Widening health disparities between rural and urban areas 1 are exacerbated by social risk factors like food insecurity, unemployment, and underinsurance. The interplay of these factors is particularly significant for maternal and child health, mental health and substance use disorders, and preventable chronic diseases. Rural–urban health disparities are perhaps most clearly observed in the numerous unaddressed chronic diseases that are driven by social determinants of health. Rural communities have higher mortality rates for suicide, diabetes, heart disease, cancer, respiratory disease, and stroke. 2
Growing health and socioeconomic disparities between rural and urban areas are playing out at a time when urban health care systems are increasingly buying rural hospitals and practices to gain market share and manage costs. One driver of this consolidation is the shift from fee-for-service to alternative and value-based care payment models. Continuing health system consolidation, the increasing number of patients covered in value-based care payment models, and the growing need to address the social determinants of health driving costs will incentivize academic health centers (AHCs) to develop partnerships with rural communities. In collaboration with their community partners, AHCs will want to identify local population health needs and design interprofessional models of practice and training to meet those needs. Once implemented, AHCs and their community partners will need to evaluate the impact of these new team-based models of care on outcomes, and document and disseminate findings (Figure 1).
In this commentary, we first examine the landscape of rural health care and health professions training, considering current opportunities and challenges to interprofessional, team-based models. We then provide 3 examples of successful interprofessional practice and education models in rural communities and outline observations and lessons learned. With this information, AHCs and their community partners will be able to understand which models are successful in lowering costs, enhancing the care experience, improving population health, addressing burnout, and advancing health equity in the rural communities they serve. 3
Current Opportunities and Challenges to Interprofessional Health Care and Training in Rural Settings
Payment transformation and health system consolidation
Between 2005 and 2016, approximately 12% of rural hospitals merged, 4 and evidence suggests that those mergers may benefit rural areas. A recent study found that rural hospital mergers were associated with improved outcomes for acute myocardial infection, heart failure, and stroke. 5
The shift from fee-for-service to alternative payment models is also incentivizing urban hospitals to purchase rural hospitals and practices to increase market share. While rural practices have been less likely to take part in alternative payment models, between 2017 and 2019, rural providers’ participation in alternative payment models increased by 109% compared with a 93% increase in non-rural areas. As a result of consolidation and payment transformation, the success of urban health care systems is increasingly linked to rural communities.
Since medical care is estimated to account for only 10%–20% of the factors that contribute to health, managing the other 80%–90% of health behaviors and social risks that drive health outcomes is key to improving population health and lowering costs. 6 Alternative payment models that provide financial incentives for managing the social risk factors that drive utilization and increase costs are a key component of efforts to shift the health care system toward value-based care. 7 Unlike fee-for-service payment models that reimburse based on the volume of services provided, value-based care reimburses providers based on the quality of care, health outcomes, and cost. 8 As Dow and Thibault have noted, the move toward value-based, population-focused models for payment require problem-solving approaches that integrate the expertise of many different types of health care workers. 9 Thus, to manage costs, increase quality, and improve population health outcomes, AHCs will need to develop and deploy a diverse workforce comprising not only physicians, nurses, pharmacists, and other traditional health professionals but also community health workers, public health workers, social workers, doulas, medical lawyers, clergy, and other community-based workers. 10 This transition will require rethinking how health care workers are trained.
Traditionally, under a fee-for-service system, health care systems and AHCs have had an incentive to maximize the use of billing providers and to train the next generation of health workers to practice in a fee-for-service model. Yet the sum of forces at play—continuing health system consolidation and the increasing proportion of patients covered in value-based payment models—mean that hospitals and health systems need to invest now in team-based care models of practice and training in rural communities.
