Issues We Supported in 2007
Rural Health Association Health Policy Documents notebook.doc
Issues Addressed-
Substance Abuse (Alcohol, Tobacco and Illicit Drugs)
Rural Access to Health Care
1) Substance Abuse
(Alcohol, Tobacco and Illicit Drugs)
Special Populations
Mental/Behavioral Health
Health Professions Education
Health Promotion/Disease Prevention
Statement of the Problem
Alcohol consumption, tobacco usage and illicit drug abuse are contributing factors to many health related problems. Poverty, lack of emphasis on educational attainment, lower wage jobs, higher rates of unemployment and lack of access to health, social and recreational services in rural areas have a direct correlation to the prevalence of usage of these substances.
Tobacco: According to the Substance Abuse and Mental Health Services Administration (SAMHSA) Office of Applied Sciences, a study conducted in 2002 revealed the Southern states of Tennessee, Mississippi, Kentucky and Alabama had the highest percentage of current cigarette smoking than any other region of the United States. 30.5% of the population in these four states smoke, compared to 21.9% in the Pacific West states. Smokeless tobacco use was 35% higher in the southern states than in the next highest area of the Northwest United States. Among youths, use of cigarettes, smokeless tobacco, cigars and pipes was highest in rural counties (19.2% in rural areas verses 13.3 in metropolitan areas). Among youths, ages 12 to 17, 20.7% of youths in non-metropolitan areas smoke cigarettes as compared to only 11.0% of youths in metropolitan areas. The rate of illicit drug use is eight times higher among youth who smoke cigarettes.
Cigarette use is higher among persons with lower family incomes with rates almost double among persons whose family income is less than $9,000 compared to those with incomes above $75,000. Cigarette use is highest among unemployed persons (44% compared to 30% for employed persons). Tobacco use is higher among those with a high school education or less (32.5% for those without a high school education compared to 14.4% of those who are college graduates).
Alcohol: Approximately half of Americans aged 12 or older report being current drinkers of alcohol (drink is defined as a can of beer, glass of wine, shot of liquor or mixed drink with liquor in it). Current drinkers are defined as those having one drink during a 30-day period. Binge drinking is defined as five or more drinks on the same occasion within a 30-day period and heavy use is defined as five or more drinks on the same occasion at least 5 times within a 30-day period. More than 22% of persons aged 12 or over participate in binge drinking, with heavy drinking reported by 6.7% of the population. Drinking levels are also associated with tobacco use and illicit drug use. Among heavy drinkers, 61.3% smoke cigarettes while only 17.7% of non-drinkers smoke. Of those who report being heavy drinkers, 32.6% were also illicit drug users.
SAMHSA's 2002 National Survey on Drug Use and Health reports that underage drinking among youth aged 12 to 17 was higher in rural than non-rural areas. Rural youth reported lower levels of perceived risk from alcohol use, less disapproval of alcohol use, and less perceived parental disapproval of underage drinking than those in non-rural areas. Binge drinking was also higher among rural youth aged 12 to 17 than non-rural youth.
Illicit Drugs: In 2002, an estimated 19.5 million Americans or 8.3% of the population aged 12 or older were current illicit drug users with marijuana being the most commonly used illicit drug, with a rate of 6.2. Approximately 2 million persons are cocaine users, 1.2 million use hallucinogens and 166,000 persons use heroin. An estimated 6.2 million, or 2.6% of the population 12 an older, use psychotherapeutic drugs taken non-medically. Among youths aged 12 to 17, 11.6% report being current illicit drug users (SAMHSA 2002 National Survey on Drug Use and Health).
