Secondary Logo

Management Approach for Population Health Outcomes and Economic Improvement

Appointing Health Services Early Careerists to Rural Communities for Leadership Development

Shepherd, Jewel Goodman, PhD, MPA, CHES

doi: 10.1097/HCM.0000000000000263

Securing health services administrators to manage health care organizations in rural areas and small town communities presents unique challenges; however, potential benefits abound for residents in terms of improving population health outcomes from a community-based approach and stimulating the local economy. The influx of community-based approaches to revitalize small towns and rural communities is evident in the literature. Small towns and rural areas lack advanced health care practices, which results in poor health outcomes; economic development as a result of a poorly prepared workforce; and community connection to the vast array of knowledge, activities, and other supports as a result of poor physical and virtual connectivity. An approach that prompts new health management graduates to practice where they have an opportunity to cultivate the residents, the community at large, and themselves is an optimal management method in improving rural areas. This framework places emphasis on students completing a health services administration curriculum training program and beginning their careers in underserved areas to positively impact rural communities by playing a role in revitalizing the local economy and improving population health.

Author Affiliation: Health Services Administration, Beacom School of Business, University of South Dakota, Vermillion.

Correspondence: Jewel Goodman Shepherd, PhD, MPA, CHES, Health Services Administration, Beacom School of Business, University of South Dakota, 414 East Clark St, Beacom Hall, Vermillion, SD 57069 (

The author has no funding or conflicts of interest to disclose.

This article is not currently under review, nor has it been published elsewhere. No supporting data requiring human subjects' protocol were used. All ethical considerations have been adhered to and acknowledged. The manuscript has been seen and approved by all members and has not been (and will not be) submitted to any other journal while it is under consideration by this journal.

INITIATING LEADERSHIP DEVELOPMENT for community growth is necessary in the curriculum for health services administrators (HSAs). Leadership is essential to progress, competition, promotion, drive, and sustainability of community health programs.1,2 Leaders must be flexible in their styles to accommodate the organization's vision, local and global marketplace competition, and ever-changing demographics among people. In developing leaders, the role of having vision and determining how that vision is to come to fruition is a key teaching point.1,2

Curriculum for early careerists should include efficient cost allocation and collaborative care models focused on health promotion and patient education to enhance health service delivery in rural communities and small towns. Rural communities are compromised as a result of geographic location, lack of connectivity, recruitment, and retention of a trained workforce and continue to be threatened with future complex issues absent efforts addressing such disparities and voids. Promoting total wellness requires strategic partnerships and identification of concern areas in earlier stages. Graduates of health services administration programs should understand models of expanded health care capacity and how to strengthen such models with evidence-based sustainability plans and quality improvement tools such as total quality management.3

Back to Top | Article Outline


Rural communities and small towns across the United States are faced with shrinking populations, poorer health status and outcomes, loss wages, and resource depletion, leaving families significantly impacted.4 A promising approach to stimulating the economy and quality of life in rural communities is economic development strategies that work interprofessionally to increase partnership building, business development and entrepreneurship, health and environment, workforce development and employment, infrastructure design, connection with technological advances, and most importantly sustainable development. For instance, partnership building creates networks of opportunities for information sharing, an exchange of resources, and the coordination and collaboration of coalition building for joint problem solving with stakeholders. The education, skills, experiences, and creativity beyond a single organization increase the opportunity for broad-ranging areas and increased support.

Newly appointed HSAs or early careerists embarking upon new health management professions should support the efforts of startup businesses with a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in the services and processes they provide with goals to achieve equity and improve the health of rural area residents. Using a deliberate and defined quality improvement process focused on activities that are responsive to community needs and improving population health should be priority.

