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This field scan is a contribution to Thrive Rural, specifically intended to provide an understanding of the state of relevant health fields in the United States, namely public health and health care. It is a complement to the parallel scan of rural development field practice and trends, released simultaneously. This scan aims to address the overarching question: What are the potential pathways of influence for public health and health care to foster more prosperous, equitable and sustainable communities across rural America?
Through an expedited systematic review, this scan draws from practice literature in the public health and health care fields on their current state and evolution, including literature that captures convenings and agenda-setting among field leaders. Key informant conversations were conducted with select field leaders in public health and health care to complement existing research and documentation. This scan begins with background on the fields of public health and health care, and an overview of prevailing theories and frameworks that guide practice in these fields. That leads to a synthesis of current field trends and change strategies across public health and health care, and the scan concludes with findings on drivers, or levers, for change that can influence trends and change strategies within and across fields.
Thrive Rural is an ambitious effort to create a shared framework and understanding about what it will take for communities and Native nations across the rural United States to be healthy places where everyone belongs, lives with dignity, and thrives.
Introduction
Thrive Rural is an ambitious effort to create a shared framework and understanding about what it will take for communities and Native nations across the rural United States to be healthy places where everyone belongs, lives with dignity, and thrives.
This field scan is a contribution to Thrive Rural, specifically intended to provide an understanding of the state of relevant health fields in the United States, namely public health and health care. It is a complement to the parallel scan of rural development field practice and trends, released simultaneously. This scan aims to address the overarching question: What are the potential pathways of influence for public health and health care to foster more prosperous, equitable, and sustainable communities across rural America?
Through an expedited systematic review, this scan draws from practice literature in the public health and health care fields on their current state and evolution, including literature that captures convenings and agenda-setting among field leaders. Key informant conversations were conducted with select field leaders in public health and health care to complement existing research and documentation.
This scan begins with background on the fields of public health and health care, and an overview of prevailing theories and frameworks that guide practice in these fields. That leads to a synthesis of current field trends and change strategies across public health and health care, and the scan concludes with findings on drivers, or levers, for change that can influence trends and change strategies within and across fields.
Key Definitions
- Rural: The National Center for Health Statistics (NCHS) defines a rural area as a county or county-equivalent with a population less than 50,000. More specifically, “nonmetro” counties include a combination of “open countryside; rural towns (places with fewer than 2,500 people); and urban areas with populations ranging from 2,500 to 49,999 that are not part of larger labor market areas (metropolitan areas).”
- Public health system: This includes public health governmental agencies and partners (hospitals, health care providers, nonprofit organizations, extension agents, volunteers).
- Public health paradigm: This paradigm “employs a spectrum of interventions aimed at the environment, human behavior and lifestyle, and medical care” with a primary focus on populations and an emphasis on disease prevention and health promotion for communities.
- Health care sector: In the U.S., this includes clinicians, hospitals, health care facilities, insurance plans and purchasers of health care services; in configurations of groups, networks, and independent practices; can indicate public or private; includes regulators; and may be referred to as the “health care delivery system” or “health care system,” which can include contractually integrated organizations (e.g., accountable care organizations).
- Medical paradigm: This paradigm “places predominant emphasis on medical care,” with a primary focus on individuals and emphasis on disease diagnosis, treatment, and care for individuals.
Background
A brief examination of the history of public health and health care fields more generally, as well as in rural communities in particular, sheds light on the current landscape of the fields and lays the groundwork for considering trends and levers for change moving forward.
Health Care
Access to medical care has been and remains a primary focus of the U.S. health care sector. Prior to World War II, hospitals were largely private and funded by philanthropic giving, which limited access to health care for individuals in lower-income, rural areas of the U.S.
In 1946, the Hill-Burton Program (part of the Hospital Survey and Construction Act) was implemented to increase nonprofit and local government hospital capacity, including in rural counties and for those who might not be able to afford care. Subsidies from this program played a major role in the construction of new clinics and expanded access to care among nonprofit and public hospitals from 1946 to 1976, while the number of for-profit hospitals declined.