The SAMHSA Treatment Episode Data Set reports that drug abuse related emergency department visits involving amphetamines or methamphetamines increased 54% in the nation between 1995 and 2002 with more than half of those visits being persons between the ages of 18 and 34. They also report that substance abuse treatment admissions rates for narcotic painkillers increased 155% between 1992 and 2002. The increase was smallest in metropolitan areas (58%) and largest in rural areas (269%). In 2001, amphetamines including methamphetamines, were the primary substance of abuse reported in more than 98,000 substance abuse treatment admissions, representing 6% of the admissions reported that year to SAMHSA. Since 1992, methamphetamine/ amphetamine admission rates increased by 100% in 33 states, spreading from the Pacific states into the Midwest and South. According to Congressman Bart Gordon, approximately 75% of the meth lab seizures that occurred in the Southeastern United States over the past two years were in Tennessee.
Co-Occurring Disorders: The National Rural Health Association reports that the prevalence of mental health problems among rural and urban populations is comparable. Mental disorders are often accompanied by co-occurring disorders that include addictions. Approximately 70%of individuals treated for substance abuse have a lifetime history of depression and individuals with either a mental health or substance use disorder are more likely to have a co-occurring disorder. Studies have found that 23% to 56% of individuals with a diagnosable Axis I mental disorder also have a substance abuse or dependence disorder. The few rural studies on co-occurring mental health and substance abuse disorders indicate no urban-rural differences in the prevalence of such co-morbidities. While these studies indicate no differences, the serious lack of a mental health and substance abuse infrastructure means that, in rural areas, they often go untreated.
Recommendation #1:
(1) Integrated treatment, combining physical, mental health and addiction treatment, is essential to effective intervention for addiction. Primary care physicians provide the bulk of mental health services in rural areas. This occurs predominantly because of the lack of mental health and addiction specialists in rural areas and because of the stigma in rural areas associated with seeking treatment in a mental health center. Primary care physicians must be capable of screening and recognizing mental disorders, providing brief therapy when warranted, and making referrals to mental health professionals when appropriate.
Action Steps:
RHAT will encourage Tennessee's medical training programs to incorporate culturally appropriate training on mental health and addiction.
RHAT will advocate with TennCare Behavioral Health Organizations to provide community-based training in a rural inter-disciplinary mental health model using an APA developed curriculum.
RHAT will continue to advocate with TennCare Behavioral Health Organizations to provide adequate reimbursement to primary care providers for mental health services they provide.
RHAT will advocate with federal and state legislators, TennCare and other insurance providers for mental health parity.
RHAT will advocate with federal legislators to expand the Quentin Burdick Rural Interdisciplinary Training Grant Program to increase the availability of interdisciplinary training for rural mental health providers with primary care practitioners.
Recommendation # 2:
Effective, research-based prevention and early intervention programs are critical to decreasing the cycle of addiction. Understanding the physiological impact of substance abuse on the mind and body and developing programming to reinforce developmental assets is critical to preventing substance abuse in adolescents. Parents, in partnership with schools, faith-based organizations, civic groups, and community organizations can play an instrumental role in decreasing the onset of substance abuse in Tennessee's youth.
Action Steps:
a) RHAT will support the Coordinated School Health (CSH) model as an
effective way to assist schools and communities in addressing the health and well-being of children and youth and will advocate with legislators and policy-makers to provide enhanced funding for CSH programs in Tennessee.
b) RHAT will support the efforts of the American Cancer Society, American
Lung Association and American Heart Association in educating Tennesseans of the dangers of tobacco usage.
c) RHAT will continue to advocate for a portion of tobacco settlement dollars to be utilized for prevention and cessation program.
Recommendation # 3:
Federal and state funding should be increased to recruit, train and incentivize mental health and addiction specialists to locate in rural areas, which are now under-represented in those professions.
· Action Steps:
a) RHAT will advocate with state and federal legislators and policy makers to earmark a portion of existing funding through the Office of Rural Health Policy, National Health Service Corps, Substance Abuse and Mental Health Services Administration and other applicable funding streams to improve funding for rural mental health and addiction services.
b) RHAT will advocate with the TennCare Behavioral Health Organizations to insure that equity exists in access to mental health and addictions specialists for rural constituents.
c) RHAT will advocate in partnership with the Tennessee Alliance for the
Mentally Ill and other advocacy groups for an increase in community-based support services for rural areas that have historically been lacking (i.e., supported housing, case management, support groups, drop-in centers).
d) RHAT will support the concept of Drug Court programs as effective
alternatives to incarceration for non-violent, drug-addicted offenders.
