COVID-19 Pandemic 8: Rural Health Disparities & COVID-19 Panel.

Bill Finerfrock, Executive Director at the National Association of Rural Health Clinics, hosts an in-depth discussion about rural health disparities with a panel of experts from across the US. In areas where populations skew older and travel distances to the nearest specialist are getting longer as hospitals close, every health practitioner is also a first responder. Surprisingly, despite these being agricultural areas, food deserts are a real problem. Now COVID-19 is spreading to rural areas. Shannon Chambers, CPC, is with the South Carolina Office of Rural Health. Elizabeth Ellis, DNP, is a nurse practitioner who runs a rural health clinic in East Texas. Roger Wells, PA-C is a physician assistant who provides care in a rural health clinic in Lexington, Nebraska.

Episode Transcription

Podcast Episode 45
COVID-19 Pandemic 8: Rural Health Disparities & COVID-19 Panel Discussion.

Bill Finerfrock, Executive Director at the National Association of Rural Health Clinics, hosts an in-depth discussion about rural health disparities with a panel of experts from across the US. In areas where populations skew older and travel distances to the nearest specialist are getting longer as hospitals close, every health practitioner is also a first responder. Surprisingly, despite these being agricultural areas, food deserts are a real problem. Now COVID-19 is spreading to rural areas. Shannon Chambers, CPC, is with the South Carolina Office of Rural Health. Elizabeth Ellis, DNP, is a nurse practitioner who runs a rural health clinic in East Texas. Roger Wells, PA-C is a physician assistant who provides care in a rural health clinic in Lexington, Nebraska.
All views and opinions are the participants own.

Bill: I want to welcome everyone to the Movement is Life Health Disparities Podcast. And, this evening we’re going to be talking to some folks about the impact of health disparities and in particular, some of the things going on right now. And some of the issues that folks are confronting and the challenges that people find in delivering health care in rural underserved areas. With us, we have Shannon Chambers who is with the South Carolina Office of Rural Health. Elizabeth Ellis, who is with the BIS Clinic in Bedias. Is that how you pronounce it?

Elizabeth: Yes. BIS Community Clinic in Bedias, Texas.

Bill: Bedias. Alright. And Roger Wells, is in Nebraska in Lexington, Nebraska, in a rural health clinic there. Welcome, everybody. Why don’t you give our audience some insight into you, what you do in the communities where you serve? About your background, your credentials. So, folks have a sense of who they’re listening to tonight. We’ll start out with Elizabeth.

Elizabeth: My name’s Elizabeth Ellis. I’m a doctor of nursing practice, family nurse practitioner been here in Bedias, Texas now going on 12 years. And we opened our rural health clinic, coming up on three years this September. We are the only healthcare clinic in Northern Grimes County, which is quite a large County. We are located between Madisonville, Texas and College Station. It is a rural underserved area I’ve been practicing as a nurse practitioner going on 25 years now. I started my career out in rural health. A couple of years ago, I decided it was time to return back to my roots.

Bill: Roger, tell us a little bit about yourself.

Roger: Well, good evening. I’m Roger Wells. I’m a physician assistant in rural Nebraska. I’ve been a physician assistant for 33 years after initially being an athletic trainer. And previously I did primary care at the emergency department of inpatient nursing home. I had worked OB, I have a very rare degree, actually, a surgical assistant as well as physician assistant when I got out of school. I used to do OB and sigmoidoscopy and everything, so time has changed and so have I. So, at this time I work at a town of approximately 10,000 people. The median age is very young about 29, but we have a lot of Hispanic and Latino, 61%, Black and African are 7%, Asian, 1% and 31% Caucasian. It’s been an exciting experience here. And the biggest issue is our longest and largest employers are meat packing company. So, we’re in the overload with COVID-19. We have about 73 languages in this community in the last 10 years, and we’re mostly feedlots, row crop, hay and vineyards, believe it or not. So, we’re really agricultural based. It’ been a real pleasure. 34% Medicare, 13% Medicaid, 7% insured and 46% commercial because of the packing plant.

Bill: And Shannon, tell us a little bit about yourself.

