the importance of community in rural health · •• the process can be lengthier due to consensus...

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The Importance of Community in Rural Health

UND College of Nursing & Professional Disciplines

N548 Advanced Public Health Nursing

December 1, 2016

Presented by Brad Gibbens, MPADeputy Director and Assistant Professor

• Establishedin1980,atTheUniversityofNorthDakota(UND)SchoolofMedicineandHealthSciencesinGrandForks,ND

• Oneofthecountry’smostexperiencedstateruralhealthoffices

• UNDCenterofExcellenceinResearch,Scholarship,andCreativeActivity

• Hometosevennationalprograms

• RecipientoftheUNDAwardforDepartmentalExcellenceinResearch

Focuson– EducatingandInforming– Policy– ResearchandEvaluation– WorkingwithCommunities– AmericanIndians– HealthWorkforce– HospitalsandFacilities

ruralhealth.und.edu 2

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Today’sObjectives/Questions

• Whatisruralhealth?• Whataretheruralhealthissuesandconditions?• Howareruralhealthandruralcommunitiesintertwined?

o Strengthsandweaknessesofruralandurbancommunitieso RuralCommunityHealthEquityModelo Buildinghealthiercommunitieso Ahealthcommunityis….o Catalysis’sforahealthycommunityo Resourcesforbuildinghealthycommunities

• Whatiscommunityengagementandhowdowedoit?

OurValuesasaSocietyShapeOurApproachtoHealth

“Itisnotwhatwehavethatwillmakeusagreatnation.Itishowwedecidetouseit.”

TheodoreRoosevelt

“Visionistheartofseeingthingsinvisible”JonathanSwift

“Americanscanalwaysbereliedupontodotherightthing…aftertheyhaveexhausted

alltheotherpossibilities”SirWinstonChurchill

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What is Rural Health

• Rural health focuses on population health and improving health statuso “Health outcomes of a group of individuals, including the distribution of such

outcomes within the group” Dr. David Kindig, What is Population Health?o Rely on social determinants of health and their impact on the population

(Health care system, Health Behaviors, Socio-Economic factors, Physical Environment) – “drivers” of health policy (Better Health, Better Care, and Lowered Cost – Three Aims)

• Historically, rural health has focused more on infrastructure: facilities, providers, services, and programs available to the public (all with quality, access, and cost implications) – In the ACA world more emphasis on population health, but infrastructure is still critical as it is the pathway to achieve better population health. o HRSA (ORHP, SORH, Flex, NHSC) – Federal bureaucracy orientationo Infrastructure improvement- health orgs, systems, payment structureso More and more health networks – independence with collaborationo Delivery systems: CAH, clinics, public health, EMS, nursing homes/aging

services, home health, mental health, dental, pharmacy, and others

Stutsman County

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What is Rural Health?

• Rural health is not urban health in a rural or frontier areao Social determinants of health vary between urban and rural

(economics/income, education, health systems, environmental conditions)o Rural is older, poorer, less insured, and has a higher level of morbidity for a

number of conditionso Rural culture, relationships, how we do things are distinct

• Rural health needs effective health policy, and health policy needs to rely on competent researcho Policy process that is reflective of rural health needso Policy advocacy that tends to be bipartisano Varity of advocacy groupso Rural health research community

What is Rural Health?§Philosophy: rural people have the same right to expect healthy lives and

access to care as do urban people – fairness frame• Access essential services locally or regionally• Access to specialty services through network arrangements• Health outcomes should be comparable• Quality of care on par with urban• Availability of technology

§ Rural health is very community focused – interdependence frame• Integral part of what a community is and how people see themselves• Community engagement – public input is fundamental• Sectors: Economic/business, public/government, education, faith/church, and

health/human services• Direct services provided to the public and secondary impact for other sectors• Major employer

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Whataretheruralhealthissuesandconditions?

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What are Some Important Rural Health Issues? • Access to and availability of care• Financial concerns facing rural hospitals and health systems• Health disparities (inclusive of health conditions and behavioral risks)

• Health workforce• Quality of Care (inclusive of patient safety)• Health Information Technology/ Tele-health• Networks – rural/urban, primary care/public health, acute/public health• Emergency Medical Services – EMS, ambulance, quick response units• Community and Economic Development – community viability• Health Reform (cost, insurance, how we access care, community role)

Sources: 2008 Flex Rural Health Plan, 2009 Environmental Scan, and community presentation feedback surveys 2008-2015

PreliminaryCHNAIssues(2014-2016)• 34CHNAanalyzedoutof45• 151needs(range2to9rankedneeds,most4-5)• Issues

o BehavioralHealth 29outof34o AbilitytoAttractandRecruitaProvider 20o MentalHealth 18o Cost(insuranceandhealthcare) 15o Obesity/overweight 11o ChildCare 10o AvailabilityofResourcestoHelpElderly(stayinhome) 10o JobswithLivingWages 8o Wellness(lifestyle,fitness,exercise) 8o AbilitytoRecruitandRetainYoungFamilies 7o Housing 4o Bullying/Cyber-bullying 2o Poverty 2

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RuralHealthandRuralCommunityareIntertwined

• StrengthsandWeaknessesofRuralandUrbanCommunities

• RuralCommunityHealthEquityModel

• BuildingHealthierRuralCommunities

• AHealthyCommunityis….

