Health program leaders in rural Tennessee discussed the challenges of expanding access to care in their communities and how they are addressing them at the 2023 Tennessee State of Reform Conference in November.
The Tennessee Department of Health says the inaccessibility of vital resources outside of urban areas contributes to rural communities’ struggle to maintain good health. From high rates of hospital closures to food insecurity, rural Tennesseans face major health disparities compared to their urban counterparts.
Jacy Warrell is the chief executive officer of the nonprofit Rural Health Association of Tennessee (RHA). She explained the way it focuses on advocating for rural Tennesseans’ healthcare, including increasing access to care, examining social determinants of health (SDOH), and strengthening the workforce, all in order to lessen rural health disparities.
“We really work to improve health through programs and partnerships, education, advocacy, and sharing resources,” Warrell said. “We really see ourselves as a liaison between state and federal agencies and a lot of people on the ground doing the work.”
Ruby Kirby, chief executive officer of West Tennessee Healthcare Critical Access Hospitals, discussed what her hospitals in Benton and Hardeman counties do for their communities, beyond hospital care.
One of her organization’s programs was aimed at promoting physical activity and access to healthy food. For this initiative, Bolivar General Hospital, one of the critical access hospitals in West Tennessee, partnered with various organizations like the University of Tennessee, the Hardeman County Health Council, the NAACP, and other organizations in order to provide healthy food and promote fun physical activities in the community.
“We work with the community to provide care because as a critical access hospital, we can’t do it all alone,” Kirby said.
She said the program included handing out healthy food to adults and children, implementing walking trails in each municipality, setting up storybook trails and hopscotch to encourage children to get active, and more. The program was so successful that they have received another grant from the Centers for Disease Control and Prevention to address childhood obesity.
Thomas Kidd, chief executive officer at Macon Community Hospital (MCH) at the time of the conference (he has since retired), discussed the importance of access to care in rural communities.
“Being a rural community, by definition, [is that] we’re older, sicker, poorer, and less educated; that’s just rural America,” Kidd said.
MCH has recently begun a variety of programs and services, including a cardiac rehabilitation program, cardiac surgeries, a sleep center, lymphedema and pelvic floor therapy, diabetes education, and a pulmonary rehabilitation program.
The panelists also discussed several challenges rural residents face in accessing care including transportation difficulties, a lack of behavioral health services, social determinants of health that are exacerbated by rurality, the workforce shortage, and insufficient funding.
“Trying to help people think about health as more than just hospitals is one of my challenges at the state level.”
— Warrell
Kirby identified transportation as a major issue for rural residents seeking care, as well as the uninsured and underinsured populations. During 2021, 16.3 percent of rural Tennesseeans aged 18 to 64 had no health insurance, whereas urban Tennesseeans saw a slightly lower uninsured rate of 14.1 percent.
Kirby emphasized that organizations serving rural areas must form partnerships in order to address the wide variety of issues rural residents face. One of those partnerships, she said, has to be with the insurance providers.
“Let [the insurance providers] be there to hear the issues we’re having and work through it… When I first started being on the health council it was only the providers and the community primarily that was there. It’s amazing when you do a community needs assessment and you realize what your issues are and you look around the table and [say], ‘We can’t fix this, just us.’”
— Kirby
Now, the council’s membership has a variety of people and groups, including insurance companies.
Kidd highlighted Kirby’s point about transportation being a major barrier, and also mentioned how rural Tennessee is a mental health desert. MCH has taken steps in order to try to address this problem.
“We’ve partnered up with Valley Ridge mental health and our local police department,” Kidd said. “… We work together with the police and the sheriff’s department on training officers in de-escalation.”
The opioid crisis has also hit rural communities hard. Kidd said there is not enough funding for the counties to properly handle it.
The workforce shortage challenge is different in rural communities compared to urban areas. Kirby pointed out that often, people working in rural hospitals and clinics come from those areas, so they have a vested interest in their community. However, more and more people are leaving rural healthcare spaces, and the healthcare field in general.
Kidd said it’s important to connect with the potential workforce early because medical students are often not encouraged to work in rural areas. He discussed a program within MCH called service learning, which aims to get young kids interested in rural healthcare.
“We use service learning at the local school system,” Kidd said. “Students can come and shadow the department as part of their education and get credit for work.”
Some of the current providers at MCH were in the service learning program, Kidd said. He also said his hospital works to retain its current employees through gainshare bonuses, education encouragement, and internal promotions.
Warrell mentioned RHA’s workforce development program, which aims to help rural facilities bolster their healthcare teams. An integral part of supporting rural hospitals, Kirby said, is providing them with more funding.
“Money is always an issue in a small, rural community, and in small hospitals,” Kirby said. “I think we see that especially in places like Tennessee and Texas where a lot of these hospitals are closing.”
Kidd said hospitals end up losing money when a Medicaid patient comes through the door, due to lower Medicaid reimbursement rates. While he emphasized that MCH still treats everyone, regardless of their ability to pay, he said this exacerbates the issue of uncompensated care. Without adequate compensation, more rural hospitals end up closing.
“We’ve got a tremendous payer bias against the rural [hospitals],” Kidd said. “They could care less if we sign a contract with them. They’ll just give us something and say, ‘Take it or leave it.’”
Warrell concluded the panel by asking Kirby and Kidd about their goals for improving rural healthcare.
Kirby said she wishes for a long-term solution to the workforce shortage, for people to realize that rural hospital closures put a strain on larger facilities, for more people to be covered by health insurance, and for everyone to recognize that community collaboration is vital when tackling these healthcare issues.
Kidd said he wants rural hospitals to get recognition for the work they’re doing, more services so rural residents can access different kinds of care, and to promote healthier lifestyles in the rural community.
“Rural gets a bad stigma sometimes, but it’s a great place to be.”
— Kidd