November 14-18 - "RURAL HEALTH WEEK" In Alabama
Governor Robert Bentley has proclaimed the week of November 14 through 18 as “Rural Health Week” in Alabama. This recognition is to increase Alabamians awareness of the vital importance of our rural areas and the serious struggle that these areas have in getting and keeping adequate health care.
Many people make the mistake of thinking that since our rural areas have smaller populations, they are not as important as more urban areas with larger numbers of people. This is far from the truth. Rural areas are the providers of the vast majority of materials, resources, and necessities, such as food, that everyone must have in order to survive. Having healthy and vibrant rural areas is important to everyone.
There is a very strong relationship between having adequate health care and economic opportunity. An area without adequate health care is not very competitive with other areas in attracting economic opportunity and growth. Too many young residents of rural areas are being forced to go elsewhere to develop careers following college or technical training.
Perhaps the greatest evidence of the lack of economic opportunity and healthy growth is the fact that 24 rural Alabama counties have smaller populations today than they had over 100 years ago in 1910. In addition, 41 Alabama counties, 39 rural and two urban, are projected to have less population in 2040 than they had in 2010. Alabama's population growth is projected to be the lowest among all southern states, less than one half of Mississippi's growth.
Rural health care does not only provide service for rural residents. Often we or someone that we care very much for will be in a rural area and suddenly be in need of health care. The presence of adequate local health care throughout Alabama provides faster access to care that can be of vital importance to survival.
Additional indicators of the serious need for adequate rural health care include the following:
Alabama has the 3rd highest death rate among all 50 states and the rate is 10 percent higher for our rural residents than urban Alabamians.
Life expectancy is three years less for Alabamians than for the nation - 3 ½ years less for rural Alabamians and as much as nine years less in specific rural counties.
In 1980, 45 of the 54 rural counties in Alabama had hospitals that provided obstetrical service. Today only 16 of these 54 counties still have such service available. The loss of hospitals that deliver babies is greater in the 12 counties comprising the Black Belt Region. In 1980, 10 of these 12 counties had hospitals providing obstetrical service. Today only one county (Dallas) still has this service available.
Only two rural counties (Coffee and Pike) are recognized by the Health Resources and Services Administration as providing the minimal primary care service that is needed.
None of the 54 rural counties provide minimal dental service that is needed for low-income (Medicaid) patients.
None of the 54 rural counties provide minimal mental health service.
Thirteen rural Alabama counties do not have a dialysis clinic in the county.
The motor vehicle accident death rate for rural Alabamians is nearly 67 percent higher than that for our urban residents and more than 120 percent higher than the national rate.
Alabama is economically dependent upon its rural areas and our rural areas must have adequate health care to meet this need. During this special week of recognition for rural health, express your support for measures and policies that can strengthen rural health care in Alabama.
Small Rural Hospitals – Can These Provide Part Of The Solution In Rural Alabama?
Alabama currently has eight counties (Chilton, Cleburne, Coosa, Henry, Lamar, Lowndes, Macon, and Perry) with no hospital. Over the past six years, Alabama has had five rural hospitals close. This is tied with Georgia for the second highest number of rural hospital closings among all 50 states. Texas, with nine, has had the most rural hospital closings. Unfortunately, the fact that more rural Alabama hospitals are experiencing threatening financial difficulties is well known.
Many rural residents and others interested in rural health care are asking if there is a model of health care facility that can provide care similar to that received in a hospital in counties with no hospital. This need is being studied by the Alabama Hospital Association and widely discussed by many others, including the Alabama Rural Health Association.
One possibility is the Freestanding Emergency Department which is a new type of health care facility that is now authorized in Alabama. This is basically a hospital emergency department that is not attached to the hospital. Two requirements for this facility limit its possibilities in meeting the needs in rural counties. It cannot be located more than 35 miles from the parent hospital and must be directed by an Emergency Medicine physician.
A second possibility is the Critical Access Hospital (CAH) which was first authorized under federal law in 1997. A CAH is certified under Medicare conditions that differ from those for acute care hospitals. A CAH cannot have more than 25 inpatient beds; must maintain an annual average length of stay of no more than 96 hours for acute inpatient care; must offer 24-hour, 7-day-a-week emergency care; and must be located in a federally-recognized rural area.
Critical Access Hospitals are encouraged to focus on providing care for common conditions and outpatient care, while referring patients with other conditions to larger hospitals. In return, this type of hospital receives cost-based reimbursement from Medicare, instead of standard fixed reimbursement rates. This can enhance the financial status of many rural hospitals with larger percentages of Medicare patients.
Critical Access Hospitals have not been as financially feasible in Alabama as in many other states. Alabama currently has only four critical access hospitals: Red Bay Hospital in Red Bay, Choctaw General Hospital in Butler, Washington County Hospital in Chatom, and St. Vincent’s Blount in Oneonta. There are 30 Critical Access Hospitals in Georgia and 32 in Mississippi.
Currently, there is a state requirement in Alabama that acute care hospitals must have a minimum of 15 beds. Given current restrictions on inpatient stays, many rural hospitals do not have a daily census of patients that would require 15 inpatient beds. The federal requirement for critical access hospitals is that there be 25 or fewer authorized beds. There is no required minimum number of beds.
There is a federal requirement that a critical access hospital must first be an acute care hospital and then convert to a critical access hospital. A new hospital cannot be opened as a critical access hospital. With Alabama’s requirement that acute care hospitals must have 15 or more authorized beds, a new hospital must be constructed with a minimum of 15 beds, even if there is no need for so many beds.
