The challenges facing rural health organizations, even on a normal day, are many — workforce shortages, gaps in services, financial strain, and uninsured patients. COVID-19 places one more burden on these health care entities.
But, rural communities also have a track record of showing resilience, adapting evidence-based practices for their unique context, and innovating to overcome physical, geographic, and structural challenges that impact health care delivery and general well-being in rural areas.
While no doubt a challenge, the COVID-19 pandemic, too, provides an opportunity for rural health collaboratives to highlight their resiliency.
As part of ongoing efforts to support Federal Office of Rural Health Policy grantees, Georgia Health Policy Center technical assistance providers hosted a series of virtual peer learning opportunities for current grantees of the Rural Health Care Services Outreach Program, Rural Health Network Development, Small Healthcare Provider Quality Improvement, and Delta States Rural Development Network programs. The series provided the space for small group discussions on challenges, early learnings, and adaptations to their rural health and public health program implementation strategies during the COVID-19 pandemic in six topic areas.
- Community Health Workers: Providing Social Support in a Virtual World
- Data Collection and Evaluation: Adjusting Approaches During a Pandemic
- How to Deliver Effective Virtual Trainings and Meetings
- Peer Support Services and Recovery Supports during a Pandemic
- Using Telehealth in New Ways to Meet Emerging Needs
- Working with Schools: Strategies to Support the Community
Across sessions some common themes emerged, including widespread technology barriers in many rural communities (lack of broadband, inconsistent cellular service, and limited comfort with technology) that complicate the delivery of remote services and data collection efforts. However, grantees report the pandemic provides an opportunity to rapidly build their own capacity, that of providers, and of patients and clients.
Community Health Workers
Community health workers (CHWs) are often a bridge between the community and health care, public agencies, and social service organizations. They are of the community and their impact is rooted in the deep rapport and trust that they build with community members and program participants. CHWs work in clinics, as well as directly in the community (e.g., in clients’ homes, schools, places of worship, and work).
During the pandemic, the increased role of the CHW as a social support and as a lifeline for connecting clients to resources is apparent. CHWs have been working diligently through technologies and old-school methods to stay connected during this time of social distancing.
They are providing information about services and supports available to families and individuals, including food pantries, COVID-19 testing, housing supports, and mental health resources.
Challenges: In addition to limited access to technology and internet or cellular connectivity, some clients are reticent to meaningfully engage by phone or virtually. Getting clients to answer calls from unknown numbers is a challenge. Additionally, significant personal challenges (e.g., food security, mental health issues, and increasing homelessness) may be more pressing concerns to clients than chronic disease management, but they also provide an opportunity for CHWs to strengthen relationships with nontraditional partners to identify those in need, pool resources, and provide a safety net.
Innovations: Like other aspects of health care provision in the pandemic, CHWs are playing a role in telehealth visits. To remain embedded in the community, CHWs are purchasing pay-as-you-go phones and setting up Google Voice to have a dedicated local phone number. They are also reaching out to other agencies that are in touch with their clients (e.g., schools and food pantries) to check-in when clients are not answering calls.
Changes to the way people are working also have an impact on data collection and utilization for program evaluation, quality improvement, or needs assessments.
Challenges: The steep drop in the numbers of individuals coming to clinics, hospitals, and other service sites for regular care has created a real challenge for capturing many of the clinical and biometric measures that are a focus for many grantees. Further, the pandemic has necessitated that some entities deliver programs and services in conjunction with partner organizations, sometimes having to rely on other entities for primary data collection.
Innovations: Using old-school methods, like telephone and mail outreach, have been effective for connecting with patients to collect data. Others report successfully using text messages, emails, FaceTime, and Google Duo to connect with clients.
Some grantees have capitalized on the remote environment to expand organizational capacity by shifting to centralized, cloud-based data systems, instead of hard copies used in the office. The pandemic has also offered opportunities for engagement of new, nontraditional partners (e.g., convenience and grocery stores) as a way to connect with people where they are known to go, since they are not able to come to clinics as they normally would. Lastly, some rural entities have shifted their data focus from individual patients and clients to partner organizations that may be more accessible during this time to gain a better understanding of the current local landscape, do some mapping of community resources for support of local pandemic response, and inform how they may serve patients differently in the future.
Peer Support Services
Peer support is a program approach that depends upon expertise from a person with lived experience and is driven mainly by in-person contact. Grantees with peer support programs (primarily focused on mental and behavioral health) grapple with questions related to maintaining connection, establishing trust and rapport, and how to engage patients. But, early reports indicate that people are engaged and talking over common, accessible platforms, like Zoom and Facebook Live.
Challenges: Similar to CHWs and other service providers, technology and connectivity are major challenges.
Innovations: Text messaging has been a good way to make initial contact. Consenting has been effective through taking screenshots of texts and mailing documents. Innovative outreach approaches through health departments, schools, CHWs, and partner organizations, like food banks, netted some new virtual clients. Rather than having direct contact with incarcerated clients, some peer service providers are working with corrections officials and probation officers to provide some continuity of service. Peers are increasing the number of check-in calls with clients and scheduling a time to check-in when the client can be in a private space, but have observed that many clients are lonely and grateful for the chance to talk with someone.
Policy changes around telehealth have allowed inexperienced rural health care entities to experiment and learn without penalty or commitment to expensive equipment. Grantees describe using platforms, like Zoom and Doxy.me, as “jumping into the baby pool” with positive results.
Challenges: A rapidly changing environment required organizations to fast forward their telehealth initiatives during COVID-19. Limited internet connectivity and lack of experience with telehealth platforms were common challenges for both rural patients and providers.
Innovations: Entities confirm implementing virtual visits by both phone and video with innovation occurring around providing access to cellular and internet connections. Many local retail (McDonald’s), government (schools and libraries), and health care (hospitals) establishments opened their parking lots for use as hotspots. In Ohio, the government provided a map of cellphone towers with free access. In other localities, school districts working with internet providers to give free access to school students for academics and shared it with other residents for health visits. Using the same virtual platforms already in use through schools further facilitates adoption and transition to virtual service provision.
Additionally, therapists and community health workers described riding on school buses delivering meals to make connections with clients and promote use of telehealth services. Some clinics provide curbside visits or loan I-pads for patients to use in their vehicles to complete virtual visits.
With home as the office for providers using telehealth, grantees shared that it allows for flexibility in schedules, opening up more evening appointments when this works best for provider and patient.