By Atresha Singh, DMSG Student Intern
University of Denver
A Brief Summary of the Project
As an aspiring healthcare professional, it is important to consider the needs and concerns of areas that are under-served, such as rural or frontier areas. Rural and frontier areas are quite vast in Colorado and being able to learn about what healthcare resources and services are provided for them only helps to improve the needs of the communities. The difference between rural and frontier areas is that frontier areas face much greater challenges than rural areas. For example, designated frontier areas may not have a hospital and have extremely limited or unavailable public transportation. Some common problems that are noticed in rural and frontier areas in Colorado are transport, behavioral health (mental health), healthcare professional shortage, lack of access to care, and lack of funding. Increasing access to healthcare resources means creating additional healthcare facilities, community centers, health information programs, and increasing the amount of healthcare professionals that are working in those areas. The purpose of this project is to identify the healthcare problems that rural and frontier areas have and find possible solutions to implement/address these problems.
Now, it is important to note which counties in Colorado are considered rural and which are considered frontier.
| Rural Counties in Colorado | Frontier Counties in Colorado |
| Alamosa (Alamosa) Chaffee (Salida) Clear Creek (Georgetown) Delta (Delta) Eagle (Eagle) Fremont (Canon City) Garfield (Glenwood Springs) Gilpin (Central City) Gunnison (Gunnison) La Plata (Durango) Lake (Leadville) Larimer (Fort Collins) Mesa (Grand Junction) Moffat (Craig) Montezuma (Cortez) Montrose (Montrose) Morgan (Fort Morgan) Pitkin (Aspen) Pueblo (Pueblo) Routt (Steamboat Springs) San Miguel (Telluride) Summit (Breckenridge) Teller (Cripple Creek) Weld (Greeley) | Archuleta (Pagosa Springs) Baca (Springfield) Bent (Las Animas) Cheyenne (Cheyenne Wells) Conejos (Conejos) Costilla (San Luis) Crowley (Ordway) Custer (Westcliffe) Dolores (Dove Creek) Elbert (Kiowa) Grand (Hot Sulphur Springs) Hinsdale (Lake City) Huerfano (Walsenburg) Jackson (Walden) Kiowa (Eads) Kit Carson (Burlington) Las Animas (Trinidad) Lincoln (Hugo) Logan (Sterling) Mineral (Creede) Otero (La Junta) Ouray (Ouray) Park (Fairplay) Phillips (Holyoke) Prowers (Lamar) Rio Blanco (Meeker) Rio Grande (Del Norte) Saguache (Saguache) San Juan (Silverton) Sedgwick (Julesburg) Washington (Akron) Yuma (Wray) |
Additionally, knowing some current statistics about rural healthcare in Colorado is important.
- Rural Healthcare Data in Colorado
- According to the Rural Health Information Hub, as of January 2021, Colorado had:
- 32 Critical Access Hospitals
- 61 Rural Health Clinics
- 76 Federally Qualified Health Center sites located outside of Urbanized Areas
- 12 short term hospitals located outside of Urbanized Areas
- There is an estimated population of 715,485 living in rural Colorado (RHIH)
- According to the Rural Health Information Hub, as of January 2021, Colorado had:
- Healthcare Problems Both Rural and Frontier Areas are Facing
- Public Transportation
- Food Security
- Behavioral Health/Mental Health
- Healthcare Professional Shortage
- Access to Care/Resources
- Funding
- Rural Healthcare Providers in Colorado
- A major rural healthcare entity in Colorado is the Colorado Rural Health Center that has an aim to “provide programs to rural hospitals and clinics that improve quality of care, increase funding and reimbursement, workforce shortages, and assist with emergency preparedness (Colorado Rural Health Center)”.
- Services provided by this center include programs for: EMS, clinics, long term care, local public health, professionals, administration, evaluation, funding, technology, policy and advocacy, quality, and workforce.
- A special emphasis on policy and advocacy, funding, and workforce needs to be placed in these categories.
- NOTE: One of the most important state resources for rural healthcare in Colorado is the Colorado Rural Health Center
- Federal rural health resources that are important to know about are: National Rural Health Association, Office of Rural Health Policy (federal), and Health Resources and Services Administration
- A major rural healthcare entity in Colorado is the Colorado Rural Health Center that has an aim to “provide programs to rural hospitals and clinics that improve quality of care, increase funding and reimbursement, workforce shortages, and assist with emergency preparedness (Colorado Rural Health Center)”.
- Rural Healthcare in Colorado Workforce
- It is important to address the workforce currently in rural healthcare as well as the healthcare professional shortage that leads to lack of access in rural healthcare communities.
- HPSA, known as a health professional shortage area and MUA, a medically underserved area, have been identified to address healthcare access issues. A Colorado government, there are 36/47 rural and frontier counties that are labeled as HPSAs.
