U.S. mapThe National Advisory Committee
on Rural Health and Human Services

U.S. Department of Health and Human Services

The 2008 Report to the Secretary: Rural Health and Human Service Issues

April 2008

 printer-friendly 2008 Report to the Secretary (PDF, 728 KB)

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Emerging Issues and Trends


The changes that occurred between 1987 and today have influenced the strengths and weaknesses of current rural health and human services delivery systems. Several challenges are products of emerging trends in demographics, industry, or government policy. Many of these are ongoing, undermining service delivery without much foreseeable respite. This section seeks to highlight the principal issues that the Committee believes will be central to rural health and human services discussions in the years to come.

 

The Future of Rural Health Services


In recent years, there has been some improvement in rural health care delivery systems, thanks in part to a body of rural-specific initiatives developed by health care providers, advocates, and national policy makers. Unfortunately, the status of these delivery systems is still tenuous. The Committee believes that the following issue areas will determine the future ability of rural communities to meet the health care needs of their populations.

 

Ongoing Workforce Challenges

 

Text Box: Wisconsin Academy for Rural Medicine Although Wisconsin boasts 2 medical schools, the State’s 52 rural counties are home to only 11 percent of all Wisconsin physicians. As with other rural areas, this physician shortage is projected to increase as current providers retire and the needs of an aging rural population increase. In response to these significant workforce shortages, the University of Wisconsin School of Medicine and Public Health created an innovative new program, the Wisconsin Academy for Rural Medicine (WARM). Admission criteria to WARM contain a preference for applicants who are more likely to practice in rural areas, e.g., those who are from a rural community. Having welcomed its first class of medical students in fall 2007, WARM structures the medical education to deepen students’ awareness of and commitment to health in rural Wisconsin. For example, the traditional medical curriculum is enhanced by incorporating population health concepts and rural health electives. During the third and fourth years of medical school, WARM students relocate to regional rural learning sites, in order to gain practical clinical experience in rural areas. Teaching methods such as these help ensure that a robust workforce pipeline exists between health training programs and rural communities; hopefully the innovative rural focus of programs such as WARM will be considered a model by training facilities across the country. Source: Golden, R. (September 12, 2007). “Wisconsin Academy for Rural Medicine: Meeting the Healthcare Needs of Rural Wisconsin.” Remarks to the NACRHHS September Meeting. Rural workforce shortages continue to weaken health care delivery and the quality of health care services. According to The Chronicle of Higher Education, the nation will need at least 20,000 more physicians over the next decade to care for elderly patients, though fewer than 8,000 geriatricians are in practice today.1 High caseloads, long hours on call, isolation from colleagues, lack of easily accessible continuing education and professional enrichment opportunities, limited professional opportunities for spouses, and heavy school debt loads are some concerns that can deter medical students and residents from practicing in rural areas. The first half of this report described the principal Federal programs that have been created to reduce rural physician shortages; however, the Committee is concerned that several recent trends may undermine the ability of these programs to attract the next generation of physicians to rural areas. Concerning trends include the continued cuts in the HHS Title VII primary care training grants and the declining match rates for family practice residencies. These trends indicate that fewer medical students will be prepared to practice in family medicine, a disturbing prospect given that primary care physicians constitute the cornerstone of rural health care provision. While international medical graduates have helped to reduce rural physician shortages in the past, the apparent decline in applicants for the J-1 Visa Waiver program has the potential to exacerbate current and future gaps in health care access. This rural dependence on international medical graduates persists because these clinicians have filled a need in some rural communities where U.S. trained physicians have been reluctant to practice.

 

 

 

 

 

 

 Text Box: J-1 Visa Waiver Trends Rural communities are reliant on J-1 Visa Waiver physicians. Some rural advocates are concerned because waiver requests have decreased over the past 10 years by 26 percent (1,374 in 1995 to 1,012 in 2005).1 It is difficult to pinpoint what is causing this decline, because limited data and analysis are available to quantify exactly what is happening. Some have suggested that more foreign-born physicians are choosing to enter the country through the H3-B visa, which does not have a requirement to practice in underserved areas as the J-1 Visa Waiver does. Others point to tightened immigration policies after September 11, 2001. Regardless, if the trend of fewer physicians remaining in the U.S. through the J-1 Visa Waiver process continues, there could be negative consequences for underserved rural areas in need of physicians. Note: 1 U.S. Government Accountability Office. (November 2006). Foreign Physicians: Data on Use of J-1 Visa Waivers Needed to Better Address Physician Shortages. (Pub. No. GAO-07-52). Washington, D.C. 13. See also Aronson, R. (October 2007). Recent Developments with Conrad J-1 Waivers. Special Physician Newsletter. Minneapolis, MN: Aronson and Association, P.A. During its site visits, the Committee heard testimony on the inadequate supply of a range of health care professionals, from nurses and physical therapists to radiation technologists and dentists. These professionals not only face many of the same rural challenges experienced by physicians, but they also receive less Federal assistance for training. Rural facilities are disproportionately staffed by nurses who have graduated with two-year associate degrees from local community colleges, yet HHS provides support mostly for four-year baccalaureate degree tracks.2 Stronger support for local community colleges is key to strengthening the overall rural health system. Unfortunately, HHS’ orientation on this matter is unlikely to change until the rural workforce gap becomes better quantified; at present, few national studies of vacancy rates report their data by rural or urban location.

 

The shortages of rural dentists have been repeatedly emphasized during past Committee site visits. Tooth decay is the most prevalent health problem after the common cold and contributes to many serious health conditions, including heart disease, diabetes, and respiratory diseases.3 Yet even CHCs and rural Head Start facilities that have received funding for dental care struggle to recruit dentists.4

 

There are a number of reasons that rural areas struggle to attract dentists. Some cite concerns with reimbursement, while others worry about the ability to start and maintain an economically viable practice in isolated rural areas. While dental access is also inadequate in many urban areas, this report has already noted that dental shortages remain substantially worse in rural areas. The Committee is encouraged that Wisconsin and North Carolina are considering opening new dental schools to focus more directly on public health dentistry and on the needs of underserved areas. Nonetheless, the trend of vastly unmet dental needs in rural areas remains a primary concern for the future.

 

Mental health is another specialty area in which the rural health care delivery system is particularly fragile. Clinically defined mental health problems are as prevalent in rural as in urban areas, yet the data presented previously show that most rural residents do not have access to mental health care providers.5 Due to this shortage, primary care doctors who may not have adequate training in mental health care shoulder the responsibility of providing the majority of mental health services in rural areas. Additionally, residents are reluctant to seek care even when a provider is present, due to the common misconception that mental and behavioral health problems are unrelated to physical health.6 Whereas seeking treatment for physical health conditions is considered socially acceptable, there is often stigma associated with receiving mental health treatment.7 The fear of being stigmatized is compounded by the concern that confidentiality and anonymity cannot always be assured in close-knit rural communities.

 

The results of all of these workforce challenges across the various professions weigh heavily on a rural community’s ability to provide services. Health workforce shortages remain one of the principal challenges for the future of rural health care. The Chronicle of Higher Education argues that solutions will require long range planning.8 It is important that HHS play a role in addressing the looming workforce challenges. In addition, other Cabinet-level Departments have key roles, including the Department of Education and its links to community colleges, and the Department of Labor (DOL) through its administration of the Workforce Investment Act programs. The Committee believes that there is a clear need to begin a discussion among these three Cabinet-level Departments to promote coordination and joint efforts geared towards rural workforce needs.

