A. The issues faced by health care providers and patients in rural areas are different than those in urban areas. A unique set of factors creates disparities in health care services and resources not typically found in urban areas (Bushy, 2000). The following are a summary of facts from Health and Human Services (USDHHS, 2013):

B. The Health Insurance Marketplaces are expected to increase competition in the insurance market not only in urban but also in rural areas—especially in the 29 mostly rural states, where a single insurer currently dominates more than half the health insurance market (USDHHS, 2013; Joo, 2014).

C. In states that are expanding Medicaid benefits and reach, rural residents are more likely to be eligible for affordable coverage under this coverage expansion.

D. This is especially important in rural areas, where research has shown that one in five farmers faces medical debt, and families, on average, pay nearly half of their health care costs out of pocket (USDHHS, 2013).

E. Only about 10% of physicians practice in rural America despite the fact that nearly one fourth of the population lives in these areas. This is complicated by the existing shortages in primary care providers.

F. Rural residents are less likely to have employer-provided health care coverage or prescription drug coverage, and the rural poor are less likely to be covered by Medicaid benefits than their urban counterparts.

G. Although only one third of all motor vehicle accidents occur in rural areas, two thirds of the deaths attributed to these accidents occur on rural roads.

H. Rural residents are nearly twice as likely to die from unintentional injuries, other than motor vehicle accidents, than are urban residents. Rural residents are also at a significantly higher risk of death by gunshot than urban residents.

I. Rural residents tend to be poorer. On the average, per capita income is $7,417 lower than in urban areas, and rural Americans are more likely to live below the poverty level. The disparity in income is even greater for minorities living in rural areas. Nearly 24% of rural children live in poverty.

J. People who live in rural America rely more heavily on the Federal Food Stamp Program.

K. There are 2,157 Health Professional Shortage Areas (HPSAs) in rural and frontier areas of all states and US territories compared to 910 in urban areas.

L. Abuse of alcohol and use of smokeless tobacco are significant problems among rural youth. The rate of driving while under the influence of alcohol (DUI) arrests is significantly greater in nonurban counties. Forty percent of rural 12th graders reported using alcohol while driving compared to 25% of their urban counterparts. Rural eighth graders are twice as likely to smoke cigarettes (26.1% vs. 12.7% in large metro areas).

M. Anywhere from 57% to 90% of first responders in rural areas are community volunteers.

N. There are 60 dentists per 100,000 individuals in urban areas versus 40 per 100,000 in rural areas.

O. Cerebrovascular disease is reportedly 1.45 higher in nonmetropolitan statistical areas (non-MSAs) than in MSAs.

P. Hypertension is also higher in rural than urban areas (101.3 per 1,000 individuals in MSAs and 128.8 per 1,000 individuals in non-MSAs).

Q. Twenty percent of nonmetropolitan counties lack mental health services versus 5% of metropolitan counties.

R. The suicide rate among rural men is significantly higher than in urban areas, particularly among adult men and children. The suicide rate among rural women is escalating rapidly and is approaching that of men.

S. Medicare payments to rural hospitals and physicians are dramatically less than those to their urban counterparts for equivalent services. This correlates closely with the fact that more than 470 rural hospitals have closed in the past 25 years.

T. Medicare patients with acute myocardial infarction (AMI) who were treated in rural hospitals were less likely than those treated in urban hospitals to receive recommended treatments and had significantly higher adjusted 30-day post AMI death rates from all causes than those in urban hospitals.

U. Rural residents have greater transportation difficulties reaching health care providers, often traveling great distances to reach a doctor or hospital (Morgan & Fahs, 2007).

V. Death and serious injury accidents account for 60% of total rural accidents versus only 48% of urban.

W. The federal government uses two definitions for “rural,” along with many variants that are important for the case manager to know. These designations and descriptions may result in different funding and
reimbursement opportunities or may provide benefits not available to urban areas.

X. Case managers and program leaders, especially those who practice in rural and remote areas, must be knowledgeable in the issues and concerns rural area residents and health care seekers face. Such awareness assists in designing effective case management programs, roles, and strategies, which ultimately enhance the health of the rural communities (Davis et al., 2014).