Shannon: Hey, I’m Shannon Chambers. I’m with the South Carolina office of rural health. In that role, I support the 84 rural health clinics across our state for many things from billing and coding to compliance, anything really that they need. I have been doing a lot with rural testing across South Carolina for the last month. So, yet another hat.

Bill: Both Roger and Elizabeth mentioned that they’re in rural health clinics, but Shannon, why don’t you tell our audience a little bit about what is a rural health clinic?

Shannon: While it is a clinic that is located in a rural area, there are two types of rural health clinics. There’s a provider-based rural health clinic, which is normally owned and operated by a bigger hospital system. And then, we have our independent rural health clinics, which are standalone. And I think the important thing to remember here is these are the centers and clinics that really support those rural regions, in their communities. They are the backbone of a lot of these communities.

Bill: So, Elizabeth and Roger, you both have had lengthy careers. Roger, you said you have always been out there in Nebraska and previously being an athletic trainer. Elizabeth, you were coming back to your roots. Why rural? What was it that made you want to practice in a rural underserved area? We’ll start out with, Elizabeth?

Elizabeth: With my initial career outside of college, just out of college, I traveled rural Mississippi Delta, and I met a nurse practitioner, serving a very underserved area there and was so impressed with what she was doing for her patients. I decided that’s what I needed to be doing. I love rural health because the people, number one, they don’t have access to health and being there for them provides them an opportunity that they may not have otherwise and being there to help educate and coach and live with them alongside of them and with their health issues and their family issues, it’s extremely rewarding to be able to serve them. Rural America, which is about 20% of America, the health disparities are nothing like urban areas. We have higher comorbid conditions. Most patients have more than four, sometimes 20 plus diagnoses, and they’re poor, they’re underserved. They have limited access to quality healthcare, or they may have to drive long distances to get that healthcare. They have, transportation liabilities, and we actually serve a tremendous amount of people who are uninsured, who don’t qualify for Medicaid, they’re not quite Medicare age and they are agricultural farmers and laborers and they just don’t make enough to be able to pay for insurance. And so, they often go many years without any healthcare until they hit Medicare. So, we’re doing our best to try and treat them and manage them and give them an opportunity to manage their health before it becomes too late. We also work with them on their agricultural exposure and their safety issues on the farm and exposure to chemicals and products and injuries. Really try and increase education that they may not have otherwise. That’s why I love doing rural health because otherwise, I feel like I’m serving my mission and these people are tremendously grateful and they become a part of you, and they become family.

Bill: I hear that a lot. Roger, how about for you? Why rural?

Roger: I chose the rural track because of my wife’s family. My wife’s grandfather had COPD was very, very bad and I watched him suffer and the lack of resources that would allow him just to have basic care on occasions about his disease and watched him fade away. And I tried as much as I could to help him out to assist him as much as possible, but it really hurts to watch that and watch the resources that were limited and be able to do nothing. That was terrible. And then my father developed heart disease and I watched him get infection after he had his bypass and then develop hepatitis C and all those issues that they didn’t understand their habits. My passion became to take care of them. And luckily, and being blessed as much as I have, I had the opportunity to go back into the actual rural area where I grew up in a population about 80 people and started a practice there and develop myself and take care of things. And I was really allowed to go on and do some national things because of my passion. I was able to continue forward and now I have a tremendous job to pushing that forward to other people who are now not able to get what they need. Just like Elizabeth said she identified all these issues that are not recognized on a piece of paper or a dot that gets checked. And these social determinants of health more important than anything else we do. If we don’t open our arms to this and wrap our arms around it, can be a lot of people get hurt and I’m just really honored to be here, to help explain this. At least my feeling having that and witness that disability being blocked and taking my dad to ventricular tachycardia and taking him to the hospital and actually driving him 2 1/2 hours to Omaha was a real awakening for me. And I’ll tell you what it opened up my heart to a lot of people.

Bill: You both touched on the health disparities and of course this is the Health Disparities Podcast. What are some of the drivers that you see in health disparities? And Shannon, I want to bring you in, kind of from a statewide perspective in South Carolina. What do you see as some of the major drivers of health disparities in rural communities in South Carolina?

