SARAH: This is At the Core of Care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families, and communities. I'm Sarah Hexem Hubbard with the Pennsylvania Nursing Workforce Coalition and the Executive Director of the National Nurse-Led Care Consortium.
On this episode, we're gonna talk about the latest trends around rural health with Lisa Davis. Lisa is the director of the federally funded Pennsylvania Office of Rural Health. She is also an Outreach Associate Professor of Health Policy and Administration at Penn State University Park. As the director of Pennsylvania's Office of Rural Health, Lisa makes sure that the state office exceeds its federal mission of being a source of networking, coordination, and technical assistance to advance rural health care delivery.
She serves on various local, state, and national boards focused on rural health and is a member of the Pennsylvania Nursing Workforce Coalition's Nurse Diversity Council.
Lisa, welcome to At the Core of Care.
LISA: Thank you so much for having me.
SARAH: So we have known each other for a while now. But I don't know what drew you to the issue of rural health to begin with, and you have devoted your career to this area of healthcare.
LISA: Well, I have to tell you. I actually did not know that there was a career in rural health. Penn State had started the Pennsylvania Office of Rural Health when I was in graduate school many, many years ago, and I interviewed for a position as the first full-time staff person, which was the outreach coordinator position at the time, and I absolutely fell in love with rural health.
I had always focused on the sort of un and underinsured and very vulnerable populations, and also wanted very much to get into policy. And so this really combined both of those passions. And I realized that I had not ever anticipated that I would meet a group of people in communities across the state and nationally who were so incredibly smart, talented, knowledgeable, and passionate about the work that we were doing, and they're also a tremendous amount of fun.
And so the rural health community is pretty small across the country, so we're a pretty tight-knit group. And I find that what we're doing is absolutely essential since Pennsylvania is such a rural state.
SARAH: Yeah. And so after Texas and North Carolina, Pennsylvania has the third biggest rural population.
LISA: So correct.
SARAH: Curious if you could share a little bit about the concept of rurality, how that's defined, and why that matters.
LISA: Well, it matters a great deal especially if you are a facility that can be reimbursed at a particular level or be designated as a particular kind of facility. Same with a clinic, if it's not in a federally designated rural area. So I can tell you that at the federal level, there's probably no less than 40 different definitions of rural. And so, it's a bit challenging. You know, Department of Ag has one, Education has one, and so on.
We focus on the US Census Bureau and the Office of Management and Budget, and also a definition that was developed solely to focus on rural because all the other definitions sort of treat rural as whatever is outside of metropolitan or sort of a populated area. So the Rural-Urban Commuting Area, otherwise known as RUCA, was developed so that we would have a much clearer definition of what is rural, what is not rural, what's urban, and what is non-urban.
So, essentially, there is no straightforward definition. I wish I could tell you it is X and that is it. But a definition of rural really depends on if you have a population of anywhere between 5,000 and below or 5,000 up to 10,000 that is not contiguous to a metropolitan or urbanized area. So it really does need to be geographically isolated, and not be part of what's considered to be a metropolitan statistical area.
So we have counties in Pennsylvania that have more four-legged than two-legged creatures, that have no hospitals, very few primary care clinics or dental clinics and really essentially are what you would consider to be very, very rural. But, one county I'm thinking of a particular, is located inside a large metropolitan statistical area because everyone in that county empties out into another county during the day to go to work, and that commuting for work is considered to be a proxy for commuting for other goods and services like healthcare.
But, what I can tell you, is that Pennsylvania has 67 counties and 48 of them are considered to be rural. And up until the 2000 census, we were the most rural state in the nation. So when I would talk with my colleagues from Wyoming and Montana, and so on, when they would say, you're not rural. But they’re frontier, which is a very different definition. And we have maybe, I think two frontier communities in Pennsylvania.
But in the 2000 census, the US Census Bureau snuck in a sort of a mid-level definition called micropolitan. And so a lot of our folks that were in rural communities now we're considered to be micropolitan. But we're now number three. And of course, I still think we're number one.
