Opportunities and Challenges Facing Rural Public Health Agencies - - PowerPoint PPT Presentation

Opportunities and Challenges Facing Rural Public Health Agencies

Kate Beatty & Michael Meit

Rural Health Disparities

Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2015 on CDC WONDER Online Database, released December, 2016. Accessed at http://wonder.cdc.gov/mcd-icd10.html

Trends in Age-adjusted Mortality Rate by Sex and Rurality, 1999-2015

*Aggregate includes both Metro and Nonmetro. Both rates are inclusive of individuals ages 25-64.

50 100 150 200 250 300 350 400 450 500 Aggregate U.S. Nonmetro

Rural Health Disparities: Adolescent Smoking

Cigarette smoking in the past month among adolescents 12-17 years of age by rurality

11.0 15.9 16.1 15.2 18.9 5.2 7.8 8.7 9.7 11.3 2 4 6 8 10 12 14 16 18 20 Large central Large fringe Small metro Micropolitan Non-core Percent 1999 2010-2011 Ivey-Stephenson, A. Z. (2017). Suicide Trends Among and Within Urbanization Levels by Sex, Race/Ethnicity, Age Group, and Mechanism of Death—United States, 2001–2015. MMWR. Surveillance Summaries, 66.

Rural Health Disparities: Adult Smoking

Cigarette smoking among persons 18 years of age and older by rurality

22.6 21.6 25.4 26.1 28.5 15.8 17.8 20.0 27.1 27.0 5 10 15 20 25 30 Large central Large fringe Small metro Micropolitan Non-core Percent 1997-1998 2010-2011 Meit, M., Knudson, A., Gilbert, T., et al. (2014). The 2014 Update of the Rural-Urban Chartbook. Retrieved from: https://www.ruralhealthinfo.org/resources/5696

Rural Health Disparities: Obesity

Obesity among persons 18 years of age and older by rurality

19.1 17.7 19.8 20.5 22.7 27.4 29.0 30.6 34.9 36.9 5 10 15 20 25 30 35 40 Large central Large fringe Small metro Micropolitan Non-core Percent 1997-1998 2010-2011 Meit, M., Knudson, A., Gilbert, T., et al. (2014). The 2014 Update of the Rural-Urban Chartbook. Retrieved from: https://www.ruralhealthinfo.org/resources/5696

Rural Health Disparities: Activity Limitation

Meit, M., Knudson, A., Gilbert, T., et al. (2014). The 2014 Update of the Rural-Urban Chartbook. Retrieved from: https://www.ruralhealthinfo.org/resources/5696

Limitation of activity caused by chronic health conditions among persons 18 years of age and older by rurality

14.0 13.0 15.8 17.6 18.2 12.9 11.9 14.7 17.1 18.8 2 4 6 8 10 12 14 16 18 20 Large central Large fringe Small metro Micropolitan Non-core Percent 1997-1998 2010-2011

NACCHO LHD Analysis by Geography

• Investigate differences between urban and rural

health agencies in terms of:

– Funding sources; – Clinical and population-based service provision; and – Impact of health reform on health department’s role.

• Identify opportunities and challenges facing rural

public health agencies

Methods – Quantitative Analyses

• Data

– 2016 NACCHO National Profile of Local Health Departments data

• Zip codes of LHDs were used to identify corresponding

Rural Urban Commuting Codes (RUCA), which served as the measure of rurality

– “Small rural” – Included census tracts with towns < 10,000 population and tracts tied to small towns – “Large rural” – Included census tracts with towns between 10,000 and 49,999 and census tracts tied to those towns through commuting – “Urban” – Included census tracts with towns > 50,000

NACCHO Profile Analysis – Small versus Rural

Urban n(%) Large Rural n(%) Small Rural n(%) Total <50,000 224 (20.2) 205 (18.5) 680 (61.3) 1109 50,000-99,999 126 (40.9 136 (44.2) 46 (14.9) 308 100,000+ 438 (85.4) 58 (11.3) 17 (3.3) 513

Data source: Rural-Urban Analysis of 2016 NACCHO Profile Data

Methods – Quantitative Analyses

1. Revenue sources

– Local, state, Federal (direct and pass through), Medicare and Medicaid, private insurance, patient personal fees, non-clinical fees and fines, private foundations, other revenue sources

2. Population-based services

– Epidemiology and surveillance, population-based primary prevention, regulations, inspections and licensing, other environmental and population-based services

3. Clinical services

– Immunizations, screenings, treatment for communicable diseases, maternal and child health, and other services – LHD’s response indicated whether or not the service was performed directly by the LHD, contracted out by the LHD, or provided by others in the community independent

• f LHD funding
• Variables Analyzed

Methods – Qualitative Analysis

• Several selection criteria were used to develop a list of potential health

departments for the case studies.

