Hemodialysis Nurse Practitioner Challenges in Rural Areas 

Shawona Daniel, RN, PhD, CRNP, ANP-BC & Laura Steadman, Ed.D., CRNP, MSN, RN

Nurse practitioners (NPs) play a crucial role in delivering specialized care to rural patients with chronic kidney disease (CKD), where nephrologist availability is limited (Schreiber, 2020). While NPs have the expertise to fill this gap through patient assessments, complication monitoring, and dialysis prescriptions (Kaiser et al., 2019), hemodialysis NPs in rural areas face several challenges that potentially impacts the quality of care provided to these patients. One of the most significant challenges is scarcity of healthcare resources, such as primary care providers, specialized providers such as nephrologists, and other vital medical resources (Jones & Smith, 2020). Additionally, many patients living in rural areas must travel long distances to reach dialysis centers, resulting in missed or delayed treatments and increasing complications’ risks (Anderson & Roberts, 2021). Lack of public transportation options and financial constraints compound this issue. Insufficient resources and adequate support further hinder the NP’s ability to manage complex cases, making it difficult to provide the highest level of care.

Despite these challenges, hemodialysis NPs in rural areas are key in improving patient outcomes. For example, NPs reduce the need for patients to travel long distances for care, which is particularly beneficial for individuals with limited mobility or financial resources (Ryan & Stone, 2021). NPs offer education related to treatment adherence, diet modifications, and the importance of regular follow-ups, which also significantly improve patient outcomes. Overall, NPs ensure a holistic approach to CKD treatment and support the broader healthcare infrastructure in rural regions, highlighting their importance in the healthcare system. Addressing CKD care barriers through community stakeholders, policy changes, and community, regional, and national resources also significantly enhance care in underserved rural communities.

References

Anderson, L., & Roberts, L. (2021). Transportation barriers for dialysis patients in rural areas: Implications for care. Journal of Rural Health, 37(2), 201-208. https://doi.org/10.1111/jrh.12456

Jones, T., & Smith, D. (2020). Barriers to nephrology care in rural communities: The role of nurse practitioners. Nephrology Nursing Journal, 47(3), 221-228.

Kaiser, M., Jones, T., & Smith, D. (2019). The role of nurse practitioners in managing chronic kidney disease in underserved areas. Journal of Rural Health, 35(3), 357-365. https://doi.org/10.1111/jrh.12345

Ryan, R., & Stone, M. (2021). Addressing healthcare gaps in rural communities: The role of nurse practitioners in dialysis care. Nephrology Nursing Journal, 48(4), 297-305.

Schreiber, M. (2020). The impact of nurse practitioners on rural healthcare: Enhancing dialysis care in underserved populations. Journal of Nephrology, 40(5), 411-418. https://doi.org/10.1016/j.jn.2020.06.017

Let’s Stop Suicide in our Rural Communities

Joan Grant Keltner

Suicide is among the top 15 leading causes of death, currently ranking as #11 in the United States (CDC Wonder, 2025) and a high priority in rural American. In fact, suicide rates in rural areas have steadily inclined and almost doubled over the last decade, with rates increasing 46% in more rural and less densely populated locations compared to 27.3% in urban areas. American Indians and Alaska Native people in rural areas have the highest rates of suicide (CDC, 2024). For both males and females, firearms, suffocation, and poisoning are the most common forms of reported suicide. Suicide rates for males are significantly higher than females and those who live in rural areas have 1.5 higher rates for emergency department visits for nonfatal self-harm when compared to their urban counterparts (Garnett et al., 2022).

So how can health providers implement strategies to lessen suicide in their communities? The Suicide Prevention Resource for Action offers strategies, methods for advancing these strategies, and the best evidence to lessen suicide in communities and states (CDC, 2022). Select strategies include: 

• Enhancing economic assistance programs (e.g., finances and better housing)

• Promoting safe environments (e.g., lessen access to common methods used for suicide, such as firearms, develop community and organizational policies that enhance and support healthy living, and develop community policies and practices that lessen access to and use of illegal substance use),

• Increasing access to and delivery of suicide prevention programs (e.g., promote health insurance policies to promote coverage of mental health conditions, offer grants and other incentives for health providers, and create emergency help lines and resources),

• Generating healthy connections (e.g., enhance healthy norms by peers, and engage community constituents in shared activities),

• Enhancing coping and problem-solving skill training (e.g., provide social support and resilience programs, offer parenting programs regarding healthy parenting skills and relationships),

• Identifying and assisting suicide-risk individuals (e.g., train gatekeepers such as personnel staffing hotlines in suicide prevention assessment and dialogue, and promptly respond to crises, ensuring safety and follow-up after a suicide), and

• Decreasing potential personal and environmental harms (e.g., intervene after a suicide, using debriefing sessions, counseling, and support groups for surviving friends, family members/significant others; report and message about suicide safely and provide suicide prevention public messaging among community members about warning signs and resources available to help individuals at risk for suicide before a crisis occurs).

