Health Resources and Services Administration
Office of Rural Health Policy
June 8-10, 2003
The 44th meeting of the National Advisory Committee on Rural Health (NACRH) was held June 8-10, 2003, at the Westin Riverwalk Hotel in San Antonio, Texas and the Holiday Inn in Uvalde, Texas.
San Antonio, Texas
Dr. Brand convened the meeting following brief meetings of the sub-committees on Mental Health, Oral Health and Aging that were held earlier in the day. Dr. Brand welcomed the Committee on behalf of the Chairman, Governor David Beasely, who was unavoidably delayed.
Members present at the meeting were: Mr. James Ahrens; Stephanie Bailey, MD, MSHA; Mr. Evan Dillard; Joellen Edwards, Ph.D.; Michael Enright, Ph.D.; Dana Fitzsimmons, R.Ph.; Ms. Rachel Gonazles Hanson; Keith Mueller, Ph.D.; Glenn Steele, M.D., Ph.D.; Mary Wakefield, Ph.D.; Steve Eckstat, D.O.; and Monnieque Singleton, M.D. Those not in attendance were: Senator Raymond Rawson, D.D.S.; Ms. Sally Richardson; and Mr. David Berk. Present from the Office of Rural Health Policy were Marcia Brand, Ph.D.; Mr. Tom Morris, MPA; Ms. Michele Pray-Gibson; and Ms. Jennifer Riggle, J.D.
Dr. Brand introduced the five attendees at the meeting serving as Ex-Officio members for this meeting. They are:
James Agras, Chairman and CEO of Triangle Tech Group, Pittsburgh, PA
Bessie Freeman-Watson, Director of Youth Services, Suffolk, VA
Lenard Kaye, Professor, School of Social Work, Public Policy and Health at the University of Maine, Orono, ME
Sister Janice Otis, SE Idaho Community Action Agency, Pocatello, ID
Honorable Larry Keith Otis, Mayor of Tupelo, MS
Dr. Brand also announced that this would be the final meeting for six members of the Committee whose appointments have expired. The six members are: Monnieque Singleton, M.D.; Steve Eckstat, D.O.; Mary Wakefield, Ph.D.; Dana Fitzsimmons, R.Ph.; Ms. Rachel Gonzales Hanson; and Mr. James Ahrens.
Dr. Sanchez addressed the Committee on public health issues in Texas. He directs the Texas Department of Health, which has about five thousand employees and eight regional health offices. He described the five priorities of the Department and their focus on the twenty-percent of Texans who live in rural areas of the State. The priorities are: (1) Improve immunization rates; (2) Improve fitness through nutrition and exercise; (3) Improve bio-terrorism and public health preparedness; (4) Eliminate health disparities, including disparities between urban and rural areas; and (5) Provide good stewardship of public funds.
Dr. Sanchez then described major demographic shifts in rural Texas. Some rural counties in West Texas are losing population while counties in East Texas are growing. East Texas is experiencing a rapid growth of the Hispanic population. Limited resources for health services challenge both rural areas of the State. He noted that Texas is making good use of telecommunications technologies in providing health services to rural Texans.
Dr. Sanchez called for a paradigm shift in public health to address the epidemic of obesity in the United States. He stated that sixty-percent of adults in the country are overweight or obese, and that obesity is growing in both the elderly population and among young children. The problem is particularly acute for Hispanic and Black populations. The long-term health consequences will be severe and costly, and could overwhelm the health care system. A paradigm shift is needed to emphasize public health and medical interventions to combat obesity because there are not enough resources to pay for the consequences of neglect. In Texas he hopes to promote school-based programs in health and fitness, as well as other measures to address the issue. He stressed the importance of collaborative efforts with schools, Agricultural Extension Services, and other agencies.
Dr. Singleton asked about the relationship between obesity and poverty. Dr. Sanchez replied that the relationship is not always clear, but the two are closely linked and it is a nationwide problem.
Dr. Steele inquired about the cultural aspects of obesity. Dr. Sanchez stated that Texas is a highly diversified state and that cultural factors are significant. School-based programs are highly adaptable to cultural differences.
The sub-committees on Oral Health, Mental Health, and Aging met for one hour in the afternoon and then reported their discussions to the full-committee.
