Today we talk with Jennifer Houlihan, Vice President of Value-based Care and Population Health for Atrium Health Wake Forest Baptist, about some of the pressing issues and health care concerns facing rural communities and how they are assessed. Jennifer, Welcome to the Move to Value Podcast.

Can you tell me about the correlation between rural communities, rural hospitals, and poor health

Rural Americans really face numerous health disparities compared with their urban counterparts. 15% of all Americans live in rural areas with higher risk of death. And so, thinking about rural communities, rural hospitals, rural healthcare, there are five leading causes are heart disease, cancer, uh respiratory diseases, stroke. And all of those are impacting how we think about health care delivery, what we need from our rural hospitals, and also what the community focuses on. So, rural hospitals are at risk for closure. There are quite a few that have closed over the last several years and yet there's a greater need as the population ages, the prevalence and incidence of disease grows, uh and we're at risk for access challenges in this community. And so, our rural providers really become that, especially in primary care, that critical piece to provide that medical home support, to manage these healthcare conditions. And then, hospitals often are an anchor in the rural community and, really important part, they're often the largest employer and have a long-standing history of pride in those communities. So, when you think about the ability to seek care close to home, to be able to have providers in your backyard, and be able to care for your population, not only with the chronic disease piece, but again significant disparities and some of the social drivers I know we'll talk about. So, really all of that is connected and real challenges being faced by our rural hospitals and communities.

I see. So, what are the socioeconomic factors that are in play here?

Yeah, so specifically I'll talk about North Carolina, but really this would be applicable much more broadly. But typically, in North Carolina, what we're seeing is about 16,000 year lower median household income. 26.7% more likely to have children living in poverty, which is a significant socioeconomic factor and often a leading indicator from any other social drivers. 21% fewer adults with post-secondary education and approximately 13 to 14% more uninsured residents under the age of 65. So, all of those, in addition to you know some of the higher percentages of chronic disease, that all presents significant challenges for rural communities and the providers and being able to care for them.

Can you tell us about some of the health issues that rural communities are facing?

Sure. Yeah. There's a couple. So, part of rural hospitals, and we have a several rural hospitals within the Atrium Health system, with our health department partners every three years we do a robust community health needs assessment. So, looking across all of our rural communities, we actually kind of ranked through all of them. Obesity is actually the most prominent issue, uh closely followed by substance misuse, mental health, chronic disease, educational attainment, and teen pregnancy. But when we looked across all of them, obesity and chronic disease is typically the number one. With, I would say substance abuse and mental health continuing to grow, and certainly post COVID, that's actually, that has actually grown and sort of needs and identified stats in the community as well.

Well Jennifer, are there new strategies in play for rural health that will hopefully improve outcomes?

There are quite a few strategies. And so, I think some of that is, again, what we're, every, really every year, we're looking at what strategies are working and what aren't. So, a couple different ways we're looking at that, so I'll just talk about from a health system perspective some of the strategies that we have focused on are really making sure we're improving access. And so, whether that's actually hiring more OBGYN or primary care into the community, as well as training more residents in the community to hopefully increase that pipeline. So residents, providers, will want to stay and start their practice there. But other ways we're thinking about access are virtual. So obviously COVID expanded our use of virtual but continuing to provide virtual primary care as well as e-consults. So, that's really a way to supplement primary care and close the specialty care gap. So, we have kind of created a very robust program within the enterprise that all of our primary care would have access to all the specialties across. So, that can certainly cut down on driving time and also timeliness to be able to get some of that specialty support.

The other piece is really thinking about more creative ways to partner with our ED, our hospitalists. Really partnering some of our transitions of care team, or our care management team, to be more aligned. So, when patients are either transitioning out, or even before they're in, knowing that there’s sort of this continue approach. Also, looking at things like remote patient monitoring. Allowing us to do more management in patients homes. And really, we've done that with COVID, but now expanding to congestive heart failure, etc. And then, again, kind of making sure that we're using data where we can to really understand maybe who some of our highest risk patients are that we need to proactively reach out to. Whether that's through some of our social work, community health worker initiatives, to be able to manage them.

From a CHNA standpoint, that again, that is another way we're thinking about. And that's usually done more in partnership. So, with our, that could be, of course, our local public health departments. We have supported the development and implementation of federally qualified health centers to expand access points. Certainly, funding for farmers market transportation initiatives. Partnering with our schools on, could be, healthy meals, physical activity programs. Brenner FIT is a great example. There's a Brenner FIT component, but really that focuses on healthy eating for patients and their families. And then, certainly our faith health NC has done a lot of work with local congregations, and we actually have one of our faith health leads, many in our rural hospitals. So, really supporting that linkage back to the faith health community and developing transportation supports or maybe where congregations are driving patients. But also making different investments in some of those more social drivers.

Outstanding. So, you touched on this a bit, and I’d like to hear more about the community health needs assessments that you are involved with?

Yeah. So, those are, you know. Post the Affordable Health Care Act, all nonprofit hospitals were required now to conduct a community health needs assessment every three years. And health departments also have usually an accreditation requirement associated with that. I think for our system, we were always doing assessments, working closely with our local health department and nonprofit and foundation partners, but this really is, now under post ACA, there is a little bit more, I guess, guidelines on what to include in that.

So, that includes everything from understanding our own data, so really taking a look at ED and hospitalization, but understanding certainly for our self-pay and underserved populations, looking at our own EMR data of chronic disease prevalence and seeing, you know, what are patients coming in for, are we seeing increases decreases in certain conditions. But then it's also really supplementing with secondary data, so Center for Disease Control data, CMS data, census data, American Community Survey data, which is looking a lot of what's happening with income and poverty and more of a holistic look. And then, we use a lot of the county health rankings data, which does a great job sort of summarizing that. But more importantly, it's also collecting primary care data, so actually holding focus groups, and doing surveys with our residents and community members to find out what they feel is working well, what are barriers to health, what are gaps still in the community. And then, usually the process, once you sort of integrate all of this rich primary and secondary data, really coming together with your community partners to sort of prioritize where do we need to focus. And that really is then developing. And all of these reports are available publicly online. You can go to our Atrium Health website. You can go to our specific hospital websites. And then, in addition to that, and they're approved by our board, so there's higher visibility there. They actually, these findings and assessments, actually get reviewed at the at the leadership level. And then, the result of that is to develop a plan of how we are going to tackle that, and it's called an implementation strategy. So, that's also publicly available. And there you would find what are we proposing to do to tackle obesity in this county or these are the investments that we've made, this is how we'll evaluate success. And so, all of that would be captured in that strategy.

I would say health systems have been doing this work for years, it's just provides a little bit more of a structure. And then our health department, and oftentimes our competitor hospitals, are partners in this work too because it's really about sort of coming together to address these social needs regardless of whether there's competition or not.

Well Jenifer, where do we go from here?

One of the things we're working to address to is educating the next generation overall care providers. So, I think maybe even the last question. I think just even how does value-based care and pop health get infused or integrated into medical school curriculums today. But certainly, knowing that some of the rural population challenges are going to be more heightened or more prevalent than maybe in some other non-rural practices. So, I think that the educational pipeline is critical. And so, we're just add that, that again, that's certainly not my area of expertise, but that is one way. Because access at the end of the day, we're trying to ensure adequate access. That's one of the other pieces that we want to continue to support and emphasize as well.