We know that to be successful, understanding contributing factors and successful suicide prevention and action efforts must be developed in collaboration with rural community leaders to make them culturally appropriate. Because few treatments ae successful in preventing suicide, programs focused on prevention are key. These programs specifically focus on significant factors in their rural communities that increase the risk of suicide, such as limited financial means and access to firearms. Evidence supports the use of web-based programs that are anonymous and more available in rural areas, with the ability to be expanded (Barnhorst et al., 2021). Together, it takes a community of rural advocates, organizational and policy leaders, and health professionals to address this issue.

References

Barnhorst, A., Gonzales, H., & Asif-Sattar, R. (2021). Suicide prevention efforts in the United States and their effectiveness. Current Opinion in Psychiatry, 34(3), 299–305. https://doi.org/10.1097/YCO.0000000000000682

CDC. (2022). Suicide Prevention Resource for Action: A compilation of the best available evidence. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. https://www.cdc.gov/suicide/pdf/preventionresource.pdf

CDC. (2024, May 16). Suicide in rural America. https://www.cdc.gov/rural-health/php/public-health-strategy/suicide-in-rural-america-prevention-strategies.html

CDC Wonder. (2025). Provisional mortality statistics, 2018 through last week results form: Deaths occurring through February 08, 2025 as of February 16, 2025. https://wonder.cdc.gov/controller/datarequest/D176;jsessionid=9B483D0152104F6CE5EA87902C99

Garnett, M. F., Curtin, S. C., Stone, D.M. (2022). Suicide mortality in the United States, 2000–2020. NCHS Data Brief, no 433. National Center for Health Statistics. 2022. https://dx.doi.org/10.15620/cdc:114217

Rural Illicit Drug Use and Drug Overdose Deaths 

Joan Grant Keltner

While individuals who report illicit drug use is lower in rural areas, deaths from drug overdosages now exceed those in urban areas (CDC, 2024). Even though urban districts have higher rates for cocaine, heroin, and synthetic opioid (e.g., fentanyl, fentanyl analogs, and tramadol) use, deaths from psychostimulants with an abuse potential is about one-third higher in rural counties when compared to urban ones. Death rates from using natural (e.g., opium, morphine, codeine) and semisynthetic (e.g., oxycodone, hydrocodone) opioids also is higher in rural counties when compared to individuals living in urban counties (Spencer et al., 2022). Ongoing contributors to this problem include chronic health problems; limited finances; higher rates of unemployment; greater usage of prescription opioids to increase productivity in manual labor industries, such as mining; and limited health providers and treatment facilities within a reasonable distance to address substance use disorders. Stigma and negative opinions that using these agents is an individual weakness are other factors (NORC Walsh Center for Rural Health Analysis, 2020). 

Rural communities have a variety of barriers including inadequate detoxification and behavioral health services. The need to travel long distances to access these services is another barrier. Prevention programs are too few, spread over large geographic areas in rural communities. Inadequate fiscal and support services for long-term recovery programs and a lack of privacy in some rural communities are other barriers to treatment. Limited health provider training for individuals presenting with a drug overdose is another significant issue (Rural Health Information Hub, 2024). 

Gale and colleagues (2020) offer numerous strategies for rural community leaders to address this problem by assessing, engaging communities, and screening for illicit drug use. These experts also suggest employing strategies for preventing (school-based educational programs, drug take-back programs, and prescribing guidelines), treating (integrated substance use assessment and treatment within primary care, telehealth, and medication-assisted treatment programs), and recovery (use of support groups and self-health, coaching, recovery coaches, and vocational training) in addressing substance use and associated deaths in rural communities. Other strategies also include:

1. Engaging rural communities through community coalitions identifying financial and personal resources to assist rural communities in implementing these broad-based coalitions;

2. Developing models and programs using specific interventions to help individuals with lower incomes who sell their prescription medications to meet their basic needs; 

3. Disseminating programs, providing key information focused on strategies to lessen stigma and physical and psychological harm; 

4. Preventing accidental deaths through programs to enhance safe storage and disposal of these drugs; 

5. Providing technology to enhance implementation of these educational programs; 

6. Engaging key rural community stakeholders and organizations (e.g., RNO, Rural Health Organizations, etc.) in sharing educational materials and implementing these programs and supportive funding to support these efforts;

7. Supporting the availability of recovery and peer support services for drug users; 

8. Encouraging local public health departments in developing community-based prevention, harm-reduction, and overdose prevention programs;

9. Engaging rural law enforcement officials and public health officials, and substance use professionals in a process to support develop models and programs that focus on using substance use treatment instead of judicial consequences; and

10. Encouraging governing authorities to share prescribing guidelines and supportive programs with rural providers through telemedicine and video technology (Gale, 2016).