Dr. Bailey reported that the sub-committee on Oral Health will focus its attention on strategies to achieve greater coordination among federal programs in oral health, strategies for integrating oral health more closely with other health care programs, and strategies for expanding training opportunities for mid-level oral health professionals. The sub-committee will examine the role of federal health professions training authorities and draw upon the Surgeon General's recommendation on oral health in Healthy People 2010.
Dr. Enright reported that the sub-committee on mental health will concentrate on defining the range of mental health providers and identifying barriers to mental health care in rural areas of the country. The sub-committee will consider professional licensure issues, scope of practice issues, training programs for integrating mental health and physical health, payment issues, and privacy concerns. Some tentative recommendations for the sub-committee report have been identified.
Dr. Wakefield reported that the sub-committee has data on the demographics of aging in the United States and will consider social and economic indicators specific to the rural elderly population. The group will be looking closely at aging programs in the Department of Health and Human Services. She noted that participation in these programs has declined. The challenge is to identifying strategies for increasing program awareness and participation by rural elderly populations. Other issues such as transportation and state budget pressures will also be addressed.
Mr. Morris provided a brief report on a recent survey of federal advisory committees conducted by the General Services Administration, Office of Government Wide Policy. The purpose of this survey was to provide performance measurement data that would help federal agencies determine the effectiveness of their committees. Mr. Morris reported that the National Advisory Committee on Rural Health scored in the top ten-percent of all federal advisory committees. In response to the survey, members of the Committee indicated an overall satisfaction rate of sixty-seven percent. This response was very high compared to results elsewhere in government. Overall, the survey was a very positive report on the Committee.
Mr. Easley encouraged the Committee to examine economic models that work for rural frontier areas of the country. Much of Texas includes frontier areas where local economies are in decline. He emphasized the need for economic models that look beyond the recruitment and retention of health workers and place greater emphasis on increasing training capacity. He explained the role and potential of community colleges for training health professionals who would serve frontier communities.
Patti J. Patterson, M.D., Vice President, Rural Community Health, Texas Tech University Health Sciences Center
Dr. Patterson spoke about the role of Texas community colleges in training health workers and cautioned about the potential effects of state budget cuts in rural counties of the state.
Elaine Neenan, D.D.S. MS, MPH, Associate Dean for External Affairs, University of Texas Health Sciences Center Dental School
Dr. Neenan's responsibilities include working with dental students to find opportunities for them to practice in rural communities. She stressed the need for increased field positions for dentists in the National Health Service Corps and for additional loan repayment positions. She recommended that the Committee look at what dental schools are doing to recruit students from rural areas. She also mentioned the need to examine state licensure problems that affect movement of dentists from state-to-state. She stated that the American Dental Association must get involved with efforts to strengthen dentistry in rural communities. She emphasized the importance of fluoridated water supplies in rural communities.
Dr. Singleton asked whether dental schools are providing services in rural areas. Dr. Neenan replied that dental schools are probably unable to do much more than they are already doing. Dental students are not the most efficient providers since they are still in the learning process. She focused on the need for dental extenders in rural areas and for prevention programs in oral health.
Following public comments, the meeting was adjourned until Monday morning in Uvalde, Texas.
On Monday morning the Committee conducted a site visit to Southwest Community Health Development, Inc., a Federally Qualified Health Center serving Uvalde and its surrounding three counties. The visit was lead by Committee Member Rachel Gonzales Hanson, Chief Executive Officer of the organization. The Center has been serving patients for twenty years and now has about thirty thousand office visits per year. It has five medical and two dental providers on staff. Following a tour of the facility, the Committee was given a presentation on oral health.
Dr. Baber, a Captain in the United States Public Health Service Commissioned Corp, reported that the number of Dental Officers in the Commissioned Corp has increased to between twelve and fifteen, and that recent legislation requiring Community Health Centers to provide dental services may help to further increase this number. He described the new Ready Responder Program of the Health Resources and Services Administration that has identified a cadre of dentists, physicians and other providers who can be deployed in the event of a national emergency or disaster.
