U.S.
Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
2004
In recent years, concern for rural populations
has emerged in Congress and in other upper levels of government.
The creation of the Federal Office of Rural Health Policy (ORHP)
exemplified this new recognition of the significant challenges and
difficulties facing rural residents in a rapidly urbanizing Nation.
Although there are multiple definitions of "rurality,"
the U.S. Bureau of the Census and the U.S. Office of Management
and Budget (OMB) provide the most common measurements of rurality.
The Census Bureau describes all territories, populations and residential
spaces in urbanized areas or in locations of 2,500 or more people
outside of urbanized locations as "urban." By default,
"rural" areas are all areas not defined as urban. The
OMB's definition uses the urban/ rural definitions formulated by
the Census Bureau to classify counties as either "metropolitan"
or "non-metropolitan."1 According to
the 1990 census, there were 61,648,330 people living in rural areas,
constituting a population greater than that of the UK, Spain, France
or Italy in 1996.1 Rural America touches almost
every State and the majority of the land is defined as rural for
a number of Western States.
Research has found that the rural population
of the U.S. differs significantly from the urban population in ways
such as age, income, education and health status. The rural population
tends to be older than the urban population. According to Rural
Health in the U.S., in 1996, the median age of the U.S. non-metropolitan
population was 35.6 years in contrast to the median age of 33.8
for the metropolitan population.1 Generally, non-metropolitan
populations have higher rates of poverty and unemployment and have
less years of education than their metropolitan counterparts.2
Rural residents also experience poorer health status. There are
higher rates of chronic disease, infant mortality, accidental injuries
related to farming activities, occupational hazards and trauma mortality
in rural areas as compared to metropolitan areas.3
A compounding factor affecting these already poor indicators is
the significant lack of access to health care in rural communities.
Research has found that there are serious barriers preventing residents
from obtaining health care. Data from studies reveals that rural
families have less insurance coverage and pay a higher proportion
of their income for insurance premiums than urban families.4
Rural residents are more likely to cite a lack of local resources
and transportation difficulties as reasons for their inability to
receive care.4 Long distances between rural and
urban communities and inadequate rural public transportation systems
further worsen these conditions.4 There is also
a shortage of specialists and primary care providers in rural America.
In 1996, there were 54.6 patient care specialists per 100,000 people
in non-metropolitan communities compared to 190 specialists per
100,000 people in metropolitan areas.4 Subsequently,
all of these factors prevent rural residents, who statistically
are already disadvantaged regarding age, poverty and health status,
from obtaining adequate health care services.
Rural access issues have recently secured
a wider visibility since the creation of the Department of Health
and Human Services (HHS) Rural Task Force by Secretary Tommy Thompson.
The HHS Rural Task Force, a workgroup dedicated to addressing rural
concerns and problems, identified three areas that inhibit the expansion
of services to rural areas: statutory barriers, regulatory barriers
and resource barriers. Statutory barriers refer to legislative requirements
that indirectly disadvantage rural communities. Programs that require
substantial State matching funds often are inaccessible to States
with larger rural constituencies and limited population bases.5
Similarly, programs that allocate funds using formulas based on
costs and the numbers of people served may hurt rural communities
that have smaller populations and cannot easily minimize costs.5
Another example is that funds are often funneled to populations
through the State in such forms as "block grants." However,
some States are not as concerned with rural interests and the funds
may be allocated in such a manner that they ultimately only benefit
urban populations.5 Regulatory barriers include
inadequate definitions of "rurality" that often result
in the exclusion of certain communities from access to funding opportunities
even if they actually do have rural needs.6 7
Collection and evaluation of data can be difficult for rural communities
because of the diversity of rural areas and the smaller sample sizes.6
In addition, regulations often do not consider the varied and unique
needs of rural areas that may require alternative means of service
and resource development.6 Limited resources can
also be insufficient for the extent of rural residents' needs. Improvements
in infrastructure would relieve such problems as the lack of public
transportation, workforce shortage, inadequate technology to support
higher levels of services and lack of equipment for distance-based
education.8
All of these barriers inhibiting the improvement
of services for rural residents stem in part from the area-specific,
highly localized needs of rural communities. The HHS Rural Task
Force Report to the Secretary acknowledges that the "regional
nature of rural America makes it hard to serve rural residents."9
Specifically, strong regional and State identities, different ethnicities
and diverse health needs across large areas can make it difficult
for residents to obtain services in locations outside of their community.