Case Study Type Geographic Service Area Expanding or Reducing Direct Services State Medicaid Expansion Status Number of LHDs meeting criteria Urban Health Department Urban Reducing Expanding 47 Large Rural Health Department Micropolitan (Large Rural) Expanding Expanding 11 Small Rural Health Department Rural (Small Rural) Reducing Expanding 41

• From the list of eligible health departments for each case study type, we

intentionally selected health departments we thought may be able to highlight the diverging roles of public health agencies in urban and rural communities

Methods – Qualitative Analysis

• We conducted interviews with representatives
• f the following health departments:

– Urban – Louisville Metro Department of Public Health and Wellness (Kentucky) – Large Rural – Clinton County Health Department (Ohio) – Small Rural – Lincoln County Health Department (Washington)

Findings – Revenue Sources

Proportion of revenue Urban Large Rural Small Rural Sig. Local Sources 42.8 25.6 22.2 0.001 State Sources 15.7 21.1 19.3 0.001 Federal Pass Through 16.1 20.1 22.6 0.001 Federal Direct 2.7 1.0 1.0 0.001 Medicare/Medicaid 6.0 13.3 15.2 0.001 Private Insurance 1.1 2.9 3.4 0.001 Patient Personal Fees 1.3 2.7 2.7 0.001 Non-clinical Fees & Fines 8.8 6.0 2.9 0.001 Private Foundations 0.5 0.8 0.8 NS Other 2.8 2.5 3.7 NS

• Proportion of revenue by rurality
• Urban HDs rely more heavily on local sources than large rural and small rural LHDs
• Both large rural and small rural LHDs rely more heavily on state and federal pass through revenue

than urban LHDs

• The proportion of funds that came from clinical funding sources, including Medicare/Medicaid,

private insurance, and personal patient fees were significantly higher for large and small rural HDs compared to urban LHDs.

Findings – Revenue Sources

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

Urban Large Rural Small Rural

Local Sources State Sources Federal Pass Through Federal Direct Medicare/Medicaid Private Insurance Patient Personal Fees Non-clinical Fees & Fines Private Foundations

Local Health Department Revenues by Degree of Rurality

Data source: Rural-Urban Analysis of 2016 NACCHO Profile Data

Findings – Service Provision

• Clinical Services

– In terms of services performed by the LHD directly, rural LHDs were more likely to provide immunizations, screenings, treatment of communicable diseases, and maternal and child health services than urban LHDs.

• Population-based Services

– In terms of services performed by the LHD directly, rural LHDs (both large and small) were more likely to report conducting communicable disease and infectious disease epidemiology and surveillance. – Urban LHDs were more likely to provide environmental surveillance.

Findings

• Urban Health Department – Louisville Metro

Department of Public Health and Wellness (Kentucky)

– Louisville is a large city with three major hospitals and a strong FQHC that sees the majority of the remaining uninsured population, so the HD no longer needs to serve in the role of safety net provider – HD has transitioned away from providing direct clinical services to focus more on policy and systems change – HD has a strong local tax base which allows them to support these activities

Findings

• Large Rural Health Department – Clinton County

Health District (Ohio)

– HD serves a population of 42,000 people with 11 full-time and 12 part-time staff – In collaboration with a consortium of LHDs in Ohio, Clinton County Health District has established a billing system for their immunization program

• Since health reform, more individuals have become insured in

Clinton County, but there continue to be access issues

– Generating revenue from their expanded immunization program has helped sustain and expand other programs

Findings

• Small Rural Health Department – Lincoln County Health

Department (Washington)

– HD serves a population of approximately 10,000 with 5 full-time employees – As a small agency with limited capacities, the Lincoln County Health Department has always provided fewer direct clinical services compared to larger rural agencies – HD has stopped providing immunizations, STD and HIV testing, instead leveraging their strong relationship with the public hospital district and other providers to ensure access to services – HD has transitioned to role of “convener” – however, noted that this was only possible due to their collaborative relationship with the hospital district, which all small rural LHDs may not have

Policy Implications

• Urban communities are served by LHDs with more local revenue

and more community capacity to provide the clinical services vital to those who need care. They can focus more on population-based services.