The current financial crisis among many of Alabama’s rural hospitals may make the time right for Alabama to take a look at our regulatory requirements for acute care hospitals to consider allowing our rural areas to have hospitals with fewer than 15 beds. These facilities could operate as acute care hospitals or convert to critical access hospitals without being required to have more beds than they can realistically expect to need. This could be done as a change in regulatory requirements for acute care hospitals or by authorizing a new type of hospital – the Small Rural Hospital. Either of these approaches would require approximately a year to complete the legal procedure if there is no opposition, possibly more time if there is opposition.
Several states already have rural hospitals with small numbers of authorized beds, including Tennessee and Mississippi. The Johnson County Community Hospital in Mountain City, Tennessee is a 2-bed critical access hospital with 78 employees that operates at a profit when the annual critical access hospital payment is received. The emergency department at this facility treats patients with minor conditions and sends then home, stabilizes patients with more serious conditions for transfer to a larger hospital, or keeps those who should be observed overnight. The emergency department utilizes tele-medicine and an emergency department staffing service. There is a certified rural health clinic affiliated with this hospital. Major services such as radiology, other scanning, laboratory, and therapy is provided. This small hospital even provides obstetrical service.
The Greene County Hospital in Leakesville, Mississippi is currently a 3-bed critical access hospital that is being expanded to seven beds in a county that does not have a single physician, like Coosa County here in Alabama. This hospital has 55 employees and is also operating at a profit. There is a 60-bed nursing home attached to this hospital and it has a certified rural health clinic. The services provided at this hospital are quite similar to those in Mountain City except that tele-medicine is not being utilized and the emergency department is staffed by four advanced practice nurses (Certified Registered Nurse Practitioners) who commute from Mobile, Alabama to provide this coverage. Advanced practice nurses cannot provide this coverage in Alabama, though there is some discussion about considering this coverage to hold down costs during early morning hours when patient traffic is light.
Can small rural hospitals like these provide part of the solution to our rural hospital crisis in Alabama? One thing for certain is that continuing to allow rural hospitals to close is not part of the solution.
Alabama Rural Health Talking Points - 2016
Life expectancy at birth for rural Alabamians is one-half of a year lower than that for urban Alabama residents and 3 ½ years lower than that for the nation. Life expectancy for residents of Wilcox County is 9 years lower than that for the nation.
More than one in every five rural residents is eligible for Medicaid.
Nearly one half (47%) of all rural children are eligible for Medicaid.
14 rural counties have between 10 and 16 percent of all households with no vehicle.
Only two of Alabama’s 54 rural counties (Coffee and Pike) are not entirely or partially classified as primary care shortage areas. There are 4.1 primary care physicians per 10,000 population in Alabama’s rural counties compared to 7.9 for urban residents.
All of Alabama’s 54 rural counties are classified as dental shortage areas for the delivery of service to the low-income population. Only Shelby County and a portion of Madison County are not currently classified as dental care shortage areas. There are 2.7 dentists per 10,000 population in Alabama’s rural counties compared to 5.5 for urban residents.
Alabama currently has three counties (Coosa, Greene, and Lowndes) with no full-time dentists in the entire county. Coosa does not have a physician in the entire county.
All of Alabama’s 54 rural counties are classified as mental health care shortage areas for providing mental health care to the entire or low-income populations. Only Madison County is not currently classified as mental health care shortage areas.
In 1980, 45 of Alabama’s 54 rural counties had hospitals providing obstetrical service. Today only 16 of the 54 counties offer this basic service. In 1980, 10 of the 12 Black Belt Region counties had hospitals providing obstetrical service. Today only one still offers this service.
More than ¼ of all births to rural Alabama women involve mothers who received less than adequate prenatal care during their pregnancy.
13 rural Alabama counties do not have a dialysis clinic.
7 rural counties (Cleburne, Coosa, Henry, Lamar, Lowndes, Macon, and Perry) do not have a hospital.
Having healthy population growth is a basic requirement for attracting and keeping adequate health care services. Between 1910 and 2010, 24 of Alabama’s 54 rural counties actually lost population. 39 of the 54 rural counties and 2 of the 13 urban counties are projected to lose population between 2010 and 2040.
Obesity is a major risk factor for numerous serious health conditions. There are 10 rural Alabama counties with between 40 and 49% of the adult population being obese.
The mortality rate for rural Alabama residents is over 10% higher than that for urban residents.
The chronic lower respiratory diseases mortality rate for rural Alabama residents is nearly 38% higher than that for urban residents and nearly 57% higher than that for the nation.
The motor vehicle accident mortality rate for rural Alabama residents is nearly 67% higher than that for urban residents and more than 120% higher than the national rate.
ARHA Announces Drive to Establish Student Chapters
Funding For New Student Chapter Available
Your Alabama Rural Health Association has received funding that will be used to establish new chapters of the Alabama Student Rural Health Association on campuses of Alabama's public and private colleges, universities, and community colleges.
Student membership in ASRHA is a bargain at a cost of only $25 per school year. Included in this membership is annual membership in the campus ASRHA chapter (on campuses with ASRHA chapters), a full annual membership in the Alabama Rural Health Association, and a school year student membership in the National Rural Health Association. For additional information on student memberships and benefits, select "Join ARHA".
Student members can also seek election as an officer in their campus chapter or seek election to the student position on the ARHA Board of Directors.
Campus ASRHA chapters will have regular meetings during which information of value to students pursuing health related careers will be provided. A listing of possible program topics and speakers is currently being developed. Chapters will also conduct health related community projects. Each campus chapter must have a faculty/staff sponsor to oversee the chapter activities.
To assist in establishing campus chapters of ASRHA, the following are being sought:
Students with an interest in helping to establish a chapter at their school.
Faculty/staff at Alabama schools interested in serving as a campus sponsor.
Potential speakers on topics of interest to health related program students.
Please contact ARHA to assist with this program or if you have questions or recommendations.