Challenges and opportunities in diagnosing and managing mild traumatic brain injury in rural settings.

INTRODUCTION: There is some evidence to suggest that Americans living in rural areas are at increased risk for sustaining a traumatic brain injury (TBI) compared to those living in urban areas. In addition, once a TBI has been sustained, rural residents have worse outcomes, including a higher risk of death. Individuals living in rural areas tend to live farther from hospitals and have less access to TBI specialists. Aside from these factors, little is known what challenges healthcare providers practicing in rural areas face in diagnosing and managing TBI in their patients and what can be done to overcome these challenges. METHODS: Seven focus groups and one individual interview were conducted with a total of 18 healthcare providers who mostly practiced in primary care or emergency department settings in rural areas. Providers were asked about common mechanisms of TBI in patients that they treat, challenges they face in initial and follow-up care, and opportunities for improvement in their practice. RESULTS: The rural healthcare providers reported that common mechanisms of injury included sports-related injuries for their pediatric and adolescent patients and work-related accidents, motor vehicle crashes, and falls among their adult patients. Most providers felt prepared to diagnose and manage their patients with TBI, but acknowledged a series of challenges they face, including pushback from parents, athletes, and coaches and lack of specialists to whom they could refer. They also noted that patients had their own barriers to overcome for timely and adequate care, including lack of access to transportation, difficulties with cost and insurance, and denial about the seriousness of the injury. Despite these challenges, the focus group participants also outlined benefits to practicing in a rural area and several ways that their practice could improve with support. CONCLUSION: Rural healthcare providers may be comfortable diagnosing, treating, and managing their patients who present with a suspected TBI, but they also face many challenges in their practice. In this study it was continually noted that there was lack of resources and a lack of awareness, or recognition of the seriousness of TBI, among the providers' patient populations. Education about common symptoms and the need for evaluation after an injury is needed. The use of telemedicine, an increasingly common technology, may help close some gaps in access to services. People living in rural areas may be at increased risk for TBI. Healthcare providers who work in these areas face many challenges but have found ways to successfully manage the treatment of this injury in their patients.

A Practice Report From the Northern Dental Access Center: Offering Wraparound Services at a Community Dental Access Clinic to Improve Treatment Outcomes Among Rural Populations in Poverty.

CONTEXT: Rural populations suffer significant adverse health outcomes without reliable access to dental care, including increased emergency department use for oral health. The Northern Dental Access Program (Northern Dental) serves more than 20 counties in Greater Minnesota and bordering states. Its population is generally poor and less healthy than the rest of the state, with high rates of Medicaid. APPROACH: Evaluation of Northern Dental focused primarily on utilization of dental and nondental wraparound/support services. First, descriptive analyses were conducted, including assessing the patient population, visit, and client counts over time. Measures include procedures performed, visits, unique clients, active client base (based on previous visits in 12, 18, or 24 months), treatment plan completion, and use of wraparound services. RESULTS: Between 2009 and 2016, Northern Dental saw 20 367 unique clients. The staff performed more than 307 000 prevention and screening procedures, more than 55 000 fillings and restorations, and 20 000 oral surgery/endodontic procedures. Overall, 32% of patients (n = 6 626) completed their treatment plans. Bivariate comparisons suggested that those who were provided transportation assistance (5% of all patients) were more likely to complete their treatment than the overall patient population. Overall, in 2016, a total of 1 748 unduplicated clients worked with the staff more than 3 800 times to receive referrals and wraparound services. This represented about 27% of all clients seen in 2016 who had at least 1 clinical visit. DISCUSSION: Evaluation of Northern Dental's practice and approach shows sustained growth over time in service provision to the Medicaid population in Greater Minnesota, high need for transportation assistance, and significant interest in wraparound services. Transportation assistance involved substantial outlays from Northern Dental but resulted in substantially higher reimbursement, billing, and treatment completion for patients. IMPLICATIONS FOR PRACTICE: Wraparound services are typically supported through grants and charitable giving. Evidence like this can inform policy makers and insurance companies, making the case for reimbursing nonprofits that provide them.