Shannon: Transportation is huge still. That is something that, if we could build the Uber of rural health, where we could get people to their doctor’s appointments. I’m in a state where we have very high diabetes, especially being in the South. And I think that is a huge issue for our people and trying to make sure that as we start to think about ways that, we can improve chronic disease, how are we going to reach those people? Especially during all of this COVID stuff, where people are not showing up for their preventative visits. They’re too scared to come into the doctor’s office. And trying to remind people that, at this point, if you don’t take care of the wellness stuff and the preventative stuff, that’s going to help alleviate some of those health disparities moving forward.

Bill: Elizabeth in your community Roger, talked about the demographics of his community, the large minority population, in his area, the multitude of languages. Is that typical of what you see, in your community as well?
I asked that because I think, there’s often a perception that rural America is white America, that it’s predominantly a Caucasian population. And yet, as Roger said, and we look at many rural communities actually is a much more diverse community out there. What’s your experience in your part of Texas?

Elizabeth: We are probably not quite as diverse as Roger’s area in Nebraska, but we certainly are. We have a significant, population of Hispanics, African American. We have native Indian population, and then we certainly have Caucasian, and we also have, an increasing Asian and Indian population here in our area. I have a tremendous, Medicare-aged population. They are my largest, population, probably over 60% of the patients that I serve are 65 and older. Then the predominance of the rest is in the middle, but we do have a significant diverse population. It is not limited to just white America.

Bill: In terms of comorbid conditions or things may be associated with that, what are some of the comorbid conditions that you see, that seem to be very dominant in your community?

Elizabeth: Well with genetics it’s predominantly what a lot of people think of first and that’s diabetes, and then hypertension, and then, of course, with so many rural Americans, they have a significant history of smoking and other types of tobacco use and agricultural exposure. That’s the biggest reason for their COPD, because of the conditions in the dust and the chemicals and things that they, are exposed to every day in their careers and their livelihoods that has increased their COPD and emphysema, but those are our largest, and then, all of that leads to heart conditions. I would say probably over 50 plus percent of the population is diabetic and hypertension with heart disease. And then COPD is following right behind.

Bill: Roger, is that a typical of what you experience in Nebraska?

Roger: Let’s step back and I think this is really important. 120 miles from here exactly right. 120 miles from here, white, COPD, diabetes, etc. Here, no, the average age, 29 to 30 years old. And so, our issue is cultural understanding to understand a person, their wants, needs, and preferences. Can you shake their hand? Can you look in their eyes and acknowledge them? Is that something that they like to do? What’s the priority in life? Many of these people have 7 or 10 or 15 people at a household and they have COVID-19 and how are you going to help these people? So, their priority with the resources they have is much different than they are a hundred miles from here, or like Elizabeth is speaking about there, which is completely different. And we’d have to be able to look at these communities so much differently because everybody, like you said, their previous thought process is rural America. Just 120 miles away, it can be completely different. Healthcare maintenance, such as colonoscopies, mammograms are not even thought of because many of these cultures only go when they’re sick or they have a broken arm, or they have a large laceration. We don’t look at wellness. We look at, injury and trauma and trying to take these cultures and shift them into a wellness program is paid by their insurance because we have 47% paid by insurance and try to get them into the clinic and understand that there’s a whole new shift for me to try to understand and assist this population that’s been abused. And then, like Elizabeth said, and so did Shannon, they don’t want the specialty clinics, they didn’t even think about specialty clinics. And if something’s wrong that we can’t fix that, what are we going there for. It’s something you have to have a discussion about. And then, worst for me is to try to understand the interpreter to get a relationship with a patient who’s not going to tell you about incest or any problem within the family. And those things are really difficult. So, understanding the culture has to come first and then going back and looking at the wants, needs and preferences has been an eye-opener and a great experience for me.