Together rural health providers in conjunction with key stakeholder leaders in rural communities can address and lessen negative outcomes associated with illicit drug use and drug overdose deaths in rural communities.

References

Centers for Disease Control and Prevention. (2024, May 16). Drug overdose in rural America as a public health issue. https://www.cdc.gov/rural-health/php/public-health-strategy/public-health-considerations-for-drug-overdose-in-rural-america.html

Gale, J. A. (2016). Rural communities in crisis: Strategies to address the opioid crisis. https://www.ruralhealth.us/getmedia/fb3ba3cc-ac75-4828-833c-a1aa5f060917/RuralCommunitiesinCrisisStrategiestoAddresstheOpioidCrisisPolicyPaperApril2016.pdf

Gale, J, Kahn-Troster, S, Croll, Z, First, N. (2020, June). Engaging critical access hospitals in addressing rural substance use. University of Southern Maine. Flex Monitoring Team. Briefing Paper #44.

NORC Walsh Center for Rural Health Analysis. (2020). Rural prevention and treatment of substance use disorders toolkit. Rural Health Information Hub. https://www.ruralhealthinfo.org/toolkits/substance-abuse.

Rural Health Information Hub. (2024). Substance use and misuse in rural areas.  https://www.ruralhealthinfo.org/topics/substance-use#local-treatment

Spencer, M. R., Garnett, M. F., & Miniño, A. M. (2022). Urban–rural differences in drug overdose death rates, 2020. NCHS Data Brief, No. 440. National Center for Health Statistics. https.  https://dx.doi.org/10.15620/cdc:118601

Infant Mortality Related to Premature Births in Rural Areas

Jennifer E. Humphries, DNP, CRNP, NNP-BC 

Premature birth is defined as babies born prior to 37-weeks’ gestation. Out of the top 10 most rural states (World Population Review, 2024), three of those states. Alabama, Mississippi, and West Virginia, have the highest rate for premature births, with rates ranging from 12.84-14.8% (Centers for Disease Control [CDC], 2022). An ongoing assessment and intervention are imperative to promote healthier pregnancies. Identifying the barriers and creating awareness can help reduce premature births and reduce infant mortality rates.

Many risk factors contribute to preterm birth. Women with previous preterm labor or birth, multiple infants (twins, triplets, etc.), and reproductive anomalies are some factors that can’t be changed. However, there are risk factors that can be prevented or managed to help reduce the risk of premature labor. These conditions include sexually transmitted diseases, infections such as urinary tract infections (UTI) or vaginal infections, hypertension, obesity, and diabetes or gestational diabetes (National Institute for Health, 2023). Often, medical conditions such as hypertension and diabetes mellitus, women waiting longer to access prenatal care, and inadequate maternal healthcare services offered by too few health providers in rural areas magnify this issue. 

Social determinants such as ethnicity, maternal age, poverty, level of education and environmental factors also play a role in preterm labor or birth that contributes to increased mortality rates, especially in rural areas. African American women are more likely to have preterm infants compared to white women (National Institute for Health, 2023). Educating women about their health can be the first step in improving healthy pregnancies. Education should include avoiding alcohol, smoking, and drugs. Additionally, the importance of seeing the provider regularly should be discussed with women (Alabama Department of Public Health, 2024). No prenatal care or limited prenatal care can lead to a delay in discovering any underlying concerns. With the decrease in the number of birthing hospitals and maternity access in rural areas, also known as maternity care deserts, the complexity of maternal care remains a concern (March of Dimes, 2023).

The importance of creating awareness and addressing factors contributing to preterm births is imperative to improve the overall health of babies and mothers. Collaborations among individuals and organizations (e.g., state public health agencies; state perinatal programs designed to improve the physical and psychosocial well-being of women, infants, and families; and health providers) can create an awareness to address these health disparities, implement evidenced based practice, and improve the overall health of women in rural areas.

References

Alabama Department of Public Health. (2024, September 10). Infant mortality. Retrieved from Alabama Department of Public Health: https://www.alabamapublichealth.gov/perinatal/infant-mortality.html 

Centers for Disease Control [CDC]. (2022, February 25). Percentage of births born preterm by state. Retrieved from National Center for Health Statistics: https://www.cdc.gov/nchs/pressroom/sosmap/preterm_births/preterm.htm

March of Dimes. (2023). Where you lives matters: maternity care in Alabama . Retrieved from Healthy Moms. Strong Babies: https://www.marchofdimes.org/peristats/assets/s3/reports/mcd/Maternity-Care-Report-Alabama.pdf 