Assessing Effectiveness and Cost-Benefit of the Trinity Hospital Twin City Fit For Life Program for Weight Loss and Diabetes Prevention in a Rural Midwestern Town.

INTRODUCTION: Obesity is a top public health priority in the United States. This article reports on the Fit For Life (FFL) health education program designed to address the determinants of obesity in rural settings and help participants lose weight. PURPOSE AND OBJECTIVES: We evaluated the implementation of the original FFL program, a replication program, and a diabetes-focused program. INTERVENTION APPROACH: The original FFL program (2006 to 2012) was a 12-week session of classes meeting once weekly. Lecture topics included stress management, nutrition, healthy eating, reading food labels, fitness, disease prevention, and healthy aging. The replication program, conducted in 4 locations from 2012 to 2015, helped determine if the FFL program could be implemented on a larger scale, with outcomes similar to the original program. The longer, more-intensive FFL diabetes prevention program, conducted in 2016 and 2017, sought to reduce the number of rural adults at risk for diabetes. EVALUATION METHODS: We evaluated FFL participation and outcome data from 2009 through first quarter 2017. We calculated rates of course participation and completion and measured changes in several health indicators. We constructed a linear regression model to examine the impact of health behaviors on weight loss and calculated program cost-effectiveness. RESULTS: From 2009 to 2017, FFL was delivered to over 1,200 people; 82% of participants completed the program. Completing participants lost an average of 2.7 kg or 3% of their total weight. Overall, 68% of participants said they exercised more per week at the end of the program than at the beginning. Estimated cost per kilogram lost for replication sites was between $73 and $101 for original FFL, in line with other programs. The more resource-intensive diabetes prevention program cost per kilogram lost was $151 to $171. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Weight loss and lifestyle management are major ways to counteract obesity. Improving program options, especially in rural locales, should be a key policy priority. These programs should be considered for population-based expansion, perhaps by health departments or public-private health care consortiums.

Rural Collaborative Model for Diabetes Prevention and Management: A Case Study.

Diabetes disproportionately affects racial and ethnic minorities, rural, and impoverished populations. This case study describes the program components and key lessons learned from implementing Vivir Mejor! (Live Better!), a diabetes prevention and management program tailored for the rural, Mexican American population. The program used workforce innovations and multisector partnerships to engage and activate a rural, mostly Hispanic population. Community health worker (CHW) roles were designed to reach and support distinct populations. Promotoras focused exclusively on health education and patient navigators individually coached patients with chronic disease management issues for the high-risk patient population. To extend diabetes health education to the broader community in Santa Cruz County, promotoras trained lay leaders to become peer educators. Multisector partnerships allowed the program to offer health and social services around diabetes care. The partners also supported provider engagement through continuing education workshops and digital story screening to encourage referrals to the program. Multisector partnerships, including partnering with critical access hospitals, for diabetes management and prevention, as well as using different types of CHWs to implement programs that target high- and low-risk populations are innovative and valuable components of the Vivir Mejor!

The Double Disparity Facing Rural Local Health Departments.

Residents of rural jurisdictions face significant health challenges, including some of the highest rates of risky health behaviors and worst health outcomes of any group in the country. Rural communities are served by smaller local health departments (LHDs) that are more understaffed and underfunded than their suburban and urban peers. As a result of history and current need, rural LHDs are more likely than their urban peers to be providers of direct health services, leading to relatively lower levels of population-focused activities. This review examines the double disparity faced by rural LHDs and their constituents: pervasively poorer health behaviors and outcomes and a historical lack of investment by local, state, and federal public health entities.

Impact of a Community Dental Access Program on Emergency Dental Admissions in Rural Maryland.

