Looking at the Rural Homelessness Experience: Definitions, Data, and Solutions

From the Rural Health Information Hub

by Kay Miller Temple, MD

“Since it is clearly linked to certain medical conditions — and intuitively linked to overall health and well-being — housing is included in several federal health agencies’ social determinants of health (SDOH) frameworks. The Office of Disease Prevention and Health Promotion points to another housing experience linked to health and well-being: homelessness, described by some experts as “housing deprivation in its most severe form.”

Medical Conditions and the Homelessness Experience

“The Centers for Disease Control and Prevention Office for State, Tribal, and Territorial Support (CSTLTS) points out that homelessness creates health problems that “result from various factors, such as barriers to care, lack of access to adequate food and protection, and limited resources and social services.” Experts in the field of homelessness and public health said this is not only costly in terms of annual healthcare dollars — higher for those experiencing homelessness in contrast for those in more secure housing situations — but costly in terms of the negative impact on human dignity and well-being.”

Read more at: https://www.ruralhealthinfo.org/rural-monitor/rural-homelessness/

Nursing shortage affects rural Missourians more


Rural Missouri counties also have highest percentage of nurses over age 54, nearing retirement

Research News

COLUMBIA, Mo. — While the United States faces a nationwide nursing shortage, a recent study at the University of Missouri found rural Missouri counties experience nursing shortages at a greater rate than the state’s metropolitan counties. In addition, the study found rural Missouri counties have a higher percentage of older nurses nearing retirement, which could have a severe impact on the future of the state’s nursing workforce.

Anne Heyen, an assistant teaching professor in the MU Sinclair School of Nursing, analyzed workforce data of nearly 136,000 licensed Missouri nurses to identify the age and geographical disparities across the state.

“Out of the 114 total counties in Missouri, 97 are designated as health care professional shortage areas, and a majority of these counties are rural,” Heyen said. “By identifying the specific areas where there is the greatest need for more nurses, we can better tailor our response to help Missouri have a more balanced nursing workforce.”

The study found 31% of all Missouri nurses are older than the age of 54, and rural Missouri counties had higher percentages of nurses over the age of 54 compared to their urban counterparts, including three rural counties–Dekalb, Reynolds and Worth–where where more than half of the nurses are over age 54.

“In some of these rural areas where nearly half of the nursing workforce is nearing retirement, now is the time to be proactive and start thinking about who is going to replace them 10 years down the road,” Heyen said. “Research has shown nurses tend to stay and work where they are educated, which can influence young nurses to stay in urban areas where there tend to be more educational resources.”

Heyen added higher pay and more job opportunities in cities also lead young nursing students to pursue work in the urban areas they are often educated in, which contributes to the geographical disparities for the nursing shortage.

“This research identifies the specific areas in Missouri facing nursing shortages so that potential solutions can be targeted to the areas with the greatest needs,” Heyen said.

Institutions of higher education can play a key role in addressing the disparities, according to Heyen.

“Whether it’s potentially partnering with community colleges in rural areas or establishing satellite campuses with dual credit options or more outreach programs, universities and their nursing schools can use this information to brainstorm solutions to assist underserved communities and provide more educational and employment opportunities to nursing students in the areas that need it most,” Heyen said. “The overall goal of this research is to make sure everyone in Missouri ultimately has access to the health care they need, regardless of where they live, and identifying where the nursing shortages occur is a key first step.”

As an assistant teaching professor, Heyen is passionate about educating the next generation of nurses, who will be in high demand as the need for nurses rises.

“It feels rewarding to see the nursing students I have taught go out into the world and make a positive difference at a time when they are so desperately needed,” Heyen said. “Mizzou and the University of Missouri System are well poised to help address these challenges going forward, given their influence and impact throughout the state.”

To help meet the nursing shortage, the Sinclair School of Nursing’s new 64,585-square-foot facility, expected to be completed on MU’s campus by spring 2022, will allow the school to increase class sizes and graduate more nurses. In addition, the school is placing an emphasis on recruiting more students from the 25-county service area MU Health Care oversees, as students who come from a rural area are more likely to return there for work after they graduate.

“Show me the nursing shortage: Location matters in Missouri nursing shortage” was recently published in the Journal of Nursing Regulation. Co-authors on the study include Lori Scheidt and Tracy Greever-Rice.