Taking a similar approach of federally qualified community health centers, early careerists should enhance their agency's service delivery model to take an innovative approach to accessing health resources, health education, and health promotion.5 The initiation of cost-effective and resource-sharing projects that best address the access to care needs of rural residents is a unique approach to designing delivery systems that are specific to improving health outcomes among minorities and persons with such chronic conditions as diabetes, cardiovascular disease, respiratory illness, obesity, and oral health problems. Providing a seamless continuum of high-quality health care and partnering with other service organizations to enhance overall coordination and navigation of care would be ideal for HSAs managing facilities that have an increased patient population of rural residents. Additionally, health navigation services such as enrollment in health plans, prescription medication access, and oral health prevention services centrally located would help to relieve the disproportionate burden of chronic disease management and promote care coordination.5

There is an increasing need for the exploration of improving knowledge and increasing awareness of the possibilities of telehealth utilization in rural communities. Recognizing the importance of technological connectivity supports in real time is important to health promotion efforts that seek to utilize technology for health service delivery.4 For instance, access and stigma can impact mental and medical health help-seeking behaviors. Little is known about the barriers that discourage professionals from practicing in rural areas, but a common concern is that integrating an outsider into a rural community presents a unique set of challenges and competing cultural and communal society demands.4 Another concern is provider readiness and technological resource availability, which must be addressed in preparation of telehealth service delivery for rural and remote areas.4,6-8

Early careerists managing rural population patients should be encouraged to educate communities about specialties and care providers and support initiatives to increase provider accessibility in and to rural communities and strive to maintain a connection both virtually and personally.4

Back to Top | Article Outline


Health care delivery has been redesigned to meet the varying needs of patients, particularly underserved communities and rural areas, to lessen the impact of poor care management at the individual and system level. This research suggests a strategic focus on the aims of collaborating with local workforce development office, focusing on health promotion such as childhood obesity and physical activity, aligning health education and the shared medical appointment, and, lastly, controlling costs.

Back to Top | Article Outline


Reports of success with high-risk workers when they are trained for a specific job and skill set are evident in the literature.9 Single-curriculum training programs that include specialized vocational certification at an individualized pace to promote success in job placement upon completion exceed historical job training programs. Job Corps is an example of a comprehensive federally funded job training program that offers not only access to vocational training but also additional resources that promote self-sufficiency such as access to health care, meals, counseling, and marketability for increased employability. The Department of Labor conducted an evaluation to compare employment and earnings with crime involvement and welfare benefit receipt and found that participants of the program were significantly more likely to be employed and earning higher wages than their counterparts. To be successful in competing for employment, individuals require some minimal skills. Residents in small town and rural communities often lack those basic needed skills. Specific and high-level skill requirement is increasing in the job market and therefore putting the high-risk worker or unemployed at a disadvantage.9

There exists a need among technology-based firms who require single-curriculum skilled laborers.9 Leaders in industry have built their workforce by instituting in-house training and collaborating with educational institutions to shape their workforce into the type of trained staff required for their organization's productivity. Reinvesting in young, minority, underskilled, and other hard-to-reach persons requires strategic, practical training programs to address barriers and assist these individuals with becoming productive citizens of the communities in which they live by focusing on job training and self-sufficiency. This is necessary for small town and rural areas.9

In the past decade, job intervention programs have become vital to providing an optimistic focus for high-risk workers.10 Community-based programs with affiliate partners can initiate single-curriculum training programs for this group of workers. Such community-based resources can better prepare the unemployed with applying for vacancies. The expansion of access to, accountability of, and participation in workforce development is critical to improving the economic situation of the overall labor market, particularly in rural areas and small towns.10

Back to Top | Article Outline


Return on investment for chronic care disease management model implementation can be tremendous if demonstrated through improved health status and reduction in health care cost. At the same time, this is difficult to determine because limited published literature exists on the evidence of the cost-effectiveness of the majority of health promotion programs.11-14 Therefore, the question that remains is how can community-level health system organizations provide an effective chronic disease management model where immediate and sustainable access, service cost, and health education are geared toward reducing the toll of chronic illnesses. The logical deduction would be health promotion.11-14

Health promotion has been relatively neglected by health economists because of the lack of demand, largely the misunderstanding that exists around health economics, and its impact on promotion efficiency and cost-effectiveness.11-14 Applying standard economic techniques to health promotion programs for several reasons presents challenges. Health promotion is expected to reduce future health care costs through the avoidance of disease. In a return on investment model, the objectives of health promotion are to reduce morbidity and mortality and to minimize associated costs. Even when prevention programs are able to show some effectiveness, the successful results do not show considerable reductions in total costs. From a policy perspective, health promotion is not intended to replace treatment, and therefore, attention should focus on marginal cost and benefit shifts of resources between health promotion and treatment. Health economics gives health promotion a voice in resource reallocation.11-14