In his presentation on oral health, Dr. Baber highlighted the widespread prevalence of oral disease in adults and children, and the cost in terms of health care and the overall economy. He defined what is meant by oral health and the relationships between oral disease and other physical ailments. He described the close relationship that exists between oral health, diabetes, cardiovascular disease, and perinatal outcomes. He stressed that oral health services can no longer be considered as adjunct, discretionary services in any system of comprehensive primary care. Speaking about the dental health workforce, Dr Baber stated that the supply of new dentists is not keeping pace with retirements. The dental workforce is also unevenly distributed throughout the country and there are many unfilled positions for dental school faculty. Dr. Baber then described the characteristics of oral health practices, highlighting that one-hundred-fifty million Americans lack dental insurance and that many states have no adult Medicaid oral health benefits. Dr Baber discussed the goals of the Oral Health Department at Community Health Development, Inc. and how the Center coordinates dental and medical services for its patients. He described how oral health and medical services are coordinated for pre-natal patients, diabetic patients, and hypertensive patients. Finally, Dr. Baber talked about the Center's cooperative programs with the University of Texas Head Start Programs and the Uvalde school system.
Dr. Steele asked about the incentives for dentists to join the Commissioned Corp. Dr. Baber responded that the incentives are mostly personal and not monetary.
Dr. Bailey asked what lay behind the small number of dentists in the Corp. Dr. Baber answered that physicians have dominated the program. He encouraged rural communities to pursue dental extenders and argued for an expanded scope of services for dental hygienists and technicians.
Dr. Wakefield asked if there is a role for faith-based organization in accessing dental services. Dr. Baber believes that such organizations can improve access to oral health through transportation programs and other assistance.
Mr. Ahrens spoke about the need for demonstration programs on expanded roles for dental hygienists and dental assistants.
Mr. Botello spoke to the Committee on aging issues nationally and in Southwest Texas. He spoke about the growing aging population and high poverty rates in his service areas. He stated that operations at his Senior Center must change to eliminate waiting lists for delivered meals and meet other needs of the aging population. Mr. Botello advocated for increased funding of federal aging programs under the Older Americans Act, an expanded role for senior centers to include home visits and case-management services, increased day care services at the centers, and lower client to management ratios. He also supported national initiatives to train family caregivers and to increase research on the nutritional needs of the elderly. He mentioned that housing shortages and hazards in the home are important issues for the aged population. Further, he cited a need for elderly abuse programs and greater emphasis on health promotion and prevention programs for the elderly.
Dr. Kaye responded to Mr. Botello by citing statistics on elderly abuse. He also said that the percentage of elderly persons in Uvalde is very high, consistent with national data showing that the percentage of elderly persons living in rural areas is higher than for urban areas.
Dr. Mueller asked if devolution of aging programs from the federal government to the state and local levels was working. Mr. Botello believes that devolution is not working well because funding has been reduced. He views devolution as a code word for neglect.
Ms. Freeman-Watson asked how the needy among the elderly population in Uvalde are identified. Mr. Botello responded that his Center does not recruit clients. Most learn about it by word of mouth. No one is turned away from the Center. However, there is an application process for delivered meals.
Ms. Williams defined the characteristics of a perfect Southwest Texas rural community where mental health services were widely available and easily accessible. In such a community mental health specialists would be easily accessed; primary care providers would be knowledgeable in mental health screening and assessment; referrals from primary care providers to mental health specialists would be easily arranged; mental health providers would accept all uninsured and underinsured clients; transportation would be available; and local community health centers would provide comprehensive mental health and case management services. She then described the realities in Southwest Texas where mental health specialists are in short supply and exiting primary care providers are over extended. Nonetheless, primary care providers have become a de facto resource for mental health services. This de facto system has evolved due to the severe lack of mental health providers, lack of inpatient psychiatric care, the social stigma of mental illness, economic issues, and other factors.
The Southwest Texas Network convened a focus group of medical personnel and community leaders to study these issues. Their findings identified challenges related to the lack of crisis capacity for mental health services, difficulties in recruitment of mental health personnel, transportation barriers, cultural and social stigmas related to mental illness, and the limited knowledge of primary care physicians in dealing with mental illness. Options being pursued to address these challenges include a Website to promote mental health referrals and pro bono mental health clinics at Community Health Centers. Other options proposed would address mental health education for primary care providers and assistance with the development of Community Health Center mental health programs.