A. Health Professional Shortage Areas (HPSAs)—Areas designated by the Health Resources and Services Administration (USDHHS, HRSA, 2015) as having shortages of primary care, dental care, or mental health providers. They may be geographic (e.g., a county or service area), population (e.g., low income or Medicaid eligible), or facilities (e.g., Federally Qualified Health Centers or state or federal prisons).

B. Index of Medical Underservice (IMU)—A score that is used to determine whether a geographic area can be designated as underserved or well served. The index involves four variables: ratio of primary medical care physicians per 1,000 population, infant mortality rate, percentage of the population with incomes below the poverty level, and percentage of the population age 65 or over. The value of each of these variables for the service area is converted to a weighted value, according to established criteria. The four values are summed to obtain the area’s IMU score (HRSA, 2015).

C. Metropolitan Statistical Areas (MSA)—A geographical region with a relatively high population density at its core and close economic ties throughout the area. Such regions neither are legally incorporated as a city or town would be nor are they legal administrative divisions like counties and states. Such designation is made by the Office of Management and Budget (OMB) for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. An MSA is core urban area with 50,000 or more population size.

D. Medically Underserved Area (MUA)—A designation of a geographic area that is given based on the Index of Medical Underservice (IMU) score. The IMU scale ranges from 0 to 100, where 0 represents completely underserved and 100 represents best served. Under the established criteria, each service area found to have an IMU of 62.0 or less qualifies for designation as an MUA (HRSA, 2015).

E. Medically Underserved Population (MUP)—A designation that involves application of the Index of Medical Underservice (IMU) to data on an underserved population group within an area of residence to obtain a score for the population group. Population groups where MUP determination is considered are usually those with economic barriers such as low-income or Medicaid-eligible populations or experiencing cultural and/or linguistic access barriers to primary medical care services. The MUP process involves assembling the same data elements and carrying out the same computational steps as stated for MUAs (HRSA, 2015).

F. Micropolitan Statistical Area—A geographic region that contains an urban core population of at least 10,000, but less than 50,000 (US Census Bureau, 2015).

G. Rural—Characteristics of country life. Encompasses all populations, housing, and territories not included in designated “urban” areas.

H. Rural Areas—(See rural) Nonurban areas characteristic of low population density, small settlements, and tend to focus more on agriculture as life resources.

I. Rural-Urban Commuting Area (RUCA)—Is a census tract-based classification scheme completed using the standard Bureau of Census’ urbanized area and urban cluster definitions (population density and urbanization) in combination with work commuting information. The classification contains two levels. Whole numbers (1 to 10) delineate metropolitan, micropolitan, small town, and rural commuting areas based on the size and direction of the primary (largest) commuting flows. 1 indicates most urban flow, while 10 indicates most rural flow (USDA, 2015).

J. Urbanized Area—Is a location characterized by high human population density and vast human-built features in comparison to the areas surrounding it. Urban areas may be cities or towns. The geographical territory is identified according to criteria and must encompass at least 2,500 people, at least 1,500 of which reside outside institutional group quarters (US Census Bureau, 2010).

K. Urban Clusters—Based on the Census Bureau’s geographical designations, an urban cluster represents densely developed territory and encompasses residential, commercial, and other nonresidential urban land uses. To be designated as an UC, the area must have at least 2,500 and less than 50,000 people, compared to urbanized areas (UAs), which require to have 50,000 or more residents (US Census Bureau, 2010).

A. The Case Management Society of America (CMSA) describes in its standards of practice for case management (CMSA, 2010) that case management practice extends across all health care settings and by providers of various professional disciplines. This without a doubt applies to the provision of case management services in rural areas.

B. Rural case management programs are designed similarly to those in urban and metropolitan areas. They include same aims/goals, roles, functions, strategies, and approaches as those of general practice or care settings. Case managers share similar responsibilities; however, the population served and the health care concerns addressed vary because the health care disparity issues, resources, and services available in rural regions are different than urban areas (Stanton & Packa, 2001).

C. Rural case managers may use the CMSA standards as a guide for the implementation of their roles. All of the standards are relevant to the practice of rural case managers including the legal and ethical considerations.

D. Case managers in the rural care settings must demonstrate awareness and competence in the CMSA standards of practice. They also must inform their employers and other professionals they collaborate with when dealing with clients/support systems about the existence of these standards and their value and need to adhere to them (Mullahy, 2014; Pyrillis, 2015).