National Institute for Health. (2023, May 9). What are the risk factors for preterm labor and birth? Retrieved from U.S Department of Health and Human Services: https://www.nichd.nih.gov/health/topics/preterm/conditioninfo/who_risk

World Population Review. (2024). Most rural states 2024. https://worldpopulationreview.com/state-rankings/most-rural-states

Managing Food Insecurity in Rural Areas

In 2023, almost 14% of U. S. households had food insecurity. In rural areas, thisprevalence is even higher at 15.4% (Rabbitt et al., 2023). We also know that healthy food is difficult to obtain in low-income households, especially in rural communities. Ultimately, fewer monies and geographic access to healthy foods leads to lower dietary quality among those in rural households with low-incomes (Ohri-Vachaspati et al., 2019). These food struggles relate to many factors including the inability to buy nutritious food (e.g., high-quality protein, fruits, and vegetables) because of either unemployment, low-income or seasonal jobs, high food prices, needing to use funds for essential household and medical needs, selecting poor food choices because of tiredness from working long hours, and because grocery stores with wholesome foods often are many miles away from their home (Byker Shanks et al., 2022).

These families use many support systems to obtain food, such as local food pantries, food assistance programs, school meals, and borrowing either money or food from family and friends. Rural residents also take advantage of gardening, hunting, fishing, and canning food for later use by their families. They also use money-saving strategies to buy more food by visiting stores who offer coupons or sales, purchasing generic brands, buying bulk items or dented /damaged packages and cans, and comparing grocery store unit prices for specific items. They also serve simple meals with fewer food options (Byker Shanks et al., 2022).

Despite these various strategies, many rural households with low incomes still struggle to feed their family desirable and nutritious food, which requires a multi-level approach to this problem. Nurse practitioners, nutritionists, social workers, other health providers along with community stakeholders are key in developing creative strategies to help these families secure more nutritious food options for themselves and their families. Health providers can share information about federal nutrition programs and do referrals to departments of human services during wellness examinations. Free educational programs on nutrition are important. Community stakeholders can advocate for policies to address food insecurity. Community efforts to emphasize the value of food programs for children and their parents and the elderly are a high priority, including community food trucks, food shelters/pantries, and emergency food programs. Community connections and events can provide opportunities to enhance social networks, with shared transportation to food stores, farmer’s markets, and neighborhood sponsored community gardens, with childcare/supervision. These social events also provide opportunities to make friends and share ideas for nutritious meals and strategies to prepare time-saving meal plans (American Hospital Association, 2024; Schuler et al., 2024). Together, these group efforts can improve rural food insecurity.

References

American Hospital Association. (2024). Hospitals and food insecurity. https://trustees.aha.org/articles/1299-hospitals-and-foodinsecurity#:~:text=Hospitals%20and%20health%20care%20providers,dietitians%20and%20nutritionists%20for%20counseling

Byker Shanks, C., Andress, L., Hardison-Moody, A., Jilcott Pitts, S., Patton-Lopez, M., Prewitt, T. E., Dupuis, V., Wong, K., Kirk-Epstein, M., Engelhard, E., Hake, M., Osborne, I., Hoff, C., & Haynes-Maslow, L. (2022). Food insecurity in the rural United States: An examination of struggles and coping mechanisms to feed a family among households with a low-income. Nutrients, 14(24), 5250. https://doi.org/10.3390/nu14245250

Ohri-Vachaspati, P., DeWeese, R. S., Acciai, F., DeLia, D., Tulloch, D., Tong, D., Lorts, C., & Yedidia, M.J. (2019). Healthy food access in low-income high-minority communities: A longitudinal assessment-2009–2017. International Journal of Environmental Research in Public Health. 16, 2354. https://doi.org/10.3390/ijerph16132354

Rabbitt, M. P., Reed-Jones, Hales, L. J., & Burke, M. P. (2023, September). Household food security in the United States in 2023. USDA, Economic Research Service, ERR-337. https://www.ers.usda.gov/webdocs/publications/109896/err-337.pdf

Schuler, B. R., Shipe, S. L., O'Reilly, N., Uhl, A., Vazquez, C. E., Tripicchio, G. L., & Hernandez, D. C. (2024). Balancing nutrition and budgets: Socio-ecological impacts on nutritional environments of families with low incomes. Appetite, 203, 107706. https://doi.org/10.1016/j.appet.2024.107706

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

Individuals who live in rural areas have significantly higher rates of COPD and COPD-related hospitalizations and deaths than those who live in urban areas. In fact, those who experience COPD and reside in rural counties (8.2%) are almost double the number of those individuals who live in urban areas (4.7%). States with higher quartiles for COPD are Alabama, Arkansas, Indiana, Kentucky, Mississippi, Tennessee, and West Virginia, four of which have higher percentages of rural residents (Croft et al., 2015). These rural individuals are more likely to experience negative social determinants of health, such as lower incomes, education, chronic illness and comorbidities, and disability, with more individuals commonly foregoing medical care due to having inadequate health insurance and monies (Gaffney et al., 2022).