 

Current and Future Rural Health Care Reforms

 

Whereas rural workforce shortages have remained a national concern for over 20 years, several innovative health-related reforms currently being discussed and implemented also have the potential to substantially transform the rural health delivery system. Indeed, health care reform is emerging as a leading national issue, with many State and national policy makers seeking to restructure the health care system to better coordinate care, improve quality of care provided, and reduce costs. The Committee strongly believes that the Executive and Legislative branches must both continue to recognize the special needs of rural areas as they examine health care reform issues in the future to prevent unintended consequences of undifferentiated policy decisions, such as those that caused the widespread rural hospital closures following the 1983 IPPS reform. Given these and other well-documented policy implementation difficulties, the Committee hopes that the Secretary will closely monitor the initiatives discussed below.

 

Quality

 

As noted previously, one of the key changes in the past 20 years has been the emerging focus on quality improvement and medical error reduction. To date, CMS has highlighted the importance of health care quality by establishing public reporting and taking initial steps towards a pay-for-performance mechanism. However, rural advocates have voiced concerns that these new systems do not take into account the distinctive features of rural health care, namely the lower volume of patients, fewer acute cases, and high rates of transfers to larger tertiary hospitals. There is growing recognition of the need to assess the rural relevance of national quality measures and patient safety interventions, and to develop new measures and interventions for processes that are especially pertinent to rural settings, such as triage, stabilization, and transfer of emergency patients.9 It is important to note that while rural hospitals have a different case mix than urban hospitals, they do provide important acute care services as well as emergency and transfer services.

 

In its 2007 working paper regarding the development of a Value-Based Purchasing (VBP) plan for Medicare inpatient payment, CMS acknowledged many of these ongoing challenges, including low volume and case mix, but did not identify specific ways to address these issues.10 As CMS and Congress consider how and when to implement a VBP plan that is relevant for rural providers, they must remember to accommodate the distinctive features of rural health care providers and to incorporate CAHs, who are not paid within the IPPS and therefore not currently included in the VBP plan.

 

In addition to the adaptation of quality policies to the rural setting, future challenges in rural quality improvement include addressing and reducing the large standard deviation in rural hospitals’ quality scores. Some rural hospitals seem to perform notably better and improve faster than others. While waiting for researchers to determine the causes underlying these disparities, multiple initiatives are underway to equip rural providers with quality improvement resources and technical assistance. For the first time, CMS included a specific rural-focused task in the 8th Scope of Work for the Quality Improvement Organizations (QIOs), a nationwide network of contractors dedicated to improving the quality of care for Medicare beneficiaries. The new task encouraged QIOs to support CAHs in data reporting and quality improvement efforts and to help all rural hospitals improve their patient safety culture. The Committee believes that it is important that the 9th Scope of Work maintains an explicit role for working with rural providers, particularly CAHs. In many States, Flex grant funds are being used to promote quality improvement activities in CAHs, such as quality benchmarking programs, peer review systems, and staff training in quality improvement techniques.

 

Health Information Technology

 

The national quality movement has led to a larger discussion of how to use HIT to improve quality of care and increase efficiency. HIT is envisioned as a technology application that will enable the seamless transfer of patient data across the continuum of care. Though HIT does not necessarily allow for communication or interoperability, it encourages better coordination of patient care. These facilitated exchanges could be of particular use in rural areas, where patients often receive care in more than one setting. However, as noted previously, rural health care providers have lagged behind their urban peers with regard to the automated systems needed for HIT implementation.

 

President Bush has called for all Americans to have an electronic health record by 2014.11 The Medicare Payment Advisory Commission (MedPAC), the Institute of Medicine, and other national organizations have proposed several strategies to attain this goal, including technical assistance and financial incentives for health care providers to adopt HIT.12 In an effort to facilitate the use of electronic health records, the Federal Communications Commission announced in November 2007 that it would provide $417 million over three years to help build high-speed Internet networks for rural and underserved health care clinics nationwide. Within HHS, the Agency for Healthcare Research and Quality (AHRQ) awarded more than $15.3 million in grants in fiscal year 2005 to small and rural communities to plan, implement, and demonstrate the value of HIT to improve patient safety.13 AHRQ has also established an online National Resource Center for Health Information Technology with tools and resources for implementing HIT in small and rural communities.14 In fiscal year 2007, ORHP granted $25 million to implement HIT systems in rural health care networks across 16 States.

 

Text Box: Toyota’s Employee Health Care Model “Our health care costs per U.S. plant worker had doubled over five years,” explained Dr. Ford Brewer, Medical Director for Toyota Motor Engineering and Manufacturing, North America. In an effort to contain rising health care costs, Toyota will implement a novel, integrated health care system at its new manufacturing plant in Tupelo, Mississippi. Instead of contracting with an insurance company to provide health insurance plans to the employees, or “team members,” Toyota will directly contract with hospitals and health care providers, thereby incurring an immediate cost savings of 25 percent. As part of the quality health and wellness initiative at Toyota, designers of the health care system placed a strong focus on disease management. A primary care clinic, pharmacy, and occupational health care will be available on-site. Easy access to quality preventative and primary care services can help reduce the absentee rate of employees, which has been shown to increase productivity and retention rates. In addition, readily available preventative care can reduce long-term expenses on costly specialty care and hospitalizations. In the Toyota model, specialty care is accessed through the physician network, established by direct contracting between Toyota and local providers with high quality rankings. An integrated data system will be able to track patient records, facilitating and simplifying patient flow through the health care system. Team members will have the option to use providers outside the network, but with higher associated co-payments and deductibles. Toyota has extended the health care system to family members of employees and suppliers. In designing its own health care plan, the company was also able to consider the unique needs of its team members; for example, the on-site pharmacy will open at 4 a.m., two hours before one standard work shift begins. The on-site injury programs are open 22 hours per day. Should any team member be injured on the job, the incident will be examined through the occupation health model processes, in order to prevent future accidents and eliminate possible systematic risks. While it is recognized that this model of patient-centered care is not easily transferable to other employers, it can perhaps provide inspiration for other rural employers to develop innovative solutions for employee health care coverage. It illustrates an integrated health care model with components that can yield better community health and cost savings to both the employer and employee. Toyota has taken a couple years to plan this design properly; however, the new health care system is expected to pay for itself within two years and yield significant long-term cost savings for the company. Source: Brewer, F. (September 12, 2007). “Toyota Family Health Center/Innovative Health Network Update.” Remarks to the NACRHHS September Meeting.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Medicare Modernization Act (MMA): Medicare Advantage (Part C) and Prescription Drug Benefit (Part D)

  Another looming challenge in rural areas is access to pharmaceutical services, given that the economic viability of community pharmacies is becoming increasingly threatened. While the Medicare prescription drug benefit, known as Part D, has benefited low-income rural seniors, it has created cash flow problems for rural pharmacists by changing their customer mix from one that was largely cash-based to one that is now dominated by third-party private sector payers. In addition, the Deficit Reduction Act of 2005 decreased the payment quantities that community pharmacists receive from Medicaid. Instead of relying on an Average Wholesale Price (AWP), the Medicaid reimbursement for prescription drugs is now based on Average Manufacturers Price (AMP), which is generally lower, although there are current legal challenges to the rule’s implementation. In a report dated December 2006, the GAO found that an AMP-based Federal Upper Limit reimbursement will fall an average of 36 percent below pharmacy acquisition costs for multiple-source outpatient prescription drugs.16

 

These recent changes to the Medicaid payment methodology, coupled with the Part D pressures, have the potential to destabilize sole community independent pharmacies, which are the only providers of pharmacy services in many parts of rural America.17 The Committee is concerned about the impact on rural patients, for whom such pharmacies may be the only local sources of pharmacy services. In addition, rural pharmacists often provide clinical services to rural hospitals and nursing homes part-time, representing important community health cornerstones. Rural pharmacy closure may make it difficult for residents to obtain emergency medicines or medication counseling, which has the potential to increase the number of adverse drug events among seniors taking multiple prescription drugs.

