Unite Us Live: Closing the Rural Health Gap

Good afternoon, everyone. Thanks so much for joining us today. I’m Katie Keating, vice president of solutions engineering here at Unite Us, and I’m thrilled to be here with you all to chat about one of the most pressing topics on the mind of everyone across government and health care right now, and that is rural health. States are actively preparing for or at this point in the process of launching their rural health transformation programs, aligning with the CMS goal to deliver meaningful outcomes for their communities. While there are proven models like Missouri’s Torch program, which we’ve been proud to support here at Unite Us, no two programs will look exactly the same.

Meeting this challenge isn’t easy. It’s inherently complex work, but there’s a great opportunity with $50,000,000,000 in investment in rural health care to create the potential for transformative change in how care is delivered and measured. And that’s what makes this moment especially timely as CMS is set to begin evaluation and audits as soon as August, which is now less than four months away. At Unite Us, we partner closely with state and local leaders on exactly these challenges, connecting health and community based services and making sure the data is there to not just support activity reporting, but evaluation of impact.

So today, I am thrilled to be introducing my colleague, Doctor Lisa Patton. Doctor Patton brings deep expertise across federal policy, program implementation and evaluation, and rural health from leadership roles at the federal level to advising on national quality measurement and leading large scale evaluation across substance use and rural health programs.

Welcome.

Thank you so much, Katie. Hi, everyone. It’s great to be here with you all today.

So Doctor Patton, I’m gonna jump right into it as we only have twenty minutes today. You have really seen this work from every angle, so we’re really looking forward to your perspective today. Let’s start from the fact that no one is starting from scratch here, but what are some of the lessons learned from past programs that states should be thinking about as they launch these new initiatives and gear up for rapid program evaluation?

Thank you, Katie. So having been in the federal government when really large scale infusions of dollars went out to address the opioid epidemic about ten years ago, there were a lot of lessons learned. So I think that states have been very ambitious and that’s what we wanna see in their goal setting and their objectives, and really driving transformation in a variety of ways, whether it’s workforce enhancement, using new technologies and innovations, mobile health, using telehealth advantageously. There are so many ways to go about this.

And so I think in terms of lessons learned, we know that people start out with the greatest of intentions. And really, when that implementation starts to unfold and especially with this timing for reporting coming up, we wanna make sure that states have all the support they need to really thoughtfully implement and get those services out to rural communities. I think this is an incredible chance for people, grantees, and states to be able to address challenges that have often been funded more so in urban and suburban settings.

And so for those states that have really been able to amplify the rural voice of late, they’re really on target now, they’re moving things. And so we really wanna be able to support them as well as those states that may not have taken such a focused look at these issues that are at hand for now.

Yeah. I think that when we were evaluating the applications, of course, we saw a wide variety of sort of thought that went into them and states that seemed prepared to really start reporting right away versus folks who had a little bit more of a vision than understanding what they were gonna measure.

Yeah. And so in some states, those rural partnerships run deep, and they’ve really been reflecting on what those individual rural communities look like and the challenges they face. I think one of the issues is that people often think of rural communities as very homogeneous and that’s not often the case. And we really have to understand what are the baseline data telling us, what are community residents telling us, where are those challenges, and how can they best be addressed with this ample funding?

Yeah. I think that as you are talking about that, one of the things, we did a little LinkedIn poll before this as well. And you hit on one of the key concerns right there, which is around workforce challenges and not being homogeneous. So when you think about some of those particular challenges in rural health, what are some of the things that come to mind for you?

Something that I’ve actually been tackling for a long time, I’ve been working almost exclusively in rural health for about the past six years. But one of the challenges that we’ve seen for quite some time is the aging demographic of providers themselves. And rural communities really perhaps bore more the brunt of this during the pandemic workforce exodus. But a lot of older providers are sort of aging out, looking forward to retirement. And so that institutional memory, that legacy that they bring to this work, having treated multiple generations of families, knowing friends, neighbors, fellow churchgoers, and the chronic conditions they’re facing, a lot of that kind of important information is now being lost.

And we see it even now with older providers wanting to move into different areas of their lives. And so I think the workforce expansion is a real tricky piece. Building on the loosening of the telehealth regulations that have occurred, that’s gonna be a key component to meeting some of these needs. Really remote patient monitoring, figuring out how to help folks manage their own care or with the assistance of caregivers, family members, peer support specialists, for example. How do we adequately tap into the variety of resources that rural communities have on hand, and people who really wanna be helpful to friends, family, neighbors?