The report says, "Frontier areas, populated largely by white
Americans, differ greatly in their health needs from Southeastern
rural communities, populated largely by African Americans."9
Because of these regionalized health needs, most current HHS programs
and resources are not always applicable to particular rural communities.
According to the report, there are 225 HHS programs that currently
serve rural areas. However, the report admits, "rural communities
struggle to access resources because individual programs have unique
application, implementation and evaluation requirements."10
Essentially, Federal programs are not sufficiently flexible to meet
the unique and diverse needs of rural populations. Subsequently,
rural residents are often unable to benefit from available resources
and services.
Negative rural implications of current Federal
policies are most apparent in the widespread prevalence of the categorical
funding methodology. Categorically funded programs require organizations
to fulfill certain requirements and identify specific needs before
they can qualify for funding. However, many rural proponents say
that "categories of funding begin to define the need rather
than the need defining the response."9 Such
funding methodologies require rural communities to reframe their
needs according to the eligibility provisions. Often these communities
do not have the available resources to locate particular programs
that could potentially benefit their community out of a wide and
confusing range of Federal services. The categorical methodology
then requires these communities to narrow their services according
to required program specifications and to generate comprehensive
reports. This arduous process and the restrictive qualifications
of categorically funded programs often prevent rural organizations
from applying for the needed resources and services. Twenty years
ago, all that existed for rural communities were categorically funded
grant programs. In recent years, policy changes regarding rural
health and services have resulted in the emergence of more rural-friendly
programs. The Rural Health Care Services Outreach Grant Program
is one Federal program that employs a non-categorical funding methodology.
This program considers the diversity of rural America and has provided
rural communities with a more flexible mechanism of receiving Federal
funds for specific health care needs.
The Outreach program began in the late 1980s.
The Senate Appropriations Committee allocated funds in the 1991
budget for "Health Services Outreach Grants in ruralareas."11
The Appropriations Committee intended for these grants to "outreach
to populations in rural areas [that] do not normally seek health
or mental health services
the forgotten populations in rural
America" and "enable services to be provided to rural
populations that are not receiving them
to enhance service
capacity or expand service area
increasing the number of individuals
and families receiving services."11 In addition
to the expansion of services to rural communities, these grants
were intended to promote community health service collaboration.
The Committee believed that "community and migrant health centers,
local health departments and private medicine by and large do not
cooperate and coordinate." Subsequently, the report emphasized
the need to "facilitate integration and coordination of services
in or among rural communities
enhance linkages, integration
and cooperation" among organizations that are eligible to receive
grants.11
The creation of the Outreach program was
originally due to the efforts of several constituencies. Rural advocates
had long complained that the categorical nature of discretionary
grants and limitations in block grants created a need for a dedicated
grant funding source for rural communities. Those concerns were
echoed by the National Advisory Committee on Rural Health, and were
heard by Congressional staff working on the Senate Rural Health
Caucus and the House Rural Health Coalition.
With the support of the Appropriations Committee
and several key Congressmen, legislation was passed between 1990
and 1991 to allocate funds for the Outreach program. The new program
was received in the 1991 budget with an allocation of $19, 518,
000.11 Although these funds had been formally
allocated, there was no authorization or law behind the allocation.
Essentially, the program was the creation of the Senate Appropriations
Committee, which cited Section 301 of the Public Health Services
Act as its legislative basis.11 The actual authorizing
legislation did not emerge until the mid 1990s. The formal authorization
for the Rural Health Care Services Outreach Grant Program was through
Section 330A of the Public Health Services Act as amended by the
Health Centers Consolidation Act of 1996, Public Law 104-299. The
law indicated that the purpose of the Rural Health Care Services
Outreach Grant Program is to "expand access to, coordinate,
restrain the cost of, and improve the quality of essential health
care services, including preventive and emergency services, through
the development of integrated health care delivery systems or networks
in rural areas and regions."12
Initially, the Senate Appropriations Committee
required the Health Resources and Services Administration (HRSA)
to manage the program through the Office of the Administrator. The
Office of the Administrator would seek the advice of the ORHP and
other HRSA bureaus in the operation of the program.11
By November of 1990 the program was placed under the direct jurisdiction
of ORHP in recognition of the need to designate a specific entity
within HRSA to direct and operate the program. A HRSA-directed task
force was also established for the purposes of designing a grant
program with content that would meet the needs of all populations
and interests. The initial schedule specified that the program would
be completed by the end of the year. The application process was
to start in January and continue until awards were posted in September
of 1991.