 

Another challenge for rural health care pertains to the Medicare Advantage (MA) program, also known as Part C. New options through MA create more choices for beneficiaries, but if MA is implemented in a manner that is not sensitive to the rural context, it could adversely affect health care delivery in rural communities. The Committee focused heavily on this issue in its 2007 report and recommended that the Secretary facilitate the dissemination of information more widely to rural beneficiaries and providers so that they can make well-informed decisions about Medicare options. CMS has taken steps to work with MA plans to curtail deceptive and fraudulent marketing and enrollment practices.

Text Box: State Oversight of Medicare Advantage Plans Over the past two years, the Committee has heard complaints from health care providers and beneficiaries about aggressive and misleading marketing practices by insurance companies selling Medicare Advantage (MA) plans. The Committee learned firsthand about this issue from Wisconsin Insurance Commissioner Sean Dilweg, who testified during the Committee’s September 2007 meeting in Madison. The Commissioner stated that since January 1, 2006, the Wisconsin Office of the Insurance Commissioner has received more than 400 complaints from consumers about the marketing and sales of MA plans. Dilweg noted that some consumers have found MA plans difficult to navigate due to the number of options available and the lack of clarity regarding the differences between MA plans and traditional Medicare. In the worst cases, deceptive marketing practices have included forged signatures on enrollment forms, mass enrollments, and door-to-door sales at nursing homes, leaving beneficiaries unsure about their benefit packages, out-of-pocket expenses, and access to their customary network of local providers. Wisconsin is not alone in this problem; according to the National Association of Insurance Commissioners (NAIC), most State insurance departments have received complaints regarding inappropriate marketing practices of MA plans, including cases which may even be considered fraud. These types of marketing practices are normally prohibited by State law or controlled by the State regulatory structure. However, as Commissioner Dilweg testified, State regulators are limited in their ability to hold insurance companies accountable for inappropriate marketing, sales, or advertising of MA plans. State regulatory authority is confined to the licensure, solvency, and regulation of individual agent and broker conduct; State appointment laws are preempted by Federal law and the marketing guidelines for MA plans are determined by CMS. As a result, State regulators who receive MA complaints from beneficiaries cannot take any action other than referring the complaints to CMS. CMS, however, has taken steps to address some of the marketing and sales concerns. In June of 2007, seven health plan sponsors signed an agreement with CMS to voluntarily suspend the marketing of their MA private fee-for-service (MA PFFS) health plans because of questionable and unscrupulous sales and marketing practices. The 2008 CMS Call letter for MA, effective October 1, 2007, requires increased oversight on PFFS plan marketing. These changes should ensure that the organizations and sales agents correctly represent their plan offerings through mechanisms such as outbound verification calls, disclaimer language, and documentation of agenda and broker training. These requirements will hopefully improve the operation and accountability of MA PFFS plans. Sources: Dilweg, S. (September 13, 2007). “Medicare Advantage Private Fee-For-Service Plans.” Remarks to the NACRHHS September Meeting; Dilweg, S. (May 22, 2007). “Testimony of Sean Dilweg, Commissioner of Insurance, State of Wisconsin.” Testimony before the House of Representatives, Committee on Ways and Means, Subcommittee on Health. http://waysandmeans.house.gov/hearings.asp?formmode=view&id=5964




































 

Utilization

 The percent of eligible individuals utilizing a human services program varies greatly from program to program and community to community. Rural Americans rely more on some programs compared to urban Americans, but not in all cases. However, during site visits the Committee has confirmed that utilization often falls well below the number of all eligible individuals, even when there is demonstrated need and available support. Approximately 20 percent of eligible low-income workers who would qualify do not receive the Earned Income Tax Credit.40 Similarly, the percentage of single mothers eligible for welfare payments but not receiving them has steadily risen since 1990 and reached 19.6 percent in 2005.41 Even the greater rural uptake on the food stamp program compared to urban areas leaves 22 percent of eligible rural Americans without access to potentially essential food stamps. One of the most difficult challenges in human services delivery is connecting individuals to resources; people must be aware of programs, able to access them appropriately, and willing to seek necessary help. In rural America, geographic dispersion complicates outreach activities to promote awareness and transportation to ensure access. In addition, as discussed previously in this section, some socio-cultural norms may discourage people from seeking help. Thus, creating resources is only the first step in ensuring that people receive the support they need. Planners must also develop strategies to address the challenges so that they connect people to these services.

 

Rural Human Services Workforce and Caseloads

 

Rural areas continue to experience workforce shortages; many human services struggle to attract and retain human services professionals in rural areas. They often cannot achieve the economies of scale necessary to support specialty service providers. In addition, it is more difficult to retain staff because social workers and case managers often have fewer opportunities for professional advancement.42 During site visits, the Committee noted much frustration and concern with high staff turnover, increased caseloads per staff, and burnout among human services workers.43 A 2001 study found that on average, counties experienced an increase in administrative workload, with non-metropolitan counties reporting a 70 percent workload increase for child care, 56 percent for Federal and State transportation programs, 38 percent for food stamps, and 67 percent for workforce training and development.44 In addition, human services staff members work with populations that more frequently have mental health or substance abuse issues, though few staff have the certification or receive the pay commensurate with such responsibilities. The Committee expects that the human services workforce will continue to be a pressing issue.

 

There are no formal training programs for human services workers within HHS. The Committee believes that training local people who are more likely to remain and work in the area can help remedy these personnel shortages. Much of this training can be done at the community college level. HHS could partner with the Department of Education and the DOL Workforce Investment Act programs to help support training of needed human services workers at the associate degree level.

 

Text Box: Difficulty for Human Services Workers The work environment in human services casework is growing increasingly difficult. “We used to work with people. Today, my caseworkers spend at least 50 percent of their time behind the computer,” said Fred Crawford, director of the Logan County, Colorado Department of Social Services. “We have so much accountability and so much detail that it’s not possible to get the job done without massive amounts of computer work.” While accountability is important, the human services work environment is growing less fulfilling, making it more difficult to fill necessary staff positions. In addition, Crawford lamented that allocations change, making it a “gamble” to spend for any one program. The rules are also becoming more complex and changing frequently. In this environment, Crawford emphasized the problem of high staff turnover. He described difficulty in retaining case workers, citing that the average case worker in Logan County stays for only 18 months. This more challenging work environment and continual high turnover threaten the human services workforce and the capacity of the human services delivery system. Source: Crawford, F. (June 11, 2007). Remarks to the NACRHHS June Meeting.























Rural areas also need to capitalize on informal and personal collaborations to succeed.45 Time and resources spent creating an appropriate infrastructure can yield longer term successful outcomes. One study reported that rural social workers experience higher levels of job satisfaction and have greater autonomy and decision-making power.46 These factors could be leveraged to enhance the human services workforce.

 

Positive Directions

 

In spite of these troubling trends, the Committee recognizes three paradigms that would serve rural human services as they face upcoming challenges.