• Catalysis'sforaHealthyCommunity

• ResourcesforBuildingHealthyCommunities

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RuralandUrbanStrengthsandWeaknesses

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Rural Urban

Weaknesses••Lackofcohesiveness

••Limitedinformalsupport••Competitionamongproviders••Competitionforfundraising••Morecontentious-fractions••Lesssenseof"community"

Strengths••Morestable/diversifiedeconomy

••Availabilityofresources••Availabilityofprofessionals

••Growinganddiversepopulation••Changeisnatural

Weaknesses••Skewedpopulationdemographics

••Fluctuatingeconomy••Resistancetochange

••Shortageofprofessionals••Lackofresources••Over-tappedstaff

Strengths••Stronginformalsupportnetwork

••Fundraising••Cohesive

••Establishedinterdependence••Collaboration

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BuildingHealthierRuralCommunitiesMeansWhat?

• Healthierpopulation/clients/patients• Underlyinggoalwithinhealthreformofthe

deliverysystem• Senseofinterdependencyandequity• Localleadershipfromhealthsectorand

othercommunitysectors– partnershipsandcommunitycoalitions

• Requiressincere communityengagement• Greaterindividualresponsibilitywithin

thecommunityforoneshealthbutwithcommunitystructuresforsupportandguidance

• AhealthycommunityisaØ dynamiccommunityØ changingcommunityØ faircommunityØ engagedcommunity

• Inahealthycommunity,Ø diversityisvaluedØ peoplefeelincluded,respected,and

trustedØ peopleworktogetherØ assetsarevaluedØ thegoalistheoverallhealthofthecommunity

Source:adaptedfromhttp://sarahefrost.blogspot.com/2011/07/what-makes-community-healthy-why-not.html

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WhatCanActasCatalystsforBuildingaHealthyCommunity

• CommunityHealthNeedsAssessment(CHNA)andImplementationPlan• FunctionwithintheACA– understandingcommunityneedsandmeeting

thoseneeds• Fostersalevelofcommunityengagement– needsassessment,key

informant,andfocusgroups,CHNAteam,individualcommittees• Collaborationbetweenhospitalsandpublichealth(required)andother

communitygroups(health,civic,business,school,faith-based)• Opportunityforcommunitycollaborationtodevelopanimplementation

planforcommunityhealthimprovement• Followthroughisimperative• Whatarethegoals,objectives,timeframe,andultimatelyoutcomes(how

tomeasuretheoutcomes)?

ResourcestoAidinBuildingaHealthierRuralCommunity

• CHNA – processandplatformthatcanleadtoaHealthierCommunity

• CommunityHealthImprovementPlan – resultsfromtheCHNAandisaroadmaptobuildahealthiercommunity

• AHealthierCommunitycomesfromthededicationandhardworkofthepeoplewhotakeresponsibilityandprovideleadership

o Workgroupsandcommittees– diversity,buildleadership,buildconfidence

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ResourcestoAidinBuildingaHealthierRuralCommunity

• GeneralAdvice:ThinkTeam– RememberValuesandCommonBeliefso Ateam,acoalitionofcommittedpeopleworkingtogethero Manyhoursofworkovertime(butthinkofeatinganelephantJ )o Compromise– don’texpecttogeteverythingyouwanto Flexibility– listen,adjust,try/fail,andkeepmovingo Bigpicture– whatisneededforthecommunity(commongood)o Methodicalsmallstepstogetthere– goals,objectives,actionsteps

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ResourcestoAidinBuildingaHealthierRuralCommunity

• CDCMakingHealthyLivingEasier(http://www.cdc.gov/nccdphp/dch/programs/index.htm)

• BuildingHealthierCommunitiesKeyResourceList(http://www.muskegonhealth.net/programs/educational/building_healthy_communities_resources.pdf)

• RuralHealthInformationHub(RHIhub)(https://www.ruralhealthinfo.org/)o GrantWritingforRuralHealthcareProjects

(https://www.ruralhealthinfo.org/topics/grantwriting)o HealthcareAccessinRuralCommunities

(https://www.ruralhealthinfo.org/topics/healthcare-access)o ConductingRuralHealthResearch,NeedsAssessment,andProgram

Evaluation(https://ruralhealthinfo.org/topics/rural-health-research-assessment-evaluation )

RuralHealthInformationHub(continued)

o EvidencedBasedToolkitsforRuralCommunityHealth(https://www.ruralhealthinfo.org/community-health/toolkits)

o RuralHealthModelsandInnovations(https://www/ruralhealthinfo.org/community-health/project-examples )

o SupportingRuralCommunityHealth(https://www.ruralhealthinfo.org/community-health/support )

o FindingStatisticsandDataRelatedtoRuralHealth(https://www.ruralhealthinfo.org/topics/statistics-and-data)

o CommunityVitalityandRuralHealthcare(https://www.ruralhealthinfo.org/topics/community-vitality-and-rural-healthcare)

o RuralTribalHealth(https://www.ruralhealthinfo.org/topics/rural-tribal-health)

o SocialDeterminantsofHealthforRuralPeople(https://www.ruralhealthinfo.org/topics/social-determinants-of-health)

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WhatisCommunityEngagementandHowdoWedoit?