The identification of priorities and preferences
within the selection process was based on careful research that
determined specific areas of critical rural health need. The implementation
workgroup in ORHP identified several review criteria. Reviewers
were instructed to favor applications from communities with higher
poverty, greater medical under-service and isolation that proposed
projects specifically designed to respond to these needs. Projects
that contained substantial community-based strategic planning and
community involvement in the application process were also favored.
Reviewers were instructed to adhere to the larger goals important
to rural communities such as the improvement of pregnancy outcomes,
increasing the number of people receiving primary care services
and the provision of information and referral services to isolated
populations.13 Such priorities were meant to guide
applicants as well as reviewers. The workgroup hoped that these
priorities would send a signal to rural communities of ORHP's recognition
of these problems and needs, and would also serve to encourage those
in certain fields to apply. For example, there is a tremendous stigma
attached to mental illness, particularly in small, localized rural
communities. Rural residents are reluctant to seek help and mental
health professionals are reluctant to practice in rural areas. A
mental health priority could potentially encourage the development
of programs designed to meet this need in ways that overcome these
rural barriers. Although a factor for the reviewers to consider,
priorities are primarily used to guide applicants and are not used
as a screen to eliminate applicants.
While the Outreach program has developed
and changed over the last decade from the initial model, the guiding
principles and goals remain the same. It is still primarily a program
that seeks to address barriers to health care access within rural
communities. The non-categorical funding mechanism enables communities
to take advantage of government resources in the design and implementation
of projects that are specifically tailored toward their populations'
unique health needs. Projects are therefore expected to be responsive
to any "unique cultural [or] linguistic needs" of the
targeted population.14 At the same time, an underlying
goal of the Outreach program is to identify successful models and
strategies of service to rural communities and facilitate exportation
of these ideas to communities with similar needs. In order to accomplish
this goal, the program seeks to encourage "creative or effective"
models of outreach and service delivery, or alternatively, the use
of existing models in innovative ways, to address the specific needs
of a community.14 To promote effective dissemination
of such "best practices," applicants are required to submit
a Dissemination Plan describing their strategy to distribute information
about the project on a local, State and national level.15
ORHP facilitates the dissemination process through the publication
of summarized descriptions of completed Outreach projects.
To truly enhance access, grantees are required
to develop sustainability plans, with the understanding that grant
funding is meant as "seed money" only. Projects are expected
to use grant funds as the basis for instituting a long-standing
health service delivery mechanism in their community that will grow
and develop long after Federal funding has ended. Sustainability
plans must indicate funding options that will enable projects to
transfer easily from Federal to non-Federal funding sources.15
A related goal of the Outreach program is the improvement of rural
health care services through the promotion of coordination and collaboration
between providers. Projects must have the significant participation
of at least three different health care organizations, such as hospitals,
health departments, Community Health Centers, Rural Health Clinics
and private practitioners. Each member must have a meaningful role
in the planning and implementation of the proposed project.16
Throughout the years, Outreach program staff
have realized that community involvement in these projects is crucial
their successful continuation. In instances where the community
is not engaged in the project, residents usually will not take advantage
of the services. It is necessary to give the community ownership
over the project by allowing them to identify and prioritize local
needs. Applicants are currently advised to seek "significant
community involvement in the project" from the very beginning.
A consensus regarding community needs and goals highlights the projects'
potential to secure support from all levels of the community that
persists after grant support ends.16
Since the creation of the Outreach program,
a variety of projects have been funded in various States. From 1991
to 2004, funding has been provided to 561 grantees in 48 States
and 3 Territories.17 The Outreach program grants
have been awarded to local governments, rural hospitals and a wide
variety of community health and social service organizations. Projects
tailored toward the promotion of mental health, substance abuse
treatment, and physical health, are encouraged. Emerging technologies
such as recent advances in telehealth and telemedicine have provided
a new avenue for the improvement of access to health care services.
To promote the development of these new technologies and services,
the Outreach program encourages using these services to address
the needs of target populations.
Most projects are tailored to the unique
demographic characteristics of particular communities' population.