 

Community Flexibility and Funding Streams

 

In lieu of continuing to try to fit rural America to one-size-fits-all programs, the Committee proposes that communities be given flexibility in allocating funding and designing local programs in order to tailor them to local needs. Discretionary Federal grant programs have strict guidelines for spending and are targeted toward specific needs, to ensure efficient and appropriate resource allocation. Unfortunately, this specificity can be in tension with the ability to integrate across programs or geographical boundaries; thus it is sometimes called “silo” funding. This limitation makes adapting funding to specific community needs difficult. On the other hand, block grants give the States great flexibility. However, these grants rely on a population-based funding mechanism which may have unintended consequences for small and isolated rural areas with dispersed populations. One of the questions is whether or not block grant funding flows to the intended recipients equally regardless of geography. Unfortunately, there are little data available to answer this question. It may be that by allowing communities some flexibility with their funding but maintaining a framework and guidelines, communities can develop support services that more appropriately fit their needs. However, the Committee also recognizes the need for accountability and oversight. The funds should be used for specific human services needs and administrators should be required to adhere to a basic framework with reporting performance measures connected to the funding goals. For a further discussion of funding silos, see Building Rural Communities, p. 58.

Text Box: One-Stop Shopping in Humboldt County The Del Norte County ADRC in rural California has combined several Area Agency on Aging (AAA) services along with non-age specific disability services in a central one-stop location. When seniors or people with disabilities go to the Del Norte Community Wellness Center, they can find senior information and assistance, health insurance counseling, a volunteer center, and a community clinic and health care provider. Co-location has provided cost savings in rent to the ADRC. It has the possible additional benefit of integrating social services from the ADRC with the health clinic. This partnership ultimately benefits county residents who do not have to travel great distances to multiple locations in order to find information, case management, and services. This move into the Del Norte Community Wellness Center not only provides an ongoing cost savings to agencies and programs, but also represents easier access to health care and human services, and the potential for coordinated care.

One-Stop Shopping

 

The problems confronted when delivering human services in rural communities are numerous. Many programs lack necessary resources, have poor mechanisms for service delivery, and must confront long distances and transportation difficulties. As a result, many programs can only be offered in a fragmented manner that may impair the ability of rural citizens to gain useful access to them.  When service agencies fail to work together, gaps in services and duplicative actions can emerge. Without a centralized organization for human services distribution, rural residents may find themselves in need but with no way to identify and access resources.

 

A ‘one-stop shopping’ model for human services distribution may be a constructive method for providing access to necessary supports for people in need. Traditionally, one-stop shopping has been seen as an ideal model that has been successfully implemented in various metropolitan areas. However, this model may not have penetrated non-metropolitan communities to its full potential. In part, this lack of proliferation may be due to the difficulties for a dispersed population when several resources are localized in one center. Effective one-stop shopping in rural areas would require innovations to allow transportability, whether it is centralized administration and local outreach, a mobile unit instead of or in addition to an office building, mobile case workers, or a hotline. Indiana and Utah have pioneered an on-line one-stop shop for human services. The ONE Application is a web site with convenient eligibility and application functions for all State human services programs.47 This model holds potential for populations that have familiarity with and access to the Internet, which may be a limiting factor in many rural areas. In addition, the Committee has recognized the need for and reliance on a strong volunteer base. On its June 2007 site visit, the Committee was informed that the Area Agency on Aging (AAA) in Fort Morgan, Colorado, received 27,000 hours of volunteer support in the past year and that volunteers logged more than 16,000 miles, which helped enable programs to reach dispersed individuals.48 Further, a collaborative model where multiple programs work together, e.g., traveling to small population centers together or sharing audiovisual equipment for presentations, can further augment available resources. The Committee recommends examining sites that are moving toward effective rural one-stop shopping and transportability of services, and supporting projects that foster these goals.

Text Box: The Ingram Leadership Institute What do the Mayor of Saltillo, MS, the President of Lee County NAACP, and the Director of the Northeast Mississippi Regional American Red Cross have in common? They all graduated from the Jim Ingram Community Leadership Institute and are applying skills they learned in the program to better lead their community. Administered by the Tupelo Chamber of Commerce, a division of the Community Development Foundation, the Ingram Leadership Institute is a three year program that strives to cultivate local leadership and to enhance personal and professional development. The program entails one year of training and nearly two years of community re-investment, to ensure that graduates employ their new skills toward the benefit of the community. The Chamber of Commerce in Tupelo, Mississippi, understood the need for effective local leadership and its investments through the Ingram Leadership Institute are paying off; so far it has provided training to 110 successful graduates, and counting!

Leadership and Planning

 

Rural human services face several challenges: high demand despite limited resources and access, growing need from increasing demographic pressures, and a workforce that needs to develop in both numbers and qualifications. The Committee recognizes that local leadership and planning are essential in confronting these issues and working with State and local government to achieve effective solutions. Because the people who need human services are not necessarily best positioned to promote them, rural America requires strong leaders to carry the charge. Thoughtful planning can help resolve inefficiencies and ensure that services provided match rural residents’ needs. Effective leadership can better align community resources to improve performance and catalyze regional improvements. In addition, these community leaders can more productively partner with Federal and State agencies to create synergies in total available resources. Leadership and planning are discussed in the following section on community development, p. 58.

 







Conclusion

 

This section on human services examines human services as one aspect of population well-being. However, the human services system is intricately connected to the health care, education, and other systems in contributing to both individual and community well-being. Moving forward, policy makers must recognize that human services function within this broader system and focus on it as one important component of a community’s development.

 

Building Rural Communities

Health and human services play a pivotal role in developing and sustaining vibrant rural communities because these services allow communities to maintain the well-being of their residents. The relationship between a community and health and human services is a self-reinforcing cycle: while these services stabilize and support the community, the community itself must be well-equipped in order to deliver effective and comprehensive health and human services. There is currently no over-arching strategy to support rural communities in their efforts to put together comprehensive health and human services. Rural communities can easily be hindered while trying to navigate the rules and procedures related to the patchwork of Federal programs that support health and human services. Typically, urban local governments are often able to devote considerable legal and administrative expertise to such matters. The Committee believes that more must be done to give rural communities the tools to work with the programs and available resources. Community development is further challenged by current budgetary realities that limit the resources available to expand or develop new programs.

 

Given the fragmentation of service delivery and the budget limitations, the Committee believes that rural community development can best be supported by: (1) fostering cooperation, collaboration, and integration of programs at the local, State, and Federal level and (2) cultivating and training community leaders to facilitate collaboration and to guide and develop the community.

Text Box: Successful Community Collaboration: North Colorado Health Alliance Rural North Colorado is facing a perfect storm in terms of population growth, high percentages of the population under 200 percent of the Federal poverty level, and large numbers of uninsured. In response, between seeing patients and serving with the Weld County Department of Public Health and Environment, Dr. Mark Wallace organized the North Colorado Health Alliance (NCHA). Comprised of public and private health and human services providers in Weld and Larimer Counties, NCHA strives to ensure that all underserved residents have access to care through an integrated service delivery system. For example, NCHA sends a mobile unit throughout the counties to bring checkups, pap smears, screenings, and primary care to people living in isolated areas. NCHA reaches out to community stakeholders in order to develop collaborative systems of care, workforce development strategies, and programs for improved quality of care. As Wallace noted on creative rural leaders, “innovation doesn’t come from a different set of tools, but from someone who tries to use the tools differently.” Source: Wallace, M. (June 10, 2007). “Health Care Access, System Integration, and Community Partnerships.” Remarks to the NACRHHS June Meeting.