2) Rural Access To Health Care
Statement of the Problem
Primary care providers in Tennessee have been stressed on many fronts in the last decade:
- High TennCare patient load with greater impact from
o Major loss of income from bankruptcies of three major MCOs.
o Higher overhead
o Patient population with higher level of illness (acuity)
o Fewer sub-specialists who will accept TennCare
Increasing overhead by paperwork required by cost containment efforts of insurers, HIPPA, rising malpractice costs
- Increasing uninsured populations due to migration of jobs to foreign countries
Many counties in Tennessee are designated as federal health professional shortage areas for primary care and 94 out of 95 counties are designated as either partial or whole medically underserved areas. There are several counties in Tennessee with no Community Health Center (CHC) or Rural Health Clinic (RHC) presence. This is especially true in rural West Tennessee.
Rural areas have fewer specialists and ancillary services, and geographic isolation acts as a barrier to access to many people.
While there are many funding programs designed to supplement deficiencies in access to care, the effectiveness of this funding is often diminished to the fact that the target populations are spread over a wide geographic area.
Behavioral problems are usually presented in the context of medical care or noted by educational professionals in children. In rural areas, however, behavioral care is often extracted from the locations where populations seek health care, and not available in local communities.
Recommendation
Community-based primary care services must be strengthened and access to care for all people in rural Tennessee must be accelerated and accomplished. RHAT seeks to maximize access to services that are shown to be efficacious through evidence-based, peer-reviewed studies. In areas of political controversy, RHAT seeks the greatest good of patients and populations above the interests of professional groups and special interest organizations. RHAT seeks to support programs that foster growth to independence in patients and populations, rather than programs which create dependence.
Action Steps:
a) RHAT will support the Rural Graduate Medical Education Program (R-GME) for increasing providers to rural areas through the creation of a central statewide office; monitor the progress of that office, and assess the impact of the office on access to primary care in rural Tennessee.
b) RHAT will support the expansion of CHCs and RHCs into underserved areas with no safety net provider.
c) RHAT will support the development of programs that increase awareness of all health care providers and patients of the existing services.
d) RHAT will support the development of programs that improve the effective use and coordination of existing services in the community.
e) RHAT will utilize the broad scope of health care participants in its membership to promote better utilization and coordination of health care services that already exist, and develop mechanisms for alleviating gaps and barriers in access to health care.
f) RHAT will partner with Tennessee Primary Care Association (TPCA) to advocate for and support the expansion of CHCs and RHCs.
g) RHAT will work to reduce the malpractice threat to health care providers in Tennessee and work to provide positive effective techniques for improving quality in health care.
h) RHAT will work with the Tennessee Office of Rural Health and the Tennessee EMS for Children program to provide advocacy, support and education to assist rural providers in accessing appropriate training.
i) RHAT will continue to monitor national legislation that affects elder rural Tennesseans and support that which benefits rural citizens fairly and will coordinate advocacy efforts with the Tennessee Primary Care Association and the Area Agencies on Aging.
3) Special Populations
Statement of the Problem
The most common train of thought when minority health care is discussed is that of urban rather than rural communities. In the United States, minorities comprise 15 percent of the total rural population and account for 30 percent of the rural poor. Problems of chronic poverty, lack of stable medical care, language barriers, non-traditional and/or culturally insensitive medical treatment are just a few of the points faced by these under-served populations. Issues of access, availability and affordable combined with cultural concerns and geographic barriers are double indemnity in the provision of health services delivery to minorities.