- HPSA requirements include high prevalence of poverty and less than 1 provider per 3, 500 residents
- This link is a fantastic overview of rural area provider overviews and rural challenges: https://www.colorado.gov/pacific/sites/default/files/11%20-%20Colorado%20Rural%20Health%20Center%20%20-%202016%20Snapshot.pdf
- An interesting fact that caught my attention was the cycle of recruiting a physician for rural areas and how time consuming this process is as well as low retention rates of the physicians.
- It is important to address the workforce currently in rural healthcare as well as the healthcare professional shortage that leads to lack of access in rural healthcare communities.
- Problems in Creating a Strong Healthcare System in Rural Areas
- Public Transportation
- There is a severe lack of transportation in rural areas compared to urban areas. It takes a long time for patients to reach major city hospitals for proper care. An even more pressing problem is how long it could take an emergency responder to arrive at a rural emergency (statistically shown as much longer time of arrival than urban emergencies).
- Food Security
- Behavioral Health
- Lack of psychologists, counselors, therapists, or social workers in rural counties
- Healthcare Professional Shortage
- Drastic unbalance of provider per population
- Funding
- To keep rural health care facilities running, grants need to be severely increased as well as a push on Medicare and Medicaid funding and reimbursements needs to be advocated for. There are a few known policies and acts that have been created to increase rural health funding and rural healthcare services, but not nearly enough with the constant population growth in these areas.
- Access to Care
- The most important barrier/problem to overcome. With uninsured residents, lack of hospitals, and lack of sustainable trauma centers, rural areas really need to become a prime priority in healthcare.
- Telehealth
- Public Transportation
- Rural vs Frontier Designations and what it means for Healthcare
- According to RHIhub, “frontier areas are the most remote and sparsely populated places along the rural-urban continuum” (there is not a single universally accepted definition of frontier)
- This means residents of these areas live far from healthcare, schools, grocery stores, and other necessities.
- Frontier counties/areas are defined at a community level but are mostly designated that label by the county
- In order for an area to be considered as frontier, it has to have these factors considered: (all points gathered from RHIhub)
- Population density
- Distance from a population center or specific service
- Travel time to reach a population center or service
- Functional association with other places
- Availability of paved roads
- Frontier areas face much greater challenges regarding healthcare than by rural communities
- Challenges Include:
- Maintaining their healthcare workforce
- Not being able to compete with wages and amenities offered to healthcare professionals by hospitals and clinics in metropolitan areas
- Many frontier counties do not have a hospital
- Some frontier areas cope with seasonal variations in healthcare demand (when there is a surge of tourists or seasonal workers)
- This leaves health resources very limited, including limited volunteer health services
- Limited or unavailable public transportations options for low-income households, the elderly, and people with disabilities.
- Frontier and Rural communities are at higher risk for substance abuse, suicide, cigarette smoking, and death from unintentional injuries such as farming equipment accidents
- Funding or Reimbursement Advantages to Being Considered a Frontier Area
- Frontier areas can access grants and enhanced reimbursements through the Health Professional Shortage Area (HPSA) and Medically Underserved Area (MUA) designations.
- There are provisions of the Affordable Care Act that highlights frontier communities and states that it provides protections to hospitals and physicians in eligible frontier states by establishing a floor on the Medicare wage adjustment factor and practice expense index
- Challenges Include:
- According to RHIhub, “frontier areas are the most remote and sparsely populated places along the rural-urban continuum” (there is not a single universally accepted definition of frontier)
- Who Plays a Role in Healthcare for Rural and Frontier Communities?
- Who should care about rural and frontier communities?
- The residents living in these areas care a lot for the healthcare of the community they grew up in as well as for themselves and their families
- Healthcare professionals of all disciplines should care.
- The government should care because these are areas that still have less resources and access to healthcare.
- Community health workers are placed with a large burden of helping these communities and advocating for culturally competent health services and funds
- Community paramedics care a lot and play a critical role in providing primary healthcare and preventive services
- Telehealth workers should care about these communities because their resources can enhance the quality and accessibility of care
- Who should care about rural and frontier communities?
Take-Aways
Some important take-aways from my on-going research on rural and frontier areas in Colorado are:
- Frontier areas face much greater challenges regarding healthcare than by rural areas/communities
- Everyone should care about rural and frontier communities. Healthcare is a human right, and everyone should have equal access to it. When asking the question “Who cares?”, the responsibility should be shared across the spectrum (i.e., government, hospitals, physicians, community workers, etc.)
- Telehealth/telemedicine services are a healthcare resource/service to solve problems of these communities but need to have continued reimbursements to providers after the pandemic. Telehealth needs to resolve significant regulatory issues in states and at a federal level before been a full front helper to these communities
Perspectives from Healthcare Professionals about Rural and Frontier Healthcare in Colorado
I took some time speaking to healthcare professionals and asking them about their perspectives and experience about rural and frontier healthcare and wanted to share some key take-aways from each conversation. For privacy reasons, names and workplaces of these individuals have been omitted.