Barriers to Collaboration and Coordination

 

Communities stand to benefit from cooperation across health care and human services programs.  Close partnerships can encourage communities to collaborate across various programs that target the same population, resulting in more comprehensive, coordinated service delivery.  Better coordination of programs can improve the quality of care provided to clients and create cost savings for providers and Federal programs.  For example, networks of providers can create economies of scale by pooling resources to fill a common need.  Collaboration can also shift an administrator’s focus from program specifics to overall community welfare.  On the whole, better collaboration and coordination between programs could permit rural communities to maximize the impact of scarce resources.

 

And yet Federal programs are administered through a number of different channels, frequently referred to as functioning in ‘silos,’ and therefore have varied requirements for eligibility, information systems, data reporting, and evaluation.  The incongruity among funding requirements arises out of the incremental nature of policy development:  the legislation that established today’s health and human services programs was enacted in a piecemeal fashion.  The resulting lack of alignment in requirements renders the coordination of numerous programs at the local level difficult and daunting, particularly in small rural communities with limited physical or human capital.  Even though several programs may be designed for similar populations, the inclination to coordinate and streamline service delivery can be defeated when a staff is faced with the bewildering array of differing requirements for eligibility, application processes, and reporting, each in separate systems.  These funding silos run the risk of disregarding the needs of specific communities and mandating inefficient implementation practices.

Text Box: In (Partial) Praise of Silos Funding for Federal programs is often described as being provided in ‘silos,’ too restrictive and inflexible to be tailored to local needs. Many have conjectured that service delivery would be improved if Federal funding had fewer strings attached. For example, if the funds were administered through a single, unrestricted pot, State and local governments could use local wisdom to direct funds to the right places. A myriad of interest groups petition the Federal government for a share of its limited resources. One way to think about silos is as Christmas club accounts or IRAs, mechanisms that accumulate resources and earmark them for a specific use. Individual health and human services programs are usually the product of strong and continuous advocacy, and are maintained because their citizen advocates and the Congressional advocates fight hard to make sure that the programs remain separate and that each year they receive the resources required to provide the benefits. Though we can think of situations in which eliminating silos could yield substantial benefits, we should be careful in what we wish for. Local leaders with the flexibility to move funds from one program to another might, in a world of flexibility, deem it in the public interest to divert the health and human services funds to build a new bridge or to repave a critical road. Silos can hinder program coordination and efforts to tailor services to local needs; however, a more flexible approach could hamper program oversight and accountability. As such, for all their disadvantages, silos can serve a useful purpose. They can protect the integrity of rural health and human services, by containing and guarding the resources earmarked for specific Federal programs. While silos may not be an ideal model, any alternative mechanisms must ensure that accountability is not sacrificed for flexibility. Source: Hoyer, T. (October 2007). “In (Partial) Praise of Silos.” Eye on Health. Sauk City, WI: Rural Wisconsin Health Cooperative. 4-6.






























In 2001, HHS created a Department-wide HHS Rural Task Force, an internal coordinating body of HHS officials. It was charged with assessing how HHS programs and initiatives serve rural America. The Rural Task Force’s 2002 report to the Secretary, One Department Serving Rural America, found that HHS funded more than 225 programs serving rural communities but that communities struggled to use these resources efficiently because individual programs had unique eligibility criteria, applications processes, implementation constraints, and evaluation requirements.49 When the Rural Assistance Center analyzed all of the HHS funding announcements in 2006, it found that only nine grant programs either required or strongly encouraged collaboration or coordination of services as eligibility criteria for the grant funds.50 Some of the program segregation inadvertently created by Federal legislation is mirrored at the State level, since States must adhere to Federal requirements to receive funding.

 

Finally, barriers can emerge at the community level. Rural areas, by their very nature, face a high degree of geographic isolation. Lengthy travel times and transportation costs can consume valuable resources. As a result, it is difficult to reach out to rural residents so as to increase awareness and facilitate access. Models of service delivery common in urban areas can be inefficient in rural areas, because the smaller population base frequently acts as a barrier to economies of scale.

 

These problems are not all caused by the structure and administration of the programs. The Committee has learned that some rural communities may be reluctant to work with neighboring communities, due to competition and local rivalries. At the Committee’s June 2007 site visit, Dr. Jack Westfall presented an example of neighboring rural communities that had a history of mistrust and competition, which curtailed attempts at service coordination. Part of this hostility may be driven by a perceived ‘zero-sum’ nature of resource allocation. If one rural community can attract an employer or recruit a physician, it may be at the expense of its neighbor. It is difficult to ascertain how often local rivalries prevent collaboration for health and human services delivery, but it is important to understand that such factors exist.

 

Text Box: Service Coordination in the Ho-Chunk Nation Jean-Ann Day, the Social Services Director for the Ho-Chunk Nation, believes that rural community development extends beyond township limits and jurisdictions. The Ho-Chunk Nation consists of 6,750 tribal members, half of whom live in rural Wisconsin while the other half are scattered across the United States. The Ho-Chunk Nation, a rural “community” far more expansive than most, nonetheless experiences significant needs for health and human services. By carefully coordinating services and mobilizing resources from Tribal gaming facilities, Day has been able to provide her remote community with youth programs, programs for the aged, a child care voucher program, emergency financial assistance programs, and activities to address domestic violence. While this success is notable, Day maintains that a creative, mutually supportive relationship between States, Tribes, and the Federal government is necessary. “By working together, we can become great Nations with great families.” Source: Day, J.A. (September 13, 2007). “Health & Human Services for Minority Peoples in Rural Wisconsin.” Remarks to the NACRHHS September Meeting. Better Coordination: Looking at HHS and Beyond

 

Five years after its inception, the HHS Rural Task Force still exists and remains complementary to the NACRHHS, but the sense of urgency and purpose that accompanied its creation and first few years have not been sustained. The Rural Task Force continues to enjoy strong commitment from HRSA and the HHS Office of Intergovernmental Affairs, but the Committee believes that for the Rural Task Force’s work to continue, the Secretary must recognize the importance of the recommended initiatives and give the Rural Task Force a renewed mandate to accomplish them.

 

While the NACRHHS is charged with advising the Secretary of HHS on rural issues, it has also become apparent that many programs critical to rural communities are situated in other Cabinet-level Departments. HHS must better coordinate with programs in other Departments in order to provide essential support to rural communities. The following Departments administer significant programs for rural communities:

 

• The U.S. Department of Agriculture (USDA):  The USDA has long been an important rural partner.  Rural Development is one of the seven USDA core mission areas, administering $86 billion in loans and nearly $16 billion in programs through loans, loan guarantees, and grants.  These financial programs, outlined in Appendix C, support rural economic development, essential public facilities and services, technical assistance and information for business cooperatives, and community empowerment programs.  State Offices of Rural Development assist USDA in administering these crucial programs. “In a typical year, Rural Development programs create or preserve more than 150,000 rural jobs, enable 40,000 to 50,000 rural Americans to buy homes and help 450,000 low-income rural people rent apartments or other housing.”51  While the Rural Development programs specifically target rural America, rural residents also benefit from other USDA programs, such as food stamps and agricultural support.

