Establishing a Care Continuum in Rural America

  Rural residents are typically older, poorer, and have fewer physicians to care for them. They are also nearly twice as likely to die from unintentional injuries other than motor vehicle accidents, according to the NRHA. Additionally, Medicare reports that its patients with acute myocardial infarction who are treated in rural hospitals are less likely than those treated in urban hospitals to receive recommended treatment. This article will illustrate some of the challenges that providing healthcare in rural America presents and how taking a proactive role can improve the overall continuity of care in one’s community.

Lagging Rural Recruitment

  It has long been estimated that the US will continue to experience an increasing shortage of healthcare professionals that will place increasing constraints on those who practice, particularly in the field of wound care, due to increased number of patients who live with chronic wounds. These challenges are expected to be especially evident for those in rural areas where the employee pool is already limited. A study from the Center for the Health Professions at the University of California, San Francisco, reports the shortage is a chronic problem in low-income and rural areas and that residents in these areas could encounter more difficulties in accessing care. (This doesn’t apply strictly to physicians and nurses.) By 2014, the Association of Academic Health Centers anticipates 82,000 nationwide openings will exist for dental hygienists, while other estimated deficits include 43,000 for occupational therapists, 72,000 for physical therapists, 40,000 for physician assistants, and 57,000 for respiratory therapists.   When considering the potential effects of healthcare reform on our present economic situation, one might wonder how rural healthcare staffs are going to care for an increased number of patients when considering the compounded challenges of caring for an aging US population. As an experienced provider in a rural setting, I face issues on a daily basis related to workforce shortages, increased patient caseloads, more work hours, increased physical and emotional stress, difficulty finding staff coverage for personal time off, and even finding the time to attend continuing education (CE) sessions.   Then, there are times when census is down in a rural facility. While this might seem to present a relief, it’s often the opposite as facilities find themselves forced to decrease their workforce. In particular, rural areas are not typically known for enticing new graduates, established practitioners, or industry specialists to relocate. Pay is usually less and establishing a practice is difficult due to lower populations, to name a few reasons. In addition, for those with families there’s difficulty in a spouse finding work and limited school choices for children.   Another obstacle experienced by providers is secondhand — many rural residents have serious transportation and income barriers. I’ve known local patients who’ve had to decide to go through with an amputation because they could not afford gas, as treatment meant driving 120 miles round trip daily to a facility, or because they had difficulty finding someone to take them to an out-of-town facility. (Some small towns do not have taxis.)

A Personal Journey

  In 2001, I moved to Louisiana from Florida, eventually settling long-term in Natchitoches, a city located in the North Central part of the state, in 2006. Most people can’t pronounce our city (na’-ka-tosh), but as locals, we believe we were put “on the map” when Steel Magnolias filmed here in 1989. A quaint, little town that’s also famous for its annual Christmas festival and considered to be a great place to retire, Natchitoches is a place where everyone knows each other, where many people live in historic plantation homes, and where there’s not much industrialization. Store selections are limited and are highlighted by a Walmart and what might be considered a strip mall. We have a total of about 25 physicians in town, including two general surgeons, a cardiologist, and an orthopedist surgeon with hospital privileges. We have a dermatologist and a podiatrist available, but only on an outpatient basis. And if someone becomes emergently ill or requires specialty care they can expect to travel 60-80 miles if a specialist isn’t in town.   While in Florida, I worked in a hospital that housed more than 1,000 beds in a city that was home to 240,000 people, and we had many resources available to assist the well-being of our patients. Today, I’m in a small town of 18,000 people with a 70-bed hospital. Relocating was something I knew would not be an upward move for my career, but I felt a calling to “do the right thing” as a provider and be with my aging in-laws. I consider my situation similar to that of my father, Frank, who always worked hard, likewise cared for his in-laws (my grandparents), and always seemed to demonstrate a calm and collective demeanor in times of stress.   Being born in Puerto Rico and raised in Florida from the time of age 10, my initial “culture shock” out here was fairly superficial — my car would often get stuck in mud in my front yard after a rainstorm. But when I soon accompanied my wife’s (Anne) family on a crawfishing trip and they warned me to “watch out for gators and to swim quickly back to the tractor if I got bitten by a snake (without dropping any crawfish mind you) in order to have adequate time to make it to the hospital,” the severity of the healthcare situation really began to take hold. In time I’d learn to purchase waders, boots, a shotgun, a four-wheeler, and an anti-venom kit, and I’ve since watched educational programs on how to tame wild animals when confronted. I’ve come to really enjoy the small-town atmosphere and the people in my community, and it’s a great place to raise a family, as Anne and I have done with our daughters Hannah, Sarah, and Laura. But this on its face hasn’t necessarily solved my dilemma of constantly trying to improve local healthcare for others.   In 2006 I took a job at an acute care hospital in town. At the time, I was fairly certain that it was the only healthcare job in my field (physical therapy) available. The facility did feature a long-term acute care (LTAC) center that staffed a wound specialist who ultimately relocated. The hospital system also was involved with supplying therapy services to a local nursing home and two outpatient clinics (one in town, the other 30 miles away).   As such, my role quickly expanded when these facilities lacked staff due to vacations, participation in CE sessions, and/or vacancies. Before long, I worked more hours and more weekends than I had ever planned.   Knowing that we have minimal staff in the region, I always curtail my personal and professional schedule to be available to accommodate patients if other providers are out of town.