Early careerists, in their academic preparation, are taught to impact health outcomes from a population health approach, which means supporting policies and restrictions that regulate individual behaviors so that the entire community can experience better health outcomes. For example, reducing health consequences for nonsmokers would require restrictions for smokers.11-14 While some researchers believe that individual health is an accurate reflection of absolute wealth in the community, this is reflective of both underserved and wealthy communities. Lack of income has a tremendous impact on an individual's overall well-being. Those with adequate income can afford to purchase quality, comprehensive health insurance; the prescriptions and other health-related materials; and access to other goods that support a healthier lifestyle. The combination of access to these goods and services can ultimately transpire into improved health outcomes.11-14

Research shows that household income can have a diminishing effect on health.11-14 Initially, as income is increasing, there are positive health status changes and experiences. Progressively, though, the incremental changes in improvements become smaller even when income increases. If higher income is associated with lower mortality (death) and lower morbidity (illness), then efforts should be placed on the individual investing in his or her own health maintenance and self-managing behaviors.11-14

Unequal distribution of income may result in unequal access to health insurance, health services, and quality housing.11-14 Income inequality leads to feelings of failure and resentment and an increased likelihood for engaging in harmful behaviors, criminal activity, alcohol abuse, tobacco use, and other such poor behavioral choices.11-14 It becomes then imperative for early careerists to make an investment in promoting quality living in the communities where they manage patient populations with diminishing household incomes. An example would be early interventions for young populations that lead to adult diagnosed health issues such as unmanageable weight.

Back to Top | Article Outline

Childhood Obesity

Childhood obesity is a health problem that can heavily impact the health status of that individual into adulthood.15-17 Research shows that childhood obesity results because children are not cognitively prepared enough to make healthier choices on their own without informed knowledge; children are not the primary meal planners of their homes; children follow the behaviors of the adults in their lives; and children are considered a vulnerable population because many of their decisions are made for them. As such, children are then forced to become associated with stigmas of weight gain, poor overall health, and a higher susceptibility to other chronic health conditions. To help combat an issue such as childhood obesity, outreach into communities to implement interventions that would modify the prevalence of childhood obesity and also decrease the severity and likelihood of chronic health issues that will stretch into adulthood would be ideal.15-17 One approach would be collaborating with community partners that offer childcare and then supporting the incorporation of education to both staff and parents about the impact of childhood obesity; how to make nutritional choices; how to become active; and how to implement this information into their lifestyles. Children then benefit from knowledge increase in values about healthful living but on a level they understand. Such educational sessions could be coupled with demonstrations and be linked to technology. Once an approach has been implemented and found to be successful, then the developed intervention can be presented as a model to be replicated in other areas and further be eligible for grant funding from industry to sustain the program.15-17

Back to Top | Article Outline

Physical Activity

Another outreach aim could be the promotion of physical activity, which of its own nature is a complex behavior with many factors inclusive of individual characteristics18-22 and environmental conditions.18,22-24 Promoting change at the individual level will place emphasis on larger populations to reduce obesity to impact community-based change.22 Having community outreach efforts that are instrumental in developing interprofessional solutions such as the promotion of regular physical activity, particularly among those communities that are less likely to engage in physical activity, should be an aim of new HSAs to engage with the community or population they serve at the practice they manage. Additionally, collaborating with environmentalists to infuse discussions on the community's socioeconomic conditions and accessibility of built and natural environments that promote healthful living and will increase physical activity among certain communities is an approach to this engagement. Rural communities, unlike metropolitan areas where architects and subdivision developers provide insight on the aesthetics of neighborhoods, their characteristics, and the design of future communities that incorporate sidewalks that are pedestrian friendly, walking, and biking trails, require different types of opportunities to increase an area meeting the physical activity recommendations for the elderly and minorities and even specific to cold weather.22

