Bringing Coordinated Care to Rural Communities

Bringing Coordinated Care to Rural Communities - Healthify

In the foothills of the Appalachian Mountains, in the southeast corner of Kentucky sits a once-booming coal center. Today, Letcher County, home to 25,000 residents, is distressed; the community faces high poverty rates and poor health.

The story of Letcher County is all too familiar across rural America. About one in five Americans, 60 million in total, live in places like Letcher County.

Rural America has been hit hard in recent years. For half a century, coal mining and other industrial sectors drove the rural economy, and as a result, these regions contributed greatly to our country’s overall economic health, but now, as the coal industry has receded, so too has the wealth, and health, of these communities. Letcher County lags behind the state in nearly every key health measure: premature death, mental health, asthma, diabetes, hypertension, heart disease, stroke, cancer, and the list goes on.

Rural communities face significant health disparities that often can be traced to social and environmental issues. Not surprisingly, location is a major barrier to healthcare access for rural residents. Geographic isolation can make getting to a healthcare provider a challenge; in some cases, traveling 25 miles or more is common. What’s worse, hospitals in rural areas, struggling to stay profitable, are becoming fewer and farther between, being forced to close their doors on communities that need them the most.

Beyond environmental factors, economic conditions play a major role in the health of rural residents. Letcher County currently faces an unemployment rate of 10.8%—more than double the national rate. As a result, the county’s poverty rates are also significantly higher than the rest of America.

“If a mom doesn’t have shoes for her kids, she’s likely not getting a regular Pap smear,” says Fran Feltner, director of Kentucky Homeplace, a program run by the Center of Excellence in Rural Health at the University of Kentucky. This program found that Eastern Kentucky, not unlike many other rural communities, faces high rates of chronic and other health conditions, including diabetes, heart disease, and cancer.

Feltner and her team started Kentucky Homeplace to bridge the gap between rural communities and the healthcare system. The program pairs participating patients with community health workers that live and work in their communities. But these health workers are not just home nurses, they are true population health advocates. The healthcare professionals address social determinants of health by helping with everything from medical appointment scheduling and transportation to getting nutritious and healthy food.

Rural Healthcare - Healthify

This model is springing up around the country with state support of positions, such as patient navigators, patient advocates, and community health workers. These advocates teach patients how to use both medical and social resources efficiently and effectively, empowering them to be active participants in their health. With a reach that goes beyond the medical practice, community health workers are able to fill in the gaps between doctor visits with the cultural and social sensitivity needed to connect with each patient.

This growth and expansion of community health positions necessitate tools to help advocates, the health organizations that employ them, keep track of patients and referral resources.

Here at Healthify, we are proud to aid providers and community health workers in continuing care outside of the office with our leading database of community resources, assessing and analyzing social determinants, and care coordination. 

Improving the health of our rural communities requires us to address social needs, as well as medical conditions. Through community-based advocates and truly coordinated care, we can improve the health of those isolated in rural communities.

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Topics: community-based organizations coordinated care

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