Bolstering teams in rural areas amidst chronic workforce shortages
Building teams to address the health and social care needs of rural communities amidst chronic workforce shortages is challenging. Workforce shortages are an endemic characteristic of rural communities 11 and are a contributing factor to health disparities. Hospitals, physicians’ offices, and long-term care facilities are chronically understaffed in rural areas, and the situation has worsened during the COVID-19 pandemic. In 1980, there were 8.0 physicians per 10,000 population in rural counties, and 21.2 in urban counties, a difference of 13.2. By 2010, that gap had grown to 19.4 physicians per 10,000 population (11.2 rural vs 30.6 urban). 12 About half of rural counties do not have access to a psychologist, 13 and 37% of rural counties lack a provider who can prescribe medications for opioid use disorders. 14 From 2003 to 2018, over 1,200 independently owned rural pharmacies closed, with more than half serving as the community’s only retail pharmacy. 15 Rural workforce shortages can inhibit team-based care because there are fewer providers available to collaborate. For example, rural primary care physicians are less likely to be colocated with behavioral health providers, which makes caring for patients with behavioral and mental health needs difficult. 16
Rural training programs have the potential to address the long-elusive goal of building workforce capacity in underserved and rural communities, but they face numerous challenges distinct from their urban counterparts. Lower care volume, fewer rotation experiences and faculty preceptors, limited funding, and a lack of educational infrastructure all inhibit the efficient launch of rural training programs. 17,18 Despite these challenges, rural communities are, by necessity, innovative and resilient in their efforts to deploy and educate teams to address the health and social care needs of local populations. The innovative ways in which they have built teams to address pressing health needs provides lessons learned for larger urban systems. Below, we highlight 3 examples of rural interprofessional education and practice models that have succeeded in addressing the social determinants of health, improving health outcomes, and lowering costs.
Rural Interprofessional Practice and Training Models Designed Around Patients and Populations
We purposively chose the 3 models described in this section because they were designed around the specific health needs of patients in the local community, and they demonstrate the importance of academic–community partnerships in addressing social needs, improving health outcomes, and lowering costs. While many interprofessional models are documented in the literature, surprisingly few are based in rural communities, and even fewer incorporate both interprofessional practice and education. In many ways, these 3 models represent exemplars that could be replicated and scaled to other communities. However, they also highlight the importance of more rigorous reporting on the components of the academic–community partnerships involved, the different types of health workers deployed, and the design of the interprofessional practice and training models implemented.
The Asheville Project model
North Carolina’s Asheville Project was initiated to address the high burden of chronic disease in the community through an interprofessional care model. The team included pharmacists, primary care providers, and other health care professionals alongside learners. The 5-year diabetes study demonstrated a $1,200–$1,872 per participant per year (PPPY) decrease in direct medical costs and significant improvements in clinical outcomes at 5 years. 19 The 5-year asthma project led to a $1,995 PPPY decrease in direct and indirect costs and significant decreases in asthma-related emergency department visits and hospitalizations. 20 The 6-year cardiovascular (CV) project demonstrated a 53% reduction in the risk of having a CV event and a 46.5% decrease in the mean cost of a CV event when it did occur. 21
Although the Asheville Project meticulously documented the cost savings achieved, details on how the partnership developed and was implemented between the city of Asheville, the pharmacy benefits manager, the nonprofit health care organization, and the academic institutions are not available in the literature. Additionally, information about the Asheville Project’s team composition, the practice-based learning model used, and the degree to which the program increased local training opportunities, developed local preceptors, and affected local workforce recruitment and retention has not been described in the literature.
The Boise Interprofessional Academic Patient Aligned Care model
The United States Department of Veterans Affairs’ (VA’s) practice-based learning models, which are aimed at addressing high-need patients in rural areas, are exemplars in their documentation, including detailed information about team composition, practice-based learning models used, and the outcomes achieved. In 2012, the VA invested in 5 Centers of Excellence of Primary Care Education (CoEPCE) to develop new models of learning in practice, 22 including the Boise Interprofessional Academic Patient Aligned Care (iAPACT). The iAPACT model included nurse practitioner students and residents, physician residents, pharmacy residents, psychology interns, and psychology postdoctoral fellows who provided care to high-risk, high-need veterans. The program improved chronic disease quality metrics related to diabetes and hypertension, as well as statistically significantly decreased hospitalizations. The model was successfully replicated in rural settings, including the VA’s community-based outpatient clinic in Caldwell, Idaho, where a primary care provider (physician or nurse practitioner), a registered nurse care manager, a licensed vocational nurse, and a medical support assistant worked together to address the health and social care needs of the highest risk patients with chronic pain, multiple comorbidities, or psychosocial impediments to care who were also high utilizers.
