Office of Rural Health Policy

Steve North and Amanda Martin of the Center for Rural Health Innovation, which administers the Spruce Pine-based MY Health-e-Schools program.

School-based health centers fill rural provider vacuum

November 17, 2020 by Melba Newsome

School-based health centers fill rural provider vacuum - North Carolina Health News

Making healthcare available to students, faculty and staff on campus is vital to well-being in rural areas.

By Melba Newsome

Growing up in a small town in central Wisconsin, many of Steve North’s relatives and friends assumed he would follow his father into medicine but North had other ideas. He earned a liberal arts degree at the University of Wisconsin-Madison in 1993 but, instead of applying for medical school, he applied for Teach for America.

For the next two years, North taught 5th- through 8th-grade exceptional education in Edgecombe County where he saw how unaddressed medical problems kept his students from reaching their academic potential.

“The kids were frequently coming to school sick or missing lots of school,” recalls North. “I started doing some reading and got turned on to the idea of school-based health centers (SBHC), which were relatively new on the national scene at the time.”

What he learned persuaded North to finally follow in his father’s footsteps and he was accepted to medical school at UNC Chapel Hill.

While practicing family and adolescent care medicine in Bakersville, a remote mountain town with fewer than 500 residents, North continued to look for ways to provide better care to the children he served. A Jim Bernstein Community Health Leadership Fellowship gave him the support and resources to start the Center for Rural Health Innovation, a non-profit dedicated to improving rural access to health care. That led to the formation of Health-e-Schools, remote clinics that provide primary care and behavioral health services for school kids.

A doctor’s office on campus

North Carolina has been trying to solve the state’s provider scarcity problem for decades with varying degrees of success. In the western part of the state, the doctor-to-patient ratio can be as high as one to 2,000 in some of the most remote areas. School-based health clinics (SBHCs) bring together educators and health practitioners to bridge the health care and education gap and help reduce the disparities that impact school children in rural burgs.

SBHCs are essentially doctors’ offices conveniently located on campus to provide a range of health care services for students, as well as for teachers and staff. For many rural, low-income residents in health care deserts, these clinics are their only access to care.

With permission from a parent or guardian, students are enrolled at the beginning of the school year and can take advantage of available resources. In addition to seeking medical attention for acute issues such as ear and stomach aches, enrollees can also receive chronic disease management, immunizations, well-child checkups, sports physicals, adolescent medicine consultants, and hearing and vision screenings.

North Carolina law also allows minors to seek medical health services for the prevention, diagnosis and treatment of sexually transmitted diseases, pregnancy, substance misuse or emotional disturbances without parental consent.

Additionally, these clinics also help reduce the number of days of classes missed by students.

“This is a good thing because when they come back after being out for a couple of days, they’re behind and it takes a while for them to get back up to speed,” said North. “If that happens more frequently with chronic absenteeism, it can be really tough to bring students back on track.”

SBHCs continue to expand

SBHCs continue to grow across the country and the state, particularly in areas with a shortage of health care providers. Some are funded through private grants but many others are supported by state and federal appropriations. Most partner with the local school district and a community health organization, such as a community health center, hospital or local health department. All are committed to serving every student, regardless of insurance or ability to pay.

When North and the Center for Rural Health Innovation launched Health-e Schools in 2011, the program served just three schools. Now, it reaches more than 25,000 students in 80 schools across three western counties, McDowell, Mitchell and Yancey.

“Parents might work 30 miles in one direction and children go to school 20 miles in the other,” said North. “Before this, when that inevitable call comes in that said ‘Johnny is sick,’ parents had to drive to school, pick up the child and go to the doctor’s office. A lot of those people would end up in the ER who probably didn’t need to be there.”

Shows a man smiling behind a mask worn to prevent transmission of COVID-19. He's standing next to a sign for the Health-e Schools sign for a clinic site at Greenlee School. — Jason Hall, principal of Greenlee Primary School in the Mitchell County town of Spruce Pine shows off his school’s affiliation with Health-e Schools. Photo credit: Lacey Jones, RHI

Similar alliances operate all across the state. Blue Ridge Health operates 13 SBHCs in Henderson, Buncombe, Swaine, Jackson, Rutherford and Polk counties. Many of their students have an hour-long bus ride to and from school so the convenience of on-site clinics means a child doesn’t have to miss a day of school just to see a doctor.