Awards for Rural Health Care Services Outreach

Congratulations to Central Ozarks Medical Center and Katy Trail Community Health, two clients of Community Asset Builders, who received Federal Office of Rural Health Policy (FORHP), Rural Health Outreach Awards. CAB provided assistance to both organizations with the development of their submissions. The notice was published by the FORHP May 31, 2018.

Awards for Rural Health Care Services Outreach.  FORHP’s parent agency, the Health Resources and Services Administration (HRSA) recently awarded $11,961,114 to 60 rural communities for the 2018 Rural Health Care Services Outreach Program (Outreach Program).  This three-year, community-driven program requires collaboration between three or more local providers of health and/or social services to bridge together key elements of rural health care delivery.  The incoming cohort of Outreach Program awardees have proposed projects that will strengthen the health infrastructure using evidence-based strategies that have proven effective in other rural communities.  These projects will coordinate care and outreach to address health issues specific to the local population and must demonstrate improved outcomes and sustainability.  New to this program that started in 1991, is the Health Improvement Special Project (HISP), a collaboration between HRSA, the National Center for Health Statistics and the Centers for Disease Control and Prevention that will use data to assess and track cardiovascular disease risk for a subset of individuals. Twelve of the new awardees will participate in this track.  To learn more about the objectives and approach of the Rural Health Care Services Outreach program, read about the projects that were funded in the 2015-2018 cohort.

HRSA Announcement – Rural Communities Opioid Response planning grants

The Health Resources and Services Administration (HRSA) recently announced plans to award planning grants to rural communities as part of their new Rural Communities Opioid Response initiative through the Federal Office of Rural Health Policy (FORHP). This funding will specifically cover costs associated with the development of a plan to implement opioid use disorder prevention, treatment and recovery interventions designed to reduce opioid overdoses among rural populations. There are targeted counties (CDC-at-risk-communities), however any eligible organization is encouraged to apply. The lead applicant in any community or region must be part of a group including at least three (3) other partners committed to participating in the effort.

While the funding opportunity has yet to be announced, states have been encouraged to begin organizing efforts to support local applications in a coordinated fashion.  Based on this recommendation from FORHP, The State Office of Rural Health has initiated a partnership with state level organizations with staff, technical expertise and other resources to support local efforts. These partners currently include the Missouri Hospital Association, Missouri Department of Mental Health, Missouri Primary Care Association, and the Missouri Rural Health Association.

To facilitate strong planning efforts, and to reduce duplication of effort, these statewide partners will support applications from any partnerships interested in collaborating to address the opioid issue in their areas.

These partners will support applications through the provision of:

  • Data
  • Content to strengthen and align efforts
  • Grant-writing support
  • Gap analysis
  • Connecting partners not already engaged at the local level
  • Commitment to provide on-going technical assistance during the funding period and into implementation

We will be offering a conference call for all interested applicants on May 15th from 10:00 am – 11:00 am.  The dial in information is:  Access Number: 877-820-7831;  PIN Number: 35666479#.   During this call, additional information will be provided specific to the grant process, accessing support from state partners, and timelines based on the most current information provided to the State Office of Rural Health from FORHP.

Please notify Melissa VanDyne, Director of the State Office of Rural Health, via email if you are interested in applying. Her email is: Melissa.vandyne@health.mo.gov.  In this email, please include a list of the partners you anticipate will be part of your application, as well as a brief overview of the community, county or region the project will cover.  This information will assist the state partners in planning for application support.

Health Outreach Partners Releases New Report on Transportation and Health Access

The new report, Transportation and Health Access: Rides to Wellness Community Scan Project, conducted by Health Outreach Partners, describes the scope of the problem of transportation barriers to health care and its financial impact due to missed appointments. Based on a national survey with community health centers, findings show no-show rates ranging from 11-30%, but that the reasons for missed appointments are not being tracked. By addressing transportation barriers, there is greater potential for financial benefits for health centers that are also likely transferable to other health care providers. The Missouri Rural Health Association and Community Asset Builders were contributors to the report, which includes six profiles of communities – one of which is Missouri’s HealthTran initiative – who are taking action to address barriers and decrease loss of revenue.

Rides to Wellness Community Scan Project

More Than $200 Million Awarded for Mental Health and Substance Abuse Service Expansion

Last week, HRSA announced the fiscal year 2017 Access Increases in Mental Health and Substance Abuse Services (AIMS) awards. AIMS funding provides more than $200 million to 1,178 health centers to increase personnel, leverage health information technology, and provide training to support the expansion of mental health services and substance abuse services focusing on the treatment, prevention, and awareness of opioid abuse, and their integration into primary care. AIMS awards will support health centers in all 50 states, the District of Columbia, American Samoa, the Federated States of Micronesia, the Northern Mariana Islands, Puerto Rico, and the Virgin Islands.