Hill-Burton set multiple precedents for community service assurance, shaping the ways that organizations and entities receiving federal health care funds provided care for underserved populations, many of which still exist today. For example, in 1963, Hill-Burton’s separate-but-equal provision, which allowed racial discrimination in publicly supported hospitals as long as there were equivalent facilities in the same geographic area available for every race, was found unconstitutional. As a result, in 1965, when Medicare was established, hospitals desegregated to meet the eligibility criteria to receive federal funding.
In 1975, the suite of federal health care policies established through Hill-Burton were rolled into the new Public Health Service Act. This act continued to require that health care organizations and programs receiving federal funding care for those who cannot afford it (with hospitals sharing costs for patient care). However, financing for the construction of health clinics, a central feature of Hill-Burton that contributed to increased access for underserved populations, ended in 1997.
One response to rural hospital closures in the 1980s and early 1990s was the creation of the Federal Office of Rural Health Policy (FORHP) in 1987 to advise the U.S. Department of Health and Human Services (HHS) on health care issues impacting rural communities. In 1997, efforts to support hospital viability in rural areas included the designation of Critical Access Hospitals (CAHs), whose qualifying criteria emphasize providing outpatient and emergency care. The concurrently created Medicare Rural Hospital Flexibility Program (Flex Program) is intended to support CAHs, tying their eligibility for receiving Medicare reimbursements to the creation of state Rural Health Plans.
The rural health care sector’s safety net also includes rural health clinics (RHCs), certified by the Centers for Medicare & Medicaid Services (CMS); federally qualified health centers (FQHCs), which include some Tribal providers; and free clinics. All of these are intended to serve patients who “live in medically underserved or health professional shortage areas, have low incomes, are uninsured or on Medicaid, live in rural areas, and/or have other characteristics that make it difficult to access care.”
Public Health
Assumptions prevail that public health practices and policies developed for urban settings can be translated into rural settings, even though they are historically understudied in rural contexts. Public health as a field was initially an urban phenomenon, at a time when rural areas were associated with healthy living. However, the emergence of unique community-level public health issues in rural communities (e.g., hookworm in the late 1890s) shifted that understanding.
Up until the 1930s, when other sources of federal funding became available, local health departments in rural areas were often funded by private foundations, with work done by district nurses who focused on systematized sanitation efforts and educating health professionals and the public. After sanitation efforts helped stem disease spread, rural public health departments shifted focus to the delivery of basic health services, due to a lack of available care. This clinical focus for public health continues in rural areas, along with a focus on environmental health.
The persistence of the myth that rural areas are inherently clean and healthy has influenced funding and policy attention. Scholars note that this assumption has led to rural public health being deprioritized, with consequences for addressing needs in these communities. They call for appropriate funding levels for rural public health, a public health workforce trained in rural-specific and population-based practice, increased understanding of rural public health needs, and rural-specific models of practice, and practice-based research in rural communities.
Newer Frameworks for Public Health
Over the past decade in the field of public health, leaders have called for addressing health disparities by shifting from individual-level behavior changes to a focus on the social determinants of health or the “upstream” drivers of health. The public health field has, therefore, been experiencing some movement from health belief model and social cognitive theory, which focus on individual-level public health interventions, toward the social ecological model that focuses on contextual factors influencing individuals.
The transtheoretical model of change increasingly accompanies newer frameworks for health and expands options for interventions. In some practice circles, the conflict perspective now operates alongside the socioecological model. In this case, practitioners incorporate an understanding of how power dynamics shape the conditions and opportunities for individuals and communities to be healthy.
These shifts are reflected in new and evolving frameworks for practice, including the World Health Organization (WHO) framework for the social determinants of health, Public Health 3.0, and a revised version of the 10 Essential Public Health Services. These shifts in understanding health and equity have also informed an expanded range of practice strategies to affect change for the health of all people, such as Health in All Policies.
Social Determinants of Health
The WHO defines the social determinants of health (SDoH) as “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.” Factors like socioeconomic status, education, physical environment, employment, and social support networks can all affect people’s access to quality goods and services, such as health care, and ultimately impact health.
Emerging work suggests that toxic stress associated with social disadvantage, socioeconomic inequality, and racial discrimination can lead to epigenetic changes, which affect people’s ability to fight disease or stay healthy and can be passed to future generations.
