BEST PRACTICES

Rural Medicine

A look at common challenges and creative solutions for health care professionals working in rural settings.

Providing care in a rural setting

is full of rewards and challenges for Danielle Howa Pendergrass, DNP, APRN, WHNP-BC, FAANP. “The joy of living and working in a community with social cohesion is incomparable,” says the president and clinician at Eastern Utah Women’s Health in Price, Utah.

Lori Moseley, DNP, FNP-BC, CDE, a nurse practitioner at MinuteClinic in Lancaster, S.C., agrees. “I live in this community and have worked here for seven years, so I know many of the people who come in for care,” she says. “And if I don’t know them personally, I usually know someone who does. Because of that, my patients trust me,” which makes them more likely to follow medical advice.

It’s not always easy, though, and finances often crop up as a barrier to care.

The Cost of Care

For Dr. Moseley’s patients, like many patients in rural areas, the cost of care is a significant barrier.

After a visit, it can be difficult for some patients to afford needed prescriptions, she says, so she’s ready to help. “Often, I pull out my phone, find their medicine, and show them the prices,” she says. “I ask if they can afford a drug before prescribing it.” If they can’t, Dr. Moseley talks to them about online discount programs that can save a substantial sum. “A lot of people don’t know anything about those types of programs,” she says.

Many of Dr. Howa Pendergrass’ patients face similar concerns. Most of her patients work in the volatile mining, trucking, and energy industries. “Many families have jobs and insurance one day and are laid off the next,” she says. “As a result, many people simply can’t afford to access health care.” Further, many of her patients have lower socioeconomic status, which comes with “lower health literacy, inability to purchase healthy foods due to food deserts, and no public transportation options.”

With a mission statement of equitable access to care for all, regardless of insurance status, Dr. Howa Pendergrass works tirelessly to secure federal, state, and local funding to provide care for three vast rural counties. Here are just a few of her strategies: • The clinic became a Health Resources and Services Administration (HRSA)-designated site. HRSA programs provide health care to people who are geographically isolated and economically or medically vulnerable. • The clinic works with community partners to share resources and coordinate the care of marginalized citizens. • The clinic also became a research site, enabling it to provide no-cost services for qualifying patients. Grants and studies cover primary care visits, services for all methods of contraception, screening and treatment for sexually transmitted infections, mental and behavioral health care, and care for pregnant women using substances.

Sliding-scale fees help patients as well, adds Ed Friedmann, PA, BS, physician assistant and clinic administrator at the Redfield Medical Clinic in Redfield, Iowa. If a patient doesn’t have health insurance or has a high deductible, Friedmann will charge based on income. “Most patients want to pay their way. If they pay $20 or so, they feel better about it,” he says. “In a small town, we try to take care of each other.”

Getting Patients to the Care

In addition to financial challenges, many rural patients don’t have reliable transportation to get to a clinic or a specialist.

At a Glance

• For many patients in rural areas, the cost of care is a significant barrier. Community resources, research partnerships, and sliding fee scales can help patients access care.

• Patients may need help finding transportation or may need home care to stay well.

• Telehealth gives rural patients access to a wide variety of specialists with no transportation needed, but they may need your help to use technology.

BEST PRACTICES

Challenging Archaic Rules

To improve care in rural areas, clinicians need to educate lawmakers. Archaic governmental regulations—such as a law in Iowa that requires physician oversight at clinics staffed by experienced PAs that are more than 30 miles from a physician’s office—limit access to care, notes Ed Friedmann, PA, BS, physician assistant and clinic administrator at the Redfield Medical Clinic in Redfield, Iowa.

“If you can trust a PA up to 30 miles away, then you can trust them up to 60 or more miles away,” he says. With modern technology making it easy to communicate with physicians as needed, the regulation is not necessary.

“Tell the people who make policy decisions about your problems and how they can be improved,” urges Friedmann, who has worked with Congressional members and the state legislature to change laws. “When I started practicing in 1977, PAs didn’t have prescribing privileges, and now we do. You might be amazed at how responsive lawmakers can be about improving access to care.”

Case in point: On Jan. 1, a federal law became effective that allows PAs to get direct Medicare payments, like NPs do, instead of the payments going through an employer. “Our clinic can now get paid directly for necessary lab and EKG services.”