Several rural COPD investigations are underway, including one 6-year study of4,000 individuals examining regional differences in disease rates of COPD and other diseases in rural Appalachia and the Mississippi Delta. Another 5-year study is determining whether a short questionnaire and breathing test can help identify more people with COPD in primary care settings, potentially improving their quality of life and outcomes. Yet another investigation is exploring whether video telehealth pulmonary rehabilitation lessens COPD-related hospital readmissions and improves quality of life. Some rural counties already have used pulmonary rehabilitation programs to improve health outcomes and quality of life of these individuals (Doyle et al., 2017).

A recent systematic review of six telehealth and five non-telehealth self- management interventions delivered to rural adults with COPD, was promising in showing how telehealth interventions could be as useful as non-telehealth interventions for improving COPD self-management (Stellefson et al., 2022). Another systematic review and meta-analysis of 19 studies comparing the effect of minimal equipment and exercise equipment-based programs on exercise capacity, health-related quality of life, and strength in pulmonary rehabilitation. There was no difference between the two programs for either exercise or strength, but better health-related quality of life was seen when using minimal equipment. These findings suggest pulmonary rehabilitation programs using minimal equipment may be a suitable intervention where access to gymnasium equipment is limited, as in rural areas (Cheng et al., 2023). Some of these studies and others can be identified by using the COPD National Action Plan Community Action Tool., a public, online categorical list of activities for key stakeholders such as rural nurses who desire to implement useful interventions to improve the quality of care they provide for individuals living with COPD (NHLBI, 2021; 2023).

References

Cheng, S. W. M., McKeough, Z. J., McNamara, R. J., & Alison, J. A. (2023). Pulmonary rehabilitation using minimal equipment for people with chronic obstructive pulmonary disease: A systematic review and meta-analysis. Physical therapy, 103(5), pzad013. https://doiorg.uab.idm.oclc.org/10.1093/ptj/pzad013

Croft, J. B., Wheaton, A. G., Liu, Y., et al. (2018). Urban-rural county and state differences in chronic obstructive pulmonary disease — United States, 2015. MMWR: Morbidity & Mortality Weekly Report, 67, 205 211. http://dx.doi.org/10.15585/mmwr.mm6707a1

Doyle, D., Tommarello, C., Broce, M., Emmett, M., & Pollard, C. (2017). Implementation and outcomes of a community-based pulmonary rehabilitation program in rural appalachia. Journal of Cardiopulmonary Rehabilitation and Prevention, 37(4), 295–298. https://doi.org/10.1097/HCR.0000000000000247

Gaffney, A. W., Hawks, L., White, A. C., Woolhandler, S., Himmelstein, D., Christiani, D. C., & McCormick, D. (2022). Health care disparities across the urban-rural divide: A national study of individuals with COPD. The Journal of Rural Health, 38(1), 207–216. https://doi.org/10.1111/jrh.12525 

NIH: National Heart, Lung, and Blood Institute. (2021, February). COPD National Action Plan: Community Action Tool. https://cnap.nhlbi.nih.gov/index.php/

NIH: National Heart, Lung, and Blood Institute. (2023, November 15). Making strides to address COPD in rural communities. https://www.nhlbi.nih.gov/news/2023/making strides-address-copd-rural-communities

Stellefson, M., Kinder, C., Boyd, I., Elijah, O., Naher, S., & McFadden, N. (2022). COPD self-management for adults living in rural areas: Systematic review of telehealth and non-telehealth interventions. American Journal of Health Education, 53(5), 269–281. https://doi.org/10.1080/19325037.2022.2100525

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

Almost 90,000 people in the U. S are diagnosed with Parkinson’s disease annually and 1.2 million individuals are estimated to have this chronic illness by 2030 (Willis et al., 2022). The leading risk factor is age or those who are 65 years and older. Males also have a higher prevalence. Genetic and environmental factors also play a significant role. A higher incidence is found in topographical areas of the “Rust Belt” located in the midwestern and northeastern areas of the U.S., specifically Southern California, Southeastern Texas, Central Pennsylvania, and Florida (Parkinson’s Foundation, 2022).

Rural areas also are impacted because of the increased risk to farmers from pesticides (Shrestha et al., 2020). Use of amphetamine or methamphetamine, heavy metals, air pollution, traumatic brain injury, and trichloroethylene (Ascherio & Schwarzschild, 2016; De Miranda et al., 2022) found in ground water (The MNT Editorial Team. 2021) are other risk factors.