Bill: We’ve talked a little bit about the comorbid conditions. And one of the things that we see, nationally, is the correlation between the presence of comorbid conditions and the severity of COVID-19. Tell us a little bit about what you’re seeing in the way of COVID and what impact it has had in your communities both from a patient or clinical perspective, but also from an economic perspective because one of the things that, we’re seeing is that, as a consequence of COVID, a lot of patients are just staying away, and they’re not going to the doctor, or they’re not going to the nurse practitioner or the PA or whomever they’re staying home and, of course, that means you’re not getting revenue. What’s been the impact both clinically and economically, in your community. And then, Shannon, in your state to try and help shine a light on this for our audience. We’ll start out this time with, Elizabeth, what you’re seeing in your community with regard to COVID?

Elizabeth: In rural America, I think we’re fortunate in that being rural has kept us, and less exposure, but in my County, there’s very few jobs in the area. So, they have to travel outside of our County to larger areas, metropolitan areas to get employment. So therefore, they’re leaving the County and getting potentially at risk and getting exposed, and then coming back into the County, in addition. But our County itself has had very few cases. I think we’re like at 60-odd right now. And the majority of those cases unfortunately have been in our detention center. So, there’s been very few, residents that actually, have come down with COVID and we’ve been very fortunate that way. But unfortunately, the TDC system is a large employer. So, all of those employees who work in the detention system are getting exposed and that’s increasing our risk. Being a travel through community, our County is a pass-through community for so many other areas to get to another distance location that is potentially putting us at risk. The biggest impact for these folks is their loss of business because they have shut down their small businesses or their livelihoods, whether it be the cafe, whether it be a hairdresser or our beef farmers, which is our largest employment and our chicken farmers here in the area. Nobody’s buying beef, right now. Therefore, their livelihood is at risk. And they have no other source of income, for so many. Unfortunately, because we’ve had to social distance and shut down operation that has made a tremendous financial impact adversely on almost all of the citizens here in our area.

Bill: And how about your clinic itself?

Elizabeth: It’s made a financial adverse impact. It has hurt us tremendously because patients are doing what they were told to do and that’s staying at home. And we did not get the authority to be able to do telehealth, being a rural health clinic until almost a month in, I think pretty close, at least four plus weeks in. And so that impacted us. My clinic did actually have to shut down for several days because a person of investigation we were exposed to and the CDC here in the area, wanted us to shut down until we knew the outcome because we are such a small building and such a small clinic. Yes, financially, it has adversely impacted us, as I think it has all of the healthcare providers in the area, in the neighboring communities.

Bill: Now, Roger, your experience in Nebraska and where you are, is quite different than what Elizabeth has experienced, at least in terms of the COVID situation. Tell us a little bit about what you’re seeing in your area with regard to COVID and the impact that that’s had.

Roger: Well, COVID-19 has been devasting to this community because we have 10,000 people. We have over 810, actually 812 yesterday, documented COVID-19 patients. Those people are only tested usually at the health department or if they come to our emergency department and are admitted. And we know that around 30% of these people are going to have false negatives. And so, we don’t really have an idea of how many there is, but the use of PPE, the use of specialty doors, not allowing people to even walk into the clinic door until they’re screened outside in the street and then you walk in. Having special doors for the sick patients, special doors for the clinic, trying to keep the very ill and the very old and high-risk patients in a separate area has been a real challenge. Luckily, we have a great administrative team and medical staff that really take care of things, but in spite of that, it has been devastating to the whole community in the medical field, because we don’t have any surgeries. We don’t have any inpatients unless they’re COVID-19 and their PPE and their costs is just huge, more than any percentage points that they’re going to get as a benefit reimbursement. But when we look at the comorbidities, you’re looking at 2,500 workers in one beef packing plant, and it’s not the beef packing plant issue. These people need to work. They go to work and, you know, as well I do,17% of people don’t even have a temperature. And they’re going to work and they’re taking everybody’s temperature on the way in, but they’re just holding their cough, and they’re going to work. And by the time they spread it because they want to work and they’re proud to work and they’re very good people. And so, this thing just gets spread and still spreading. I walked into the hallway today and they were having trouble with a very heavy lady getting her up a little ramp. So, I grabbed and hold the ramp and went up and she goes sorry, she’s COVID man. Get out of here. And so, by the time I even knew about it, those kinds of people are showing up at our doorstep in large numbers. It’s the comorbidities as Elizabeth has gone to, and it’s a lot of Hispanic, probably 60, 70%, because they all live in households that we spoke about earlier, that commingle. And then just because they’re proud individuals that want to work, and so, most of them would call up, and even after two to three weeks are not able to go back to work because they’re in such severe health. So, it’s been a challenge. Luckily, on the other side of the coin, when you lose the whole ambulance crew or two hospice nurses or Meals on Wheels, now look who’s getting hurt. The elderly is getting hurt. And now they’re going out to try to get meals and they’re trying to go to the local grocery store to get food. And now, we just contaminated them. So, this is a cycle of things that no one would really look at in a city.