Administrative Director of Hospital Medicine
“Coming from an administrative standpoint, issues around access/distance are great. The largest issue being discharge disposition barriers. While telehealth has helped triaging and dropped ER visits during COVID, it is not a primary care physician’s office, and some services cannot be safely delivered via telehealth. Additionally, being understaffed and being on divert is never a good feeling for any hospital and really shows the strain the hospital is feeling. “
MD and CEO of a Health System
“Creating a strong community of care and having several volunteers conduct outreach in rural areas has changed the face of rural healthcare in Wisconsin. Doctor “X” strongly believes in the use of telehealth/telemedicine. She has been able to fund a system in which iPad are delivered to those in rural communities so they can have access to telehealth. “
Neonatal Nurse Practitioner
“When working at designated community hospitals, the general process occurred a lot slower compared to bigger hospitals in which there were more staff to complete the process and who had more experience. Community hospitals tend to have lower levels of care and lack resources. For example, Castle Rock hospital did not have a 24-hour pharmacy.”
Director of Medical Staff Services
“In rural healthcare, resources can be combined. This can lead to stress and burnout of rural healthcare workers. Additionally, the two largest challenges to overcome to provide adequate healthcare resources in these communities are mental health resources and overcoming economies of scale. Mental health resources are scarce to come by in rural communities. Additionally, if rural healthcare facilities stand alone and are not attached to an urban system, then factors such as electronic medical records, funding, and additional resources are extremely difficult to come by.”
Questions to Consider: The Author’s Perspective
- How would you define healthcare management?
- In layman’s terms, healthcare management can be defined as managing and directing healthcare organizations/units to ensure the most apt and helpful healthcare services to every patient in need of healthcare services.
- From my master’s program at University of Denver, I have learned that the balance in healthcare between patient care and being a business is skewed, with more of an emphasis on the business side. A strong emphasis on federal, state, and local policies and financial monetary profits is placed. To keep the healthcare industry going, much more is happening behind the scenes that many can imagine. The healthcare industry is a business that needs to have profits to keep running and providing resources to others. In my opinion, the scales need to be balanced, with more of an effort towards ensuring quality patient care.
- What does “increasing access to healthcare resources in underserved communities” mean?
- Underserved communities are known as places that lack adequate healthcare according to the number of people in that community. Increasing access to healthcare resources means creating additional healthcare facilities, community centers, health information programs, and increasing the amount of healthcare professionals that are working in those areas. Underserved is the key term in this statement; there should be an adequate amount of healthcare resources, facilities, funding and professionals in rural areas.
- Who will be investing in healthcare technology and increasing the scope of telemedicine?
- Medicare and Medicaid need to be some of the primary investors in healthcare technology. Private and public investors, healthcare tech firms, pharmaceutical companies, and many more should all invest in healthcare technology. Big names such as Johnson and Johnson should be running to invest more in healthcare technology. The tragedy here is that everyone is out to make a profit and does not comply to create healthcare technology that is available and for the best interest of the public. Surgical robots are being created but are pushing the cost of surgeries to unattainable costs.
- How will healthcare be financially sustainable by making it more accessible to those in rural areas who need it?
- This is really the million-dollar question. I must admit that my understanding of healthcare finance is limited, only because it feels like this industry is out to look at only growth and value and not the overall health and accessibility of patients. I can give you my best response of placing more importance on early prevention and better public health efforts to offset future health costs. Creating community centers to educate the public about chronic diseases and how to take care of one’s health, what food to eat and buy, can help offset the tremendous costs of having to run in and out of hospitals. I think healthcare will be stretching itself by making it more accessible to those in rural areas who need it, but it is pertinent this happens for the greater good. I am a strong believer of the patient/consumer being an integral part of healthcare, and cost cutting in areas such as some provider specialties, hospital profits, and unnecessary testing for procedures should be pushed for. Everyone should have access to healthcare.
- How can healthcare reach in the rural areas be benefitted by financially supporting the growing telehealth sector?
- The growth of the telehealth sector can truly be beneficial to increasing healthcare access in rural areas. Once proper technology is available in the healthcare sector, then having virtual appointments and check ins can really help diagnose early onsets of conditions. Hosting virtual webinars about education and proper health can increase public health engagement and provide education to those in rural areas. Mental health and physical health can be emphasized with a touch of a phone app, or a video call. The accessibility of healthcare support is the key attraction of telehealth. Being able to contact a healthcare professional whenever needed is a game changer. I also hope telehealth can team with emergency services and provide faster response times or faster transportation times of EMS services.
- Costs can be significantly reduced with virtual healthcare services, and accessibility will be increased. Initial costs of implementing technology and transportation will be a burden, but for the future of available healthcare sources.
About the Author
Atresha Singh (Trish) is a student intern at the Denver Medical Study Group (DMSG). She is a master’s in science candidate for the Healthcare Management program at University of Denver. She is pursuing a master’s in Healthcare Management with a concentration in Healthcare Policy and Regulatory leadership with a specialized certification in Global Health Management.
480-376-4294
Leave a Reply