Forming An Education Continuum

  In 2009, I launched a wound care project that has established and maintained a wound care continuum with the support of my supervisor and a team of healthcare professionals. Through a dedicated team effort we educate patients and providers on evidence-based practice, bringing education to rural areas that integrates “best” practice with clinical practice and improves communication between clinicians through the continuum. We inform others of available innovative dressings, introduce advanced modalities, and have developed a network of wound care health professionals in and out of town. Our goals and the action plan consist of the following:   Improving wound care knowledge. For community members, we speak/educate at church organizations, National Council of Aging meetings, hospital forums, and community health fairs. For healthcare professionals, we’ve partnered with a CE company to bring 2-3 yearly courses to town. This allows clinicians to get educated without worrying about staff coverage and travel expenses. Personally, I set a goal of attaining multiple wound care credentials in order to improve my own education and be more valuable as a resource. I now teach CE classes for companies at their request. We’ve also introduced wound care vendors and products to the area. They bring samples and allow us to use new products, and assist in educating others (in a strictly enforced non-biased manner). We’ve also been known to host diner-based educational meetings with participants who travel from nearby towns and well-known speakers who fly in. Our reach has grown to provide for a company in Lafayette via live presentations, monthly webinars, and referral sources. I’ve also started my own consulting/education business (Cane River Therapy Services) that provides facilities and organizations with specific training on various wound care subjects (as requested) as well as staff coverage when a therapist is needed.   Centralizing communication. Since we do not yet have a dedicated wound center (though we are getting closer to that reality), we maintain open lines of communication through my employment within the LTAC center, local outpatient therapy clinics, acute hospital, nursing homes, and home health agencies. I’m on everyone’s speed dial and have become the communications “middle man” in those instances when a physician or therapist isn’t within reach.   Improving use of dressings and introducing advanced modalities. We conduct research with the nursing homes and home health agencies to learn which products they’re carrying and which are producing better outcomes.   Through the assistance of vendors we’ve also improved educating staff on proper dressing use and patient compliance. We’ve also trialed (and now use) low-frequency ultrasound devices, and the results have been phenomenal in improving our outcomes, especially in areas with limited resources.   Developing the expert network. I’ve recruited a group of “physician champions”— Dr. William A. Ball Jr., MD, FACS; Dharam Gurwara, MD; Kerry Thibodeoux, MD, FACS; Gary Mazzanti, MD; and others — who serve specific local regions to help foster timely communication to area staff and vendors to keep the continuum strong.

Dedicated to Rural Community

Over the years, I’ve been offered many job opportunities with better working conditions and more career growth, but did not pursue them as I am quite fulfilled working with my colleagues and in my community. More recently, I’ve also had the chance to improve outcomes within my facility and beyond.   In order to earn enough of a consistent living to support my family and remain a “full time” healthcare provider in this region that I’m so passionate about, I spend my “off days” lecturing, seeking out per-diem time as best I can, picking up “odd jobs” such as home painting and remodeling, and continuing to grow my side business. Yes, rural areas present challenges to our committed healthcare providers, which, in turn, creates a difficult environment to attract new, younger providers.   The effort can be daunting and exhausting at times, but rural healthcare overall needs increased attention in order to provide the necessary, timely, and appropriate care to our aging population. Thanks to the help of a great team of local and more distant clinicians we’ve been successful in improving communication and care. Frank Aviles, Jr. is clinical director of therapy services and wound specialist at a rural long-term acute care facility; owner, instructor and consultant for Cane River Therapy Services; and instructor for the Academy of Lymphatic Studies. He can be reached at 318-228-5056 or at crts@cp-tel.net.

References

1. Rosenblatt R, Hart, LG. Physicians and rural America. West J Med. 2000;173 (5):348-351. 2. American Academy of Family Physicians. Rural Practice, Keeping Physicians In. Accessed online at www.aafp.org/online/en/home/policy/policies/r/ruralpracticekeep.html. 3. Chang J, et al. More Choices, Better Coverage: Health Insurance Reform and Rural America. Accessed online at www.healthreform.gov/reports/ruralamerica/ruralmorechoicesmorecoverage.pdf.