Bill: Shannon, in South Carolina, kind of what has been the experience? You were telling me the other day about some, effort you’re doing to increase testing. And, there was a particular community, you were telling me about where they started doing testing and what they found. Tell us a little bit about that.

Shannon: Sure. So, really across our state, we’ve had about 9,300 positive cases, and about 400 deaths, and that’s probably as of yesterday. 46% of those deaths are, African American so of course, trying to get more education. As for the clinic that you’re referring to, we recently had one of our rural health clinics to do a testing site, a community testing site, and had over a hundred people come through and only one of them were showing symptoms out of that testing site. They had 14 people that were positive, 13 of those people were Hispanic. So, what they’re trying to do now is go back and contact trace to see if they all live in the same location or our DHEC, Department of Health and Environmental Control is handling a lot of the contact tracing here in our state. It’s been interesting because what our office was able to do was to take their brochure and then also translate it over to Spanish. And they had a whole bunch of Hispanic people that came through that testing site and realize that that is definitely a best practice. We have another site that is going to go up in the first week of June, and we’re already working on assisting them with developing the resources so that they can also reach into their Hispanic communities there.

I would say one of the really cool things that our office, recently heard about is a small community that we’re doing testing in the first week of June, they actually reached out to the local, like Sonic and McDonald’s etc., and they’re going to run the testing information across their signs to let the community know that’s a resource and that it’s coming. So, it’s been very interesting to see the different small communities and how they’re standing up for each other. I have two independent clinics getting ready to run one testing site. And you just don’t hear about that. That’s fantastic. We’re really proud of them.

Bill: Elizabeth, are you doing much testing in your area?

Elizabeth: Probably not. Not as much as some of the clinics that Shannon spoke of because we haven’t had as many patients come to us with symptoms, but I have done a significant amount. Fortunately, none of my patients have tested positive, but we also know that there’s probably a 30% false negative on some of those patients. The lower half of the County does have drive-through testing, located with one of the critical access hospitals there. And, then the neighboring big counties, have a drive-through testing and they are doing a tremendous amount. Our neighboring counties, Walker County, Montgomery County and Brazoria, and then, we are just North of Houston and had tremendous cases. And I’m just waiting for the repercussions of our folks who are traveling back and forth to go to work.

Bill: Roger, are you doing much testing out your way or just dealing with the consequences or little bit of both?

Roger: We try to follow the CDC guidelines. We’re only allocated very small amount of testing and we were testing in the clinic trying to at least find the positive people. Initially, that was stopped unless they have severe symptoms, we test them mostly through the health department, activity that we can get done. We call the health department, they okay the tests we do, the health departments through them. We do have now the ability to use in-house testing. We just started that Monday. It’s very few, taking on, with certain company. We do have some available to do that for the patients who are inpatient but again, that’s very limited. So, most of our issue is education. So, I can spend time on telehealth or telemedicine, what you want to call it. We do a lot of education about what’s going to happen. How long is it going to take, what symptoms you’re going to have? My baby has gotten it now, he’s seven months old was my first patient this morning. What do I do? Is it going to get this neonatal syndrome that comes around in six months, what am I to watch for? And so, we spend much more time rather than testing, because unless they’re very, very ill to just do the educational piece and be accessible for them in the future.

Bill: You touched on social determinants of health a little bit. I’d like to focus a little bit more on that. What are some of the key social determinants of health that you see in your communities or your state and some ideas on what you think might be able to be done to try and address those? Let’s start with Elizabeth.