OBJECTIVES: To characterize the expansion of a community dental access program (CDP) in rural Maryland providing urgent dental care to low-income individuals, as well as the CDP's impact on dental-related visits to a regional emergency department (ED). METHODS: We used de-identified CDP and ED claims data to construct a data set of weekly counts of CDP visits and dental-related ED visits among Maryland adults. A time series model examined the association over time between visits to the CDP and ED visits for fiscal years (FYs) 2011 through 2015. RESULTS: The CDP served approximately 1600 unique clients across 2700 visits during FYs 2011 through 2015. The model suggested that if the CDP had not provided services during that time period, about 670 more dental-related visits to the ED would have occurred, resulting in $215 000 more in charges. CONCLUSIONS: Effective ED dental diversion programs can result in substantial cost savings to taxpayers, and more appropriate and cost-effective care for the patient. POLICY IMPLICATIONS: Community dental access programs may be a viable way to patch the dental safety net in rural communities while holistic solutions are developed.

Rural reinvestment: A path forward to addressing geographic health inequities.

The Centers for Disease Control and Prevention (CDC) produced two reports, in 2017 and 2021, highlighting rural inequities across the five leading causes of death. These reports were pivotal in bringing attention to geographic disparities in preventable deaths. The 2024 update provides similar focus and attention and shows concerning trends over time, given that inequities have increased significantly across four of the five leading causes of death. The purpose of this commentary is to highlight these ongoing health inequities and create dialogue among public health professionals as to how we regain trust and work collaboratively with rural communities to address these ongoing and growing challenges.

Buprenorphine Prescribing and Challenges Faced Among National Health Service Corps Clinicians.

Importance: The National Health Service Corps (NHSC) Loan Repayment Program (LRP) expansion in fiscal year (FY) 2019 intended to improve access to medication for opioid use disorder (MOUD) by adding more clinicians who could prescribe buprenorphine. However, some clinicians still face barriers to prescribing, which may vary between rural and nonrural areas. Objective: To examine the growth in buprenorphine prescribing by NHSC clinicians for Medicaid beneficiaries during the NHSC LRP expansion and describe the challenges to prescribing that persist in rural and nonrural areas. Design, Setting, and Participants: This cross-sectional study analyzed preexpansion and postexpansion Medicaid claims data to evaluate the percentage of prescriptions of buprenorphine filled during FY 2017 through 2021. This study also analyzed challenges and barriers to prescribing MOUD between rural and urban areas, using results from annual surveys conducted with NHSC clinicians and sites from FY 2019 through FY 2021. Exposure: Prescribing of buprenorphine by NHSC clinicians. Main Outcomes and Measures: The main outcomes were the percentage and number of Medicaid beneficiaries with opioid use disorder (OUD) who filled a prescription for buprenorphine before and after the LRP expansion and the challenges NHSC clinicians and sites faced in providing substance use disorder and OUD services. Survey results were analyzed using descriptive statistics. Results: During FYs 2017 through 2021, 7828 NHSC clinicians prescribed buprenorphine (standard LRP: mean [SD] age, 38.1 [8.4] years and 4807 females [78.9%]; expansion LRPs: mean [SD] age, 39.4 [8.1] years and 1307 females [75.0%]). A total of 3297 NHSC clinicians and 4732 NHSC sites responded to at least 1 survey question to the 3 surveys. The overall percentage of Medicaid beneficiaries with OUD who filled a prescription for buprenorphine during the first 2.5 years post expansion increased significantly from 18.9% before to 43.7% after expansion (an increase of 123 422 beneficiaries; P < .001). The percentage more than doubled among beneficiaries living in areas with a high Social Vulnerability Index score (from 17.0% to 36.7%; an increase of 31 964) and among beneficiaries living in rural areas (from 20.8% to 55.7%; an increase of 45 523). However, 773 of 2140 clinicians (36.1%; 95% CI, 33.6%-38.6%) reported a lack of mental health services to complement medication for OUD treatment, and 290 of 1032 clinicians (28.1%; 95% CI, 24.7%-31.7%) reported that they did not prescribe buprenorphine due to a lack of supervision, mentorship, or peer consultation. Conclusions and Relevance: These findings suggest that although the X-waiver requirement has been removed and Substance Abuse and Mental Health Services Administration guidelines encourage all eligible clinicians to screen and offer patients with OUD buprenorphine, as permissible by state law, more trained health care workers and improved care coordination for counseling and referral services are needed to support comprehensive OUD treatment.

