Top Ten Tips Palliative Clinicians Should Know About Rural Palliative Care in the United States
Publication: Journal of Palliative Medicine
Volume 27, Issue Number 9
Abstract
Palliative care improves outcomes, yet rural residents often lack adequate and equitable access. This study provides practical tips to address palliative care (PC)-related challenges in rural communities. Strategies include engaging trusted community partners, addressing cultural factors, improving pediatric care, utilizing telehealth, networking with rural teams including caregivers, and expanding roles for nurses and advanced practice providers. Despite complex barriers to access, providers can tailor PC to be patient-centered, respect local values, and bridge gaps. The “Top 10” format emphasizes the relevant issues to enable clinicians to provide optimal care for people from rural areas.
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References
1. Bakitas MA, Elk R, Astin M, et al. Systematic review of palliative care in the rural setting. Cancer Control 2015;22(4):450–464.
2. Kavalieratos D, Corbelli J, Zhang D, et al. Association between palliative care and patient and caregiver outcomes: A systematic review and meta-analysis. JAMA 2016;316(20):2104–2114.
3. Haun MW, Estel S, Rücker G, et al. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev 2017;6(6):CD011129.
4. Bakitas M, Allen Watts K, Malone E, et al. Forging a new frontier: Providing palliative care to people with cancer in rural and remote areas. JCO 2020;38(9):963–973.
5. US Census. Story Map Series. mtgis-portal.geo.census.gov; 2010. Available from https://mtgis-portal.geo.census.gov/arcgis/apps/MapSeries/index.html?appid=49cd4bc9c8eb444ab51218c1d5001ef6 [Last accessed: December 7, 2023].
6. Morrison RS, Augustin R, Souvanna P, et al. America's care of serious illness: A state-by-state report card on access to palliative care in our nation's hospitals. J Palliat Med 2011;14(10):1094–1096.
7. Basu S, Berkowitz SA, Phillips RL, et al. Association of primary care physician supply with population mortality in the United States, 2005–2015. JAMA Intern Med 2019;179(4):506–514.
8. Rural Health Information Hub. Rural Healthcare Workforce; February 24, 2023. Available from: https://www.ruralhealthinfo.org/topics/health-care-workforce [Last accessed: August 10, 2023].
9. Bauerly BC, McCord RF, Hulkower R, et al. Broadband access as a public health issue: The role of law in expanding broadband access and connecting underserved communities for better health outcomes. J Law Med Ethics 2019;47(2_suppl):39–42.
10. Economic Research Service (ERS), U.S. Department of Agriculture. State Fact Sheets: United States. ERS: Washington, DC; June 16, 2023. Available from: https://data.ers.usda.gov/reports.aspx?ID=17854#P9eae4d3b0fb1469292b32de6a9886959_2_39iT0 [Last accessed: December 7, 2023].
11. Terlizzi EP, Cohen RA. Geographic Variation in Health Insurance Coverage: United States, 2020. National Health Statistics Reports; No. 168. National Center for Health Statistics: Hyattsville, MD; 2022.
12. Foutz J, Artiga S, Garfield R. The Role of Medicaid in Rural America. Kaiser Family Foundation: Washington, DC; 2017. Available from: https://www.kff.org/medicaid/issue-brief/the-role-of-medicaid-in-rural-america/ [Last accessed: December 7, 2023].
13. Rural Health Information Hub. Chronic Disease in Rural America; May 20, 2022. Available from: https://www.ruralhealthinfo.org/topics/chronic-disease#urban-comparison [Last accessed: December 7, 2023].
14. Curtin SC, Spencer MR. Trends in Death Rates in Urban and Rural Areas: United States, 1999–2019. NCHS Data Brief, No. 417. National Center for Health Statistics: Hyattsville, MD; 2021.
15. Cosby AG, McDoom-Echebiri MM, James W, et al. Growth and persistence of place-based mortality in the United States: The Rural Mortality Penalty. Am J Public Health 2019;109(1):155–162.
16. Rural Health Information Hub. February 24, 2023. Rural Healthcare Workforce. Available from: https://www.ruralhealthinfo.org/topics/health-care-workforce [Last accessed: December 7, 2023].