SARAH: And for those who lost track in all of those different definitions, I always remember how Lisa described it to me maybe 10 years ago of, you know, Pennsylvania people think about the rural ‘T’ and really it's the rural ‘J.’ And so for those that are familiar with Pennsylvania, you have urban centers, Philadelphia and Pittsburgh, and then quite a lot of the center top and then that little curve at the bottom of the state that fit that definition of rurality.
So according to CDC and, many other sources, rural residents face many healthcare challenges. You know, most specifically I think, less access to specialized medical care and emergency services. But really a variety of things. Can you give us an overview of some of the unique factors that
LISA: Yes. So, when we talk about rural healthcare challenges, we talk about it under an overall rubric of access. And that is access to healthcare providers, including clinicians, and also facilities. Challenges with payment mechanisms, so how one pays for one's healthcare.
And then the third is the infrastructure, which is really the transportation, the geography, and high-speed internet. So when we look at providers, in general, we see that we have far fewer primary care providers in rural communities than we do in urban areas. That is across every single discipline: primary care, specialized care psychiatrists, nurse practitioners, physician assistants, dentists, dental hygienists, and so on.
So, in Pennsylvania, about 23% of the population lives in areas that are designated as rural. And so we're talking about a very large part of Pennsylvania. You know, as you were saying, we have the rural T and the world J. We also have a line that sort of goes across the northern tier that also connects very rural areas that sort of falls outside of being a specific letter in the alphabet.
So we have a lot of geography to cover. So having access to primary care is essential. That's the way people enter the healthcare delivery system. And we do have a really robust system of federally qualified health centers, federally qualified health center lookalikes, and rural health clinics.
And that is enormously helpful. But there are still areas in this state where it's very challenging to be able to access primary care services. Then when you begin to move towards specialized care, especially things like mental and behavioral health services or psychiatric services or maternity care, which I do want to talk about here in a second.
There are significant challenges. We also are seeing that across the state, even though we do have a lot of primary care clinics, we have, depending upon which definition of rural you are using, we have anywhere between 48 to 60 small rural hospitals. That's not very many hospitals to cover the entire state.
The state has 150 general acute care hospitals. So if only 60 of those are in rural communities, you can imagine how many places there are in the state that have no hospitals or have very limited access.
In fact, we have nine counties in Pennsylvania that do not have a hospital, and that becomes a real challenge because the hospital, in addition to the primary care services, is the center of healthcare for a community. It is where people go for emergency care. It's where they go for a whole wide array of primary care services for, you know, broken bones and the flu and all sorts of things, pneumonia and so on; diabetes care, all kinds of chronic healthcare conditions.
And if it's challenging to get to your hospital, that can really significantly interfere with your ability to be able to get the care that you need. The state has something called 17 Critical access hospitals, which are very small, very rural hospitals that are geographically isolated. And if they convert to designation as a critical access hospital, they get enhanced reimbursement through Medicare and also through Medicaid.
And then we have 70 rural health clinics, which from the naked eye look very much like a general primary care center. But they receive their designation as a rural health clinic where they do not need to have the direct oversight of a physician that other kinds of primary care clinics have.
And that is in recognition that it is so challenging to attract and retain healthcare providers in rural areas. So, rural health clinics are led by nurse practitioners. So those are just some of the issues that I can talk about in terms of facilities. We could spend an entire semester talking about it.
But the other is, when we talk about the types of individuals who are living in rural communities. Now, what I'm about to say is a complete generalization, but for the most part, rural residents tend to be older, sicker, and less financially advantaged than their urban counterparts.
They tend to have higher rates of chronic health conditions, such as cardiovascular disease and diabetes, and complications from stroke. They may or may not have full-time employment through an employer that offers healthcare insurance. And if they offer insurance, it may be a very narrow type of policy that may not cover dependents.
So we see a higher reliance in rural communities on the public insurance programs, Medicare and Medicaid, and CHIP, for access to healthcare and insurance coverage. For the most part, those tend to reimburse at a lower cost than private insurers.