Back to Top | Article Outline


Patients need a basic level of education to perform, implement, and understand the treatment modules that accompany their diagnoses, particularly chronic conditions requiring self-management.25 To contribute to improving their own health status, individuals are expected to enact some emotional regulation to the process of modifying their lifestyle in an effective manner to strive for goals specific to a healthier position of that condition for the interaction of social and medical experiences. Patient education needs to be accessible, individualized, and disease-specific to measure impact.25

Health care systems are moving toward the implementation of the shared medical appointment where patients with similar characteristics participate in a group session.26 Rothrock et al26 demonstrated that modifications are necessary in busy settings where it is unlikely for each patient to be seen individually for patient education following their clinical visit in a study seeking to determine if the inclusion of patient education to routine clinical management improved health outcomes and reduced utilization of health care resources. In addition to didactic clinical management education, patients were also in need of patient education that addressed cultural, social, familial, and health beliefs and attitudes. Findings suggested that intensive education of patients by trained lay instructors conveyed significant benefits to participating patients and reduced the number of health care visits and utilization of resources.26 This is an ideal setting because health educators can provide service to multiple patients. This shared decision-making process is a cost-effective measure in terms of time, expenses, effort, and energy. Shared medical appointments are a practical solution to providing comprehensive education in a group setting for the patients and their respective support system.27 Taking steps to inform patients of their conditions and providing them the self-management tools that are proven to impact their clinical outcomes are considered building an informed patient. Patients who are uninformed have the potential to cost a health care organization in terms overuse of health care services if needs go unmet.26

With the increase in diagnoses of chronic conditions, there has been a transition in health care from focusing on disease-oriented etiologies to examining the interacting influences of factors rooted in culture, race/ethnicity, policy, and environment.28 Health care systems are now implementing care-management programs that are coordinated partnerships and shared decision making between the patient, the patient's support system/caregiver, and health care providers.27,29,30 This framework is a solution to reduce overall costs, hospitalizations, and avoidable readmissions associated with chronic disease.27 Additionally, this approach is patient centered and places emphasis on managing the complex clinical needs around chronic disease management and surveillance and encouraging such lifestyle changes as increased compliance.

Back to Top | Article Outline

Medication Adherence

Research on drug treatment regimens shows that nonadherence on the patient's part may negatively influence a patient's health status.31 Improving adherence to long-term medication regimens requires combinations of information. The successful management of the regimen is dependent on counseling about the importance of adherence, and how to organize medication taking, reminders about appointments, rewards and recognition for the patient's efforts to follow the regimen, and enlisting social support from family and friends are all methods that are best presented by a health educator or health navigator at the community health level. Successful interventions for long-term regimens are all labor-intensive but ultimately can be cost-effective.31 Encouraging early careerists to incorporate outreach efforts at the practice they manage can provide residents increased knowledge of how lifestyle changes coupled with medication adherence can improve health outcomes.

Back to Top | Article Outline


Early careerists realize that resource allocation is important to initial execution and sustainment of quality health services when considering the implementation of health services, resources, treatment, and interventions. A decision maker's major objective is to maximize population health, subject to resource constraints.32 The outcomes of alternatives can be specified by health states, changes, and durations; however, limited resources require selective cost considerations. Health care cost is imperative, and the use of cost-minimization analysis to compare interventions with the same effectiveness solely on the basis of cost, or the net difference in resource costs, is not as effective as analyzing costs with respect to benefit and promotion of prevention and education and the reduction and mitigating the impact of a poorer health condition.32