17. Salako A, Ullrich F, Mueller K. Update: Independently owned pharmacy closures in Rural America, 2003–2018. Rural Policy Brief 2018;2018(2):1–6.
18. Hawryluk M. The Last Drugstore: How Rural Communities Are Losing Their Pharmacies. KFF Health News; November 15, 2021. Available from: https://kffhealthnews.org/news/article/last-drugstore-how-rural-communities-lose-independent-pharmacies/ [Last accessed: December 7, 2023].
19. Suntai Z, Won CR, Noh H. Access barrier in rural older adults' use of pain management and palliative care services: A systematic review. Am J Hosp Palliat Care 2021;38(5):494–502.
20. Karlin-Smith S, Ehley B. Opioids in America: 5 Unintended Consequences of Addressing the Opioid Crisis; May 8, 2018. https://www.politico.com/story/2018/05/08/opioid-epidemic-consequences-502619 [Last accessed: December 7, 2023]
21. Garcia MC, Heilig CM, Lee SH, et al. Opioid prescribing rates in Nonmetropolitan and Metropolitan Counties among primary care providers using an Electronic Health Record System—United States, 2014–2017. MMWR Morb Mortal Wkly Rep 2019;68:25–30.
22. Busza J, Dauya E, Makamba M, et al. “I will not stop visiting!” A qualitative study of community health workers' reluctance to withdraw household support following the end of a community-based intervention in Zimbabwe. BMC Health Serv Res 2018;18(1):718.
23. Ajilore O, Willingham CZ. Adversity and Assets: Identifying Rural Opportunities. October 21, 2019. Available from: https://www.americanprogress.org/article/adversity-assets-identifying-rural-opportunities/#:~:text=44-,Community%20social%20capital,community%20interconnectedness%2C%20and%20civic%20engagement [Last accessed: December 7, 2023].
24. Johnstone G, Davey L, Cato J, et al. Enhancing palliative care at home: A generalist community nursing case study. Aust J Adv Nurs 2023;40(2):41–46.
25. Ferrell BR, Twaddle ML, Melnick A, et al. National consensus project clinical practice guidelines for quality palliative care guidelines. J Palliat Med 2018;21(12):1684–1689.
26. O'Brien V, Jenkins LS, Munnings M, et al. Palliative care made visible: Developing a rural model for the Western Cape Province, South Africa. Afr J Prim Health Care Fam Med 2019;11(1):e1–e11.
27. Broglio K, Pandey S, Eichholz Heller F, et al. First responders: Educating interdisciplinary champions to provide primary palliative care (QI802). J Pain Symptom Manage 2018;55(2):701–702.
28. Fornehed MLC, Mixer SJ, Lindley LC. Families' decision making at end of life in Rural Appalachia. J Hosp Palliat Nurs 2020;22(3):188–195.
29. Mixer SJ, Fornehed ML, Varney J, et al. Culturally congruent end-of-life care for rural Appalachian people and their families. J Hosp Palliat Nurs 2014;16(8):526–535.
30. Stone W, Keim-Malpass J, Cozad MJ, et al. Pediatric end-of-life care in rural America: A systematic review. Am J Hosp Palliat Med 2022;39(9):1098–1104.
31. Cai Y, Lalani N. Examining barriers and facilitators to palliative care access in rural areas: A scoping review. Am J Hosp Palliat Med 2022;39(1):123–130.
32. Author interview. Personal communication; Patricia Justis, 2023.
33. Center to Advance Palliative Care. America's Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation's Hospitals. Center to Advance Palliative Care; 2019. Available from: https://reportcard.capc.org/wp-content/uploads/2020/05/CAPC_State by-State-Report-Card_051120.pdf [Last accessed: December 7, 2023].
34. Bazargan M, Bazargan-Hejazi S. Disparities in palliative and hospice care and completion of advance care planning and directives among non-Hispanic Blacks: A scoping review of recent literature. Am J Hosp Palliat Care 2021;38(6):688–718.
35. Johnson KS. Racial and ethnic disparities in palliative care. J Palliat Med 2013;16(11):1329–1334.
36. Lalani N, Cai Y. Palliative care for rural growth and wellbeing: Identifying perceived barriers and facilitators in access to palliative care in rural Indiana, USA. BMC Palliat Care 2022;21(1):1–13.
