RUPRI Health Panel ¢ J \ 4 www. rupri.org Keith J. Mueller, PhD, Chair University of Iowa RURAL POLICY RESEARCH INSTITUTE Policy Brief - January 2022 HIGH-PERFORMING RURAL HEALTH SYSTEM Prepared by the RUPRI Health Panel: Andrew Coburn, PhD; Alva O. Ferdinand, DrPH, JD; Alana Knudson, PhD; Jennifer Lundblad, PhD, MBA; A. Clinton MacKinney, MD, MS; Timothy McBride, PhD; Keith J. Mueller, PhD; Guest Author, Hannah Rochford, MPH. Introduction In September 2011, the RUPRI Health Panel published "The High Performance Rural Health Care System of the Future." Recognizing that the context for health policy and system development has changed considerably in the past 10 years, this document offers a revised vision statement and updates the high-performing rural health system pillars. High-Performing Rural Health System Foundational to the Health and Well-Being of Rural Residents AFFORDABILITY COMMUNITY HEALTH The Consistent, Systematic, and Just Treatment of All Individuals | | Equity Foundations Creating aspirational goals for the rural health system (which we label as pillars) starts with a clear vision: The RUPRI Health Panel envisions rural health services that are affordable and accessible for all rural residents through a sustainable health system that delivers high quality, high value services. A high- performing rural health system informed by the needs of each unique rural community and population groups will improve community health and well-being. Inclusivity requires that the rural health system ensures that all individuals, regardless of personal characteristics or social circumstances, have the opportunity to reach and maintain their best possible health and well-being. Furthermore, "all individuals must have comparable opportunities to obtain services needed to ensure good health."! Recent events have renewed consideration of how differential treatments of some people and populations inhibit their ability to achieve and maintain optimum health. The Panel developed this definition of equity to inform our subsequent discussion of the pillars: The term equity means the consistent, systematic, and just treatment of all individuals. Equity considers those who live in underserved rural communities, including those who identify with sub-populations who are treated differently because of personal characteristics and/or social circumstances. Moreover, equity requires special consideration of those who have been systematically denied opportunities to access necessary health services and achieve their best possible health and well-being. The inter-connected pillars described in the next section are aspirational goals essential to achieving an equitable, high-performing rural health system. The World Healthcare Organization characterizes a health system as "all organizations, people and actions whose primary intent is to promote, restore or maintain health."2 Consistent with this, we define the health system to be the organization of all public and private policies, programs, health care providers, health care institutions, and resources that deliver health care services to U.S. citizens. Pillars Accessibility A high-performing rural health system provides . ; equitable access to health services for all The High-Performing Rural Health individuals and facilitates equal opportunity for | 5¥Stem ensures that rural residents can optimal health and well-being by proactively obtain the health care, public health, supporting historically underserved populations "4 social services they need. and those experiencing lower quality outcomes. 1 Mueller, K. J. and Mackinney, A. C. (2006) Care Across the Continuum: Access to Health Care Services in Rural America. The Journal of Rural Health 22:1. Pp 44. 2 World Health Organization (2007) Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action. Geneva, Switzerland: WHO. ISBN 978 92 4 15607 7 Although rural communities differ in the level and range of services that can be supported and sustained, essential rural community health services include primary care, emergency medical services, and public health.? Primary care is the cornerstone and entry point of a high-performing rural health system. Rural interdisciplinary health teams provide person-centered services to individuals and communities. The team is not only accessible for timely episodic and chronic care, but anticipates and provides preventive care. The team ensures that health-related social needs are addressed seamlessly with coordinated services. Not all health services can be provided locally or in-person. For services not available locally, the rural health system develops and supports a regional health infrastructure that includes transportation, technology, and provider relationships to make accessible the full continuum of health services. Affordability The affordability of the rural high-performing rural health system, for individuals, families, employers, and society, is essential for ensuring equitable access to the health system. The affordability of health insurance and/or health care is defined relative to one's ability to pay, with the understanding that individuals, families, businesses, and other organizations have varying abilities to pay based on their income or revenues. In the high-performing rural health system, overall affordability is achieved through an emphasis on primary care, efficient delivery of health services, and attention to the broader social needs of citizens and the community that drive health care costs. Community Health The health and well-being of all people and communities is a top priority in the high- performing rural health system. Health care, public health, social service payments, and delivery models prioritize prevention, well-being, and social determinants of health. Prevention and screening services that help avoid or delay the onset of chronic disease are readily accessible. Resources are allocated to advance opportunities for underserved rural communities, which include a disproportionate percentage of residents who have chronic health conditions, are older adults, and/or lack adequate health insurance coverage. Further, public policies and actions by health related organizations focus on meeting the needs of rural underserved populations who are further marginalized based on race/ethnicity, sexual orientation, economic status, or other circumstances. Updates to these policies and actions are based on ongoing, in-depth assessments of the barriers to optimal health. The High-Performing Rural Health System seeks to improve the health of all residents by emphasizing prevention and focusing on underserved populations. Quality In a high-performing rural health system, all members of a community achieve their best possible health. The health system responds to the unique needs of each rural person and assures that they receive the highest quality care. Further, the high- 3 Mueller, K. J., and MacKinney, A. C. 2006. Care Across the Continuum: Access to Health Care Services in Rural America. Journal of Rural Health 22(1):43-9. 3 performing rural health system defines quality in a way that goes beyond clinical considerations toward a more comprehensive whole-person approach. At the individual level, health care is a partnership between the patient and the health care team, each sharing responsibility for health decisions and behaviors. The primary care team serves as the hub of patient information flow and interactions. Shared decision-making and other person- centered tools are used to evaluate treatment options and community supports that respectfully consider both patient preferences and values, and clinical and scientific evidence. Clinicians are culturally aware, delivering care and information sensitive to the patient's and family's unique circumstances and needs. At the health care organization level, quality is supported and continually improved through training, resources, tools, technology, and guidance. Priorities include assessing and addressing individual and population health needs and goals, committing to transparency and public reporting using rural relevant quality measures, providing culturally and linguistically appropriate services, and participating in payment systems that reward quality. Rural health systems deliver quality and service levels on par with their urban counterparts for those services delivered in rural areas, and quality innovation is fostered to facilitate rapid adoption of best practices within and across organizations and communities. Health care payment policies reward, and thus sustain, the delivery of value-based care, i.e., high quality and patient-centered care that is as efficient as service volumes allow. Across individual, system and societal levels, the High-Performing Rural Health System responds to the unique needs of each rural person using a whole-person approach. Conclusion As health services delivery, organization, and financing change, consideration should be given to how such changes contribute to achieving the high-performing rural health system envisioned here and described by the four pillars. The RUPRI Health Panel will use the high-performing rural health system vision and pillars to guide its analysis of proposed, enacted, and implemented public policies. The pillars are aspirational goals, each describing an essential component and all four are necessary to achieve the vision. In addition to using the framework of the pillars to analyze policy and program development, the RUPRI Health Panel will continue to help policy makers and stakeholders consider new means of achieving the goals embedded in each pillar, thereby advancing understanding and action toward the vision of a high-performing rural health system. Acknowledgements This report was supported through a cooperative agreement with the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), US Department of Health and Human Services (HHS), under cooperative agreement/grant #U18RH30805. The information, conclusions and opinions expressed in this report are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.