Ms. Williams recommended capacity enhancement grant for Community Health Centers, technical assistance to these centers for the start-up of mental health services, and continuing education in mental illness for health professionals in primary care settings. She also recommended rural mental health advocacy programs at the state and national levels and awareness campaigns for medical schools to promote the need for mental health services in rural areas.
Dr. Enright and Mr. Ahrens asked about the availability of mental health nurse practitioners. Ms. Williams replied that only three are working in the three counties under discussion, and suggested that tuition assistance and loan repayment programs would be incentives for increasing the numbers.
In response to a question from Dr. Singleton about telehealth services, the speaker stated that while privacy issues are under examination, no services are currently available in the three county area. Dr. Enright then stated that telemedicine works well in mental health for consultations between doctors on psychopharmacology and other issues, but that psychiatric consultations with patients are problematic.
Dr. Steele asked about the importance of cultural issues in local mental health services. Ms. Williams said that issues related to stigma, language barriers, and denial are extremely important in the delivery of services.
Dr. Edwards asked whether the Network was working with medical schools to recruit mental health providers. The speaker answered that little was being done in this area. Ms. Gonzales Hanson added that internships for medical students are not available in the community and that state licensing issues constrain the possibilities for internships.
Dr. Singleton asked about payment for mental health services. Ms. Williams said that Medicare pays more than Medicaid, and that low payment levels are a deterrent to recruitment of practitioners.
During general discussion following the presentation, it was mentioned that scope of practice issues and licensure issues are a big problem in recruiting mental health social workers. Due to widespread shortages of mental health professionals in the area, it is difficult for social workers to obtain the supervision they require for obtaining a clinical license.
The three subcommittees adjourned to separate rooms to continue their deliberations on recommendations for the annual report.
Governor Beasley announced that the next meeting of the Committee would be held in Charlestown, West Virginia of September 7-9, 2003.
Governor Beasley congratulated the Committee for the positive results from the survey of federal advisory committees. He also stated that he would be writing to the Secretary for assistance in identifying human service issues that should be addressed by the Committee.
There were no public comments and the meeting was adjourned until Tuesday morning.
Governor Beasley opened the session by thanking Ms. Rachel Gonzales Hanson for her work in hosting the meeting.
Governor Beasley announced that Mr. Morris would be scheduling conference calls for the subcommittees during July and August. The subcommittees will prepare draft chapters for the annual report that will be available for the meeting in September. Governor Beasley stated that the annual report will have four chapters, one for each subcommittee and an overview chapter on the status of rural health.
Governor Beasley and Mr. Morris lead a discussion on the letter to the Secretary reporting results from the meeting in Texas. The Committee Members offered their suggestions on the content of the letter.
Dr. Wakefield urged that the letter refer to comments from the Texas Health Commissioner on the issue of obesity and the need for public health intervention strategies. Dr. Bailey stated that the long-term costs of obesity should be mentioned.
Dr. Mueller and Dr. Kaye agreed that obesity is an issue that cuts across the work of each subcommittee and should be at the forefront of the Committee's concerns.
Dr. Steele and Mr. Ahrens both commented that prevention programs on obesity would be a tough sell at the state level where there is more interest in the treatment of disease.
Ms. Gonzales Hanson suggested that the Secretary should consider calling a conference of health leaders on the issue of obesity.
Governor Beasley stated that oral health is an epidemic and will be discussed in the letter to the Secretary.
Dr. Mueller was impressed with the potential for integrating oral and physical health described by Dr. Baber in his presentation. Dr. Mueller asked that these themes be included in the letter to the Secretary.
Ms. Gonzales Hanson offered that the letter should express support for loan repayments for dentists and urge more emphasis on getting dentists into the health manpower pipeline.
Dr. Edwards said that the letter should affirm the importance of the Administration's decision to increase funding for Community Health Centers.
At the suggestion of Dr. Steele, the Committee agreed that the letter must stress the importance of scope of practice issues in rural health.
Dr. Enright suggested that the letter refer to testimony at the meeting that confirmed the role of rural primary care practitioner as the front line of defense for mental illness.
There were no public comments.
The meeting was adjourned.