37. Carson S. Body, Mind and Spirit: Parish Nurses Provide Care. Gather Magazine. October 4, 2021. Available from: https://www.gathermagazine.org/body-mind-and-spirit-parish-nurses-provide-care [Last accessed: December 7, 2023].
38. Lalani N, Hamash K, Wang Y. Palliative care needs and preferences of older adults with advanced or serious chronic illnesses and their families in rural communities of Indiana, USA. J Rural Health; In Press;
39. Hawkins-Taylor C, Mollman S, Walstrom B, et al. Perceptions of palliative care: Voices from rural South Dakota. J Hosp Palliat Med 2021;38(6):557–565.
40. NHPCO Pediatric Facts and Figures; 2023. Available from: https://www.nhpco.org/wp-content/uploads/NHPCO_Pediatric_Facts_Figures_2023.pdf [Last accessed: December 7, 2023].
41. Bogetz JF, Anderson A, Holland M, et al. Pediatric hospice and palliative care services and needs across the Northwest United States. J Pain Symptom Manage 2022;64(1):e7–e14.
42. Pediatric Concurrent Care. NHPCO. Available from: https://www.nhpco.org/palliativecare/pediatrics/pediatric-concurrent-care. [Last accessed: December 7, 2023].
43. Sustainability Strategies for Community-Based Palliative Care a Blueprint for Supporting Rural Palliative Care Services. Available from: https://stratishealth.org/wp-content/uploads/2023/05/Sustainability-Strategies-for-Community-based-Palliative-Care_2023-Update-1.pdf [Last accessed: December 7, 2023].
44. Rural Health Information Hub. Rural Health Clinics (RHCs). Grand Forks, ND; 2023. Available from: https://www.ruralhealthinfo.org/topics/rural-health-clinics [Last accessed: December 7, 2023].
45. Rural Health Information Hub. Federally Qualified Health Centers (FQHCs) and the Health Center Program. Grand Forks, ND; 2023: Available from https://www.ruralhealthinfo.org/topics/federally-qualified-health-centers [Last accessed: December 7, 2023].
46. Rural Health Information Hub. How Does Medicare Reimburse RHCs? Grand Forks, ND; 2023. Available from: https://www.ruralhealthinfo.org/topics/rural-health-clinics#medicare [Last accessed: December 7, 2023].
47. Stratis Health. Sustainability Strategies for Community-based Palliative Care. Bloomington, MN; 2021. Available from: https://stratishealth.org/wp-content/uploads/2020/07/Sustainability-Strategies-for-Rural-Community-Based-Palliative-Care.pdf [Last accessed: December 7, 2023].
48. U.S. Centers for Medicare & Medicaid Services. Chronic Care Management and Connected Care. Baltimore, MD; 2023. Available from: https://www.cms.gov/about-cms/agency-information/omh/health-equity-programs/c2c/ccm [Last accessed: December 7, 2023].
49. Chronic Care Management—Care Management Medicare Reimbursement Strategies for Rural Providers. Available from: https://www.ruralhealthinfo.org/care-management/chronic-care-management [Last accessed: December 7, 2023].
50. Federal Communications Commission FCC 21-18. Available from: https://docs.fcc.gov/public/attachments/FCC-21-18A1.pdf [Last accessed: December 7, 2023].
51. Lally K, Kematic BS, Gorman D, et al. Rapid conversion of a palliative care outpatient clinic to telehealth. CO Oncol Pract 2021;17(1):e62–e67.
52. Bandini JI, Scherling A, Farmer C, et al. Experiences with telehealth for outpatient palliative care: Findings from a Mixed-Methods Study of Patients and Providers across the United States. J Palliat Med 2022;25(7):1079–1087.
53. ECHO Institute New Mexico Hub. Palliative Care ECHO Program. Albuquerque, NM; 2023. Available from: https://hsc.unm.edu/news/2022/09/echo-new-mexico-health-workers-compassionate-end-of-life-care.html [Last accessed: December 7, 2023].