Dr. Moseley notes that most specialists in her area are a 40-minute drive away—a distance that patients sometimes don’t want to travel. When that happens, “I don’t sugarcoat it,” she says. “I tell them that we have done all we can at MinuteClinic and they have to go to a higher level of care.”

Getting to a specialist—or even a local clinic—can be further complicated by a lack of transportation, Friedmann adds. That’s where clinics and communities need to get creative: • A van service can help patients get to routine appointments, but the need to plan ahead can make it difficult for acute situations. • In Friedmann’s community, a group of retired volunteers steps in to provide rides for acute needs and specialty appointments. • In Lexington, Neb., in-town patients can use a local, community-supported bus system that is handicapped accessible, says Roger D. Wells, PA-C, MS, a physician assistant and family medicine specialist at Lexington Regional Health Care. • Patients can sometimes turn to a local employer or family member to get a ride. • Home care may be the best option for some patients. In a growing number of states, PAs and NPs can now certify patients for home health care, so Friedmann makes house calls outside of clinic hours in the evening or on weekends.

While those ideas work for some patients, there will always be others who don’t have access to vans or volunteers, buses or bosses. For them, telehealth is a game-changer.

Employing Telehealth

Telehealth can take care right into patients’ homes, no matter how far away they may be, and it connects urban and rural providers, says Sarah Hohman, deputy director of Government Affairs at the National Association of Rural Health Clinics in Alexandria, Va. There are a wide variety of HIPAA-compliant platforms to choose from.

Telehealth also provides access to specialists who aren’t plentiful in rural areas. For example, Eastern Utah Women’s Health collaborates with a mental health clinic to offer telepsychiatry. The facility became the first integrated behavioral and physical health clinic in the state.

Communication Strategies

For patients for whom English is a second language, use plain language when speaking and back it up with written handouts, emails, and texts, advises Danielle Howa Pendergrass, DNP, APRN, WHNP-BC, FAANP, president and clinician at Eastern Utah Women’s Health in Price, Utah. She also uses videos to allow patients to quickly learn and visualize skills such as taking their own blood pressure or using contraceptives.

“Return demonstration through role-playing when learning new techniques or synthesizing information is helpful to assess understanding and confidence in a new skill,” she says.

Given its large Spanish- and Somali-speaking populations, Lexington Regional Health Care has in-house interpreters for those languages, says Roger D. Wells, PA-C, MS, a physician assistant and family medicine specialist at Lexington Regional Health Care. Computer-assisted interpreters are available for patients with other language requirements. Translation services are becoming more broadly available through telehealth and other technologies.

Wells tries to be cognizant of varying cultural care preferences. For example, some patients prefer limited eye contact, some women don’t want their care administered by men, and some people find shaking hands socially inappropriate.

“Be honest and upfront with patients,” Wells says. “Tell them that you don’t always understand their needs or preferences. Let them guide you in the social arena, and then discuss their diagnosis and adjust acceptable alternatives for treatments.”

BE HONEST AND UPFRONT WITH PATIENTS. TELL THEM THAT YOU DON’T ALWAYS UNDERSTAND THEIR NEEDS OR PREFERENCES. LET THEM GUIDE YOU.

— Roger D. Wells, PA-C, MS

Help Less Tech-Savvy Patients

Telehealth is only as useful as a patient’s access to it, so Dr. Howa Pendergrass’ clinic partners with local libraries to provide internet access to patients who don’t have it at home. To help patients feel comfortable with using new technology, the clinic uses emails, text messages, and video instructions on how to use any device to “see” a provider.

Patients are also encouraged to text or call with questions before a visit. “This decreases anxiety and confusion about using a new service,” Dr. Howa Pendergrass says.

“The traditional telephone has worked well for years,” Friedmann adds. “It’s not uncommon for a patient to call and ask whether or not they should come in to see me. Sometimes, I can even prescribe systemic treatment in the interim,” saving them a trip.

Relationship Building

While they are faced with a multitude of challenges, health-care professionals working in rural areas often say that the sense of community makes it all worthwhile. “We care about our patients and we want to make sure they know that,” Dr. Moseley says. That means she takes extra time to make sure her patients know what they need, whether that means writing instructions, walking through the store to show patients the over-the-counter medication she recommends, or helping them find the most affordable medication.

“I want every patient to feel like their needs are the most important thing to me at that moment.” C