Sarah: So what you're describing, especially, you know, looking at nine counties that don't even have hospitals. But also when you were speaking about primary care and the different types of providers that we see, to what extent has the makeup of healthcare delivery changed in your time at the Office of Rural Health?
LISA: I think here in the state one way that it has changed significantly is that Pennsylvania, I think, is one of the leaders across the country in consolidation of healthcare providers. So we have several very large healthcare systems that have essentially… not gobbled up, I don't mean that in a negative way, but they have purchased these small rural hospitals. And one of the challenges that we find with that and that we try, and do a great deal of education about, is that purchasing a small rural hospital is not just a way to bring additional patients into the tertiary care facility. In rural communities, the local hospital is a part of the fabric of the community, and we always encourage large healthcare delivery systems to be able to invest in their communities.
So that's been one change. The other big change that came about was in 2010 when the Affordable Care Act was signed. And that, of course, essentially changed so much because we saw that there were no longer restrictions on preexisting conditions. And we saw that individuals could be insured up to age 26. And we also saw the establishment of the federal, and now we have the state-based, marketplaces. And another big component of that really was a big impact across the country and here in the state, was Medicaid expansion. And that, I think, was a boon for Pennsylvania because the way that the Medicaid program is set up, it's a federal, state program. And so the federal government reimburses the state for a particular percentage of the amount that they spend on Medicaid Under the Affordable Care Act any new patients who came into Medicaid after the ACA was passed as part of the Medicaid expansion, the federal government would pay the states 100% of that cost. So it was advantageous for the state.
The other piece that was very advantageous for that was that now individuals who no longer had a way to pay for healthcare could pay for healthcare so that when they went to the hospital or the primary care clinic, they had a way to reimburse the clinics and the hospitals for that time. And then, you know, another really important piece that often doesn't get talked about, is that patients have access to care. And that is the number one predictor of whether or not someone will utilize care and potentially be healthier. So I would say that those are the two biggest things that I have seen since I came in.
SARAH: I loved how you described that with hospitals really being core to the communities that they're serving, you know, and there's so much of the local economy that is dependent on the healthcare sector. I mean that's true of all counties, urban, rural, and everything between. And rural hospitals in particular have experienced consolidation, and many closing over the last several years.
So recognizing the impact that you've seen from those closures and also the impact of access to public insurance for rural Pennsylvanians, what are some of the potential impacts for rural care in some of the conversations happening right now related to Medicaid?
LISA: Well, because Medicaid is a large pair of healthcare here in the state, especially labor and delivery, and also long-term care. Medicaid pays for 59% of all long-term care here in the state. If there are changes to Medicaid, we will absolutely see individuals who will lose their insurance coverage. And the idea is to implement work requirements. Many who are on Medicaid already are working. They just happen to be working for companies that do not provide health insurance. So they may be working, let's say 20, 30, 40 hours a week, but they're on Medicaid. So they obviously will not be required to have work requirements because they are working.
But for those who are not employed and who must go out and search for work. The question is, where are they going to go look for work? And how will they get there? If there's no car, we have very few public transportation systems in rural Pennsylvania, we have a couple, but they're not robust. It's not like being in Philadelphia or being in Pittsburgh. So those are some of these challenges. How will people get there?
What kinds of jobs are available? Because we have a really low unemployment rate right now in Pennsylvania, and we also know that during COVID, we lost hospital and clinic employees because they were able to go to positions at convenience stores or other kinds of jobs like that where they made essentially the same money, but they didn't have to do things like, worry about getting Covid or having to deal with irate patients and so on. So I think there's a real concern about that, and if that should happen, then all hospitals, including rural hospitals, will see an uptick in the number of uncompensated care that they provide because all community hospitals, all 501C3 hospitals, have to provide care regardless of a patient's ability to pay.
So that's going to be an issue that we're going to have to address. The other is if the subsidies for the health insurance marketplace should end, we are looking at thousands and thousands of individuals in Pennsylvania who will likely lose insurance because they are not able to afford the full premium. So we're now going to be looking at additional individuals who are uninsured.