Award recipients are invited to view a brief video on the AIMS technical assistance website highlighting the awards and important information for award recipients.



HealthTran highlighted in Politico Magazine April 24, 2017

Why doctors should consider giving their patients a ride

Our Missouri pilot project showed that free trips to the doctor pay off for everyone

In 2014, Leo Haralson’s big toe turned black, a casualty of his battle with diabetes. A veteran and a former software developer for the U.S. Navy, he had insurance through both Medicare and the Veterans Affairs Department, so getting good health care shouldn’t have been a problem. But after the toe was amputated, he developed an infection that spread to his bones. Haralson needed daily oxygen treatments at a hospital to halt the infection.

Haralson and his wife, 65, motorcycle enthusiasts originally from Wisconsin, had retired to southern Missouri, seeking a warmer climate and a home in the middle of the country so they could drive off in any direction. They built their dream home on the outskirts of the town of Mountain View, named for its commanding view of the Ozarks. But his wife could no longer drive, and with his foot in bandages, Leo couldn’t either. The hospital was 30 miles down Highway 60 from his home, and the local transit provider has bus service only on Wednesdays. Without a way to get to the hospital every day for a month, Haralson faced losing his leg—and his ability to live independently.

Transportation comes up in virtually every conversation about rural health care, particularly in the past few years as hospital closures have increased the distances many patients need to travel. Missouri has closed three hospitals since 2010, victims of cutbacks in reimbursement from insurers and the government. Distances patients must travel are increasing.

As policymakers look at ways to improve the health of rural Americans, it’s becoming increasingly clear that transportation is a critical missing link between patients and providers.

The problem isn’t necessarily a lack of rides; many places, like Missouri, have a variety of transportation options for people who can’t drive. Medicaid provides some non-emergency transportation for eligible patients. Some local communities run van services, particularly for seniors. The Southern Missouri Transportation System and OATS, a nonprofit transit company, provide van services, as well. And there are medical transportation services including emergency ambulances.

But all of those systems have problems and gaps. For Medicaid, rides must be ordered five days in advance, and cannot include secondary stops, even just to visit a pharmacy to fill a prescription after the doctor visit, without prior approval. Van and bus services run once or twice a week on fixed schedules and routes that may not match a patient’s appointment times. And ambulances are expensive.

There’s a bigger problem, too: The current system puts the burden of navigating those options and schedules on patients, even as they are struggling with illness and symptoms like pain, confusion and fatigue. In Missouri, we have found that when getting a ride isn’t simple and affordable, patients will forgo care. And that means that their conditions can worsen until they become acute and result in an ambulance ride to the ER instead—the most expensive option of all.

Clearly, the existing system doesn’t work well for anybody. Patients are overwhelmed and often give up. Doctors and hospitals lose time and revenues because of “no-shows.” And ambulance companies are transporting patients who didn’t know whom else to call—and then don’t get paid if an insurance company or Medicaid decides it wasn’t an actual emergency.

As a health care consultant and the executive director of the Missouri Rural Health Association, I helped develop a program to test whether there was a better way. We got seed money to hire a “mobility coordinator” who could arrange rides for patients who needed them. Our program, called HealthTran, trained clinic and hospital staff to ask patients at the time they made appointments whether they needed a ride. And if they did, they alerted the HealthTran coordinator who would contact them, assess their transportation needs and figure out a cost-effective solution.

Leo Haralson was one of HealthTran’s first patients. In his case, the coordinator determined that because of his infection, he needed private rides from his home in Mountain View to Ozarks Medical Center in West Plains, 30 miles away. She arranged 70 rides for him at a cost of $6,000. That wasn’t cheap, but it paid off. The hospital benefited by being able to bill Medicare $13,000 for the oxygen treatments and avoiding penalties for a hospital readmission. Medicare saved the cost of a leg amputation and possible transfer to a nursing home.

As always in health care, a key questions is, “Who pays”? What HealthTran learned is that it’s actually cost-effective for clinics and hospitals to provide the service at no cost to the patients because providing rides reduced the number of no-shows.

Here was how it played out at one hospital system: In just 17 months, HealthTran provided 2,470 rides for patients receiving services, at a cost of just over $66,000. Including staffing, the total cost of coordinating and paying for transportation was approximately $95,000, an average of $33 per ride. These patients resulted in over $730,000 in payments to the hospital and its clinics. In short, for every $1 invested in transportation, the hospital earned $7.68 in reimbursement.