So, how can rural health professionals assist rural individuals and their families who are impacted by Parkinson’s disease? Support groups in rural areas are beneficial to both patients with Parkinson’ s disease and their family members. A key factor is communication, providing interactions to enhance education in sharing and learning valuable information about the disease and its management from both expert guest speakers as well as individuals with Parkinson’s disease who have similar symptoms. Another significant component of communication is emotional support that occurs from these interactions to decrease isolation and enhance the development of social activities among group members (Bush et al., 2018).

Strategies for encouraging both online and face-to-face support groups are to post local flyers and make public announcements about meeting times and Parkinson’s topics in common places and through local avenues (radio, grocery stores, beauty shops), especially when guest speakers ae talking management strategies for common issues. Using public places with handicapped access, such as libraries, schools, etc. also is valuable in enhancing these support groups. Another option is to start a statewide website and newsletter to provide information about Parkinson’s disease and engage rural stakeholders (Bush et al., 2018).

The Parkinson’s Foundation (2024) also provides resources and support for health providers, as well as for individuals with Parkinson’s disease and their care partners, including an online global network for identifying treatment centers, as well as online communication groups, educational materials, and monthly podcasts. This organization currently offers grants to rural communities that focus on education and exercise programs, address mental health issues, and provide support for care partners. Together, we can enhance the lives of those with Parkinson’s and their family members.

References

Ascherio, A., Schwarzschild, M. A. (2016). The epidemiology of Parkinson’s disease: Risk factors and prevention. Lancet Neurology, 15(12), 1257-1272. https://doi.org/10.1016/S1474-4422(16)30230-7 25

Bush, E. J., Singh, R. L., Hidecker, M. J. C., & Carrico, C. P. (2018). Parkinson’s disease support groups in rural America: Barriers, resources, and opportunities. The Qualitative Report, 23(6), 1381-1400. https://nsuworks.nova.edu/tqr/vol23/iss6/8

De Miranda, B. R., Goldman, S M., Miller, G. W., Greenamyre, J. T., & Dorsey, E. R. (2022). Preventing Parkinson’s disease: An environmental agenda. Journal of Parkinsons Disease, 12(1), 45-68. https://doi.org/10.3233/JPD-212922

Parkinson’s Foundation. (2022). Prevalence and incidence. https://www.parkinson.org/understanding-parkinsons/statistics/prevalence-incidence

Parkinson’s Foundation. (2024). Better lives. Together. https://www.parkinson.org/

Shrestha S., Parks C. G., Umbach D. M., Richards-Barber, M., Hofmann, J. N., Chen, H., Blair, A., Beane Freeman, L. E., & Sandler, D. P. (2020). Pesticide use and incident Parkinson’s disease in a cohort of farmers and their spouses. Environmental Research,191, 110186. https://doi.org/10.1016/j.envres.2020.110186

The MNT Editorial Team. (2021). What are the risk factors for Parkinson’s disease? https://www.medicalnewstoday.com/articles/323440

Willis, A. W., Roberts, E., Beck, J. C., Fiske, B., Ross, W., Savica, R., Van Den Eeden, S. K., Tanner, C. M., Marras, C., & Parkinson’s Foundation P4 Group (2022). Incidence of Parkinson disease in North America. NPJ Parkinson's Disease, 8(1), 170. https://doi.org/10.1038/s41531-022-00410-y

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

While nearly 60 million residents live in rural areas, only 10% of general surgeons provide healthcare to these individuals. These rural patients also face many barriers, such as lower yearly incomes, inadequate health insurance coverage, a higher incidence of more complex chronic illnesses, and geographical barriers to sufficient healthcare to meet their needs. However, surgeons offer both physical and economic benefits to rural communities (e.g., almost $1-3 million/year in financial worth and 40% of revenues of small rural hospitals; Sarap, & Reiss, 2024).

These rural health providers have significant caseloads with inadequate relief coverage (e.g., every 2 to 3 days), which impacts their recruitment to rural areas (Sarap, & Reiss, 2024). Unfortunately, older surgeons also are facing retirement and there is a lack of surgeons willing to move to rural areas, instead choosing to specialize in selective illnesses. Compounding the significant demands of their practice, these rural surgeons and supportive health providers are significantly impaired without adequately equipped diagnostic and laboratory facilities and operating rooms (Kirby Surgical Center, 2024). Time, technology, and geographical constraints also impact rural surgeons’ and other health providers’ need to learn the latest surgical advancements for their patients (Sarap, & Reiss, 2024).