And so I think there are a variety of technology supports that can be in place. And then I really like the way we’re trying to incentivize new workforce, working with community colleges, working with other allied health professions to get more resources out into these communities who will stay. And helping that to be a sustainable part of these grant fundings is critical to look at.

Yeah. I love that look at who else can be a caregiver. We know a lot of times, when you and I first worked together, you taught me about the sandwich generation and folks who are both caring for aging parents and children at the same time. One of the things I’ve seen too is looking at the expansion of the workforce is really considering other folks in the community who can help. So community health workers, doulas for maternal health programs, and how we can expand that aperture of what care really looks like.

Yeah. Absolutely. And I think this is a real opportunity to be innovative about that, to perhaps look at building out skills in ways that we haven’t had the chance to do before, and bringing along people because even part time resources can be a big boon for a rural community where there may not be a tremendous need in a specific area. But a few part time folks can really make all the difference in what care looks like and what those health outcomes are for those residents.

Yeah. When we think about outcomes, one of the things that is really focused on in these applications is really ensuring sustainability going forward. And so when you think about how you’ve supported implementation and evaluation in the past, when you think about this sort of five year horizon, we need to sort of get the money out and get acting short term. But how do we also make sure that we are looking at the long term as a goal?

Yes. And one of the conversations as a federal HHSer myself, the conversation we’ve always had with the grantees around this is think about sustainability from the very beginning. What do you hope to leave behind? What are the infrastructure elements, staffing, data capacity, reporting? This is a tremendous amount of money to steward, and states do a great job at that. But this is going to be a lot of moving parts and figuring out how to distribute those funding streams, how to ensure that you’re getting those short term, intermediate, and long term goals met, and then being able to pull back and say, well, maybe we wanna shift funding in a particular way.

And so I think it’s really about this being a living, breathing project, where there’s a lot of hands on and thoughtful communication about what is working, having those stakeholders in the communities tell you we’re seeing these great advances or this really isn’t working for us. So we need a mobile health clinic. We need a kiosk because broadband is an issue here and we can’t be assured that some of our residents are comfortable with the technology. Let’s get them in here to the central location, whether it’s a library parking lot or something like that, to ensure that they can get their needs met.

And so I think it’s really about focusing on the nuances of those residents that we’re trying to serve and what makes sense for them, then tracking those outcomes and not being afraid to say something isn’t working. I think we have to be willing to do that and try some different approaches.

I think that’s important to talk about because so often when we think about a new model, it really is a hypothesis and a test, and we need to make sure we’re able to respond to what we’re learning real time.

Yeah. And I’ve done a lot of work with social determinants of health and how communities can be successful in addressing some of those key drivers of health. And it really does take that understanding of what’s most critical in a particular setting. And so if that legwork hasn’t been done in rural, then now is the time, right? Find out what’s most important to those residents and figure out how to really begin to implement around that.

Yeah, we were really proud to see the Missouri Torch work called out in the NOFO because Unite Us as the platform has supported Missouri Torch in really bringing connected community care into the sustainability model. And what we found there is that of course paying for those wraparound services are really important in sort of getting people to optimal outcomes.

Mhmm.

That program has been doing evaluation, which has shown that they’re having some amazing results from having almost a 20% achievement in controlled blood pressure, which we know can lead to reduction in negative outcomes from death by stroke or heart disease. And then as well, one of the things that I found particularly interesting is that they’ve also raised almost twenty percent the ability to get people connected to behavioral health services after emergency department visits.

That’s important. I find, yeah.

Yep. And we know that can really lead to much better outcomes for folks. And so I love that they are taking that as they’re learning it and continuing to expand as they think about how to expand that across the state.

Yeah. And I’ll just share a quick example. We did a study, when we worked together a few years ago, and the setting will remain nameless, but it was a hospital system. And providers were having trouble really driving down some of those chronic conditions, blood pressure, diabetes, what were those numbers looking like, and they couldn’t quite figure out where the gap was.

And what they discovered is that a lot of their patients were not able to fill their prescriptions. And so they would come into the doctor, they would get the prescription, they would have a great visit, and then they came back, there was no shift in any of their indicators. And so what they did, that hospital setting ended up putting in a program with a pharmacy that was nearby so that they could actually real time provide the prescription and then have it delivered and get it to the person before they even left that primary care setting.