On the other end of the state, the Pender Alliance for Teen Health (PATH) operates three SBHCs in southeastern Pender County, filling a big gap in a place where families routinely drive 50 miles one-way to see a health care provider.

“We have certainly improved their access,” said Kimberly Collins, lead nurse for Pender County Schools. “More kids are getting their annual physicals and getting vaccinated on time. Our staff is able to see them for whatever needs they might have without having to leave work or take a whole day off, or even a half a day off.”

Using high-definition video conferencing with specially equipped stethoscopes and cameras, a centrally located health care provider can examine students at multiple schools without traveling.

As these programs continue to grow, equipping them with these tools becomes more economical, said North.

“It used to cost $30,000 to put telemedicine technology in a school,” he said. “We can now equip a school nurse for about $2,000, with a better piece of equipment that they can take from school to school.”

Behavioral care a gaping need

A study in JAMA Pediatrics found that 72 percent of North Carolina children diagnosed with a behavioral health condition waited more than a year to meet with a licensed mental health provider. According to a brief from the North Carolina Institute of Medicine, this is due in large part to the shortage of specialized instructional support personnel such as nurses, counselors, psychologists and social workers. For example, the recommended ratio is one social worker for every 250 students. North Carolina has one for every 1,427 students, according to the NC IOM report.

Lack of high-speed internet can complicate telehealth delivery in rural communities but SBHCs have made great strides in using technology to connect students to counselors, psychologists and social workers.

In September 2018, Hurricane Florence dropped more than 40 inches of rain in one day on Pender County. Up to 70 percent of the county was under water, 3,000 homes were damaged, and tens of thousands of residents were displaced. Schools remained closed for 29 days while families tried to rebuild or relocate.

By the time the coronavirus pandemic hit 18 months later, hundreds of families still lacked permanent housing.

“The pandemic is like a second wave gut punch for Pender County,” said Sandy Rowe, PATH executive director. “We were still reeling from Florence. With the poverty, remote areas and the domestic violence against our kids, they are feeling like they can’t count on anything.

“We’ve focused on doing what we can to reach them and offer services early enough in the process so that we don’t have a bigger problem later on.”

When a post-Hurricane Florence mental health risk assessment found that 30 percent of the children were at risk for depression, PATH stepped in to add two full-time teletherapy counselors and a health coach to its team of providers. It also boosted preventive measures by developing a mindfulness curriculum for teachers.

Blue Ridge has on-staff counselors for district students and Health-e-Schools partners with Mission Health to address the needs of students with complex mental health issues. Instead of missing school and possibly driving an hour to see a therapist, they can see a mental health provider and still get back to class before the school day ends.

There is a growing recognition of the value SBHCs have to their communities. In 2016, the Federal Office of Rural Health Policy and the Health Resources and Services Administration encouraged expanding access to SBHCs and provided more than $6 million in grants for rural telehealth programs. Last year, HRSA awarded $11 million to SBHCs for technological upgrades.

This is a win-win that bodes well for the growth of SBHCs, particularly in rural areas.

Melba Newsome is a 2020 EWA Reporting Fellow. This story is produced as part of EWA’s drive to support enterprising journalism that informs the public about consequential issues in education.

Report Points to Disparity in Rural/Urban Life Expectancy

February 9, 2016 by Taylor Sisk

Report Points to Disparity in Rural/Urban Life Expectancy - North Carolina Health News

A national advisory committee finds that health disparities between rural and urban communities have widened. Similar disparities are found in North Carolina.

By Taylor Sisk

A recent report by the National Advisory Committee on Rural Health and Human Services indicates that life expectancy in rural American communities is consistently lower than in urban areas.