Public Health 3.0
In 2016, the U.S. Department of Health and Human Services released Public Health 3.0: A Call to Action to Create a 21st Century Public Health Infrastructure – a white paper calling for an enhanced scope of practice for public health. Public Health 3.0 “leverages multi-sector collaboration to address the non-medical care and social determinants in communities, with local public health entities at the core, serving as Chief Health Strategist in their communities.”
The core functions of Public Health 3.0 include:
- Strong leadership and workforce
- Strategic partnerships (across public and private sectors)
- Flexible and sustainable funding
- Timely and locally relevant data, metrics and analytics
- Enhanced foundational infrastructure
10 Essential Public Health Services
Originally developed in 1994, the 10 Essential Public Health Services framework has been widely used in public health, influencing leadership, practice, curricula in educational programs, and accreditation standards.
In 2020, the de Beaumont Foundation, the Public Health National Center for Innovations, and a task force of public health experts released a new version of the framework and statement:
“The 10 Essential Public Health Services provide a framework for public health to protect and promote the health of all people in all communities. To achieve equity, the Essential Public Health Services actively promote policies, systems, and overall community conditions that enable optimal health for all and seek to remove systemic and structural barriers that have resulted in health inequities. Such barriers include poverty, racism, gender discrimination, ableism, and other forms of oppression. Everyone should have a fair and just opportunity to achieve optimal health and well-being.”
Health in All Policies
Health in All Policies (HiAP) is a collaborative approach to improving the health of communities by incorporating health, equity, and sustainability into decision- and policy-making across sectors and policy areas.
Grounded in social ecological theory, HiAP is a framework for action to address the social determinants of health. Internationally, recognition of the importance of intersectoral action for health dates back to a 1978 declaration adopted at the International Conference on Primary Health Care.
In 2009, the Partnership for Sustainable Communities – a collaboration of the Environmental Protection Agency, Department of Transportation, and Department of Housing and Urban Development – was one of the first initiatives recognized as adopting a HiAP framework in the U.S., followed by the State of California’s Health in All Policies Task Force in 2010.
Community Resilience Framework
This framework is defined as “a measure of the sustained ability of a community to utilize available resources to respond to, withstand, and recover from adverse situations” and has emerged as a way to understand factors and mechanisms influencing outcomes in rural communities as well as disparities between rural communities.
The framework ties community viability to “the labor and health capacity of its residents,” with proponents arguing that “the more diverse and interconnected a community is across businesses and households, the greater its resilience to shocks.”
For example, an individual’s loss of income is tied to a household’s reduced wealth, which affects determinants of health – such as housing, transportation, and nutrition – and long-term health and employment outcomes. Ensuing population decline contributes to diminished capacity to sustain health facilities, quality education, and retention of “the most educated and capable youth and adults,” leading to whole-community impacts.
Case studies support the idea that community wealth and resiliency emerge from multiple underlying mechanisms, citing health (and education) as vital to community adaptability and attracting new residents.
Trends in Public Health and Health Care
Although public health and health care field catalysts and champions are advancing the newer frameworks like Public Health 3.0, Health in All Policies, and Triple Aim, standard practice still emphasizes individual-level health behavior and treatment as opposed to the systemic, economic, social and political factors that impact health. Within the public health and health care landscape of standard practice and newer frameworks, the following additional trends and themes are also emerging in practice. These trends can be harnessed across health-related fields to advance prosperous, equitable and sustainable communities across rural America.
Emphasis on Community Engagement. Public Health 3.0 and the revised 10 Essential Public Health Services call for increased community engagement to create the conditions for health for all. Community engagement entails structured mechanisms for community members to have a say in the programs and policies that impact their lives. Community engagement in the development, implementation and evaluation of programs and policies is widely identified as a key factor in efforts to achieve health and well-being for community members; the approach is supported by multiple federal, state and local health and public health agencies, academic institutions and community partners.
The ACA provides some incentives for community engagement – for example, the requirement that 501(c)(3) nonprofit hospital organizations conduct community health needs assessments (CHNAs) to maintain their tax-exempt status. This provision requires that nonprofit hospitals partner with public and community health programs to conduct CHNAs and develop strategies to address the identified needs (community health improvement plans (CHIPs)). This provision has influenced practices in the health care sector around community engagement and community collaborations to make health improvements. Organizations such as the WHO and Centers for Disease Control (CDC) have centered community engagement in their models; these organizations’ ability to attract and leverage funding has helped a plethora of community engagement frameworks, tools and research emerge that use health and health equity contexts. While not rural-specific, the emphasis on community engagement in public health policies and practices is transferable to rural settings.