Text Box: Rural Eligibility for CDBG Funds The Community Development Block Grant (CDBG) primarily seeks to develop viable urban communities, as authorized under Title 1 of the Housing and Community Development Act of 1974, Public Law 93-383. The CDBG eligibility criteria allocate funds annually to “entitlement communities,” which are central cities of Metropolitan Statistical Areas, metropolitan cities with at least 50,000 residents, and qualified urban counties with more than 200,000 inhabitants. In 1981, Congress amended the authorization to enable States to administer a portion of the funds, “with the view that States are in the best position to know and to respond to the needs of local governments.”1 The States can now administer CDBG funds to non-entitlement areas, which are all communities that do not qualify for HUD’s “entitlement” category. Rural areas fall within the “non-entitlement” designation and therefore compete with smaller metropolitan areas to receive non-entitlement CDBG funds; there is no specific set-aside for rural areas. In fiscal year 2007, the CDBG granted approximately $2.6 billion directly to entitlement communities directly and $1.1 billion to non-entitled communities through State competitions.2 While there is less funding available to non-entitled communities, the CDBG represents an important step towards providing rural areas with critical community development assistance. Notes: 1 Office of Community Planning and Development. (n.d.). “CDBG Entitlement Community Grant.” U.S. Department of Housing and Urban Development. http://www.hud.gov/offices/cpd/communitydevelopment/programs/entitlement/ 2 Office of Community Planning and Development. (n.d.). “Community Planning and Development Appropriations Budget.” U.S. Department of Housing and Urban Development. http://www.hud.gov/offices/cpd/about/budget/

• The U.S. Department of the Treasury (Treasury): The Treasury administers the EITC, one of the most significant sources of support for low-income rural residents, discussed earlier. Since 2000, the Treasury has also administered the New Markets Tax Credit (NMTC), which permits taxpayers to receive a Federal income tax credit for investing in designated Community Development Entities (CDEs), financial institutions that serve primarily low-income communities. In turn, CDEs make seven-year investments, ranging from affordable housing units to small business financing. As of February 2007, NMTC recipients had raised $7.1 billion to invest in low-income communities, many in rural areas.52

 

• The U.S. Department of Labor (DOL): Rural communities have substantially benefited from the DOL’s Workforce Investment Act (WIA), a comprehensive initiative that helps States and localities design and implement innovative employment programs for current workers, potential employees, and local employers. The WIA seeks to increase employment, retention, earnings, productivity, and competitiveness, characteristics that are often sub-standard in rural economies. Low-income rural residents also benefit from the WIA’s efforts to reduce welfare dependence; these efforts include teaching them skills so that they can move more effectively into the workforce. As part of its efforts to cultivate economically competitive skills within the rural workforce, the DOL also supports distance-learning and scholarships for rural students through Rural Education grants.

 

• The U.S. Department of Housing and Urban Development (HUD): One of HUD’s longest-running programs, the Community Development Block Grant (CDBG), funds anti-poverty programs, infrastructure development, and affordable housing, primarily to urban communities.  CDBG funds, $3.7 billion in fiscal year 2007, support activities that benefit low- and moderate-income people, maintain public services and spaces, or address urgent threats to health or safety.  These are activities that are particularly needed in distressed rural areas.

 

• The U.S. Department of Transportation (DOT): Without efficient transportation systems, it is more challenging for rural communities to provide health and human services and achieve economic viability, due to geographic isolation and dispersion. Limited mobility directly affects the delivery of health care and human services, communities’ access to outside products, and the ability of low-income residents to connect to jobs. In addition, there is no Federally-designated body to plan transportation in small communities and rural areas, whereas metropolitan areas benefit from specially designated organizations that do so. The DOT seeks to bridge this gap through the Rural Transportation Initiative, an array of grant programs and technical assistance that enables communities to plan, develop, and improve transportation infrastructure.53

 

• The Department of Commerce (Commerce): Within Commerce, the Economic Development Administration (EDA) and the Minority Business Development Administration (MBDA) seek to promote employment and business growth through targeted programs and grants. While most of these programs do not specifically target rural areas, the EDA has funded several studies examining rural economic development strategies. The MBDA and the USDA entered into a Memorandum of Understanding in 2000, in order to “increase rural business financing for minority-owned rural firms and cooperatives in an effort to further expand and create new markets to provide jobs for rural Americans.”54 The Committee hopes that this cross-Departmental relationship can be expanded, so that Commerce can play a more deliberate role in rural economic development.

 

As the Committee has conducted site visits in rural communities over the years, it has become more apparent that there is a need for a coordinated rural strategy by each of the Cabinet-level Departments, in order to share information, coordinate efforts, and provide more effective rural programs.

 

Rural Leadership Development

 

The Committee recognizes that local leadership is an important catalyst for rural community development. Motivated people who are well-connected and understand local needs are often able to use resources effectively. The IOM argues that the success of any rural health care initiative depends on the involvement of such community leaders:

Every rural community needs its own health care leadership to participate in strategic planning, oversee the management of services delivered locally, and ensure accountability to local needs. Committed leadership of senior clinicians and administrators is key to the institutional and environmental changes necessary to achieve improved quality of care and patient safety.55

While the IOM report focused solely on health care, the core message can be applied to all sectors of the rural community. The prevalence of impoverished areas, population loss, and gaps in service infrastructure in rural America accentuates the need for community activists who can maximize the impact of available resources.

 

Within the public health sector, there is an emerging conviction that overall population welfare can be addressed and maintained best by collaborations within the local community, especially between health care providers and human services programs. This “third revolution in public health” is substantiated by the IOM’s assessment that governmental public health agencies, currently the backbone of the public health system, could achieve more widespread population health improvements if they build and maintain partnerships with community-based organizations.56

Rural communities must build a population health focus into decision-making within the health care sector, as well as in other key areas (e.g., religious institutions, agricultural extensions, rural cooperatives, education, community and environmental planning) that influence population health. Most important, rural communities must reorient their quality improvement strategies from an exclusively patient- and provider-centric approach to one that also addresses the problems and needs of rural communities and populations.57

This movement towards increased community collaboration stands to greatly benefit rural areas, stretching scarce resources and distinct skill sets to cover local health needs holistically.

 

Text Box: An Example of Local Leadership in Rural Colorado During its June 2007 site visit to Colorado, the Committee learned that one local leader, Kindra Mulch, was behind the many successes of the Health and Human Services Department in Kit Carson County, Colorado. Mulch has spearheaded every public health challenge that the community has brought to her attention, from family planning to immunizations to emergency preparedness. Her willingness to coordinate such disparate programs as child welfare, chronic disease management, and animal odor control in her community resulted in the merging of the County Board of Health, the County Board of Human Services, and several State and Federal programs under one roof. By emphasizing flexibility and striving for a generalist model of service integration, Mulch and her staff are able to pursue innovative initiatives to meet emerging local needs. In order to overcome the challenges of rural service delivery, she told the Committee, a successful rural leader must be energetic enough to tackle problems proactively and practical enough to realize when local context requires that programs be creatively adapted. While the Committee recognizes that Mulch’s extraordinary facility for personally coordinating programs is not a feasible model for all counties, the successes achieved by her efforts are demonstrated proof that, with effort and communication, it is possible to coordinate rural health and human services programs effectively. Source: Mulch, K. (June 10, 2007). “A Historical Perspective and a Future Hope for Health and Human Services.” Remarks to the NACRHHS June Meeting. Indeed, as noted earlier, traditional service models are not always effective in rural areas due to unique demographics and long distances. Local initiative is needed to streamline service delivery and combine programs so as to offer comprehensive and coordinated care and support. The Committee believes that HHS, along with other Federal Departments with key rural programs, can and should play a role in developing these future leaders, perhaps by refining the focus of existing leadership training models.

