CDC-funded state arthritis
programs highlight the challenges to addressing rural health disparities and
provide best practices for engagement and sustainability of programs in remote
areas.
November 15, 2019
- Arthritis is an expensive disease to treat. Improper management of it
can lead to joint replacements and high medication utilization. In order to
minimize these and promote better health outcomes, all three states’ arthritis
programs are integrating evidence-based programs into rural areas and focusing
on upstream investments and community partnerships.
And in rural areas, those problems are
exacerbated. Patients living in rural areas get arthritis, too, but they face
considerable healthcare barriers that those living in urban areas usually
don’t.
The Center for
Disease Control and Prevention (CDC) funds 13 state arthritis management and
prevention programs with the goal of improving the quality of life for
residents with arthritis.
Funding is
distributed throughout five years for states to expand the accessibility of
arthritis appropriate, evidence-based interventions; increase provider’s
patient counseling and referrals to evidence-based lifestyle management
programs; promote walking to manage arthritis symptoms; and raise
awareness of the burden of disease.
“The arthritis
program’s entire purpose is to help people with arthritis and other chronic
conditions be able to live happier, healthier lives, reduce the morbidity that
comes along with arthritis, enhance individual’s quality of life, and reduce
health disparities,” said Stephanie George, MPH, epidemiologist/evaluator Utah
Department of Health, one of the states participating in the CDC program.
While each state is
partnering with different organizations to fulfill their mission, several
states are placing particular emphasis on their rural communities. Leaders in
Washington, Oregon, and Utah’s arthritis programs spoke with PatientEngagementHIT.com
to offer insight into program sustainability and success in rural areas.
Targeting Rural Areas
According to the CDC, one in five urban
residents is diagnosed with arthritis compared to one in three rural residents.
An increased burden of disease in rural areas emphasizes a need to promote
disease management and preventive services in these areas.
This urban-rural
health disparity is not exclusive to arthritis.
“In Washington state,
rural areas tend to have a higher degree of health disparities overall,” noted
Amy Ellings, MPH, Healthy Eating Active Program manager, Washington State
Department of Health.
This trend is seen
across the country. So, state arthritis programs hope the healthy lifestyle
habits participants learn through their programs will aid in managing arthritis
symptoms and other chronic conditions.
“In rural areas,
there’s a higher prevalence of disease and the negative effects of these
diseases. These evidence-based programs have been shown to impact health
outcomes and reduce the negative effects of chronic disease,” explained George.
Despite a larger
prevalence of disease, many rural areas have difficulty accessing these
programs.
“We know by doing an
analysis of locations that rural areas have lower access to these programs,”
Ellings pointed out. “We’re working with organizations to offer these programs
in rural areas.”
All three state
program leaders emphasized the importance of targeting their programs in rural
areas given the limited access rural residents have to high-quality care.
“The places where
people live, work, play, learn, and age have such a significant impact on their
health,” said J. Hildegard Hinkel, MPH, program analyst and community programs
liaison for Oregon Health Authority. “It is really important to support rural
communities by engaging them in finding solutions.”
Barriers in Rural Communities
Many of the health
challenges individuals living in rural areas face are not unique, but the
barriers keeping them from receiving high-quality and timely access to care can
be.
All three program
leaders noted that transportation and accessibility to care options were the
two biggest barriers rural residents face.
“Transportation is a
huge issue, especially because arthritis impacts older adults at higher rates.
Older adults have more mobility challenges that can present additional challenges
on top of being more spread out in rural areas,” said Hinkel.
George emphasized
that participants having limited access to transportation is compounded by the
fact that individuals in rural areas tend to be more spread out, making it
difficult to find a central location to hold a class.
“The biggest barrier
is often the physical location to hold the classes. There may not be a space
big enough for a walking program or space allocated for an educational class,”
continued George. “There are workarounds, such as having them in church
buildings or schools, but the spaces available are reduced in rural areas. It’s
going to be a barrier for participants, too, who may be further away to make it
there, especially in the colder months.”
Ellings added that it
is not just personal transportation that is a limitation.
“They may not have
access to public transportation or their own transportation if they’re
traveling from further distances,” she suggested.
The program leads
stressed that transportation goes hand-in-hand with the accessibility of
programs and high-quality care.
“Access to care is
another barrier. Are there programs available? Is there infrastructure? Do they
have access to health care? Are there doctors and other health professionals
connected to self-management programs? Do they understand how they can help
their patients make connections?” questioned Hinkel.
This is complicated
by the fact that rural areas have fewer providers who are often widely spread
throughout the community.
“In these rural
areas, there is less staff with more responsibilities,” articulated
George. “For example, if we’re contracting with the local health department
implement the class, the health education specialists may be in charge of an
arthritis program and a tobacco effort. They have a lot of different
responsibilities and fewer resources to make those things happen.”
To try and overcome
these compounding barriers in rural locations, the arthritis programs promote
healthy lifestyle choices. The aim is that patients in areas with limited
access to providers can still be educated about arthritis management best
practices in order to make healthy lifestyle choices regardless of
infrastructural barriers around them.
“Improving health
outcomes is huge, but these self-management education programs are not only
teaching people about a disease, they’re teaching them skills to manage it
better themselves and communicate better with their doctor,” said George.
