in rural settingsAccess to oral health services in rural communities very limitedRural elderly face significant challenges in accessing needed servicesNot necessarily family-centered report

  • Behavioral health (BH) and primary care in rural settingsPrimary care practitioners have major responsibilities for diagnosing and treating common mental illnesses (depression)BH services are highly fragmented due to staff shortagesSeparate facilities for mental and physical health careAutonomous BH and primary care providers practice with informal referral relationshipsPrimary care and BH providers do not share joint responsibility for managing patients

  • Behavioral health (BH) and primary care in rural settings: BarriersHigher percentage un- and under-insured for both physical and mental healthMedicare rules set standard. Higher copaysOnly certain professionals reimbursed (not marriage and family therapists)Rural areas have less reimbursable providers to work underHigher copays + less choice + cost sensitive consumers => less access

  • Behavioral health (BH) and primary care in rural settings: StrategiesDiagnosis and treatment by a fully integrated clinical teamCo-location of providersDual certification of providersUnknown efficacy of these approachesUse 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 suppliesOlder populations (lifetime of risks, old habits)Increased povertyLess food choice (soda bottle babies)Limited access to oral health care

  • Rural oral health statusUntreated dental caries31.7% rural, 25.2% urban Lost all teeth16.3% rural, 8.8% urban (45-64 yr olds)37% rural, 27% urban (65+)

  • Access to Oral Health CareFactors limiting accessGeographic isolation/lack of adequate transportation Lack of dentists participating in publicly financed programs (~16% nationwide)Low public financing (
  • Health challenges for rural older adults40% of all older adults report good healthRural older adults report fair to poor health 1 more than urban older adultsContinuous povertyDifficulty accessing transportationDistance to careLack of knowledge of available servicesLack of nearby younger family caretakersShortage of qualified workers

  • Rural elderly face significant challenges in accessing needed services1.6 million older adults in nursing homesFewer home and community based services makes nursing home use greater in rural66.7/1000 beds rural51.9/1000 beds urban Medicaid 10.1% rural, 8.2% urban

  • Emerging IssuesObesity and wellnessHigher rates of chronic disease and limitations on activities of daily livingHigher rates of obesityRegular physical activity reduces risk yet inactive leisure time more common among rural residents. StrategiesSteps to a Healthier US community grant program (CDC) for diabetes, obesity and asthma preventionTargets prevention efforts: physical inactivity, poor nutrition, tobacco use$13.7 million, $4.4 to small cities and rural communitiesAt-risk populations (ethnic, low-income, disabled, youth, senior citizens, uninsured, underinsured=rural)Small city/rural communities component (Washington, NY, Arizona, Colorado)

  • Emerging Issues: contd.Access to specialized services (terminal illness)Travel far for diagnosis and treatmentLack of hospice care Health system changesVulnerability of rural providers to rapid increase in insurance plans that intend to have consumers avoid providers with higher pricesConsumers 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 healthKnowledgeWhat works, what doesntResourcesIncomeInsuranceFormal support (health care system)

  • ReferencesDoherty, 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: contd.Rural Health Policy Institute, U of Nebraska, http://www.rupri.org/HealthPolicy/



    Trends in the Health of Americans Chartbook:http://www.cdc.gov/nchs/products/pubs/pubd/hus/metro.htm

  • References: contd.http://www.shepscenter.unc.edu/research_programs/Rural_Program/mapbook2003/totalpopulation.pdfMap bookhttp://factfinder.census.gov/servlet/BasicFactsServletGeographic 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: contd.Uba, Laura. Cultural barriers to