 

Several different programs have emerged to help train community leaders. The Rural Leadership North Dakota (RLND) program is one of the few that focuses specifically on the needs of small rural communities. Indeed, RLND seeks to help its community leaders understand the resource spectrum, foster connections across long distances, and manage an independent project in their home communities. Operated by the North Dakota State University Extension Service, RLND encompasses all forms of rural community growth and prosperity instead of focusing specifically on health and human services.

 

In addition to executing innovative projects independently, rural leaders are also needed to foster committed, sustainable partnerships with community stakeholders. Employers, schools, and local government can play important roles in service delivery; dedicated local leaders are needed to engage and coordinate all partners. In order to promote such inclusive partnerships, the Healthy Wisconsin Leadership Institute has structured its leadership training around cross-sector community teams. Members of these teams are leaders in either the same geographic service area (e.g., within a county) or the same field (e.g., adolescent health). Over the course of the program, each team applies new skills to a health improvement project in its home community or field. This innovative leadership training format helps to create permanent local coalitions, catalyzing community development in Wisconsin for years to come.

 

HHS has implemented a similar program on a national scale, though it is not rural-specific. The Public Health Leadership Institute (PHLI), funded through the CDC, uses a training format that is also centered on multi-organizational teams. PHLI has trained 800 leaders since 1991, all of whom were senior leaders overseeing large regional service areas. Unlike the Healthy Wisconsin Leadership Institute, PHLI team members are grouped by State and subsequently develop a project. The objective is to create widespread alumni networks instead of founding specific localized coalitions. PHLI has identified and trained public health leaders across the nation. The Committee hopes that a similar program could pay special attention to rural issues and train leaders to foster partnerships, tie together disparate funding streams, and identify opportunities to bring together health and human services delivery in ways that build strong communities.

 

References

 

1 Rahn, D. & Wartman, S. (November 2007). “For the Health-Care Work Force, a Critical Prognosis.” The Chronicle of Higher Education. Vol. 54, no. 10.

2 Skillman, S., Palazzo, L., Hart, L.G. & Butterfield, P. (anticipated publication date: February 2008). Changes in the Rural Registered Nurse Workforce from 1980 to 2004. WWAMI Rural Health Research Center.

3 Vargas, C., Dye, B. & Hayes, K. (2003). “Oral Health Care Utilization by US Rural Residents, National Health Interview Survey 1999.” Journal of Public Health Dentistry. Vol. 63, Issue 3. 150-157.

4 Freiberg, M. (September 13, 2007). “Rural Wisconsin and the Health of our Residents.” Remarks to the NACRHHS September Meeting; and National Advisory Committee on Rural Health and Human Services. (January 2007). “Head Start in Rural Communities.” The 2007 Report to the Secretary: Rural Health and Human Service Issues. Rockville, MD: U.S. Department of Health and Human Services, Office of Rural Health Policy. 22.

5 Gamm, L., Stone, S. & Pittman, S. (2003). “Mental Health and Mental Disorders—A Rural Challenge: A Literature Review.” in Gamm, L.D., Hutchison, L.L., Dabney, B.J. & Dorsey, A.M., (Eds). (2003). Rural Healthy People 2010: A Companion Document to Healthy People 2010. Volume 2. College Station, TX: The Texas A&M University System Health Science Center, Southwest Rural Health Research Center.

6 Gale, J. & Lambert, D. (2006) “Mental Healthcare in Rural Communities: The Once and Future Role of Primary Care.” North Carolina Medical Journal. Vol. 67, Issue 1. 67.

7 Ibid.

8 Rahn, D. & Wartman, S. (November 2007). “For the Health-Care Work Force, a Critical Prognosis.” The Chronicle of Higher Education. Vol. 54, no. 10.

9 Moscovice, I., Wholey, D., Klingner, J. & Knott, A. (2004). “Measuring Rural Hospital Quality.” Journal of Rural Health. Vol. 20, no. 4. 383-393; and Coburn, A., Wakefield, M., Casey, M., Moscovice, I., Payne, S. & Loux, S. (2004). “Assuring Rural Hospital Patient Safety: What Should the Priorities be?” Journal of Rural Health. Vol. 20, no. 4. 314-326.

10 CMS Hospital Value-Based Purchasing Workgroup. (November 21, 2007). Report to Congress: Plan to Implement a Medicare Hospital Value-Based Purchasing Program. Baltimore, MD: U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.

11 The White House. (April 2004). “Transforming Health Care: The President’s Health Information Technology Plan.” A New Generation of American Innovation. Washington, D.C. 8

12 Medicare Payment Advisory Commission. (2004). “Information Technology in Health Care.” Report to the Congress: New Approaches in Medicare. Washington, D.C.: Medicare Payment Advisory Commission. 157-181; and Institute of Medicine, Committee on the Future of Rural Health Care Quality. (2005). Quality through Collaboration: The Future of Rural Health Care. Washington, D.C.: National Academies Press.

13 Agency for Healthcare Research and Quality. (October 6, 2005). AHRQ Awards Over $22.3 Million in Health Information Technology Implementation Grants. (Press Release). Washington, D.C.: U.S. Department of Health and Human Services, Office of Communications.

14 Agency for Healthcare Research and Quality. Internet Portal: “National Resource Center for Health Information Technology.” U.S. Department for Health and Human Services. http://healthit.ahrq.gov/portal/server.pt

15 American Hospital Association. (2007). Continued Progress: Hospital Use of Information Technology. Washington, D.C.: American Hospital Association. 15.

16 U.S. Government Accountability Office. (December 22, 2006). Medicaid Outpatient Prescription Drugs: Estimated 2007 Federal Upper Limits for Reimbursement Compared with Retail Pharmacy Acquisition Costs. (Pub. no. GAO-07-239R). Washington, D.C.

17 Radford, A., Mason, M., Richardson, I., Rutledge, S., Poley, S., Mueller, K. & Slifkin, R. (September 2007). One Year In: Sole Community Rural Independent Pharmacies and Medicare Part D. (RUPRI Pub. no. P2007-1). The North Carolina Rural Health Research & Policy Analysis Center and the RUPRI Center for Rural Health Policy Analysis.

18 Schoen, C., et al. (2007). “Toward Higher-Performance Health Systems: Adults’ Health Care Experiences In Seven Countries.” Health Affairs. Vol. 26, no. 6. w717-w734.

19 “Medicare Medical Home Demonstration Project.” In Tax Relief and Health Care Act of 2006. P.L. no. 109-432, Sec. 204. http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/MedHome_TaxRelief_HealthCareAct.pdf

20 Meit, M., Kennedy, A. & Riggs, T. (April 2007) Urban-to-Rural Evacuation: Planning for Population Surge. (Policy Analysis Brief. W Series, no. 9). Bethesda, MD: NORC Walsh Center for Rural Health Analysis.

21 National Association of County and City Health Officials (NACCHO). (August 2007). Federal Funding for Public Health Emergency Preparedness: Implications and Ongoing Issues for Local Health Departments. Washington, D.C.: National Association of County and City Health Officials.

22 U.S. Bureau of the Census. (2007). American Community Survey, 2006: Disability Characteristics. (S1801). Washington D.C.: U.S. Bureau of the Census.