• Many rural LHDs must retain direct care services due to community

need.

• Large and small rural LHDs are more vulnerable to changes in state

and federal funding.

• Organizations that work to support LHDs need to consider how they

can support both rural and urban health departments in pursuing their missions to improve health in their jurisdictions.

DRIVERS OF CHANGE IN PUBLIC HEALTH

Drivers of Change in PH

State and Local Public Health

State and Federal Budget Cuts Reliance on Categorical Funding Changing Environment a la Health Reform

State and Federal Budget Cuts

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

Urban Large Rural Small Rural

Local Sources State Sources Federal Pass Through Federal Direct Medicare/Medicaid Private Insurance Patient Personal Fees Non-clinical Fees & Fines Private Foundations

Local Health Department Revenues by Degree of Rurality

Data source: Rural-Urban Analysis of 2016 NACCHO Profile Data

Drivers of Change in PH

State and Local Public Health

State and Federal Budget Cuts Reliance on Categorical Funding Changing Environment a la Health Reform

Reliance on Categorical Funding

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

Urban Large Rural Small Rural

Local Sources State Sources Federal Pass Through Federal Direct Medicare/Medicaid Private Insurance Patient Personal Fees Non-clinical Fees & Fines Private Foundations

Local Health Department Revenues by Degree of Rurality

Data source: Rural-Urban Analysis of 2016 NACCHO Profile Data

Drivers of Change in PH

State and Local Public Health

State and Federal Budget Cuts Reliance on Categorical Funding Changing Environment a la Health Reform

• HDs may shift clinical

services provision to partners or other health care entities

– This may allow HDs to increase focus on core public health activities and services (e.g., policy development/support, assessment and surveillance, etc.)

LHDs are at the Crossroads

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

Urban Large Rural Small Rural

Local Sources State Sources Federal Pass Through Federal Direct Medicare/Medicaid Private Insurance Patient Personal Fees Non-clinical Fees & Fines Private Foundations Other

Local Health Department Revenues by Degree of Rurality

Data source: Rural-Urban Analysis of 2016 NACCHO Profile Data

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

Urban Large Rural Small Rural

Local Sources State Sources Federal Pass Through Federal Direct Medicare/Medicaid Private Insurance Patient Personal Fees Non-clinical Fees & Fines Private Foundations Other

• HDs may expand their

provision of clinical preventive services

– Especially true in areas where there are health provider shortages – Also dependent on local ability to bill for services

LHDs are at the Crossroads

Local Health Department Revenues by Degree of Rurality

Data source: Rural-Urban Analysis of 2016 NACCHO Profile Data

RESOURCES

31

Appalachian Overdose Mapping Tool

• In partnership with ARC, NORC developed the

Appalachian Overdose Mapping Tool –

• verdosemappingtool.norc.org

32

Opioid Misuse Community Assessment Tool

• With funding from USDA, NORC expanded the

Appalachian tool to create a national tool – Opioid Misuse Community Assessment Tool

33

Opioid Misuse Community Assessment Tool

34

How to Use

35

State View – Select Timeframe

Select timeframe

Select State

• r County

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Select Overdose Type

Select Overdose Type

37

Select Overlay

38

Zoom in to Tennessee

39

Zoom in to Tennessee

40

Zoom in to Tennessee

41

Comparing Timeframes

Drug Overdose Mortality – 2007-2011 Drug Overdose Mortality – 2012-2016

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Highlighting Counties

43

View County Details

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County Fact Sheet – Sevier County, TN

Rural Evidence-Based Toolkits

• 1. Identify

evidence-based and promising community health programs in rural communities

• 3. Disseminate

lessons learned through Evidence- Based Toolkits

• 2. Study experiences of

these programs including facilitators of their success

Rural Health Information Hub: https://www.ruralhealthinfo.org/

Rural Prevention and Treatment of Substance Abuse

Questions?

• Thank you!