May/June 2016

Practical Solutions to Rural Elders' Health Outcomes
By Mary Martin, MSN, RN, AGCNS-BC, ANCC, and Julie Finch, MSN, RN, FNP-C, AGPCNP-C, AANPCP
Today's Geriatric Medicine
Vol. 9 No. 3 P. 28

Over the past few decades, rural elders have experienced worsening health care disparities. Factors contributing to this phenomenon include their isolation, both socially and geographically, poverty, and increased participation in high-risk behaviors. Rural communities, the states, and the federal government must begin to work together in a coordinated effort to combat this trend and improve the overall health and well-being of rural elderly communities. Utilization of Critical Access Hospitals, community transition programs, and rural health care services outreach programs are some of the efforts put forth by the federal government in coordination with local communities to improve health care access and thereby improve health outcomes among rural elders. With these readily available programs, rural elders can easily access the necessary health care.

In 2015, the United States Census Bureau defined urbanized areas as those with 50,000 people or more and urban clusters as areas with 2,500 to 50,000. Any population or land falling outside of urban areas or urban clusters is consequently designated by the US Department of Health and Human Services as rural.1 In 2013, the older adult population in the United States was 44.7 million, accounting for 14.1% of the total American population.2 American elders, much like their younger counterparts, are ethnically and racially diverse, consisting of 78.8% white, 8.6% black, 7.5% Hispanic, 3.9% Asian/Pacific Islander, 0.5% Native American, 0.1% Native Hawaiian, and 0.7% who claim two or more races.2,3

In contrast to the overall US older adult population, 20% of the rural community is aged 65 and older.4 The higher representation of older adults in rural communities presents a unique set of challenges and requires strategic planning to halt the widening health care disparities noted in this population.5 The purpose of this article is to examine key factors that contribute to overall poorer health outcomes in the rural elder population and offer practical suggestions for overcoming widening health care disparities.

Factors Contributing to Poor Health Outcomes

Isolation
Social isolation is a key contributor to poorer health outcomes in the rural elderly. It occurs as elders experience greater levels of illness and are unable to maintain community-related activities, leading many older adults to feel a lack of belonging.6 As younger generations move to urban and suburban locations for jobs, rural elders often find themselves isolated from family and friends, placing them at greater risk for negative health outcomes.6 Isolation resulting from a lack of transportation can predispose rural elders to limited social interaction within the community and is often a true indicator for poorer health outcomes among this population.7

In addition to social isolation, geographical distance both to health care providers and emergency services can significantly limit rural access to timely preventive care and chronic disease management and thereby worsen health outcomes.8 Rural elders too often encounter a noticeable lack of physical resources within their communities. Sadly, many rural elders find it difficult to access health care services in their local communities because of a lack of clinics or limited clinic hours and must therefore travel great distances to obtain basic health care services.8

Poverty
In 2013, the US Census Bureau reported that 16.1% of the rural population was living in poverty, compared with 14.5% on a national scale.9 There is a larger percentage of rural elders who live at or below the poverty level and rely solely on Social Security benefits to meet monthly expenses.9 The increased incidence of poverty in this population is a significant contributor to poorer health outcomes. Rural elders without supplemental insurance policies or Medicaid must bear the financial responsibility for 20% of their medical costs not covered by traditional Medicare Part B, in addition to premiums and deductible expenses.10 Consequently, many older adults are faced with the difficult choice between purchasing prescribed medications or providing for basic needs such as housing, food, and clothing.8

High-Risk Health Behaviors
In addition to the myriad environmental barriers that contribute to poorer health outcomes among rural elders, there is a greater degree of high-risk behavior in this community. The National Rural Health Association reports that rural Americans have higher levels of alcohol and tobacco use than their urban and suburban counterparts. Additionally, it's noted that rural Americans have 128.8 per 1,000 persons with hypertension compared with 101.3 per 1,000 among the urban population.4 Increased participation in high-risk health behaviors throughout the lifespan translates to higher rates of chronic diseases, including diabetes, pulmonary disease, and heart disease, as rural individuals advance into their later years.5

Keys to Improving Outcomes

Access to Inpatient Care
Aging successfully requires a multilevel approach that first and foremost provides for increased integration of primary care services into rural settings and communities. The federal government has attempted to improve rural access to health care services in a number of ways. It has increased reimbursement for inpatient services in the rural community through the designation of critical access hospitals.11 Generally, these are small, rural hospitals that provide basic inpatient services closer to where rural elders reside, thereby decreasing the burden of travel and distance required to obtain care in the closest suburban or metropolitan hospitals.11

In addition, the Affordable Care Act (ACA) provides for the creation of resource centers within rural communities to improve the elderly population's understanding of resources available to them through the federal government.12 Lastly, there are provisions within the ACA for the Community-Based Transition Program to improve follow-up of recently hospitalized elders with the intention of decreasing readmissions rates.12