54. Expand Palliative Care. Project ECHO. Palliative in Practice; May 1, 2019. Available from: https://www.capc.org/blog/palliative-pulse-palliative-pulse-february-2018-project-echo-a-disruptive-innovation-to-expand-palliative-care [Last accessed: December 7, 2023].
55. Lopez AM, Lam K, Thota R. Barriers and facilitators to telemedicine: Can you hear me now?. Am Soc Clin Oncol Educ Book 2021;41:25–36.
56. Health Resources & Services Administration. State Medicaid Telehealth Coverage. Rockville, MD; 2023. Available from: https://telehealth.hhs.gov/providers/billing-and-reimbursement/state-medicaid-telehealth-coverage [Last accessed: December 7, 2023].
57. Health Resources & Services Administration. Telehealth Policy Changes After the COVID-19 Public Health Emergency. Rockville, MD; 2023. Available from: https://telehealth.hhs.gov/providers/telehealth-policy/policy-changes-after-the-covid-19-public-health-emergency [Last accessed: December 7, 2023].
58. U.S. Centers for Medicare & Medicaid Services. List of Telehealth Services. Baltimore, MD; 2023. Available from: https://www.cms.gov/Medicare/Medicare-general-information/telehealth/telehealth-codes [Last accessed: December 7, 2023].
59. Aldana GL, Evoh OV, Reddy A. Best practices for providing patient-centered tele-palliative care to cancer patients. Cancers (Basel) 2023;15(6):1809.
60. Quality Improvement Organizations Sharing Knowledge. Improving Health Care. Centers for Medicare & Medicaid Services Improving Individual Patient Care Making Care Safer. Available from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs/Downloads/CMS-QIO-Current-Work-Archive-Fact-Sheet-QIOs-Improving-Individual-Patient-Care.pdf [Last accessed: December 7, 2023].
61. What is a Learning & Action Network? Available from: https://www.youtube.com/watch?v=zUnEzRijSBk [Last accessed: December 7, 2023].
62. Weng K, Shearer J, Grangaard L. Successful palliative care teams in rural communities: A facilitated process. J Palliat Med 2022;25(5):734–741.
63. Mitchell GK, Senior HE, Bibo MP, et al. Evaluation of a pilot of nurse practitioner led, GP supported rural palliative care provision. BMC Palliat Care 2016;15(1):1–11.
64. Pesut B, Hooper B, Jacobsen M, et al. Nurse-led navigation to provide early palliative care in rural areas: A pilot study. BMC Palliat Care 2017;16:1–10.
65. Fitch MI, Fliedner MC, O'Connor M. Nursing perspectives on palliative care 2015. Ann Palliat Med 2015;4(3):150–155.
66. Pesut B, Hooper B, Jacobsen M et al. Nurse-led navigation to provide early palliative care in rural areas: A pilot study. BMC Palliat Care 2017;16:1–10.
67. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: The Project ENABLE II randomized controlled trial. JAMA 2009;302(7):741–749.
68. Hendricks BA, Lofton C, Azuero A et al. The project ENABLE Cornerstone randomized pilot trial: Protocol for lay navigator-led early palliative care for African-American and rural advanced cancer family caregivers. Contemp Clin Trials Commun 2019;16:100485.
69. Beresford L. Physician Assistants Pursue Larger Roles in Hospice and Palliative Care. CSU Shiley Haynes Institute for Palliative Care. April 19, 2021. Available from: https://csupalliativecare.org/physician-assistants-pursue-larger-roles-in-hospice-and-palliative-care [Last accessed: December 7, 2023].
70. Donlon R, Purington K, Williams N. A Publication of the National Academy for State Health Policy Advancing Palliative Care for Adults with Serious Illness: A National Review of State Palliative Care Policies and Programs; 2018. Available from: https://nashp.org/wp-content/uploads/2018/12/Palliative-Care-Brief-Final.pdf [Last accessed: March 8, 2024].
Information & Authors
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Published In
Journal of Palliative Medicine
Volume 27 • Issue Number 9 • September 2024
Pages: 1220 - 1228
PubMed: 38489603
Copyright
Copyright 2024, Mary Ann Liebert, Inc., publishers.
History
Published online: 17 September 2024
Published in print: September 2024
Published ahead of print: 15 March 2024
Accepted: 25 January 2024
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