• Healthcareprovidersandorganizationscannotoperateinisolation• CommunityengagementisevenmoreimportantnowasweredesigntheU.S.

healthdeliverysystem – re-focusonpopulationhealth,providersaretobeassessedandreimbursedonoutcomesandpatientsatisfaction,re-designingthedeliverysystemwithalternativepaymentoptions(e.g.,ACO)

• Communityownership– identifyneedsandworkforsolutions- communityfocused

• Buildinglocalcapacityandleadership– thinkofthenextgenerationofcommunityleadership

• Communicationandsharedunderstanding,sharedvalues

• SIMPLEANSWER:YouNeedtobeEngagedBecauseYouNeedtoSurvive

WhyisCommunityEngagementImportanttoRuralHealth?

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CommunityEngagementToolkit!

Ø OriginalconceptoutoftheCommunityTransformationGrant(end9/2014)

Ø UND– CenterforRuralHealthbelievedinthepotential,soithasbeenfinishedand“branded”.

Ø It’ssetupin5Modules,andmeantfortheusertogofromthebeginningtotheend.– Module1:FindingaCommonMission– Module2:Assessment(DefiningtheProblem)– Module3:Planning– Module4:Implementation&Evaluation– Module5:Sustainability

Ø Includesavarietyoftools,tips,andtricks,tohelpanycommunityorgroupthroughtheprocess.

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CommunityCoercion-----------

Activities/outreachoccur"to"and"for"targetpopulation

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Externalownership

Consultation

CoalitionsandPartnerships

CommunityEngagement

-----------

Activities/outreachoccur"with"target

population-----------

Communityownership=sustainability

CommunityEngagementContinuum

ThingstothinkaboutwhenconsideringaCommunityEngagementprocess…

Considerations:

•• Theprocesscanbelengthierduetoconsensusbuilding.•• Maintainingexcitementcanbedifficultiftheprocessistooslow.•• Gainingtheinvolvementofthekeyplayersorunusualsuspectsis

important,butattimesdifficult.•• Overcomingdifferencestofindacommonvisionorgoal.

Results:

•• Theresultswillbelongerlastingduetoalargerinvestedinterest.

•• Small,easywinscanbuildagreatamountofmomentum.

•• Connectionsandtrustisbuiltamongorganizations/individuals.

•• Newleaderscanbedeveloped.•• Changeisstrongerandmorepowerfulwith

investedinterestfromthecommunity.

Source: BradGibbens,DeputyDirector,CenterforRuralHealth,UNDSchoolofMedicineandHealthSciences

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Step1:OrganizeyourCommunityEngagementProcess

Step2:AssessandDevelopyourPartnershipNetwork

Step3:Firstfullgroupmeeting

Step4:SettingGoalsandCreatingVision

Step5:AssessResourceNeeds

Step6:Goingpublic!

Module 1: Finding a Common Mission The Foundation

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Step1:GapsinAnalysisand/orKnowledge

Step2:DefiningtheProblem/Need

Module 2: Assessment and Data Collection

Module 2: Tools and Samples

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Step1:DifferentTypesofPlans

Step2:UnderstandingtheCHIP

Step3:HowtoRunaPlanningMeeting

Step4:Resources

Step5:Budget,TimelineandDelegation

Module 3: Community Planning

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Module 3: Tools and Samples

Step1:WhoisResponsible?

Step2:Wheretobegin?

Step3:TheSTARTbutton!

Step4:TrackingEvaluation

Module 4: Implementation and Evaluation

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Step1:WhatdoesSustainabilityreallymean?

Step2:WhydoesSustainabilitymatter?

Step3:Whoshouldbeinvolved?

Step4:DevelopingyourSustainabilityPlan

Module 5: Sustainability

Let’srecap!Sustainability

Evaluation

Implementation

Planning

Assessment

Foundation

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CustomizedAssistance 1-800-270-1898

info@ruralhealthinfo.org

TailoredSearchesofFundingSourcesforYour

Project

FoundationDirectorySearch

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TheRuralHealthResearchGatewayprovidesaccesstoallpublicationsandprojectsfromsevendifferentresearchcenters.Visitourwebsiteformoreinformation.www.ruralhealthresearch.org

SignupforouremailorRSSalerts!www.ruralhealthresearch.org/alerts

ShawndaSchroeder,PhDPrincipalInvestigator701-777-0787•shawnda.schroeder@med.und.edu

CenterforRuralHealthUniversityofNorthDakota501N.ColumbiaRoadStop9037GrandForks,ND58202

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CenterforRuralHealthUNDSchoolofMedicineandHealthSciencesNorthColumbiaRoad,Stop9037GrandForks,NorthDakota58202-9037

701.777.2569(Brad’sphone)701.777.3848(CRH)

Brad.gibbens@med.und.edu

ruralhealth.und.edu

Contact us for more information!

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