Recommendation
RHAT will promote and support programs and initiatives that target the elimination of health care disparities among all ethnic, racial and under-served populations in Tennessee
a) RHAT will advance those strategies that encourage education, early intervention and prevention reduce the rates of morbidity and mortality due to chronic disease affecting these specific populations.
4) Mental/Behavioral Health
Statement of the Problem
People in rural areas of TN often experience problems with access to behavioral health services for both mental health disorders and substance abuse and a combination of both as in co-occurring disorders. There are 35 counties designated as federal shortage areas for mental health due to low income and 41 counties designated as federal shortage areas for mental health due to geographic factors. This is a total of 76 out of 95 counties in TN designated as federal shortage areas for mental health. There are not an adequate number of providers in rural areas and stigma regarding obtaining treatment continues to exist. Both of these factors prevent people from accessing needed behavioral health services.
Recommendation
Integrating primary care and behavioral health increases access to behavioral health care for people in rural areas. When behavioral health services are provided in the same health care setting as primary care services, people are more likely to access them. Resources should be provided to encourage integrated care and to increase the number of behavioral health providers (Licensed Clinical Social Workers and Ph.D. Psychologists) practicing in these settings.
a) RHAT will partner with Tennessee Primary Care Association to advocate for initiatives through TennCare that will promote integrated care.
b) RHAT will collaborate with other mental health, substance abuse, and co-occurring disorders associations to provide education and awareness to rural communities.
c) RHAT will work with R-GME to increase the number of behavioral health providers in rural areas.
5) Health Pessions Education
atement of the Problem
According to the 2001 Demand Assessment conducted by the Rural Health Association of Tennessee in collaboration with the stateÃs medical schools, there is continuing significant demand for additional health professionals in TennesseeÃs rural counties.
Recommendation
RHAT supports activities that relieve this demand and provide access to health care for all Tennesseans.
a) RHAT will support active efforts to recruit rural high school graduates into health professions education programs.
b) RHAT will support efforts to engage middle school students in pursuing an interest in health professions, especially 7th and 8th grade students; such as the increase of Career Days.
c) RHAT will support rural, community-based learning experiences for health professions students organized through partnerships between educational programs and rural communities.
d) RHAT will support for the preparation, recruitment and retention of professionals to address the behavioral and oral health needs in rural areas.
e) RHAT will support for the preparation and deployment of primary care physicians, nurse practitioners and physician assistants in rural areas.
f) RHAT will advocate for preparation of culturally competent health professions graduates.
g) RHAT will support for the proposed Rural Graduate Medical Education Program to establish a multi-institutional organization to recruit and retain primary care providers in rural areas.
h) RHAT will support for the amendment of the existing underused TennCare Residency Stipend Program and a stronger set of financial incentives for rural communities to use to recruit primary health care professionals.
6) Health Promotion/Disease Prevention
Statement of the Problem
Tennessee ranks 48th in overall well being of its population. In that statistic includes diabetes and obesity. In the ten priority areas * monitored by the County Health Councils of Tennessee the state does not rank above 43rd in any area. The Commissioner of Health has challenged all County Health Councils of Tennessee to develop new ideas for community intervention.
*Cardiovascular Disease (Heart disease/stroke), Diabetes, Obesity, Teenage Pregnancy, Prenatal Care, Infant Mortality, Alcohol (drug abuse), Sexually transmitted disease, and Tobacco use.
Recommendation
RHAT is committed to vigorously address the Tennessee Department of Health Program It's About Time. The program parallels the efforts advocated by RHAT that Tennessee must address the poor health issus in this state and have measureable results by 2010. Programs must have an outcome that can be measured. Disparate populations have unique nees. Strategies for health improvement must be comprehensive. Partnerships and coalitions should be nurtured. Initiatives should be community-based. Programs should have long-term sustainability.
Action statement:
RHAT will partner with the Tennessee Department of Health through the County Health Councils to advocate those programs that each of 95 counties will monitor in their counties in conjuction with the "It's About Time" program.