Article Archive
May/June 2020

Rural Health: Lessons From the Appalachian Region — Adaptive Care Connections for Geriatric Patients
By Ronna New, DO, FACOFP
Today’s Geriatric Medicine
Vol. 13 No. 3 P. 6

Each day, 30 people turn 65 in the Appalachian region, one of the most economically disadvantaged areas in the country. It’s a trend that’s expected to continue through 2025 due to the proportion of baby boomers in the region, and it’s intensifying demand for geriatric-specific health care resources.

But securing access to geriatric care in this region is no small feat. At a time when there’s high demand for access to geriatricians nationally, the following recent statistics show why the Appalachian region, like most rural communities, faces significant challenges in attracting geriatric physicians:

• Just 12% of primary care physicians and 8% of specialists work in rural areas.

• Less than 5% of medical students are from rural communities. Since medical students who have grown up in rural areas are more likely to practice in these areas, this limits the pipeline of future physicians who are naturally drawn to these areas.

For rural older adults, the health impact of the lack of specialists such as geriatricians is profound. Rural residents have a 23% higher mortality rate and a 40% higher preventable hospitalization rate than do urban residents, a recent study found. Even more striking: Lack of specialty care access in rural areas contributes to 55% of the difference in preventable admissions and 40% of the difference in mortality rates between rural and urban areas.

Scarce Resources for Care of Older Adults
Part of the challenge in pairing rural older adults with specialized resources that consider their unique needs is the persistent decline in geriatricians nationally.

Today, 1 in 6 Americans are 65 or older; by 2030, 1 in 5 Americans will be older than 65, and 31 million Americans will be 75 or older—more than ever. As the nation’s population ages, the need for geriatricians who can address the complexity of care issues older adults face—such as greater prevalence of chronic disease, declines in cognitive health, a rise in mental health issues such as depression, and increased risk for cancer—becomes greater.

Medical schools would need to train 6,250 geriatricians by 2030 to join the 7,300 geriatricians who currently practice medicine to meet the growing demand. That’s nearly 450 more medical students per year than training programs see today. Yet fewer medical students are becoming trained in this specialty, and few training programs exist for those who do express interest. One study shows 210 geriatric graduate medical programs currently are available nationally, compared with 182 in 2001—an increase of nearly 1% when population growth is factored.

States such as Oregon and Florida struggle to fill openings for geriatric fellowships. Attracting specialists to rural areas such as the Appalachian region is even harder. Obstacles sometimes include a bias against treating older adults that often stems from lack of education, as one recent essay by a geriatrician, “Aging Isn’t a Dirty Word,” shows. In rural areas such as the Appalachian region, where supply-and-demand imbalance exists for physicians of all specialties, attracting geriatricians can be a Herculean task unless a physician meets the following criteria:

• has roots in rural areas and a deep appreciation of the need for rural care resources;
• is incentivized to work in a rural area; and
• can supplement in-person care with virtual care.

Some states are exploring debt-relief programs for physicians who treat older adults in high-need areas, such as rural regions. There are also efforts to expose medical students to working with older patients early in their studies to pique interest in geriatrics and increase scholarship funding for medical students and residents who excel in geriatric care. But without an emphasis on innovative approaches to draw medical students focused on geriatrics to areas of the greatest need, the gap in care will persist and potentially worsen—especially in rural communities.

Elevating Rural Geriatric Care
Rural health care organizations can strengthen rural care connections for older adults—with or without an onsite geriatric specialist—by adopting the following key strategies:

Build time into physicians’ schedules for one-to-one conversations with geriatric patients. Given the complexity of older adults’ medical needs, it’s important to create a scheduling template for geriatricians and other physicians who work with older patients to ensure physicians have the appropriate amount of time to discuss their concerns. It also establishes the right amount of time for nurses to record vitals, a process that takes longer for older adults than younger patients.

Creating a scheduling template that builds in additional time per appointment enables geriatricians to get to know patients well enough that when subtle changes in mood and cognitive function appear, they’re detected quickly. Geriatricians can then intervene to slow aspects of the aging process.

Focus on decreasing emergency visits. One way to help older adults receive the right care in the right setting is by creating an extensivist clinic. This type of resource provides a more trusted resource for geriatric patients who are experiencing complications from kidney disease, congestive heart failure, and COPD, with specially trained resources and extended hours for treatment. It also helps older patients avoid unnecessary emergency department (ED) visits and inpatient admissions.

Provide the right training for support staff. Caring for geriatric patients requires that professionals have a great deal of patience—with both the patients and their caregivers. It’s important to hand-pick the nurses and staff who work closely with these patients, looking for the right personality and skill sets to help meet their complex needs. Once the right staff members have been selected, and depending upon their positions, they should be trained on how to effectively handle calls from older patients and their caregivers and when to seek support from a physician.

Partner with other providers in sharing patient data. A visit to the ED often is an indication of a serious health challenge ahead—even if the patient isn’t admitted to the hospital. One study shows older adults who go to the ED are 14% more likely to develop a disability within six months than are those of the same age with the same symptoms who do not seek treatment in an ED. That’s one reason it’s so important that geriatricians and others who work with older patients have access to a complete record of their medical visits, including ED visits and hospital stays, across the continuum of care.

Access to comprehensive patient data at the point of care improves one-to-one interactions with older adults, such as by prompting conversations around why they rely on the ED for after-hours care or haven’t filled recent prescriptions. It can also help physicians more quickly identify patients who show signs of health issues that are not being properly managed.

Seek ways to collaborate with geriatricians and other experts virtually. Telehealth—and increased reimbursement for telehealth services for Medicare and Medicare Advantage patients—offers strong potential to help rural providers access specialized guidance in treating older adults’ unique health needs. It also enables patients and caregivers to avoid traveling long distances for care, a challenge that is common for rural patients and their families. For example, the University of Mississippi Medical Center offers telehealth screenings for dementia and other memory issues. Meanwhile, remote patient monitoring technologies, such as for heart failure, can alert specialists in other cities to signs that the patient’s condition may require more immediate attention.

Having a geriatrician available locally is also important for establishing connections with a wide range of medical professionals in the community. When geriatricians make themselves available for urgent care consults, for example, this extends the geriatrician’s reach, delivering a valuable community service.

A Value-Based Approach to Geriatric Care
Studies show that every transition in care environments puts older adults at risk for increased medical issues and decreased cognitive function. By seeking ways to offer older patients in rural communities’ geriatric resources close to home, providers can better support a coordinated, holistic approach to care that minimizes transitions in care and empowers patients to age in place.

— Ronna New, DO, FACOFP, is a board-certified geriatrician for Holston Medical Group, which serves 250,000 patients in the Appalachian region. She is based in Bristol, Tennessee.