Healthcare Q&A: Duke Endowment’s Chris Collins discusses rural healthcare

What are some of the health issues facing rural NC?

Several confounding factors are contributing to reductions in life expectancy for rural residents. The increase in mortality for rural residents is the result of increased medical risk and lack of access to essential services.

  • Rural communities are increasingly comprised of an aging population, have a higher percent of chronic disease and have an increasing risk from unintended injury such as a car accident or drug overdose.
  • The problem is compounded for rural providers as both the population and reimbursement is decreasing. There is a higher percent of uninsured and a greater reliance on government coverage that makes a practices viability a challenge.
  • Many rural counties have long-standing health professional shortages in primary care, psychiatrists and dentists. In addition, there are 26 counties without an OB/GYN provider, 26 counties without a general surgeon and another 20 without a pediatrician. Rural hospitals are at risk for closure and low volume service lines such as maternity care are being eliminated.
How is NC working to improve rural healthcare access?

Most small rural hospitals are now merged or managed by a larger hospital system/parent organization, which creates an opportunity to access the resources of the larger health care systems.

There is an increased focus on creating access to essential services such as primary care and mental health. This has led to a rise in the number of CMS certified rural health clinics that are linked to health systems.

NC has an unusually strong primary care safety net system comprised of: Community Health Centers, Rural Health Clinics and Centers, Free Clinics and Local Health Departments that provide care for many rural communities. Through strong collaboration there has been an increase in the number of funded sites and the expansion of team-based service to include behavioral health and oral health services for low-income residents.

The NC General Assembly has a recently formed a Legislative Research Commission Committee on Access to Healthcare in Rural North Carolina. There have been several requested legislative reports / presentations with regards to rural health. Presentations are available at https://www.ncleg.net/gascripts/DocumentSites/browseDocSite.asp?nID=374.

What are examples of how NC is working to help recruit and retain rural healthcare professionals?

East Carolina University (ECU) has historically had a focus on meeting the needs of underserved regions of the state. The medical school ranks among the nation’s top five for the percentage of students practicing in primary care for the past seven years. ECU recently announced a new rural prosperity initiative that spans its various colleges and institutions.

Campbell University has targeted high need medical professionals and is partnering with multiple NC health systems to create 350 new residency positions, several of which are in rural and underserved counties.

University of North Carolina at Chapel Hill has a long-standing Kenan Primary Care Scholars program that focuses on supporting scholars interested in practicing in rural and underserved areas of North Carolina. In 2017, the UNC School of Medicine announced the creation of the Office of Rural Initiatives that links and expands several rural initiatives.

NCMS Community Practitioner Program complements HRSA’s federal and ORH’s state loan repayment programs. These programs provide loan repayment for providers serving in public or non-profit underserved settings in exchange for a time commitment. NCMS can offer loan repayment to providers practicing in private practices in rural and underserved areas.

There are several North Carolina examples of new community-based provider training programs. We have community health centers that are training primary care residents in caring for complex patients in the outpatient setting. ECU has built community-based dental residencies in high need underserved areas of the state. Campbell University operates a free clinic that offers training opportunities for its health science programs.

Community colleges are creating programs such as 2+2 that link rural students to four-year universities to complete degrees in allied health.

What are the trends in recruiting and retaining rural healthcare professionals?

Nationally, several states are working to intentionally recruit physicians from underserved areas. There are increasing efforts underway to improve and align the pipeline so that rural students remain in state for undergraduate education, medical school, complete a rural residency and receive loan repayment for a service commitment. There is a priority on creating an adequate distribution of generalist physicians to meet the demand for primary care, maternity care, mental health, and general surgery.

Due to lower population size, access to specialists has often required rural residents to travel to urban areas. If robust broadband is expanded, telehealth offers a unique opportunity to increase access to specialist consultations that might eliminate or reduce the amount of travel required.

As the US health care system moves to value based payments, there will be increased focus on moving services out of the inpatient setting and into team-based outpatient and community settings. This will require retraining existing workforce (i.e. nurses, paramedics) to function in new, redefined roles. There are opportunities for new types of workforce (i.e. community health workers). This is a critical time and it’s imperative that these efforts include a rural component both to leverage unique rural community strengthens and to not perpetuate long-standing workforce shortages.

Increasingly, government agencies are requesting and reviewing data regarding current and future workforce needs. There are discussions occurring on the optimal ways government programs can leverage health education funding to drive desired outcomes.

About Chris Collins
Associate Director, Health Care
The Duke Endowment

Before joining the Endowment in 2017, Collins was director of the N.C. Department of Health and Human Services Office of Rural Health since 2013. She previously served as the Office’s deputy director, and held a joint appointment as director of managed care with the Division of Medical Assistance. Collins has also worked as human service planner and evaluator with Buncombe County and executive director of Community Care of Western North Carolina.

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