E. This chapter introduces case managers to the differentiating factors and principles of rural case management practice, characteristics of the rural client population, and role of the case manager in such care settings. It also explains how collaboration may occur between case managers in the rural and other care settings, especially the urban-based health care organizations and providers.

A. The US Census Bureau (2015) defines various areas within the United States as either urban areas or urban clusters. These are basically delineation of geographical areas based on population density and other factors such as residential, commercial, or nonresidential.

B. The Census Bureau describes “rural” as an area that encompasses all population, housing, and territory not included within an urban area. Whatever is not urban is considered rural.

C. According to the White House Office of Management and Budget (OMB, 2013), a metropolitan area contains a core urban area of 50,000 or more in population size. A micropolitan area is an area that contains an urban core of at least 10,000 (but less than 50,000) in population size as micropolitan. Rural area, on the other hand, is any county that is not part of a metropolitan statistical area (MSA). Micropolitan counties are considered nonmetropolitan or rural along with all counties that are not classified as either metropolitan or micropolitan.

D. There are measurement challenges with both the Census Bureau and OMB definitions. Some policy experts note that the census definition classifies quite a bit of suburban area as rural. The OMB definition includes rural areas in metropolitan counties including, for example,
the Grand Canyon, which is located in a metropolitan county. Consequently, one could argue that the Census Bureau standard includes an overcount of rural population, whereas the OMB standard represents an undercount of the rural population. Case managers must be aware of these issues especially if the rural case management programs are funded and the funding is impacted by the designation.

E. The United States Department of Agriculture (USDA, 2015) defines urban (100 persons per square mile), frontier (6 or few persons per square mile), and rural (7 to 99 persons per square mile).

F. The United States Department of Agriculture (USDA, 2015) Economic Research Service (ERS), Rural Economy and Population, defines rural in terms of the economic and social factors. An area’s economic and social characteristics have significant effects on its development and need for various types of public programs.

G. To provide policy-relevant information about diverse county conditions to policymakers, public officials, and researchers, ERS has developed a set of county-level typology codes that captures differences in economic and social characteristics.

H. Health professional shortage areas (HPSA) describe the distribution and density of health professionals in a given area. These designations assist in understanding the access patients have to health care providers, services, and resources. Usually, they are designated on the basis
of counties within each state, and these can exist in all three of the following categories:

I. To better understand health professions shortages in various geographical area designations, it is important for the case manager to be familiar with the four types described below and to apply each HPSA category. This is especially important for case managers involved in health policy and access to care and services.

J. Medicare Bonus—When an area is designated as a geographic HPSA, all physicians working in the HPSA are eligible for an additional 10% Medicare payment. From primary care physicians and specialists to optometrists, chiropractors, podiatrists, and medical teleconsultants, they are all eligible for the incentive payment for practicing in the geographic HPSA.

K. Loan Forgiveness—The goal of the National Health Services Corps (NHSC, 2015) is to expand access to health care services and improve
the overall health of individuals living in medically underserved areas across the United States.

L. Visa Waiver—This program excuses foreign nationals from meeting some of the usual requirements for obtaining permanent residence in the United States. Such program enhances the provision of health care services in remote and rural areas where health care resources and services are short.

M. Veterans Health Administration (VHA, 2015), Office of Rural Health (ORH)—The VHA plays an active role in rural health care. The mission of the VHA ORH is to improve access and quality of care for enrolled rural and highly rural veterans by developing evidence-based policies and innovative practices to support the unique needs of enrolled veterans residing in geographically remote areas. Rural designation of VHA medical centers is one way of determining where health care resources may require special attention.

N. Rural designation of VHA’s health care facilities may use three schemes as follows:

A. Awareness of rural health emerged in the 1980s when health care workers began to notice disparate status of health care utilization in rural regions (RR).

B. During the 1980s, rural hospitals began to close due to low census, increased regulation and financial failure, and persistent shortages of health care professionals.

C. The 1990s witnessed anxiety and concerns about how cost containment and managed care would impact rural health. Lawmakers did not know about the implications of managed care (Coughlin, Long, & Graves, 2008).

D. There were numerous concerns about rural and remote health care delivery and resources: some of which still exist today (Box 9-1).