The NACRHHS, chaired by former Mississippi Gov. Ronnie Musgrove, provides recommendations on rural health issues to the secretary of the U.S. Department of Health and Human Services. A webinar was held Jan. 28 to discuss the results of its most recent report, “Mortality and Life Expectancy in Rural America: Connecting the Health and Human Service Safety Nets to Improve Health Outcomes over the Life Course.”

rural barns — Image courtesy Donald Lee Pardue, flickr creative commons

The report’s authors find that while life expectancy at birth for the nation’s population as a whole has been increasing for more than a century, in the past few decades the disparity between rural and urban communities has widened.

In fact, some rural counties have experienced declines in life expectancy during this period. The greatest disparities are found in Appalachia.

Data presented last year by NC Child (see interactive map below) indicates similar disparities in North Carolina.

“This rise in death rates is unique since the flu epidemic of 1918,” Wayne Myers, a committee member and former head of the federal Office of Rural Health Policy, told webinar participants. “There has not been such a large loss of life expectancy of such sustained duration in the industrial world.”

Myers called the rural/urban disparities “an equal opportunity tragedy,” in that they’re found in both majority-black as well as predominantly white communities.

Poverty bound

The committee found that almost all counties with the greatest declines in mortality are rural. From 2005 to 2009, the mortality rate in rural counties was 13 percent higher than in metro counties. (Mortality rate is the number of deaths that occur per 1,000 people in a given place and time.)

Rural/urban disparities in life expectancy also widened, and life expectancy worsened in the most rural areas.

According to NC Child’s data, life expectancy in Wake County in 2014 was 81.4 years; in the largely rural eastern county of Robeson, it was 74.2 years; and in rural Western North Carolina’s Swain County, it was 73.1.

Wake County men lived, on average, 79.3 years; Robeson County men, 71 years; and Swain County men, 70.5.

Wake County women had a life expectancy of 83.2; Robeson County women, 77.3 years; and Swain County women, 75.7.

The NACRHHS report also underscored that as poverty rates increase, life expectancy declines – and more so in rural than in urban communities.

Meanwhile, census data indicates that poverty is on the rise – again, in rural more than in urban communities. The U.S. Census Bureau’s 2013 American Community Survey found that nearly 2.6 million children in rural areas are in families with incomes below the federal poverty level ($24,250 for a family of four).

The child poverty rate of 26 percent in rural communities was up from the 1999 rate of 19 percent. The rate in urban areas rose in that same period from 16 percent to 21 percent.

In Wake County 14.3 percent of children live below the poverty level; in Robeson, the rate is as high as 46.6 percent; and in Swain, 28.8 percent.

This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina.

‘Older, poorer, sicker’

In its report, the NACRHHS suggests several sources of the rural/urban disparity in life-expectancy rates:

“In general, rural America is older, poorer, and sicker than urban America, all of which contribute to the rural-urban mortality gap. Because rural Americans are on average older than their urban counterparts they are disproportionately represented in the Medicare population.”

In addition, a number of chronic diseases affect rural residents at higher rates. Cardiovascular disease is among them. Smoking is another primary issue.

The good news regarding smoking, said the NACRHHS’s Alana Knudson, co-director of the University of Chicago’s Walsh Center for Rural Health Analysis, is that there has been an overall decrease in the past decade in adolescents who smoke. The bad news is that kids in rural areas are smoking at about twice the rate of their urban counterparts.

Rates of obesity, heart disease and cancer are high in Robeson County relative to the state average and it has the highest smoking rate in the state.

Targeted funding

“By looking at national trends, which are not good, we have missed the fact that some parts of the country are not simply not gaining in life expectancy, they are actually seeing life expectancy decline,” said NACRHHS chair Musgrove.

Throughout the past 25 years, the committee states in its report, the Department of Health and Human Services has addressed access to health care in rural communities by such measures as financing community health centers and providing differential reimbursement for low-volume, rural health care providers.

“However, access to care alone is not enough to fully address complex health outcomes including mortality and life expectancy of populations,” they write. “Approaches must strengthen the health care delivery system while increasing integration of primary, specialty, substance abuse, and mental health services with human services including economic development, employment, housing, transportation, and education.”