The VA’s CoEPCE model provides valuable lessons on the challenges of developing and implementing interprofessional education and practice redesign in the nation’s largest integrated delivery system, including the difficulties encountered in making the business case for redesigning clinic workflows, securing needed blocks of provider and staff time, countering preconceived notions of health professionals’ roles and team hierarchy, and enhancing team communication and understanding of team-based models of care. 22
The Interprofessional Care Access Network model
The Interprofessional Care Access Network (I-CAN) model is an academic–community partnership demonstrating that addressing the social care needs of patients and populations can reduce costs. 23 I-CAN’s academic partners included schools of nursing, medicine, and pharmacy. Community partners included federally qualified clinics, neighborhood community organizations, and health service agencies focused on medically underserved communities. Clients participating in I-CAN were identified by community partners. They included individuals with unstable housing, no health insurance, chronic illness and polypharmacy, and families with children with poor school attendance, signs of neglect, or developmentally disabled parents. Clients also included individuals with a history of missed appointments and inappropriate use of the emergency room and emergency medical services. Over the course of an academic term, interprofessional teams of health professions students from nursing, medicine, pharmacy, and dentistry met with clients weekly for an average of 80 minutes per visit to assess needs, set goals, and connect clients with resources to address their needs.
Evaluations of I-CAN have demonstrated reductions in health care utilization, including emergency department visits, emergency medical service calls, and hospitalizations. 24 The I-CAN model is being scaled to other sites, including rural ones. The model shows how interprofessional education can be used not only to train students to work with populations with significant social needs but also how partnering with community agencies can help reduce health system costs. An important next step will be documenting how the model was replicated in rural communities, the challenges encountered, and the patient and population outcomes achieved.
Lessons Learned and Next Steps
In preparing this commentary, we were struck by how few publications exist that describe interprofessional practice and education models in rural areas. Equally sparse is the literature on the effect of team-based models of learning and practice on patient outcomes. 25 Despite the natural ecosystem these models provide for interprofessional learning and collaborative practice, many AHCs have not systematically invested in building and sustaining team training and practice in rural areas. These few case studies demonstrate the impact of team-based models of care and education when they are designed around a specific patient population with measurable outcomes. The Asheville Project, iAPACT, and I-CAN models demonstrate the importance of academic–community partnerships in addressing social care needs, improving health outcomes, and lowering costs. They also highlight the need to assemble research teams to work with rural sites to develop rigorous data collection methods and study designs that will yield strong evidence on the relationship of team-based practice and training on patient and population health outcomes.
With responsibility for training the future health workforce and major investments in research infrastructure and educational capacity, AHCs are uniquely positioned to partner with rural communities as payment incentives change. Senior AHC leaders, state rural health organizations, health and human services agencies, primary care associations, urban health systems, and payers need to convene discussions to identify the impact that health system consolidation, value-based care payment models, and the growing need to address the social determinants of health will have on the composition and skill mix of the future workforce. This dialogue will be an important starting point for AHCs to plan for their future workforce needs and next steps needed to develop and implement effective academic–community partnerships. To accomplish this work in rural settings, AHCs will need to commit to sustaining partnerships with rural communities, networks of providers and practices, non-AHC educational organizations, and community-based agencies.
The lack of detail in the published literature about the components of rural academic–community partnerships—who was involved and how these collaborations were developed and implemented—makes it difficult to assess how outcomes such as those achieved in the Asheville Project might be replicated. Despite this, previous work conducted in urban settings might provide a useful roadmap. Findings from one study, describing an effort in which a large research university collaborated with community partners in New York City to train pediatric residents to address children’s physical and social health needs suggests that the design, implementation, and evaluation of the curriculum must be a joint effort between the AHC and community partners to ensure that academic goals are aligned with population health needs. 26 Another study that synthesized findings from multiple academic–community partnerships in prevention research highlights the importance of community involvement in the research that emerges from the partnership, including the process of “building a shared conceptual model of health and disease, the development of data collection instruments that are relevant, valid and culturally appropriate, data collection processes that enhance response rates and data quality … [and] the dissemination of findings.” 27
The pandemic has exacerbated existing workforce shortages and health disparities in both urban and rural communities, creating another incentive to develop academic–community partnerships to address critical health and social care needs. AHC leaders will want to take stock of the assets they bring to the collaboration such as existing faculty-led community-based practice and education programs, including the Area Heath Education Center networks, expertise in interprofessional teams already residing in AHC centers, and research infrastructure such as the Clinical and Translational Science Networks, and health services researchers. As described above, expertise in research and evaluation is needed to conduct more rigorous data collection and reporting on the design, team composition, interprofessional training, and the outcomes achieved. Efforts to build data systems, metrics, and standard frameworks for implementing interprofessional education and evaluating outcomes in practice settings are underway with the goal of providing much needed tools to design and implement programs while assessing outcomes. 28 Additional data will be critical to understanding effective strategies to achieve quality outcomes and cost savings and develop the business case for interprofessional practice and training models.
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