Elizabeth: Well, I think access, that’s always an issue with rural health. Even though we’re surrounded by large counties that have some bigger hospital systems to truly get to a large medical center, if you will, down in Houston, we’re almost two hours away. Now we do have, two area hospitals that are, anywhere from 35 to 45 minutes away. But lack of reliable transportation is an issue. We do have a Grimes County health transport, through the health resource center, but they only have one van. And that’s not enough to serve this large County. I think that’s one thing that has to change.

The other big issue is lack of reliable internet services. These people do not have access to that. My clinic, I’m not even on high-speed fiber and it’s just now coming into our County, and we don’t even know if we’re going to be able to afford to get hooked up. I think any rural health clinic needs to be hooked up to high-speed fiber for free given all these government grants so that we can properly serve our patients. We can then consult specialists and have them treat our patients here with faster access.
I think, access to quality food is another issue. And, our folks usually have to travel way down 35, 40 minutes to a decent grocery store or outside of the County to even get to a substantial grocery store. So that’s another problem. Yes, we do have the food bank, but as Roger led to a lot of people are very proud and that’s an issue with them.

And then in addition, the agricultural exposures, people just don’t understand what, rural America, is exposed to and the types of health issues that they do encounter in comparison to urban. Because on every street corner, in a large city, you have an emergency room, and you can look in four corners and there’s one on at least three of them. They’re about, anywhere from 15 minutes plus, to hours away, for a lot of rural America. And that’s a problem.

Bill: It would be like if you had to go from Washington DC to Baltimore for a doctor’s visit, or to go to a hospital. And people in this area, like, that’s crazy and it’s like, well, that’s, rural America, that’s 45 minutes away, and most people would be happy to be able to be 45 minutes away from a hospital, but in most cases, it’s a couple of hours. I think that’s one of the things that people don’t understand about rural. Shannon, what about for South Carolina? What are some of the key social determinants of health and what are some of the things we might be able to do to address those?

Shannon: I definitely have to agree with some of the things that Elizabeth said, transportation is something that’s really huge. Our office had actually, a few years ago, developed something called the rural health action plan, and it addressed a lot of the social determinants of health. It also looked at schools, it looked at food, it looked at access, and all of that. So, I think we learned a lot from that and how to partner with people. How to partner with technical schools, to be able to figure out how to have different programs, where the kids that are in high school are also earning credits towards degrees in college. For the social determinants of health, I have to think of it live, love and where you work and play. If that makes sense. And, we see a lot of different things such as trying to communicate with some of the department of aging and different ways that we can get senior resources out. That’s been a huge thing as part of this COVID stuff and making sure that people understand. Dropping off groceries and keeping your distance and all of that throughout this process, hand washing all of that. I think telehealth is a huge, huge opportunity for us. The problem again, is broadband. We’ve actually been able to work with some of the school districts to open up access to the iPads that some of the kids are given in certain areas and certain districts where one of them was able to actually download their telehealth app onto the iPads so that people could do free telehealth services through the iPads, which all of the technology and iPads are supported through the schools. I worry about how that’s going to work now that summer’s almost here for these kids. We’ve had additional places that have opened up Wi-Fi and said that they can do that out in their parking lots, churches and schools. It’s been a great process to sit back and watch about how people can work together. But until we can get more broadband in our rural areas, we’re just going to be stuck, not being able to do some of this telehealth stuff.

Bill: And Roger, what’s it like for you?