Evidence- and Data-Driven Decision-Making. The health care sector has benefited from increasing rigor in data gathering and quality reporting, as part of a broader trend toward evidence- and data-based decision-making in public health and the implementation of value-based frameworks. The Value Agenda includes “build an enabling information technology platform” as one of its six components. Methods have improved from perception-based interventions coupled with limited data to more rigorous methods. For example, hospital quality used to be measured by process compliance and surveys of patient experience, but evaluation now includes more objective and improved measures, such as health outcomes, costs, and quality of care via social network analysis.
The fields of public health and health care have also been influenced by the expanded use of social media and informatics, and the emergence of electronic health records (EHRs), which have enhanced surveillance and epidemiology, reduced the time between exposure to illness and source identification, and placed additional pressure on field practitioners for quick response. EHRs have increased the capacity for population health data aggregation for chronic disease surveillance. The combination of EHRs and expanded use of social media and informatics have highlighted the need to provide community context for population-level data and the need for multi-sector collaboration to address root causes of illnesses in different contexts, such as housing or food insecurity, that typically fall outside the domain of public health or health care influence. Public health and health care campaigns are also using social media as an emerging strategy to influence health behavior change or mobilize public participation.
The utility of EHRs show significant promise but are also constrained by a lack of information technology infrastructure and limited connections across data systems. The most recent Annual Update on Adoption of a Nationwide System for the Electronic Use and Exchange of Health Information reports that, “…patients often lack access to their own health information, which hinders their ability to manage their health and shop for medical care at lower prices; health care providers often lack access to patient data at the point of care, particularly when multiple health care providers maintain different pieces of data, own different systems, or use health IT solutions purchased from different developers; and payers often lack access to clinical data on groups of covered individuals to assess the value of services provided to their customers.” Despite these widely acknowledged barriers, a recent review still concludes that EHRs facilitate more than they limit public health management and surveillance, and they increase efficiency and data accuracy and precision. EHRs have also been piloted as a means to collect and review data on measures of social determinants of health and to make and track patient referrals. For example, EHRs have been used successfully to support screening for food insecurity and clinic-to-community referrals. Rural health clinics may “lag behind other office-based physicians” in using EHR, although data suggest Federally Qualified Health Centers (FQHCs), nonprofit health centers in medically underserved (including rural) areas, may be using EHR systems at comparatively higher levels.
The uptake of these promising evidence- and data-driven trends in rural public health and health care faces barriers. These include underdeveloped data technology or infrastructure, limited access to reliable data for smaller geographic areas or specific populations, a sparse evidence base to indicate effective rural strategies that improve health and equity, and relatively less field capacity in terms of professional training in epidemiology, surveillance, or population research.
Integration of Delivery Systems and Cross-Sector Collaboration. To ensure delivery of essential health care services and include strategies addressing the social determinants of health, an American Hospital Association (AHA) Taskforce on Ensuring Access in Vulnerable Communities recommends funding implementation of value-based delivery systems in critical access hospitals and small rural hospitals in the short term. It also points to emerging strategies in adjacent sectors that include addressing social determinants of health via screening and service integration. Current literature agrees that integrating social services is a suggested strategy to improve access to social services, reduce service gaps, fragmentation, and duplication, and improve health and health-related outcomes. The taskforce recommends applying these frameworks and practice changes in settings that overlap with rural areas, such as in frontier health systems experiencing “extreme geographic isolation” and in the coordination of care between Indian Health Services (IHS) and non-IHS entities.
Other broad practice changes include models that coordinate delivery of clinical preventive services (CPS) through partnerships between clinical and community systems; the resulting streamlining of patient engagement, services and follow up is intended to control costs while improving patient care experiences and population health. For example, the medical home model is based on comprehensive primary care with team-based physical, behavioral and social services. Federally Qualified Health Centers, with encouragement from the Health Resources and Services Administration (HRSA), functioned as medical homes prior to the broader recognition and adoption of the medical home model across health care organizations.