Role of the National Health Service Corps in Delivering Substance Use Disorder Treatment in Underserved Communities.

OBJECTIVE: To help address the opioid epidemic, the U.S. Health Resources and Services Administration expanded the National Health Service Corps (NHSC) to include two new loan repayment programs (LRPs)-the Substance Use Disorder LRP and the Rural Community LRP-to supplement the existing standard LRP. In this article, the authors aimed to describe the role of these NHSC programs in addressing workforce shortages and providing substance use disorder treatment, including for opioid use disorder, in underserved areas. METHODS: Administrative data on NHSC clinician locations were merged with county-level data to characterize the communities served by NHSC clinicians. Primary data from surveys and key informant interviews with NHSC site administrators (N=9) and clinicians (N=9) were used to describe changes in NHSC clinician service delivery due to the COVID-19 pandemic. RESULTS: The NHSC LRP expansion increased the number of clinicians providing behavioral health treatment in underserved areas, especially rural areas. A majority of NHSC sites surveyed have increased their provision of substance use disorder treatment since the COVID-19 pandemic began. CONCLUSIONS: This article demonstrates the valuable role of these NHSC programs as resources that policy makers can use to mitigate the challenges of health care workforce shortages and burnout.

Rural Primary Care Providers' Experience and Usage of Clinical Recommendations in the CDC Pediatric Mild Traumatic Brain Injury Guideline: A Qualitative Study.

PURPOSE: In 2018, the Centers for Disease Control and Prevention (CDC) released an evidence-based guideline on pediatric mild traumatic brain injury (mTBI) to educate health care providers on best practices of mTBI diagnosis, prognosis, and management/treatment. As residents living in rural areas have higher rates of mTBI, and may have limited access to care, it is particularly important to disseminate the CDC guideline to rural health care providers. The purpose of this paper is to describe rural health care providers' experience with pediatric mTBI patients and their perceptions on incorporating the guideline recommendations into their practice. METHOD: Interviews with 9 pediatric rural health care providers from all US regions were conducted. Interview transcripts were coded and analyzed for themes for each of the main topic areas covered in the interview guide. FINDINGS: Common causes of mTBI reported by health care providers included sports and all-terrain vehicles. While health care providers found the guideline recommendations to be helpful and feasible, they reported barriers to implementation, such as lack of access to specialists. To help with uptake of the CDC guideline, they suggested the development of concise implementation tools that can be referenced quickly, integrated into electronic health record-based systems, and that are customized by visit type and health care setting (eg, initial vs follow-up visits and emergency department vs primary care visits). CONCLUSION: Length, accessibility, and usability are important considerations when designing clinical tools for busy rural health care providers caring for pediatric patients with mTBI. Customized information, in both print and digital formats, may help with uptake of best practices.

Effect of post-discharge follow-up care on re-admissions among US veterans with congestive heart failure: a rural-urban comparison.