Access to Outpatient Care
In response to the limited health care resources within rural communities, the Health Resources and Services Administration (HRSA) has attempted to bridge the gap in provider access that too often predominates in rural settings.1 HRSA assists with the training of nurses and other clinicians to provide health care to vulnerable populations.13 Additionally, the Rural Health Care Services Outreach program provides health screenings, health education, and education to health care providers that is essential to effectively care for this vulnerable population.13

Nursing is a vital component of improving the health of rural elders. Stuck et al conducted a randomized research trial involving extensive health risk assessments that were then evaluated by nurse counselors in an effort to develop each participant's personal preventive care model. Nursing personnel then provided extensive follow-up and education associated with each participant's care model. The researchers found that at two- and eight-year intervals, program participants had statistically improved health outcomes vs the control group.14 The research design relied heavily on the vital role nursing can and should play in risk assessment, education, and close community follow-up in an attempt to promulgate better health outcomes among rural elders.14

Local Efforts
Increased access to health care services is but a single piece of the puzzle related to improving health outcomes among rural elders. Morken and Warner concluded that local governments must necessarily work with state, federal, and nonprofit organizations to develop strategic plans that include affordable housing for older adults and appropriate access to healthful foods, transportation services, and safe exercise. Elders with access to safe walking trails and group exercise activities are necessarily able to maintain a healthier weight and all the benefits that entails.6

Final Thoughts
Rural elders face a number of barriers to improving health outcomes. In efforts to overcome these barriers, it is essential that local communities work in a coordinated fashion with federal and state agencies. Rural communities must be vigilant and attempt to minimize widening health disparities while working toward the promotion of successful aging in the older adult population. This cohort is a growing demographic and encompasses a unique set of challenges that require mobilization of resources at the family, local, state, and federal level. A deficit in one or more of the key components to health, including access to care, poverty, and isolation (both physical and geographical) necessarily contributes to barriers in improving health outcomes. Therefore, it is vital that communities and health care systems work in an effective coordinated manner toward ending the continuing disparities seen in the rural elder population.

— Mary Martin, MSN, RN, AGCNS-BC, ANCC, is the clinical site coordinator/clinical instructor at Martin Methodist College Nursing Division in Pulaski, Tennessee. With certification in adult-gerontology, she has had 24 years in the nursing profession, including experience in home health care and private duty nursing.

— Julie Finch, MSN, RN, FNP-C, AGPCNP-C, AANPCP, a hospitalist at Marshall Medical Center in Lewisburg, Tennessee, is currently seeking her doctorate of nursing practice at the University of Alabama-Huntsville. She has worked in the field of nursing for more than 25 years in all regions of the United States.

References
1. Defining rural population. Health Resource Services Administration website. http://www.hrsa.gov/ruralhealth/policy/definition_of_rural.html. Updated November 2015. Accessed October 15, 2015.

2. Administration for Community Living Administration on Aging. A profile of older Americans: 2014. http://www.aoa.gov/Aging_Statistics/Profile/2014/docs/2014-Profile.pdf. Accessed September 17, 2015.

3. Ortman JM, Velkoff VA, Hogan H; US Census Bureau. An aging nation: the older population in the United States. https://www.census.gov/prod/2014pubs/p25-1140.pdf. Published May 2014. Accessed October 28, 2015.

4. What's different about rural health care? National Rural Health Association website. http://www.ruralhealthweb.org/go/left/about-rural-health/what-s-different-about-rural-health-care. Accessed September 17, 2015.

5. Singh GK, Siahpush M. Widening rural-urban disparities in life expectancy, U.S., 1969-2009. Am J Prev Med. 2014;46(2):e19-e29.

6. Morken L, Warner M. Planning for the aging population: rural responses to the challenge. National Association of Area Agencies on Aging. http://s3.amazonaws.com/mildredwarner.org/attachments/
000/000/196/original/de6841e2187c889cdf4a15a7b45512f4. Published October 2012.

7. Dury R. Social isolation and loneliness in the elderly: an exploration of some of the issues. Br J Community Nurs. 2014;19(3):125-128.

8. Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public Health. 2015;129(6):611-620.

9. DeNavas-Walt C, Proctor BD; US Census Bureau. Income and poverty in the United States: 2013. http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-249.pdf. Published September 2014. Accessed October 28, 2015.

10. Medicare 2016 costs at a glance. Medicare.gov website. https://www.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html. Accessed October 29, 2015.

11. US Department of Health and Human Services, Centers for Medicare & Medicaid Services. Critical access hospital. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/critaccesshospfctsht.pdf. Updated February 2016. Accessed October 29, 2015.

12. Agency for Healthcare Research and Quality. 2014 National Healthcare Quality & Disparities Report. http://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/nhqdr14/
2014nhqdr.pdf. Published May 2015. Accessed September 17, 2015.

13. Morris T. Aging in rural America: preserving seniors' access to healthcare. Health and Human Services website. http://www.hhs.gov/asl/testify/2008/07/t20080731f.html. Updated June 18, 2013. Accessed September 17, 2015.

14. Stuck AE, Moser A, Morf U, et al. Effect of health risk assessment and counselling on health behaviour and survival in older people: a pragmatic randomised trial. PLoS Med. 2015;12(10):e1001889.