There is a need to develop innovative ideas for addressing these healthcare needs of rural individuals, surgeons, and other healthcare providers. Creative models designed to enhance rural surgical treatment and enhance skilled practitioners include those who offer or desire the following:

• 1)       Utilizing telesurgery in which surgeons who live in non-rural areas perform surgery remotely through robotic and computer-assisted technology;
• 2)       Offering E-consultations that enhance rural and urban collaboration about complex patients and chronical illnesses and medical and surgical treatment options;
• 3)       Offering rural surgical training of health providers, such as nurses and general surgeons;
• 4)       Providing skilled surgeons, anesthetists, and nurses to staff rural surgical mobile units to treat emergencies and select surgeries;
• 5)       Establishing shared services (e.g., diagnostic procedures, treatment, after-care), and physical (e.g., equipment, medications), and personal resources (specialists traveling to rural communities during specified time frames);
• 6)       Utilizing rural resources (e.g., community health workers) and other health professionals (e.g., home health nurses) who can identify patients who need potential surgeries;
• 7)       Offering financial rewards (e.g., loan repayments; scholarships, housing) to surgeons and surgical healthcare personnel who relocate to rural areas;
• 8)       Fostering new rural healthcare personnel (e.g., surgeons, anesthetists, and nurses) to be mentored by more advanced practitioners so they can then apply these skills in their rural practice;
• 9)       Encouraging continuing education and professional development of newer surgical skills through on-line and face-to face training; and
• 10)   Encouraging health providers to take advantage of rural training programs that prepare these individuals to practice and provide excellent surgical care in rural settings (Kirby Surgical Center, 2024).

References

Kirby Surgical Center (2024). Challenges and solutions in rural surgical health services. Challenges and Solutions in Rural Surgical Services (kirbysurgicalcenter.com)

Sarap, M., & Reiss, A. D. (2024). Rewards and frustrations of rural surgery practice. American College of Surgery. https://www.facs.org/for-medical-professionals/practice-management/private-practice-small-business/rural-surgery-practice/

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

Over thirty million American have diabetes mellitus, with Type 2 (T2DM) the most common (CDC, 2024b). Unsurprisingly, T2DM is also more prevalent in rural America, (10% in rural compared to 8% in urban areas), with higher mortality rates. Potential health challenges contributing to these death statistics include more comorbidities exacerbating this chronic condition, difficulty in obtaining continuing diabetes treatment and in obtaining heart-healthy foods, and environmental factors (Dugani et al., 2022). A family history of T2DM, excessive weight, inadequate exercise, older age, and having certain racial and ethnic lineages (i.e., Alaska Native, American Indian, African American, Hispanic, and Asian or Pacific Islander) are other risks (University of Minnesota Rural Health Research Center and NORC Walsh Center for Rural Health Analysis, 2020).

While research indicates diabetes self-management education and support (DSMES) are particularly important, over 60% of rural neighborhoods are without this asset (CDC, 2024b). DSMES provides preventative interventions, improves glycemic control, self-confidence, and quality of life, with fewer complications, emergency care, and hospitalizations. Resources (CDC, 2024a; 2024c) for both T2DM health professionals and patients include the following:

• DSMES Toolkit provides a variety of tools and guidelines for DSMES services.
• Diabetes Self-Management Education and Support in Adults with Type 2 Diabetes: A Consensus Report suggests DSMES resources and improves upon patients' outcomes, potential solutions to barriers, and information about the needs of those with T2DM (Powers et al., 2020).
• Referral Process offers DSMES information and support.
• When Diabetes Self-Management Education Is Emergency Medicine suggests strategies for managing DSMES.
• Association of Diabetes Care & Education Specialists (ADCES) offers education programs by zip code and states.

• Education and Support Information sends patients this patient-friendly information on how DSMES services can help people with diabetes learn how to take care of themselves.

Medicare will reimburse 10 hrs. of DSMES if health providers meet certain guidelines for billing. Fortunately, yearly training is available either after the initial benefit period or beginning in January of the following year (ACDES; 2022). While reimbursement to private payers varies, some may follow guidelines provided by the Centers for Medicaid and Medicare Services, possibly because of cost savings in reducing costs for acute emergencies and co-morbidities. Seeking programs that provide funding to providers for DSMES services offered to uninsured individuals with T2DM offers many benefits, but providers must be patient in identifying these resources to enhance diabetes care.

References

Association of Diabetes Care & Education Specialists (ACDES; 2022). Frequently asked questions: DSMES AND DSMT reimbursement. https://www.adces.org/docs/default-source/default-document-library/ask-the-reimbursement-expert-faq-2022-final.pdf?sfvrsn=f0b49158_0

Centers for Disease Control and Prevention (CDC, 2024a). Referring patients to DSMES. https://www.cdc.gov/diabetes/hcp/dsmes/index.html

Centers for Disease Control and Prevention (CDC, 2024b). Rural health: Diabetes self-management in rural America as a public health issue. https://www.cdc.gov/rural-health/php/public-health-strategy/public-health-considerations-for-diabetes-self-management-education-and-support-in-rural-america.html

Centers for Disease Control and Prevention (CDC, 2024c). About diabetes self-management education and support. https://www.cdc.gov/diabetes/education-support-programs/index.html