Measures of Success
State arthritis
programs are evidence-based practices promoted by the CDC because they have
already undergone rigorous evaluation to demonstrate their effectiveness.
“The CDC has reviewed
the data and said that these are evidence-based programs. Our role is to roll
them out, not necessarily to create more evidence around effectiveness,”
Ellings explained.
The CDC measures
state success using the Behavioral Risk Factor Surveillance System (BRFSS), a
national survey that collects information on the health and disease status of
each state as well as preventive services.
The CDC monitors how
individuals with arthritis report their health status from year to year. While
an improvement in self-reported health status does not definitively demonstrate
the arthritis programs caused better health outcomes, it is an indication to
the CDC of general improvement.
Individual state
programs are also tracking the success of their specific programs. While each
state is using slightly different metrics, they are collectively focusing on
process measures to understand how wide their impact is.
“We have our own
measures that we report: are we expanding provider awareness of how to refer patients
to evidence-based self-management programs that support arthritis? Are we
increasing the number of places in Oregon, specifically in rural areas, that
refer to these programs?” said Hinkel.
In Washington state,
Ellings said they are looking at how many people enroll in the classes and how
many class sites or affiliates they have.
George noted that
capturing these measures is also important for program sustainability.
“Sustainability isn’t
all about funding,” she said. “We focus on retention, our environmental
support, our partnerships, and our organizational capacity. This may not seem
like a sustainability activity but that’s huge to tell our partners and
potential funders that we have evidence that people want to stay in the
program.”
Looking Upstream
In order to emphasize
a statewide change, many arthritis programs target the upstream determinants of
arthritis care management in addition to the downstream health effects.
“We work on changing
the environments we live in to make it easier for people of all ages and
abilities to get to everyday destinations in an active way, walking or using a
wheelchair,” reiterated Ellings. “We’ve been working on adopting complete
streets policies so that in the future the designs of streets take into account
active transportation. This is a very upstream approach in a rural area. We’re
changing the environment to make it easier to be active.”
Utah is promoting a
similar way of thinking, working with health systems to integrate best
practices into their existing policies.
“We were able to make
some nice breakthroughs with different health care organizations here in Utah,”
stated George. “We’re working with some health systems to build the
infrastructure and the positions to better support programs so they can
actually fund themselves.”
In Oregon, Hinkel and
her team are working on making evidence-based self-management programs a
covered benefit in health plans.
“The national
diabetes prevention program is now a covered Medicaid benefit in Oregon. It’s
also a covered Medicare benefit,” she explained. “This is a model that can be
used to sustain programs. We are in the beginning stages of exploring how this
is implemented and, ideally, this would be expanded to other self-management
programs that are evidence-based.”
A fully integrated
care network with statewide infrastructure to support healthy lifestyles is
beyond the scope of the state arthritis programs but inherent in the program’s
sustainability. Without infrastructure and reimbursement to support the
programs for arthritis management, the programs would cease to exist.
Therefore, integrating sustainable goals and looking upstream is imperative to
the success of the programs.
“A lot of big things
need to happen that are much beyond the scope of this work,” noted Ellings.
Partnering with Community Organizations
The work of the state
arthritis programs would not be successful without the community partnerships.
“We completely rely
on our partners to get our work done,” explained Ellings.
In Oregon, Hinkel
explained how they partner with organizations in areas they identified as
having the highest burden of disease.
“Some of the ways we
do this are by working with our community partners including hospitals,
clinics, senior centers, YMCAs, recreational centers, churches, and area
agencies on aging to ensure that classes are available and that people are
being referred to those classes,” Hinkel continued.
Given the difficulty
of reaching individuals in rural areas, Hinkel said they are leveraging
telehealth tools as well.
“We work with the
Oregon State University extension service to develop an email-based delivery of
Walk with Ease. If people have email access, they can participate in Walk with
Ease,” she said.
The Walk with Ease
program is an evidence-based practice that promotes physical activity as a part
of everyday life.
“Participants get
weekly emails where they can look at videos and other resources,” Hinkel
continued. “The majority of participants in that email-delivered Walk with Ease
program have been from rural and frontier areas.”
The partnership with
Oregon State University has allowed Oregon’s program to expand to areas they
may not have reached otherwise.
Community
partnerships are also helping Washington promote healthier habits. They are
partnering with the State Parks Department to promote the ParkRX program.
“It’s a healthcare
provider prescribing time in a local park to increase physical activity and experience
nature,” Ellings explained.
These community
partnerships do not manifest overnight. It takes time to develop these
relationships and an understanding of mutual benefit.
“Perseverance is
needed before these opportunities can become more sustainable,” George
explained. “Going forward, we are going to continue to meet with different
organizations to see what type of information they need to know in order to be
on board with supporting these programs.”
While many state
arthritis programs are partnering with organizations to promote similar
evidence-based programs, each state is taking a unique approach and leveraging
resources in their community to best help their residents.
“Not all communities
are going to have the same solution to the same problem,” Hinkel concluded.
“It’s those partnerships in the communities who are going to find the best
solutions to the problems that they face.”
No comments:
Post a Comment