The return on investment in transportation is so strong that it can pay off even for individual doctors. A missed appointment means missed revenue, loss of provider productivity, patient rescheduling and most likely a sicker patient. If 20 percent of scheduled appointments are missed on a weekly basis, and the average charge for that primary care visit is $150, a provider who typically sees 20 patients per day will miss out on $3,000 each week (or 1 entire day’s worth of revenue), while staffing costs remain constant. At $225 per visit for specialty care, the provider misses out on $4,500. Over the course of a year, the health care provider is missing out on $156,000 to $234,000. Considering the average cost of a ride for these patients at $33, the annual cost of paying for transportation and mobility coordination would be about $45,000. This is a $3.46 to $5.20 return for every $1 invested in transportation.

And that doesn’t even consider the improved patient outcomes and those long-term savings to the health care system.

Perhaps the biggest payoff is that it helps senior citizens like Haralson and people with disabilities to live successfully in homes of their own rather than move to nursing homes or assisted-living facilities, placements that can erode their health and cost the government and other insurers much more money in the long run. If Haralson had required a leg amputation, that would not only have cost Medicare and Medicaid upward of $1 million, but left him disabled and likely forced to move to a nursing home. Instead, Haralson was able to continue to live at home and fend for himself. These days, he’s spending his retirement helping deliver meals to homebound seniors in his community.

So, why aren’t more hospitals offering no-cost transportation to their patients? One reason is that well-intentioned federal regulations have created unnecessary hurdles. In an effort to avoid a practice known as “self-dealing,” hospitals are not allowed to directly provide transportation to patients. While there were a few instances in the past of hospitals unfairly profiting by providing transportation between nursing homes and hospitals, the practice was not widespread. Still, the rules designed to eliminate that practice now make it difficult for providers to take on the transportation problem directly. That’s why the HeathTran model offers a solution: By using an outside coordinator to make the arrangements, HealthTran helps hospitals maintain an arms-length relationship from transportation services.

In theory, driverless cars could someday address some of the need for medical transportation. But I’m skeptical that will solve the problem for most patients because a key factor in health care is human interaction. Many patients who need transportation are seniors, or have a disability that can make it hard to get to and from their front door and the vehicle without assistance. At least in Missouri, and I would venture to say in many other areas of rural America, people need a human connection—a person in the community, familiar with the community—to connect the health, transportation and payer systems in a way that makes good, common sense. And besides, we can’t wait for a driverless future. Patients in rural America need a solution now.

Missouri’s HealthTran was designed to bridge the transportation gap between patients and providers in a way that works for all sides. Rural America needs more of these solutions. If we can’t make it easier for rural patients to get to and from their homes and their doctors, the whole country will pay for it down the road in greater medical costs and poorer health outcomes.

Suzanne Alewine is a health care consultant and executive director of the Missouri Rural Health Association.

Community Asset Builders celebrating 15 years

Community Asset Builders, LLC reached a significant milestone in July 2016, celebrating 15 years of business. The company has grown from the dreams of co-founders Doris Boeckman and Suzanne Alewine, to a company that has supported more than 150 organizations through project-specific and retainer contracts, and generated more than $235 million in grant revenue for customers. As part of our celebration, we are excited to share, “15 Years of Taking Clients Beyond Their Potential,” a document that captures our journey throughout the years and summarizes the wonderful relationships that have been established to improve the health and well-being of individuals in Missouri and throughout the United States.

“It gives me great pride in joining Suzanne and our employees, clients and business partners in celebrating our company’s 15th anniversary. We have come a long way since the business first started in 2001 and we are very excited about our future as we continue to seek innovative solutions and services to meet the needs of our customers,” said Boeckman.

Community Asset Builders readied itself for growth by focusing on its core tenets:

  • Serving as a voice on community development and asset building for the communities and organizations it serves with state and national organizations;
  • Increasing access to financial resources through grant writing and fund development;
  • Providing technical assistance and planning services so clients can more effectively utilize their resources;
  • Strengthening peer networks among clients to increase opportunities for collaboration and shared learning; and
  • Challenging public and private funding sources to invest more robustly in communities where clients are serving vulnerable populations.

Our ability to engineer solutions based on the specific needs of customers has helped the company to continually grow over the past 15 years, and offers promise for future growth.