SARAH: So for more than 40 years, every state has had some type of rural health entity. And the mission is really all-encompassing. I think that you had once stated that your job is to do everything, everything related to rural health.
So can you give a little sense of your reach in Pennsylvania, some of the key programming that you do? And I'm curious about how that relates to what you're seeing from other state offices of rural health?
LISA: Our office was established here at Penn State in 1992. And we have been here at Penn State since then and have grown significantly. So, there's a state Office of Rural Health in every state in the nation. My office is one of 10 that are university-based. There are three that are 501C3s, and then the rest are in state departments of health. And so I think being at a university has been a great benefit for us because we have a lot more latitude in terms of the things that we do, although we work really closely with our state agencies, so health, human services, agriculture, economic development, aging, and so on.
And also [work] very closely with our legislature should they need any information from us, and so on. But really, where I think our sweet spot is, is knowing at an in-depth level what the issues and challenges, and successes are at the local, state, and national levels. Knowing what resources are out there, what the challenges are in accessing those resources, and in providing excellent technical assistance to those with whom we work and represent. So we may in fact be talking to a primary care clinic in a rural community, or we may be talking to a hospital that wants to convert a clinic to a rural health clinic. We might be working to bring about regional systems of care. We have a potential project like that up in the northwest where we have a pretty large maternity desert.
So we've been working with our partners to potentially implement a circuit rider program or make sure that the providers there are delivering very, very robust pre and postnatal care. Connecting that up with community health workers and having very clear plans for how a person, when they go into labor, can be transported for delivery. So you know, there are those kinds of processes that we do. We administer grant programs for very small rural hospitals. We work at just about every level in the state. And we also work nationally with all of our national partners.
So, there are a number of terrific rural health programs that are out there that either initiate or expand programs that are in states that focus on opioid use disorder, focus on rural maternity care. So it's a pretty broad spectrum of funding that's available.
SARAH: So here in Pennsylvania, you had started to mention this when speaking about the perinatal care and bringing folks together there, but looking at, you know, community health workers, community paramedicine, what are some of the other promising innovations you've seen here in the state?
LISA: When I came into rural health 30 some years ago, mobile health was a big trend at the time, and then it kind of fell off, you know, because it was expensive to operate and so on. It was 30 years ago and the equipment just was not as reliable. It wasn't as technological as it is now. So I think there are a couple of things that we are looking at in terms of where we can see some innovations. One is having communities invest locally in their healthcare delivery systems. Because healthcare is one of the top three employers in any county and in some counties it is the top employer.
So we want those dollars to stay locally. We also want to see a strong overlap between healthcare strategies and community and economic development strategies because one cannot exist without the other. You absolutely have to have a strong healthcare delivery system to bring in or retain a great economic community, and you have to have a strong economic community in order to be able to have a strong hospital. So they are intrinsically connected. We also are looking at the community health worker model, which I think is probably one of the greatest models that has started to flourish here in the state and across the country because community health workers come from the communities they serve. They understand the population. They understand what the issues are. They go through great training programs and they are supported by a healthcare delivery system. They can go out and intervene essentially and assess so that problems are addressed in the home or other ways rather than somebody coming to the emergency department. So I think that the community health worker model is just brilliant and I'm so glad that we now have the certification in the state for the CHWs. And I so hope that CHWs will be fully integrated into healthcare policy, payment and practice. So that's another way.
The other is to be looking at other kinds of services like doulas or by having mobile care, because I think that is now beginning to become very popular, not only with healthcare providers, but also in communities. Especially because we're 30-some years later, the equipment is pretty solid, and the vans are pretty solid. So being able to take that out into communities where Mrs. Jones knows that on every Thursday there will be someone in the parking lot of the Dollar General, let's say. She knows where she can go get some care.