Roger: Those are just tremendous efforts with Shannon and Elizabeth. Wow. I agree with the food deserts, because even though they have a store, it doesn’t mean you have things to put into the store to get them to get anything. The second thing is housing to be able to have housing and reimbursement for appropriate housing is really, important. Especially, as you’ve already identified before, some people have two or three or four families within a housing structure and trying to allow some for independence. I look at it, with the broadbands really 57% of the people have enough broadband to do a video chat, 57%. That would be if they have a phone. Okay. And you have to have a phone with enough memory, flip-phones are really common around here. We’re looking at issues that they estimate about 70% of your visits could be done by telehealth if we had the experience and do it successfully. If they had a blood pressure cuff, we could do some of those things like that, we could save lots and lots and lots of money, but we don’t have the ability to bend the rules to identify new challenges and new things that we could do or innovations without going through a whole, pardon my expression, act of Congress to try to get a modification and just giving us the latitude to move over here or like home health. Why couldn’t home health deliver Meals on Wheels during the same time you’re doing a home health visit? Now, all of a sudden, we have this latitude to do this, but now you’re going to take it away and kind of planning, we have to have that planning. The second thing with that is that our jobs out here are high risk. So, when you look at social determinants of health, these people are climbing a hundred feet in the air looking at elevators and crane dropping down into this bin. And that’s part of their job where they’re working on machines that has a spinning wheel it’s going around 5,000 times a minute, and it’s got a little housing trying to protect it. You’re trying to tighten the belts. These people get hurt and you don’t have the ability to transfer these people out.
So, I think interconnected abilities like, Shannon’s talking about, from the higher levels of larger institutions, coming down with a network to the smaller places like rural health clinics, which would really be viable. And then we can identify different loops, but let us have the pleasure of identifying how we can fix things. All of a sudden, we’ve given this tremendous ability to change these determinants of health, but how long is that going to last?

So, these high-risk people that get injured or high-risk jobs are using knives every day. We had a guy just 50 pounds fell 40 feet and he was bent over, and it hit him in the back. You imagine what that would be like. And those are the kinds of injuries that we see in some of these people.
So, looking through all these things and being able to have the ability to jump back and forth and try things out without having a trial of $100,000, 16 pages, just for the explanation of what we have to do, and then send it in for six months and see if anybody likes it or not. We need to move now and get this stuff done.

Bill: We’re going to start wrapping it up here, but two things that struck me as really interesting, and I think instructive, both Elizabeth and Roger you’ve mentioned food deserts and food. And I think for a lot of folks, and I think Shannon, you did as well, that when you think about rural and that, it’s farming, it’s agriculture, the idea that here you are surrounded by food. Whether it’s the animals for beef or pork or grain, and whatever you’re in. So, the thought that you would be in a food desert almost seems illogical because you’re surrounded by food. The other thing that you’ve touched on, which I think is illustrative and instructive for folks, there’s this thought that your primary care clinics and that, Oh, well, that just means you take care of the sniffles, the flu, patients who are coming in and do some preventative visits. I think about my primary care doctor here in northern Virginia, where I live and it’s a pretty slow practice, pretty laid back. They have a doc and a nurse practitioner or a doc and a PA, depending on which day of the week he switches. I never see anything in there of trauma, but both Elizabeth and Roger, you both talked about, trauma. And you’re not a primary care clinic in the sense that people think of that sometimes. You’re almost like a mini emergency room. You’re an urgent care center. You’re not just dealing with, the patient who’s come in, the farm patient. You’re an occupational health professional because you’re dealing with the occupational health issues. I think one of the messages that people need to understand too, is that being a healthcare provider in a rural area, is not just the person who’s going to give the shots, see the patient, see the flu, do the vaccinations. The patients that you’re seeing, are in many cases, very seriously injured or ill and you’re the only shop in town. And so, you’re dealing with everybody, not just that subset of patients that, a calm, easy primary care practice you might see in a suburban area.

Elizabeth: I’ll say Bill, after having practice urban healthcare for over 15 years and then returning back to rural health, I’d forgotten how complicated rural health could be and the problems and issues that we see, we are first responders, and often the first thing people walk in the door, whether it be a major trauma or a heart attack or a stroke, we’re the first line responders for these people. And having that broad skillset, it goes back to my emergency room nurse days to starting out in rural health. I had to relearn a lot of my skills and pull some of my skills back out of my repertoire, to be able to handle some of the things. I’ve seen things I haven’t seen in years, here in rural America, practicing in large urban cities. It just is the nature of things. The other biggest disparity I do have to comment on is lack of psychiatric resources and having psychiatric providers that are accessible, that their panels are not full, that they will take the patients. Even though we do have a government in a mental health resource, in the area they’re still trying to get appointments. And for them to have enough providers to serve the amount of psychiatric needs in our community is tremendous. That is a large disparity that we often forget about.