INTRODUCTION: Hospital re-admissions for patients with congestive heart failure (CHF) are relatively common and costly occurrences within the US health infrastructure, including the Veterans Affairs (VA) healthcare system. Little is known about CHF re-admissions among rural veteran patients, including the effects of socio-demographics and follow-up outpatient visits on these re-admissions. PURPOSE: To examine socio-demographics of US veterans with CHF who had 30 day potentially preventable re-admissions and compare the effect of 30 day VA post-discharge service use on these re-admissions for rural- and urban-dwelling veterans. METHODS: The 2005-2007 VA data were analyzed to examine patient characteristics and hospital admissions for 36 566 veterans with CHF. The CHF patients who were and were not re-admitted to a VA hospital within 30 days of discharge were identified. Logistic regression was used to examine and compare the effect of VA post-acute service use on re-admissions between rural- and urban-dwelling veterans. RESULTS: Re-admitted veterans tended to be older (p=.002), had disability status (p=.024) and had longer hospital stays (p<.001). Veterans Affairs follow-up visits were negatively associated with re-admissions for both rural and urban veterans with CHF (ORs 0.16-0.76). Rural veterans aged 65 years and older who had VA emergency room visits following discharge were at high risk for re-admission (OR=2.66). CONCLUSIONS: Post-acute follow-up care is an important factor for promoting recovery and good health among hospitalized veterans with CHF, regardless of their rural or urban residence. Older, rural veterans with CHF are in need of special attention for VA discharge planning and follow up with primary care providers.

Why is rural public health important? A look to the future.

Public health in the United States began as a largely urban phenomenon, dating back to the late 1700s. In those days, public health was mostly concerned with issues such as sanitation and communicable diseases, which were of greater concern in areas with higher population density. By the late 1800s, however, it was apparent that the country's population was becoming more mobile and communicable diseases were beginning to spread from urban dwellers to rural dwellers, creating a need for rural public health services. Beginning in 1908, local governmental public health began to expand its reach into rural areas, with county health departments developing rapidly until the mid-1940s. Following the passage of the Hill-Burton Act in 1945, which funded the construction of community hospitals, rural health focus shifted almost exclusively to ensuring access to healthcare services. This article provides a historical context for rural public health service delivery and a beginning discussion of implications for contemporary rural public health practice.

Disparities in pediatric asthma hospitalizations.

OBJECTIVE: The purpose of this project was to determine to what extent rural children are hospitalized for asthma, an ambulatory care sensitive condition defined by the Agency for Healthcare Research and Quality pediatric quality indicators; to analyze differences in hospitalization rates for asthma by state and by rurality; and to examine the relationships between asthma hospitalization rates and poverty, health insurance, and physician supply. METHODS: The project used 2001 through 2004 hospital inpatient discharge data for children aged 2 to 17 years from six geographically diverse states in the Healthcare Cost and Utilization Project. County-level poverty, uninsurance estimates, and physician data came from the 2004 Area Resource File. Pediatric Quality Indicator software was used to calculate county-level admission rates for asthma. Multivariate regression models were specified to assess how sensitive hospitalization rates were to characteristics of the children's counties of residence. RESULTS: Pediatric asthma hospitalization rates per 100,000 children aged 2 to 17 years varied by state ranging from 51.1 to 185.9. When comparing all six states, rural children were the most likely to be hospitalized for asthma. However, after controlling for rurality, poverty, uninsurance, and physician supply, uninsurance was the only variable to significantly impact hospitalization rates. CONCLUSIONS: These findings indicate that there are significant differences in pediatric asthma hospitalizations rates by and within states, which may best be addressed by targeting public health and healthcare interventions. In addition, the findings support efforts to increase health insurance coverage for children, especially rural children who are less likely to be insured.

Improving Chronic Disease Self-Management by Older Home Health Patients through Community Health Coaching.

The purpose of the study was to pilot test a model to reduce hospital readmissions and emergency department use of rural, older adults with chronic diseases discharged from home health services (HHS) through the use of volunteers. The study's priority population consistently experiences poorer health outcomes than their urban counterparts due in part to lower socioeconomic status, reduced access to health services, and incidence of chronic diseases. When they are hospitalized for complications due to poorly managed chronic diseases, they are frequently readmitted for the same conditions. This pilot study examines the use of volunteer community members who were trained as Health Coaches to mentor discharged HHS patients in following the self-care plan developed by their HHS RN; improving chronic disease self-management behaviors; reducing risk of falls, pneumonia, and flu; and accessing community resources. Program participants increased their ability to monitor and track their chronic health conditions, make positive lifestyle changes, and reduce incidents of falls, pneumonia and flu. Although differences in the ED and hospital admission rates after discharge from HHS between the treatment and comparison group (matched for gender, age, and chronic condition) were not statistically significant, the treatment group's rate was less than the comparison group thus suggesting a promising impact of the HC program (90 day: 263 comparison vs. 129 treatment; p = 0.65; 180 day 666.67 vs. 290.32; p = 0.19). The community health coach model offers a potential approach for improving the ability of discharged older home health patients to manage chronic conditions and ultimately reduce emergent care.