The HRSA Guide for Rural Health Care Collaboration and Coordination highlights the need for coordination and collaboration across traditional rural health providers (e.g., small rural hospitals, local public health departments, critical access hospitals), social service organizations, and community-based organizations, to create health safety nets. This coordination/collaboration is essential in rural communities due to challenges they face in financial viability of rural providers, health workforce, health care access, and social determinants of health. As early as 1994, the American Medical Association and the American Public Health Association engaged in a joint initiative that emphasized the importance of collaboration across public health and medicine in a 1997 monograph. A more recent scope of empirical studies on clinical care and public health collaborations mapped out forms of collaboration between the two fields that include: 1) coordinating health care services, 2) applying a population perspective to clinical practice, 3) identifying and addressing community health problems, and 4) strengthening health promotion and health protection. As an example, many local public health departments and hospitals are coming together to conduct joint community health needs assessments; this creates an opportunity to build relationships, share understanding, and engage in coordinated action across fields in local communities.
On more of a systems-level, the Rural Health Action Alliance, a coalition of leading health care organizations formed in November, 2020, aims to ensure equitable access to care in rural America and influence policy. The organizations that are part of the coalition include the National Rural Health Association, National Organization of State Offices of Rural Health, and national associations of multiple medical professions – such as nurses and pharmacists.
Newer trends in public health, such as Public Health 3.0, Social Determinants of Health, and Health in All Policies, encourage collaborations with sectors beyond those traditionally focused on health and include a broad range of social service, government, community development and community-based entities. The American Journal of Public Health recently emphasized the importance of cross-sector alignment in a special issue on the topic. In that issue’s introduction, Wojcik and colleagues suggest that the COVID-19 pandemic has underscored the need for cross-sector alignment: “Never in our lifetime have we seen such a need for these systems [health care, public health, and social services] to respond rapidly, equitably, and collectively.” While there have been calls for collaboration with a broad range of sectors, a recent study of the types of cross-sector collaboration enacted between public health and other social sectors – as reported by directors of health departments – found that public health collaboration was more prevalent with sectors focused on basic needs (e.g., housing and food) and less prevalent with sectors focused on infrastructure and community (e.g., economic development, environmental protections, law and justice).
Regional Consolidation and Organizational Alliance. After 9/11, emergency preparedness planning was a catalyst for in-state regionalization of local public health resources. Pandemics and climate change have reinforced this trend. In rural contexts, the coordination of public health planning and preparedness is emerging, and it has been recognized for promising cost-effectiveness owing to resource sharing and eliminating duplication of efforts. In the context of funding cuts, more complex public health challenges, the demands to address challenges with efficient solutions, and findings that rural and smaller health departments provide fewer of the 10 essential public health services, interest in sharing resources has been increasing across local health departments to improve the health of communities.
Formal and informal models of sharing resources, also called cross-jurisdictional resource sharing, include regionalization, networking and centralizing; more than 54% of local health departments share resources with at least one other health department. The Center for Sharing Public Health Services, managed by the Kansas Health Institute and funded by the Robert Wood Johnson Foundation, focuses on supporting local health departments’ exploration, implementation and evaluation of cross-jurisdictional resource sharing.
In addition to public health cross-jurisdictional resource sharing, rural health care organizations are also developing regional networks for information exchange. Some of these networks also provide the opportunity for leadership development among health care organizations and a platform for state or national level policy engagement.
Trends in the health care sector towards integrated care delivery and comprehensive services have increased expectations for actors, such as Managed Care Organizations, to bring together disparate parts of the health delivery system to improve the health and well-being of entire populations and communities. Consolidation among insurers as well as hospital-physician practice mergers strengthen market power, allowing both to increase prices. But recent analyses find that higher market power among providers in a community has “very little correlation with health outcomes.” Communities and health systems at times disagree on the level of services needed: For example, Mayo Clinic Health System (MCHS) consolidated some birthing labor and delivery services in rural southeastern Minnesota, citing declines in deliveries and overall inpatient stays as concerns for accreditation, provider skill maintenance, and provider retention. Public response was critical; the affected community organized a “Save Our Healthcare” campaign and a competing medical group plans to build a new outpatient facility.