For instance, one Outreach program grantee, The Rural Health Outreach
Program for Children in Polk County, Arkansas (1998-2001), focused
on providing services to young parents and expectant mothers. This
project responded to the high levels of poverty in Polk County where
over 60 percent of its population is classified as "working
poor." This poverty particularly affects young families. Ninety-two
percent of single mothers in this county live below the Federal
poverty level.18 The Arkansas project improved
the health of children in these families by enabling young parents
and single mothers to overcome transportation barriers to health
care services, refer them to appropriate health care facilities,
and provide education on parenting.19 In another
example, in Pike County, Kentucky over 80 percent of children from
ages 7-13 years are mildly or severely obese. This figure far exceeds
the national average. The Kid Power Program (1998-2001) established
a medically supervised program for weight-management that targeted
children of this county.19
Other projects are designed to respond to
geographic factors that result in poorer health outcomes for rural
populations. For example, the State of Alaska has more lakes, rivers
and waterways than any other State, resulting in a high incidence
of drowning. As the second leading cause of death in the State,
Alaska's drowning rate for recreational boaters exceeded the national
average by 10 percent between 1987 and 1999. The Cold Water Safety
in the Schools Program (1998-2001) was created in response to this
public health problem. This program was able to use the Outreach
program funds to train a network of teachers to deliver cold-water
safety and survival training to teachers, pool staff and children
in rural areas on a State-wide level.20
The Outreach program has had a significant
impact on the health and welfare of many rural communities. By providing
base funds for the initiation of health care services, it has facilitated
the permanent institutionalization of many programs within rural
communities. In February 2003, Ira Moskovich of the University of
Minnesota's Rural Health Research Center completed the study, "The
Impact and Sustainability of Past Grantees." He found that
during a post-grant operating period of 2 to 5 years (1994-1996)
in a sample size of 104 grantees, there was an 86 percent grantee
survival rate. Fifty-three percent of grantees had "robust"
or "moderate" post-grant capacity. 21
Eighty-eight percent of initial services of surviving grantees still
remain available. He also found that 38 percent of surviving grantees
had either expanded initial services (22 percent) or launched new
services (16 percent) after grant funds had ended.21
Overall, most projects continued after the termination of funds,
with only a small number of unsustainable projects.
Grantees have expressed their appreciation
for the "rural friendly" application process. Marian Allen
of the Cold Water Safety in the Schools Program (1998-2001) said,
"This grant was a joy to work with because of its flexibility
- all grants should be like this one." Steven Ironhill of the
Callam Country Hospital District # 1 Program (1998-2001) agreed
that the Outreach program's easily adaptable requirements were a
key incentive for initiating the process of application. He said,
"I know that the non-categorical funding nature of the Outreach
program actually made it possible for us to pursue this project."
Grantees also praised the program's focus on rural needs and populations.
Sandra Reckard of the SCORE-5 for the Heart Health Program (1998-2001)
expressed, "A lot of grants only fund urban areas-it is fantastic
that this program is geared toward rural people. As a small hospital,
we wouldn't have been able to do this program without these funds."
Ironhill added, "For rural communities, this is one of the
best uses of Federal resources that I can think of." The most
exciting results from the Outreach program are successful outcomes
and concrete results from the projects. Reckard believes, "We
have gone way beyond our expectations. The success of the project
has been the materialization of a vision that allows us to actually
see tangible benefits and an increasing amount of excitement from
the community. I've been recommending this program to other people
as well."
Although the Rural Health Care Services
Outreach Grant Program started out as simply a General Appropriations
program to test new and innovative ways of serving rural communities,
it has now grown into a formally authorized and well-known program
with a successful record of reaching hundreds of rural communities
throughout America. Through the provision of Federal funds over
the last decade, the program has been able to support improvements
in access to health care services for rural communities. Since the
first allocation in FY91 of $19.5 million, funding has increased
to $23 million in FY02. Since the creation of the program, $271.9
million in Federal funds have been awarded.
Despite this assistance, the need continues
to significantly outweigh available support. From 1991-2004, ORHP
received 3,588 Rural Health Outreach Grant Program applications,
representing nearly all States and Territories; however the Outreach
program was only able to award 628 grants to these applicants (See
Table 1 and 2 for more detailed descriptions of applicants and awardees).