Myers reiterated this, saying, “A lot of the issues, I would argue, underlying both the rural/urban disparity and the rising death rates in rural areas are not within the traditional purview of the [DHHS] secretary.”

Efforts to address these issues, he said, must include the secretaries of Commerce, Labor, Justice and Education.

Among the NACRHHS’s recommendations are calls to increase federal support of “research projects that examine behavioral health and primary care integration in rural communities to expand the evidence base for these efforts.” Another recommendation is for the DHHS secretary to direct the National Institute on Drug Abuse to conduct research into the rural/urban implications of opioid use and overdose, including heroin.

The committee also calls for an increase in funding for training primary care providers and emergency medical providers in the use of opioid overdose-treatment drugs, including naloxone.

The report states that while “rural communities face higher levels of health disparities, the funding to address this disparity is allocated on a population basis, leaving rural programs significantly underfunded. The Committee suggests that HHS consider need as a significant factor in future allocation of public health and prevention funding.”

This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina.

The Death-Rate Divergence: Urban vs. Rural

January 28, 2016 by Daily Yonder

The Death-Rate Divergence: Urban vs. Rural - North Carolina Health News

By Shawn Poynter and Tim Marema

The Daily Yonder

Rural America’s above-average mortality rate ought to be getting more attention than it is, according to a former federal health official who will be part of a presentation this week on rural life expectancy.

“Several million people dying too soon is as important as a terrorist attack, but it’s not on the candidate debates or the evening news,” said Wayne Myers, who was head of the federal Office of Rural Health Policy during the Clinton administration.

From 2005 to 2009, the rural mortality rate was 13 percent higher than the mortality rate for urban residents, according to a policy brief from the National Advisory Committee on Rural Health and Human Services. Until 1990, both urban and rural death rates were improving at about the same pace (see graph above). But since then, rural America has not been keeping pace with improvement in urban areas. Over the past quarter century, the gap has widened.

That’s bad news for the country as a whole, not just rural areas, according to Myers. The same trends may be affecting metropolitan areas but be harder to spot, he said.

“In a large complex city, you may have all sorts of trends in different demographic groups headed in different directions and cancelling each other out: trends in prosperity, security, access to medical care, drug use. You can see effects sooner on smaller, more homogenous rural populations. We need some smart statisticians willing to work on smaller populations to sort this out.”

Myers is one of the participants in a Thursday, Jan. 28, webinar that will review the National Advisory Committee’s findings. (The webinar is free and open to anyone who is interested. Registration information.)

“I hope the webinar will get some more people wanting to know why too many rural people are dying young,” Myers said. “I think that is really important. Eventually I’d like to see a group convened to sort out what is scientifically known about (1) the impact of social and economic change on people’s health, and (2) what actually works to improve the health of groups of people.”

There are many reasons the rural and urban mortality rates have diverged, according to the National Advisory Committee on Rural Health and Human Services. Rural America is “older, poorer, and sicker than urban America,” they write. Other factors include a rising rate of accidental “poisoning” (which is a polite way to say “drug overdose”), poverty, unintentional injuries (car and ATV wrecks, gun accidents, etc.) and proximity to emergency health services and lack of reliable transportation to get to medical attention. These factors have converged to make rural life expectancy a full two years short of urban life expectancy (see Figure 2).

The brief notes that “social circumstances and behavior” are major factors in premature rural deaths, contributing in more than half of rural deaths.

“When discussing mortality and life expectancy – inextricably linked to population and individual health – it is also necessary to examine aspects outside of health care that both lead to poor health and can be used to improve it,” the brief states. “This includes factors in households, schools, places of employment, transportation, and physical environments.”

The brief was presented to Department of Health & Human Services Sec. Sylvia Mathews Burwell. Among policy suggestions were support for more research and increased funding for rural medical personnel and programs.

This story originally appeared here and is shared by N.C. Health News through a content-sharing agreement with The Daily Yonder, an online publication dedicated to all things rural in the U.S.

Additional Thanks

Categories