Extending Reach and Resources through “Decentralization” / “De-professionalization“. Community health workers (CHWs) – also called lay health workers – have been a growing force for extending health care and improving the health of populations. Intended to help mitigate the barriers to health care that vulnerable populations face, CHWs provide a range of medical and nonmedical services to community members in clinical and community settings and people’s homes, including education, system navigation, social support, and social service support. Because they often share similar cultural identities and experiences with members of the communities where they work, CHWs can develop trust and rapport through cultural- and linguistic-directed support. Evidence points to CHWs’ positive influence on areas such as increased participation in cancer screenings, promotion of exercise, and decreasing blood pressure and weight, while also providing a cost-effective model of care.
In practice, CHWs have become key members of the health team and essential for the provision of primary health care and health promotion, particularly for hard-to-reach sub-populations. The ACA includes provisions supporting the implementation and evaluation of CHW programs. Most recently, using CHWs has become a strategy in the public health and health care response to COVID-19 and the pandemic’s disproportionate impact on specific places and populations. Given the health disparities and unique barriers to health care experienced in rural communities, the use of CHWs to provide culturally grounded support that attends to the rural context holds strong potential.
With similarities to community health work, the field of public health nursing, defined by the American Public Health Association as “the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences,” is positioned to bridge public health, health care and other sectors influencing community conditions. Public health nursing’s scope of practice can include supporting policy, advocacy and education in public health (e.g., infection prevention, environmental health, and outbreak and disaster response), and extends to addressing the social determinants of health. Public health nurses comprise one of the largest groups in the public health workforce, especially in rural communities, making them key actors in rural health. However, recruiting, training and retaining public health nurses is challenging in rural areas.
Other broad practice changes aimed at increasing value and driving change towards improved access to and quality of health care, as well as containing costs, include policies to expand health care professionals’ scope of practice – for example, primary care delivery through non-physician providers such as nurse practitioners. There is strong evidence that nurse practitioners provide high quality routine care equivalent to, and sometimes better than, comparable care provided by physicians. However, “professional medical groups, health care systems, and managed care organizations have typically resisted expanding the practice scope of nurse practitioners.” Resistance may be motivated by fears that such competition will negatively affect the incomes of physician providers.
Connections with Community and Economic Development
The health and community and economic development fields currently bridge their practices and strategies for change in a variety of ways. For example, the community wealth and community capitals frameworks (used by USDA and others) organize to support the development of different types of capital (natural, cultural, human, social, political, financial, and built/infrastructure capital) in communities via actions, interventions and investments – positioning improvements in health care among human capital supports/interventions, and better health care facilities among built capital supports.
The National Rural Health Association’s (NHRA) Community Health Initiative describes rural health facilities as community anchors. It focuses on supporting innovative programs in rural areas, particularly community-based programs within the realm of the public health field under the Public Health Service Act. The NORC Walsh Center for Rural Health Analysis reports that, in rural settings, health care is an important cross-sector agent for change as well as a key economic driver, which may also influence local economic development – for example, high-quality health care services may attract businesses and promote a healthy workforce.
More recently, rural economic development and rural health care are being framed together. An American Hospital Association (AHA) taskforce to examine alternative models for health care delivery in rural areas recognized additional criteria for vulnerability in some rural areas (declining and aging population, inability to attract new business, and business closures) in addition to broad criteria for vulnerability, which include lack of access to care and socioeconomic barriers. Some rural-focused research pairs its recommended approaches for a high-performance rural health care system (community-appropriate system design; service integration; flexible scope of practice; financing models promoting investment in system reform) with a comprehensive rural wealth framework.
New models proposed for the rural health care sector recommend reform focused on innovation and economic development, including more collaboration with academic medical centers, investments in regionalized care, telemedicine expansion, workforce development, and adoption of new financial and delivery models. Correspondingly, the Centers for Medicaid and Medicare Services (CMS) Rural Health Council includes three focus areas in its Rural Health Strategy: access to high-quality health care, stakeholder engagement in health care delivery and payment reform, and “addressing the unique economics of providing health care in rural America,” including “monitoring health care market impacts in rural areas.”