Bill: You see that in South Carolina, Shannon?

Shannon: We do, we have a lot that actually are really starting to work with more social workers, even in pediatric clinics, which I think is unique. As we talk about these I think as our hometown heroes, I have several who are mayors of their towns or their counties that are my providers. So, want to get something done in one of those, you’ve got the mayor, the doctor, the nurse practitioner, or the PA. So that’s been something very unique as we’ve been trying to identify resources across.

I think one of my other big worries is what happens when telehealth, goes back and maybe rural health clinics can’t be the distant provider for telehealth. The additional thing is making sure that our rural health clinics understand that while right now you can use FaceTime or Google Duo or whatever they’re called, you’ve got to be using something that’s going to be HIPAA compliant. And I think that’s going to change telehealth for a lot of us.

Bill: Roger, any comments on that? Or we’ll start to wrap it up and ask everybody to make some closing remarks or observations.

Roger: I was just thinking about what Elizabeth and Shannon said, and you’re right on track. But just to reflect in the last week, I had an acute rheumatoid flare. Okay. They can’t go to the rheumatologist is COVID time. Okay. I had a 14-year-old fall 15 to 20 feet off of a roof. You can imagine what happened to his ankle. It was a mess. We put it together until he could be seen by the orthopedic surgeon for surgery the next day, we actually had to console. Congestive heart failure. The guy who had pulmonary edema comes in with shortness of breath. And the next guy was cirrhosis was about 25 pounds of extra wire on. And there’s no specialty. There’s no ability. What we have to do is develop a team and a team may be part of the interpreter throughout the state, maybe a specialist, maybe part of the administrative staff, maybe home health.
And we need to look at these patients as a whole program for our book, if you will, that has an introduction and a bunch of chapters in it that we can take care of, but everyone has a part to write in the book and to take care of. And I think if we look at team practice, just like people here today, it works. It’s a wonderful experience. I wouldn’t trade it for the world. We have a lot of challenges, but now when we have challenges like this, it creates new opportunities. Just like the Vietnam War found that people had excessive amounts of cholesterol in their arteries. This can be a challenge that helps rural America if we take it on, I think we can.

Bill: Elizabeth, any closing comments.

Elizabeth: Well, I hope that sessions like this, are bringing an enlightenment to folks and Americans who do not live in a rural area. As the rural Americans are the ones providing many resources, not just food to the rest of America and it’s critical that we take care of these communities and their health.
And I hope that this will educate many who get very isolated in the urban area because they have access to health and specialists so easy at the fingertips, so that they will help fight for legislative change, and bring further enlightenment and resources to our rural communities. That’s my hope.

Bill: Shannon, you get the last word,

Shannon: I’m lucky I get to work for one of the offices of rural health. There is an office of rural health in every one of the 50 States across our country and I think I like to think about rural, it’s really reaching underserved residents with action and love. So, there’s your corny, rural word for today, but these people are the hometown heroes. So, the next time you drive through one of these small towns, take a second, stop, go to the local cafe. You will never meet more nicer people than just stopping in one of those small towns.

Bill: Well, I want to end with something I should have said at the beginning, and that is, thank you. Thank you for everything that you are doing. You folks are on the frontline, you’re out there. It’s clear that you have a passion for what you do, but by the same token, by doing what you’re doing, you’re making sacrifices. You’re, dealing with problems and issues that I think a lot of folks, will be surprised to hear about. But you’re doing it out of love and out of passion and it’s clear that, you’re there because you want to be and trying to make a difference in your community. So, I want to thank you for everything that you do every day to make healthcare accessible, affordable, and available, in your communities and the job that you’re doing. And, my hat is off to you.

This is the conclusion of, this episode, Health Disparities and Rural Health. I want to thank everybody for listening in. I want to thank our participants today. Roger Wells, physician assistant from Nebraska, Shannon Chambers with the South Carolina Office of Rural Health and Elizabeth Ellis, nurse practitioner, from Texas. We appreciate you being with us here, and I hope you all have a great day. Stay well and stay healthy. Thank you.

(End of recording)

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