Table 1
Office of Rural Health Policy
Funding
History of the Outreach Program
Fiscal Year |
Funding (in millions) |
FY87 |
|
FY88 |
|
FY89 |
|
FY90 |
|
FY91 |
17.8 |
FY92 |
20.7 |
FY93 |
24.9 |
FY94 |
25.7 |
FY95 |
26.1 |
FY96 |
25.5 |
FY97 |
19 |
FY98 |
26.5 |
FY99 |
16.8 |
FY00 |
23.3 |
FY01 |
22.5 |
FY02 |
23.1 |
FY03 |
20.7 |
Total |
292.6 |
Table 2
Office of Rural Health Policy
Outreach Program Applicant
Statistics
Total Applications Received
1991-2004
|
Total Number of Awards
1991-2004
|
Percent Awarded |
3588
|
628
|
17 percent
|
Notes
1. Thomas C. Ricketts, III, ed.,
Rural Health in the United States (New York: Oxford University Press,
1999), p. 7.
2. Thomas C. Ricketts, III, ed.,
Rural Health in the United States (New York: Oxford University Press,
1999), p. 17.
3. Thomas C. Ricketts, III, ed.,
Rural Health in the United States (New York: Oxford University Press,
1999), p. 19.
4. Thomas C. Ricketts, III, ed.,
Rural Health in the United States (New York: Oxford University Press,
1999), p. 26.
5. United States Department of
Health and Human Services. HHS Rural Task Force Report to the Secretary,
July 2002 (Washington, D.C.: 2002), p. 17.
6. United States Department of
Health and Human Services. HHS Rural Task Force Report to the Secretary,
July 2002 (Washington, D.C.: 2002), p. 19.
7. For example, the OMB definition
of rurality classifies San Bernardino County, CA, as rural because
it includes the City of San Bernardino, near the Pacific Coast.
The county also includes most of Death Valley, making it an urban
area under this definition.
8. United States Department of
Health and Human Services. HHS Rural Task Force Report to the Secretary,
July 2002 (Washington, D.C.: 2002), p. 21.
9. United States Department of
Health and Human Services. HHS Rural Task Force Report to the Secretary,
July 2002 (Washington, D.C.: 2002), p. 20.
10. United States Department
of Health and Human Services. HHS Rural Task Force Report to the
Secretary, July 2002 (Washington, D.C.: 2002), p. 16.
11. United States Congress. Senate
Appropriations Committee Conference Report, Senate Appropriations
Committee Report. 1990.
12. United States Department
of Health and Human Services, Health Resources and Services Administration.
Rural Health Outreach Grant Program: Program Guide and Application
Instructions, 2003. p. 5.
13. Outreach Grant Program Implementation
Workgroup, Federal Office of Rural Health Policy, 1990.
14. United States Department
of Health and Human Services, Health Resources and Services Administration.
Rural Health Outreach Grant Program: Program Guide and Application
Instructions, 2003. p. 6.
15. United States Department
of Health and Human Services, Health Resources and Services Administration.
Rural Health Outreach Grant Program: Program Guide and Application
Instructions, 2003. p. 31.
16. United States Department
of Health and Human Services, Health Resources and Services Administration.
Rural Health Outreach Grant Program: Program Guide and Application
Instructions, 2003. p. 15.
17. United States Department
of Health and Human Services, Health Resources and Services Administration,
Federal Office of Rural Health Policy. Outreach Grant Program Management.
18. United States Department
of Health and Human Services, Health Resources and Services Administration,
Federal Office of Rural Health Policy, The Outreach Sourcebook,
Volume 8, 1998-2001 (Rockville, M.D.: HRSA, 2002), p. 5.
19. United States Department
of Health and Human Services, Health Resources and Services Administration,
Federal Office of Rural Health Policy, The Outreach Sourcebook,
Volume 8, 1998-2001 (Rockville, M.D.: HRSA, 2002), p. 25.
20. United States Department
of Health and Human Services, Health Resources and Services Administration,
Federal Office of Rural Health Policy, The Outreach Sourcebook,
Volume 8, 1998-2001 (Rockville, M.D.: HRSA, 2002), p. 1.
21. Rural Health Research
Center, University of Minnesota. Presentation on the Rural Health
Outreach Grant Program: The Impact and Sustainability of Past Grantees
by Ira Moscovice. February 2003.
|