23 Ibid.

24 Eleson, C. (September 13, 2007). “The End of Child Poverty is in Sight.” Remarks to the NACRHHS September meeting.

25 Barnett, W.S., Brown, K. & Shore, R. (April 2004). “The Targeted vs. Universal Debate: Should the United States Have Preschool for All?” Preschool Policy Matters. (Policy Brief, Issue 6). New Brunswick, NJ: Rutgers University, National Institute for Early Education Research.

26 Isaacs, S.L. & Schroeder, S.A. (September 9, 2004). “Class – The Ignored Determinant in the Nation’s Health.” New England Journal of Medicine. Vol. 351, Issue 11. 1137.

27 Gould, E., Smeeding, T. & Wolfe, B. (June 2006). Trends in the Health of the Poor and Near Poor: Have the Poor and Near Poor Been Catching Up to the Non Poor in the Last 25 Years? Madison, WI: Paper presented at the annual meeting of the Economics of Population Health: Inaugural Conference of the American Society of Health Economists.

28 Wolkwitz, K. (June 2007). “Trends in Food Stamp Participation Rates 1999 to 2005.” Current Perspectives on the Food Stamp Program series. (Prepared for the U.S. Department of Agriculture, contract number FNS-03-030-TNN). Washington, D.C.: Mathematica Policy Research, Inc.

29 Cromartie, J. & Gibbs, R. (February 28, 2007). “Rural America: Then, Now, and in the Future.” Remarks to the NACRHHS February Meeting.

30 Strong, D.A., Del Grosso, P., Burwick, A., Jethwani, V. & Ponza, M. (May 2005). Rural Research Needs and Data Sources for Selected Human Services Topics. Vol. 1: Research Needs. (Prepared for the U.S. Department of Agriculture under contract no. 233-02-0086 (07)). Washington, D.C.: Mathematica Policy Research, Inc. 40.

31 Ibid.

32 Ibid, 41.

33 Wallace, M. (June 10, 2007). “Health Care Access, System Integration, and Community Partnerships.” Remarks to the NACRHHS June Meeting.

34 Strong, D.A., Del Grosso, P., Burwick, A., Jethwani, V. & Ponza, M. (May 2005). Rural Research Needs and Data Sources for Selected Human Services Topics. Vol. 1: Research Needs. (Prepared for the U.S. Department of Agriculture under contract no. 233-02-0086 (07)). Washington, D.C.: Mathematica Policy Research, Inc. 77.

35 National Advisory Committee on Rural Health and Human Services. (March 2007). The 2007 Report to the Secretary: Rural Health and Human Service Issues. Rockville, MD: U.S. Department of Health and Human Services, Office of Rural Health Policy. 18.

36 Coburn, A.F., MacKinney, A.C., McBride, T.D., Mueller, K.J., Slifkin, R.T. & Wakefield, M.K. (2007). Choosing Rural Definitions: Implications for Health Policy. (Issue Brief no. 2). Columbia, MO: Rural Policy Research Institute. 3.

37 Strong, D.A., Del Grosso, P., Burwick, A., Jethwani, V. & Ponza, M. (May 2005). Rural Research Needs and Data Sources for Selected Human Services Topics. Vol. 1: Research Needs. (Prepared for the U.S. Department of Agriculture under contract no. 233-02-0086 (07)). Washington, D.C.: Mathematica Policy Research, Inc. 77.

38 Ibid.

39 Ibid, 3-6.

40 Corbett, T. (Fall 2004). “Restructuring Human Services in Rural Communities: Thinking Outside the Box.” Rural Monitor Newsletter. Vol. 11, Issue 2. Grand Forks, ND: Rural Assistance Center.

41 Haskins, R. (April 27, 2007). “Ten Years After Welfare Reform: How is TANF Working for Needy Families?” Remarks to the National Health Policy Forum. Slide 10. (Slide credits: Blank, R., University of Michigan, Gerald R. Ford School of Public Policy.)

42 Strong, D.A., Del Grosso, P., Burwick, A., Jethwani, V. & Ponza, M. (May 2005). Rural Research Needs and Data Sources for Selected Human Services Topics. Vol. 1: Research Needs. (Prepared for the U.S. Department of Agriculture under contract no. 233-02-0086 (07)). Washington, D.C.: Mathematica Policy Research, Inc. 41.

43 Crawford, F. (June 11, 2007). Remarks to the NACRHHS June Meeting.

44 Kraybill, D. & Lobao, L. (July 2001). “County Government Survey: Changes and Challenges in the New Millennium.” (Research Report no. 1). Washington, D.C.: National Association of Counties. Rural County Governance Center.

45 Strong, D.A., Del Grosso, P., Burwick, A., Jethwani, V. & Ponza, M. (May 2005). Rural Research Needs and Data Sources for Selected Human Services Topics. Vol. 1: Research Needs. (Prepared for the U.S. Department of Agriculture under contract no. 233-02-0086 (07)). Washington, D.C.: Mathematica Policy Research, Inc. 42.

46 Landsman, M.J. (2002). “Rural Child Welfare Practice from an Organization-in-Environment Perspective.” Child Welfare. Vol. 81, no. 5. As cited in Strong, D.A., Del Grosso, P., Burwick, A., Jethwani, V. & Ponza, M. (May 2005). Rural Research Needs and Data Sources for Selected Human Services Topics. Vol. 1: Research Needs. (Prepared for the U.S. Department of Agriculture under contract no. 233-02-0086 (07)). Washington, D.C.: Mathematica Policy Research, Inc. 42.

47 Dynamic Screening Solutions, Inc. (2006). Software: “The ONE Application.” http://go-dss.com/DSS/content/index.cfm?pg=products&sub=toa

48 Baker, S. (June 11, 2007). Remarks to the NACRHHS June meeting.

49 HHS Rural Task Force. (July 2002). One Department Serving Rural America: Report to the Secretary. Washington, D.C.: U.S. Department of Health and Human Services.

50 Personal Communication, Rural Assistance Center. (March 12, 2007).

51 USDA Rural Development. (n.d.). “About Rural Development.” Washington, D.C.: U.S. Department of Agriculture. http://www.rurdev.usda.gov/rd/aboutrd.html

52 Community Development Financial Institutions Fund. (2007). “The Difference the CDFI Fund Makes.” Washington, D.C.: U.S. Department of the Treasury. http://www.cdfifund.gov/impact_we_make/overview.asp

53 National Transportation Library. (n.d.). “Rural and Agriculture Transportation: Data and Information Resources.” U.S. Department of Transportation, Research and Innovation Technology Administration. http://ntl.bts.gov/ruraltransport/index.html

54 U.S. Department of Agriculture, Rural Development & U.S. Department of Commerce, Minority Business Development Agency. (September 22, 2004). Memorandum of Understanding. RD Instruction 2000-SSS. (Pub. no. 279). Washington, D.C.: U.S. Department of Agriculture. http://www.rurdev.usda.gov/regs/regs/doc/2000sss.doc

55 Calico, F., Dillard, C., Moscovice, I. & Wakefield, M. (2003). “A Framework and Action Agenda for Quality Improvement in Rural Health Care.” Journal of Rural Health. Vol. 1, no. 3. 226-232. As cited in Institute of Medicine, Committee on the Future of Rural Health Care Quality. (2005). Quality through Collaboration: The Future of Rural Health Care. Washington, D.C.: National Academies Press. 52.

56 Breslow, L. (April 2004). “Perspectives: The Third Revolution in Health.” Annual Review of Public Health. Vol. 25, Issue 1.

57 The Institute of Medicine. (2002). The Future of the Public’s Health in the 21st Century. Washington, D.C.: The National Academies Press.

 

 

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