BY NANCY SKINNER, RN, CCM, CMGT-BC, ACM-RN, CMCN, FCM
The term rural often evokes bucolic images of vast areas of farmlands and majestic scenery rather than prompting a clear and specific definition of the word. The United States Census Bureau considers a rural area as “any population, housing or territory that is not included within an urban area” (reference 1). The United States Department of Agriculture defines a rural area as “open country and settlements with fewer than 5,000 residents and 2,000 housing units” (reference 2). It is estimated that 1 in 5 Americans, or 62.8 million people, live within the 87.4% of American land area that is rural (reference 3).
Regardless of governmental data and descriptions, it is my belief that the term rural cannot be quantified by a single descriptor, zip code, town or area. Instead, it is important to realize that for our patients a rural residence represents a symphony of challenges and barriers that might impact their ability to achieve the highest level of health and function through and across the healthcare continuum.
Many of the actions currently taken by governmental agencies to support rural health and healthcare delivery tend to focus on” Reimaging Rural Health” (reference 4). These initiatives seek to address rural health disparities through a number of avenues including enhanced alternative payment models; improved access to available technology such as telemedicine and E-consults; enlarging the pool of available healthcare professionals; and supporting the education of non-traditional care team members. While these are promising initiatives, implementation will take time, and patients who reside in a rural area require additional support today. The promotion and facilitation of that support is frequently facilitated by members of the case management community.
I live in a rural area. That rurality is not based solely on governmental definitions but on actual access to healthcare facilities and services. I choose to live here because of the beauty and serenity of the area. I also realize that the healthcare services I might require are not consistently available and, therefore, I have become an informed healthcare consumer. Unfortunately, other residents of my community may not be as prepared to understand the importance of becoming an engaged and empowered patient when episodes of care are required.
To advance patient engagement, case management professionals might wish to consider performing an even more comprehensive assessment of not only the patient’s continuing care needs but also the health-related social needs that are specific to the patient and the environment in which the patient resides. When developing a transitional care plan, the patient’s address or zip code cannot be the sole indicator of which post-acute services might be available to meet the patient’s transitional care needs. In my community, the zip code includes an area of over 163 square miles, and the town listed on my address is over 20 miles away. A neighbor recently told me that at discharge she was told hospice services would be provided for her husband. The team facilitating that discharge determined the hospice provider without input from the patient and family. It was later learned the hospice, which shared the same zip code as the patient’s residence, was 40 miles away with no local staff to meet the patient’s needs. It should be noted that in hindsight another hospice provider located in an adjacent zip code and another town was only 14 miles from the patient’s residence with staff available in the area. Although the initial hospice provider indicated they would be able to provide appropriate services, the patient’s end-of-life needs were never met. As a result, the patient was readmitted to acute care. Although the patient indicated he wished to die at home in his own bed, that final wish was not granted, and he died in the hospital shortly thereafter.
If a continuing care plan fails to meet the needs of the patient, who is accountable for the inability to achieve the desired outcome? The Standards of Practice for Case Management as presented by the Case Management Society of America indicate that client assessment is a key element of the case management process (reference 5). A component of that assessment includes a review of the social determinants of health with a consideration of the location of the patient’s residence and how the benefits or challenges of that geographic location might impact the desired outcomes of care.
To facilitate the assessment process, I believe a patient-generated questionnaire is necessary to obtain the information required to develop a valid transitional care plan for any patient who resides in a rural area. Some of the questions that might be included in that questionnaire are:
- What is the nearest town or city to your home?
- Is your residence a home? Manufactured home? A recreational vehicle? Other?
- Do you use stairs to get into your home? If yes, how many?
- If a wheelchair is needed, are the doors in the home, including the bathroom door, wide enough to allow access?
- If you need any medical equipment to help you in the home such as a hospital bed, can the equipment fit into your home?
- Do you have consistent access to running water and electricity?
- Which person will assist you after you leave the hospital? Family? Friend? Paid caregiver?
- How far is the closest full-service grocery store? Less than 10 miles? Greater than 10 miles?
- How distant is the nearest pharmacy? Less than 10 miles? Greater than 10 miles?
- How distant is the nearest hospital? Less than 10 miles? Greater than 10 miles?
- Are you or a family member able to drive to obtain groceries or other necessary goods?
- Are there any restrictions on your ability to drive, such as an inability to drive at night?
- Other than driving, is transportation available for trips to healthcare services?
- Are deliveries from grocery stores or pharmacies available in your area? Do Uber, Lyft or Door Dash come to your area?
- Do you have access to cell phone service?
- Are you able to connect to the internet?
- Are you able to access patient portals or engage in virtual conversations with your physician?
- What is your greatest concern about managing your condition at home?
Realizing this is not a comprehensive list of questions to consider for patents who reside in rural environments, it is a start. If you have additional questions or topics that should be added to the list, please reach out to me at [email protected]. It is my absolute hope that one day patient-generated responses to these questions could be transferred into the electronic medical record. This would allow the entire transdisciplinary team to be aware of the patient’s rural setting and recognize any challenges that might arise associated with that setting.
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