Implementation of Telemedicine Consultation to Assess Unplanned Transfers in Rural Long-Term Care Facilities, 2012-2015: A Pilot Study.

INTRODUCTION: Public and private entities in the United States spend billions of dollars each year on potentially avoidable hospitalizations. This is a common occurrence in long-term care (LTC) facilities, especially in rural jurisdictions. This article details the creation of a telemedicine approach to assess residents from rural LTC facilities for potential transfer to hospitals. METHODS: An electronic LTC (eLTC) pilot was conducted in 20 pilot LTC facilities from 2012-2015. Each site underwent technologic assessment and upgrading to ensure that 2-way video communication was possible. A new central "hub" was staffed with advanced practice providers and registered nurses. Long-term care pilot sites were trained and rolled out over 3 years. This article reports development and implementation of the pilot, as well as descriptive statistics associated with provider assessments and averted transfers. RESULTS: Over 3 years, 736 eLTC consultations occurred in pilot sites. One-quarter of consultations occurred between 10 pm and 9 am. Overall, approximately 31% of cases were transferred. This decreased from 54% of cases in 2013 to 17% in 2015. Rural pilot facilities had an average of 23 eLTC consults per site per year. DISCUSSION: Averted transfers represent a dramatic benefit to the residents, as potentially avoidable hospitalizations cause undue stress and allow for nosocomial infections, among other risks. In addition, averting these unnecessary transfers likely saved the taxpayers of the United States over $5 million in admission-related charges to Centers for Medicare and Medicaid Services (511 avoided transfers × $11,000 per average hospitalization from a LTC facility). CONCLUSIONS: Overall, the eLTC pilot showed promise as a proof-of-concept. The pilot's implementation resulted in increasing utilization and promising reductions in unnecessary transfers to emergency departments and hospitalizations.

In-hospital mortality among rural Medicare patients with acute myocardial infarction: the influence of demographics, transfer, and health factors.

UNLABELLED: CONTEXT/PURPOSE: Most rural hospitals can provide medical care to acute myocardial infarction (AMI) patients, but a need for advanced cardiac care requires timely transfer to a tertiary hospital. There is little information on AMI in-hospital mortality predictors among rural transfer patients. METHODS: Cross-sectional retrospective analyses on 2003-2005 Medicare hospital inpatient data from 5 states were conducted to compare predictors of in-hospital AMI mortality between rural hospital transferred and nontransferred patients. A total of 9,690 rural hospital AMI patients were identified: 3,087 were transferred to receiving hospitals and 6,603 were not transferred. Separate logistic regressions were conducted for transferred and nontransferred patient cohorts and results were compared. RESULTS: Transfer patients were younger, more likely male, had fewer comorbidities/complications, and were less likely to expire (5.3% vs 16.7%) in the hospital. Congestive heart failure and cardiac dysrhythmia were the most common comorbidities/complications among transfer and no-transfer AMI patients, but shock (OR = 9.44) and acute renal failure (OR = 3.67) had the strongest associations with in-hospital mortality for both cohorts. Undergoing a percutaneous coronary intervention (PCI) was associated with a 42% reduction in hospital mortality risk for transfer patients. CONCLUSIONS: Transfer was associated with a greater likelihood of in-hospital AMI survival, largely but not fully explained by transfer patients being younger with fewer comorbidities/complications who are receiving advanced cardiac care. Additional studies are needed to clarify other factors that explain higher in-hospital mortality among nontransfers, such as patients' health care decision-making.