Implementing a cost-effectiveness analysis is an approach to compare interventions using common measures of both cost and effectiveness, such as quality-adjusted life-years, disease incidence prevented, lives saved, and positive health outcomes32,33 Cost-effectiveness analysis is used to compare 2 options with the same goal, measuring technical efficiency only. This process requires the identification of a standard to which the alternative programs can be compared, and it requires present value of future resource costs. The process of discounting will allow for the comparison of compare future costs and consequences with present ones.32,33 Utilizing cost-effectiveness analysis on proposed health interventions ensures the HSA will (1) structure the problem by defining the objective, perspective, time frame, and analytical horizon; (2) identify the relevant alternatives that will be appropriate for the population of interest and identify the issues with current practices, potential new practices, and foregoing the implementation of any changes; (3) identify methods for measuring the results, particularly categories; and, lastly, (4) understand the adverse effects of the intervention and the identification of all associated sources of costs. Costs will include avoided costs and costs associated with lost productivity.32,33 The application of cost-benefit analysis to compare interventions using costs and benefits, such as a positive cost net benefit, is a technique reserved for comparing multiple interventions.32,33 Although used less frequently, cost-benefit analysis provides a systematic approach to estimate strengths and weaknesses of the presented alternatives. Cost-benefit analysis determines the best approach to achieve benefits as both costs and outcomes can be converted to a monetary unit to generate a cost benefit.32,33

Back to Top | Article Outline


The presented approaches can be used to control health care costs, eliminate delivery inefficiencies, and dispose of ineffective interventions to control costs without reducing quality in an effort to provide all beneficial services to the entire population.32,33 To reduce the number of infections, limit risk factors, increase the number of healthy years of life for those who are receiving treatment and care and the ability to identify interventions that reduce the impact of chronic condition epidemics, and increase effectiveness in priority setting with options are an important feature. Of importance is the necessity to propose and implement disease care models that consider the 3 main streams of cost: initial costs, those costs associated with the intervention; induced costs, those costs that have resulted from the intervention; and averted costs, those costs that would likely occur if no intervention was implemented such as future detection, diagnosis, and treatment of disease.32,33

Back to Top | Article Outline


A focus on health and environment is necessary as families in rural areas are at an increased risk of poorer health outcomes and a lower quality-of-life status as a result of decreased access to health systems capable of handling many of their issues or concerns.4 Connection with technological advances is an option, as technology has the power to transform rural communities and invite economic enterprise to replace lost jobs and build a healthy tax base. Additionally, research has greatly synthesized the benefits of telehealth as cost-effective mechanisms to improve access to quality health-related services to geographically dispersed populations. The offering of remote health care, using technology to areas that would otherwise not be medically managed, allows for improved management of diseases to make healthier lifestyle modifications, thereby promoting active self-management of diseases.4

Expansive and complex health programs necessitate an evolving role for hospitals and care systems, as well as greater integration with a variety of community organizations and other partners. Merging the resources and skills of hospitals and health care systems with community partners is essential for the integration and expansion of health management programs. Together, hospitals and care systems and their partners can create targeted population health programs that engage and communicate with the patient population and ultimately increase efficiency and quality of health care and improve health status in the community.