Dugani, S. B., Wood-Wentz, C. M., Mielke, M. M., Bailey, K. R., & Vella, A. (2022). Assessment of disparities in diabetes mortality in adults in U.S. rural vs. nonrural counties, 1999–2018. JAMA Network Open, 5(9), e2232318. https://doi.org/10.1001/jamanetworkopen.2022.32318

Powers, M. A., Bardsley, J. K., Cypress, M., Funnell, M. M, Harms, D., Hess-Fischl, A., Hooks, B., Isaacs, D., Mandel, E. D., Maryniuk, M. D., Norton, A., Rinker, J., Siminerio, L. M., Uelmen,& Sachaet, A. L. (2020). Diabetes self-management education and support in adults with type 2 diabetes: A consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. The Diabetes Educator, 46(4), 350-369. https://doi.org/10.1177/0145721720930959

University of Minnesota Rural Health Research Center and NORC Walsh Center for Rural Health Analysis. (2020). Rural diabetes prevention and management toolkit [online]. Rural Health Information Hub. https://www.ruralhealthinfo.org/toolkits/diabetes

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

Life is on a continuum from birth to death, but aging is a natural process. As we age, we encounter a variety of significant changes in our daily lives--career transitions, children growing up and leaving home, loss of loved ones, physical and psychosocial illnesses, and sometimes, changes in our ability to perform many activities of daily living. While many of us know of older individuals who can outperform us in many activities, as we age, we often experience more chronic illnesses. Individuals who live in rural locations have a higher risk for high cholesterol and blood pressure, obesity, arthritis, depressive disorder, diabetes mellitus, COPD, and heart disease (Research Triangle Institute, 2023).

As health professionals, how we meet the needs of older individuals as they face these challenges is key and a high priority in developing effective interventions. A review of 40 empirical studies confirmed older individuals face physical and psychosocial challenges and require supportive interventions directed toward their social activities and relationships, psychological well-being, mobility, self-care, and domestic life. While these individuals desire independence in managing their illness, they lack strategies health professionals can provide regarding self-care, communication, coordination of services, and knowledge about various care pathways and support servicesto enhance quality-of-life (Abdi et al., 2019). The Rural Health Information Hub (2022) and others also offer many resources for health providers.

A few strategies for these individuals include:

• ·       suggesting purposeful activities that facilitate active functional roles, such as mentoring activities (teaching preschool and school-age reading; volunteer activities; Owen et al., 2022);
• ·       providing information about developing heart healthy nutritional eating habits, quality rest and sleep habits, and mobility (e.g., with adapted exercises);
• ·       encouraging using mental stimulation activities (e.g., reading, learning new skills and hobbies), social connections (e.g., family, friends, etc., community volunteer and work groups), and emotional support (refer for counseling, telephone or face-to-face support groups, developing new hobbies) to enhance mental and emotional well-being;
• ·       teaching strength training, fall prevention and safety strategies for those who have difficulty in performing daily activities;
• ·       encourage interactions with family and friends and participating in community activities to facilitate enjoyable activities;
• ·       offer classes that focus on strength training, aerobic exercise, dietary skill building, and/or civic engagement (RIH Hub, 2022);
• ·       use trained community health workers and coaches to offer information about various illnesses such as hypertension, diabetes, mellitus, heart disease etc. (RIH Hub, 2022);
• ·       offer mobile screening clinics for chronic conditions (e.g., high blood pressure and cholesterol, obesity, diabetes mellitus, arthritis, COPD, etc. RIH Hub, 2022); and
• ·       engage rural community-based organizations, leaders, health-care systems, and providers to offer programs to enhance the well-being of older adults;

References

Abdi, S., Spann, A., Borilovic, J., de Witte, L., & Hawley, M. (2019). Understanding the care and support needs of older people: A scoping review and categorisation using the WHO international classification of functioning, disability and health framework (ICF). BMC Geriatrics, 19(1), 195. https://doi.org/10.1186/s12877-019-1189-9

Owen, R., Berry, K., & Brown, L. J. E. (2022). Enhancing older adults' well-being and quality of life through purposeful activity: A systematic review of intervention studies. The Gerontologist, 62(6), e317–e327. https://doi.org/10.1093/geront/gnab017

Research Triangle Institute (2023). Overlooked Americans: The toll of chronic disease in rural America. https://healthcare.rti.org/insights/chronic-disease-and-rural-health-disparities#:~:text=Rural%20health%20disparities%20%2D%20One%20nation%2C%20divided&text=Across%20the%20spectrum%20of%20chronic,non%2Dmetropolitan%20than%20metropolitan%20areas

Rural Health Information Hub ([RHI Hub] 2022). Chronic disease in rural America – Models and innovations. https://www.ruralhealthinfo.org/topics/chronic-disease/project-examples