And so those kinds of deeper understandings of those nuanced challenges, again back to caregivers, so if a person relies on their caregiver to ensure they’re taking their medications on time and then something happens to that caregiver, they get pulled off to address another situation, where does the person go? So having that backfill, having that variety of peer support or other emergency care situations can be very helpful.

Yeah. I think it is one of those beautiful examples of what it means to really do holistic care and understand all of the things that go into a person’s life or what they’re able to do. We have another example of where sort of tying fruit support to people in a diabetes program really helps to control A1C levels and that that is an essential linkage just as much as getting your prescription is.

Yeah. Absolutely. And I know that many of the rural health transformation plans are focused on food as medicine and different food insecurity issues. And I think that’s so important, especially for our rural communities, and figuring that out and helping people get the best sources of food and better understand nutrition for them.

Yeah. I love the idea that in rural health, it’s also like bringing things to people. So transportation might be a barrier for getting to an appointment, but it’s also a barrier for food coming to you or your prescription coming to you. And can we make that happen instead of someone having to go out and take that next step?

Yeah. And this is also an opportunity to address many of those food deserts that can be found in rural areas quite often.

Yeah. When you think about some of the opportunity here, when you’re looking ahead at the end of this five years, what are you most optimistic about as like what states can do to really be improving rural health?

Oh, I’m optimistic about a lot, Katie. I’m so excited.

Take a whole list.

I know. I’m so excited about this. I really think in many of the states, there’s a tremendous push to open up, expose health care careers as an option for middle schoolers, high schoolers, moving them into community college programs that are gonna be beneficial to them, their families, and their communities. So these may be rural residents who wanna stay in rural and they just don’t see a career path that’s gonna be fruitful. So I think this is a great chance to make that a reality for people so that some of that youth exodus from rural communities may be lower, or bring people back.

People see an opportunity for a career that they didn’t think was gonna be possible for them in their rural area. So I think the workforce is really gonna be pivotal and that’s also an area where we can build on them generationally and have that long term sustainability, because we know that when people see those careers as a path forward and it leads to positive generational outcomes, you’re gonna have a really nice feeder program then and people who wanna be involved and helping out their communities in all those ways.

I think technology is the other big play here for us. Again, I’m so excited that we’re still able to use telehealth so extensively to deal with all of these conditions and also the focus on prevention. Moving into that, prevention has always been something we’ve tried to focus on. The federal government has tried to focus on it. It’s tough because of the indicators around it and how do you know the cost associated. We’ve gotten much better at looking at those costs. But I think now the real push toward prevention, the use of much more technology innovation, these are gonna be long standing, positive outcomes for rural communities as we work through this program over the next few years.

I think that’s something important is that it’s not just sort of infrastructure for today. It’s how do we build that pipeline that pays off years from now as well. Because five years is, depending on who you talk to, both a short and a long time frame, but it’s really taking that investment to set yourself up for success going forward.

Yeah. Absolutely. And again, as we sort of started this conversation, there are states whether by necessity or just great thinking have been focused on rural for quite a while, right? And there are other states, and I’m thrilled to see them coming in as well, that this may be new territory for. But again, we can make changes together that are gonna have long lasting impacts. And so all the state health outcomes are gonna be positively affected by this. We’re gonna see change across the population level. And that is just, again, we overuse unprecedented around this funding source, but it truly is.

And again, I grew up in rural Tennessee. I have family, many, most of my family remains there. And so I’ve navigated healthcare challenges for them. And I see the changes that have and have not occurred since I moved away.

So just in our final minute here, I just wanna thank you so much for joining us today. But as your expertise as an evaluator, any last minute advice for states as they prepare to sort of report out on what they’ve been doing so far?

Be brave, be innovative, and listen to your rural partners. Listen to them, engage the community residents, and engage those stakeholders. This is just a wonderful opportunity to bring everything to bear. And again, look at those unexpected pockets of workforce opportunities. I think there’s a lot of untapped resources that we can look to.

Well, thank you so much for your excellent advice and for joining us today. It was great seeing you on a personal note and I hope you have a great afternoon.

Thank you, Katie. Great to see you too. Take care.

Been able to sit and chat for a while.

No. I know. This is so nice. But now I’m gonna have to come