Back to Top | Article Outline


1. Nahavandi A. The Art and Science of Leadership. 6th ed. Upper Saddle River, NJ: Pearson-Prentice Hall; 2012.
2. Robbins SP, DeCenzo DA, Wolter RM. Supervision Today! 7th ed. Prentice Hall: Upper Saddle River, NJ; 2013.
3. Tracy DL, Martin TC. Lean Operations Management. Dubuque, IA: Kendall Hunt Publishing Company; 2015.
4. Cohn TJ, Hastings SL. Building a practice in rural settings: special considerations. J Ment Health Couns. 2013;35(3):228–244.
5. Shepherd JG, Lemaster M. Community health centers: addressing overall health and oral health is a perfect match. Dimens Dent Hyg. 2014;12(6):60–64.
6. Patrick K. Information technology and the future of preventive medicine: potential, pitfalls, and policy. Am J Prev Med. 2000;19(2):132–135.
7. Orleans CT. Addressing multiple behavioral health risks in primary care. Broadening the focus of health behavior change research and practice. Am J Prev Med. 2004;27(2 suppl):1–3.
8. Yu CH, Parsons JA, Mamdani M, et al. A web-based intervention to support self-management of patients with type 2 diabetes mellitus: effect on self-efficacy, self-care and diabetes distress. BMC Med Inform Decis Mak. 2014;14:117.
9. Mekinda MA. Support for career development in youth: program models and evaluations. New Dir Youth Dev. 2012;2012(134):45–54.
10. Katz LF. America's Job Challenges and the Continuing Role of the U.S. Department of Labor. ILR Rev. 2014;67(spring):578–583.
11. Green L, Kreuter M. Health Promotion Planning: An Educational and Environmental Approach. Mountain View, CA: Mayfield Publishing; 1993.
12. Lucas K, Lloyd B. Health Promotion: Evidence and Experience. Health Educ Res. 2006;21(4):598–599.
13. McKenzie JF, Pinger RR. An Introduction to Community and Public Health. 8th ed. Burlington, MA: Jones and Bartlett Learning; 2012.
14. Coe G, deBeyer J. The imperative for health promotion in universal health coverage. Global Health. Sci Pract. 2014;2(1):10–22.
15. Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in public health. Obes Rev. 2004;5(suppl 1):4–104.
16. American Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Child Care and Early Education. Preventing Childhood Obesity in Early Care and Education: Selected Standards From Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs. 3rd ed. 2012. Accessed May 22, 2018.
17. World Health Organization. Population-Based Approaches to Childhood Obesity Prevention. Geneva, Switzerland: World Health Organization Document Production Services; 2012. Accessed May 22, 2018.
18. King AC, Stokols D, Talen E, Brassington GS, Killingsworth R. Theoretical approaches to the promotion of physical activity: forging a transdisciplinary paradigm. Am J Prev Med. 2002;23(2 suppl):15–25.
19. Li W, Lee A, Solmon M. Gender differences in beliefs about the influence of ability and effort in sport and physical activity. Sex Roles. 2006;54:147–156.
20. Palmer DC. The Nature and Extent of Personal, Social, Environmental and Work Influences on Physical Activity Levels Among Women: A Study of Nurses [PhD dissertation]. Lexington, KY: University of Kentucky; 2006.
21. Lee LL, Arthur A, Avis M. Using self-efficacy theory to develop interventions that help older people overcome psychological barriers to physical activity: a discussion paper. Int J Nurs Stud. 2008;45(11):1690–1699.
22. Tiraphat S, Goodman K. Keep it moving: factors to consider in establishing an interprofesisonal approach to promote physical activity among US adults in the northeast. Am J Health Res. 2016;4(2–1):28–36. Special issue: interprofessional education and collaboration is a call for improvement across the board in the health sciences.
23. Humpel N, Owen N, Leslie E. Environmental factors associated with adults' participation in physical activity: a review. Am J Prev Med. 2002;22(3):188–199.
24. Lepore SJ, Revenson TA, Weinberger SL, et al. Effects of social stressors on cardiovascular reactivity in black and white women. Ann Behav Med. 2006;31(2):120–127.
25. Hahn RA, Truman BI. Education improves public health and promotes health equity. Int J Health Serv. 2015;45(4):657–678.
26. Rothrock JF, Parada VA, Sims C, Key K, Walters NS, Zweifler RM. The impact of intensive patient education on clinical outcome in a clinic-based migraine population. Headache. 2006;46(5):726–731.
27. Bodenheimer T, Berry-Millett R. Follow the money—controlling expenditures by improving care for patients needing costly services. N Engl J Med. 2009;361(16):1521–1523.
28. Shi L. The impact of primary care: a focused review. Scientifica. 2012, 2012;2012:432892.
29. Center for Health Care Strategies, Inc. (2007). Care management definition and framework. Accessed April 8, 2018.
30. Eng TR, Gustafson DH, Henderson J, Jimison H, Patrick K. Introduction to evaluation of interactive health communication applications. Science Panel on Interactive Communication and Health. Am J Prev Med. 1999;16(1):10–15.
31. Shepherd JG, Locke E, Zhang Q, Maihafer G. Health services use and prescription access among uninsured patients managing chronic disease. J Community Health. 2013;39:572–583.
32. Rice T, Unruh L. The Economics of Health Reconsidered. Chicago, IL: Health Administration Press, A Division of the American College of Healthcare Executives; 2016.
33. Dewar DM. Health Economics. 2nd ed. Burlington, MA: Jones and Bartlett Learning; 2017.

cost-effectiveness analysis; health services administration; rural population health outcomes

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.