The other is the state is investing a great deal through the Federal Infrastructure Act funds in high-speed internet because we have places in Pennsylvania where you just don't have any coverage at all and you also don't have very strong coverage. So if someone in your house is doing one thing with the internet, you might not be able to do another. So there was extremely good mapping that occurred by Penn State Extension to map the entire state to determine where it was well-served and where it was not well-served. And so I know there's been a focus through Pennsylvania Broadband Development Authority to get the funds out all across the state, but especially in those underserved areas.
SARAH: Historically, you know, rural health, telehealth, is the immediate connection and thought around access to care, How has that changed over the course of the pandemic, in recent years? Obviously, there's still a lot of work that needs to be done related to broadband. But what are some of the developments you've seen related to telehealth?
LISA: There have been several. When the pandemic started, there was suddenly this high demand for virtual care. And what was discovered, and I'll focus mostly on CMS right now, is that they were trying to reach a number of older patients who did not have access to high speed internet, did not have a computer, may not have even had a telephone that had any sort of a screen on it. So they were able to relax their restrictions on what qualified as a telehealth visit, because it had to be before, had to be with a provider where there was an already established relationship and it needed to be essentially video-to-video. So they relaxed that, which was terrific. And there was an enormous increase in the number of claims that Medicare received in just one month for telehealth services.
The other is that telehealth has become much more robust over time. There are a lot more procedures that can done via telehealth. You know, remote patient monitoring is one thing, you know, where you have a blood pressure cuff and so on and you're connected up and have a team monitoring. But other types of services are also so good now, where the diagnostics via telehealth are very sophisticated. You can listen to all sorts of body parts. You can actually do an oral assessment. We have seen telestroke for small rural hospitals that are connected up to tertiary care facilities so that there's immediate access to a stroke expert when someone is brought into the hospital.
We have a hospital here in the state, it's a Tele- ED, so that their emergency department is not staffed by emergency docs. It is staffed by physician assistants and nurse practitioners. If a patient should come in and they would need some assistance, they are automatically connected to a tertiary care facility where they are getting that service. The other big thing that happened in the state is that we were a state that did not have telehealth parity, meaning that there was no legislation that required all insurers to pay to reimburse for telehealth. And Senator Elder Vogel had tried several times to get something passed, and this last year, in this last session, he was finally able to get something passed, which is terrific. It does not set the amount for which telehealth needs to be reimbursed, but it does say that every insurance plan needs to reimburse for telehealth services.
SARAH: Thank you again for the just wealth of information that you've been able to share with us. Are there any final thoughts that you want to share before we wrap up?
LISA: I do want to say that rural matters. If you woke up this morning in a building that had wood, you had rural to thank. If you ate breakfast or lunch or a snack, you had rural to thank. And if you have clothes on that have any sort of natural fibers, you have rural to thank. And, you know, rural areas, especially here in Pennsylvania, you know, agriculture is our largest economy, as is tourism because of all of our state parks. So rural Pennsylvania and rural America contribute significantly to the overall economy and have benefits across both rural and urban areas.
So what I would like to suggest is that we never think about rural versus urban. There's really a continuum and they all need to be connected. And I would hope that if anyone is listening and they want to make sure that we have rural programming, at least for the next couple of years, that they consider how they might be an advocate for services in their communities.
SARAH: Well, thank you for your advocacy and work to keep rural Pennsylvania and rural America healthy. So thank you so much again for joining us.
LISA: Thank you. This was really fun and I appreciate the focus on rural.
SARAH: Special thanks to Lisa Davis for joining us. You can find our most current and past episodes of At the Core of Care, wherever you get your podcast, or panursingworkforce.org. For more information on upcoming webinars and trainings for nurses to obtain continuing education credits, log on to panursingworkforce.org on social media.
And on social media, you can stay up to date with us through our handles @nurseledcare and @panursingworkforce. At the Core of Care is produced by Stephanie Marudas of Kouvenda Media and mixed by Brad Linder. I'm Sarah Hexem Hubbard of the Pennsylvania Nursing Workforce Coalition and the National Nurse-Led Care Consortium.
Thanks for joining us.
