Supporting Medical and Social Needs: Reflections on Care for Patients in Rural Communities

Supporting Medical and Social Needs: Reflections on Care for Patients in Rural Communities

By Jake Tanumihardjo

  With a recent move from rural Iowa to Chicago and getting to know each Bridging the Gap team over the last few months, I have been reflecting on many of the challenges organizations face as they work to support medical and social needs for patients in rural communities.

  When I moved to southeast Iowa, I learned directly from providers and patients about ways in which unmet needs impact health in our rural community. Patients reported both the lack of transportation options available and massive distances that they needed to cover. One mother had to drive four hours every other week to take her child to a psychiatrist to ensure her medications could be refilled. In addition to the barriers patients faced, our own health system had to contend with different rural challenges. The hospital’s Community Health Needs Assessment highlighted recruitment and retention as a local issue. The hospital had difficulty attracting a child psychiatrist to the area thus creating a major access issue. These recruitment challenges also impacted our ability to sustain some innovative programs. For example, the hospital developed a health coach program to help address non-medical needs of patients. After a few months, the program lost two of its three coaches. With no local university and a dearth of local talent, we lacked a strong network to recruit additional health coaches in our area. Unable to refill the positions, the program was shut down.

  With these rural challenges in mind, it has been encouraging to see the programs that rural Bridging the Gap sites are pursuing. Recognizing the challenges of rural geography and the scarcity of some resources, Bridging the Gap sites in rural areas are trying new strategies to identify social needs and ensure that patients can access the support and resources they need. For example, St. Mary’s and Clearwater Valley Hospitals and Clinics (SMH-CVHC) have developed relationships with local and state food banks and programs to reach community residents through co-located community health workers at food distribution sites. Western Maryland Health System (WMHS) has engaged over 800 community residents through their “Hometown Healthy Partnership”, which aims to address geographic and economic disparities through outreach to community residents, screening for social determinants, and events that convene community resources and programs to support healthy living with chronic conditions. Marshall University works with Mountain Comprehensive Health Corporation (MCHC) in Whitesburg, KY. MCHC extends their care of patients beyond the clinic walls through the “Farmacy” program in collaboration with a local Farmer’s Market to offer patients a weekly prescription for fresh produce. The program has both patient-level and community-level benefits, improving the health of individuals while also strengthening economic opportunities for local farmers.

  These projects demonstrate that though rural communities face unique challenges, there are strong community efforts out there to help address the concerns of patients and their families. SMH-CVHC, WMHS, and MCHC offer creative examples of the multi-sector collaborations necessary to help address unmet social needs. I look forward to ongoing opportunities to continue learning from the community within this initiative as we continue to identify what works best to support patients with type 2 diabetes.

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