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RURAL NEW MEXICO: PERSPECTIVES ON HEALTH CARE AND ACCESS

BRIDGING POPULATION HEALTH AND BEHAVIORAL HEALTH in RURAL NEW MEXICO

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 In the fall of 2018, the New Mexico Public Health Institute conducted the Bridging Population Health and Behavioral Health in Rural New Mexico project, a series of forums to provide opportunities for rural and frontier New Mexicans to begin transforming population health and behavioral health systems to meet local needs and resources.

See the final report of the project here.

To prepare for these day-long convenings, participants were invited to browse this interactive presentation, as well as other forum materials.

THIS PRESENTATION INTRODUCES THE FOLLOWING QUESTIONS: 

How do we define Rural versus Urban, and what does the data tell us about the difference in health indicators for Rural versus Urban?

How can geography help us to better understand causes and outcomes, demographics and the social determinants of health, disparities and inequalities?

What are the multiple factors that affect behavioral health in the community, and how can they be modified to improve community health? 

When we assess the needs and assets of ALL the people in each of our counties or communities, do we come to the same conclusions as when we look only at the patient populations, programs and priorities of the local healthcare provider systems?


       THANK YOU FOR EXPLORING THE ANSWERS TOGETHER.  

THIS IS A LIVING DOCUMENT AND WILL CONTINUE TO EVOLVE WITH YOUR INPUT.  A FINAL VERSION WILL BE PRESENTED AT THE STATEWIDE FORUM IN EARLY 2018.

    As you scroll through the presentation, you can interact with the maps (zoom in or out, click to see a pop-up with information) or select links to other web pages with detailed explanations of these issues.

WHAT IS URBAN?  WHAT IS 'RURAL'?

ALBUQUERQUE, SANTA FE, LAS CRUCES, FARMINGTON constitute New Mexico's four Metropolitan Statistical Areas (MSAs) with 100,000 or more inhabitants. These MSAs extend into a total of 7 Urban counties - outlined below in purple - containing 1,400,000 residents.  

The other 26 counties are defined as Rural. They vary in population from 800 to 73,000 and hold a total of 700,000 residents.  

Depending on which of many definitions is used to define Rural and Urban, comparisons of health disparities can vary substantially.  As the map below illustrates, there are many 'flavors' of Rural: for example, the Rural-Urban Continuum Codes (RUCC) system uses 9 categories of counties (7 found in our state). 

EXPLORE LIVE MAP - http://arcg.is/1niObK 

An alternate, 4-category method for exploring Rural versus Urban indicators is found here: New Mexico Rural-Urban Counties Comparison Tables

Defining Rural at the SUB-County level (for example, Census Tracts or Zip Codes) is an even more complex process that merits careful consideration as we go forward exploring these issues. EXPLORE Working Definitions of Rural with a map illustrating 6 ways to classify Rural geographies.

For present purposes, we will use the simplified 2-way definition of 7 Urban and 26 Rural counties. 

These definitions (and others) are used to measure health service and health status disparities, including access to healthcare and access to food

The population size of our counties varies greatly.  Bernalillo County and surrounding areas hold nearly half the state population, while we also have 8 counties with less than 5000 people each.

-D Capello

DEMOGRAPHICS & HEALTH OUTCOMES


In Rural counties there are greater proportions of both children and elders than in Urban counties. 

In other words, a higher percentage of the population is in a 'dependent' age group (under 18 or over 64 years of age) in Rural counties (41.7%) than in Urban counties (39.1%).

In Rural counties there are greater proportions of Native Americans, but smaller proportions of all other racial or ethnic groups:

As population has increased in Rural counties, growth has been driven in large part by increases in minority populations (Hispanics, Native Americans, other racial minorities, and the foreign born):

In Rural counties, the percent of people unemployed (5.9%) is significantly higher than in Urban counties (5.2%). But the percent of families below the poverty level is slightly lower (Rural = 14.9%; Urban = 15.8%).  21% of households in Rural counties receive retirement income, versus 19.5% in Urban counties.

RURAL-URBAN DIFFERENCES IN HEALTH OUTCOMES

Do the following maps of behavioral health outcomes reveal Rural-Urban disparities? What are the causes of these differences?

Persons Living with a Cognitive Disability

The above maps display population-wide measures: in other words,  measurements of outcomes in the general population of all persons of all ages, or in the general population of children or adolescents.  They are not based on sub-populations served by one medical provider system.

SOCIAL DETERMINANTS OF HEALTH

The determinants of population health include personal factors such as medical care, public health interventions, genetics and individual behavior.  

The Social Determinants of Health - perhaps more pertinent to our current exploration - include components of the social and physical environments such as income, education, employment, culture, family & community connection, safety, housing and transportation. These are the population-wide, upstream causes of the outcomes explored in the previous section.

Within the broad categories of social determinants listed below, what would be the more important factors to measure in order to better understand Behavioral Health determinants in Rural communities? Some examples and links are provided for you: 

INCOME: __________________________________________________________

                      Percent Families in Poverty

EDUCATION: ______________________________________________________

                      4th Grade Reading Proficiency

EMPLOYMENT: ____________________________________________________

CULTURE: _________________________________________________________

FAMILY: ___________________________________________________________

                   Children Cared for by Grandparents

COMMUNITY CONNECTION: ______________________________________

SAFETY: ___________________________________________________________

                    Child Abuse

HOUSING: _________________________________________________________

                    Rent Costs and Burden

TRANSPORTATION: ________________________________________________



ACCESS TO HEALTH INSURANCE & HEALTHCARE


HEALTH INSURANCE ENROLLMENT

Coverage in New Mexico has grown by nearly 70% since the inception of the Affordable Care Act  (December 2013).

MOST OF THIS INCREASE WAS AMONG LOW-INCOME ADULTS via the MEDICAID EXPANSION CATEGORY. The Medicaid increases, however, heavily favored URBAN counties (73.7%) over RURAL counties (60.6%). 

INCREASES IN MEDICAID, Interactive Map:

This map compares the increases in Medicaid enrollment. CLICK on a County to see the data.

Explore Map - http://arcg.is/1f1LLD              

Rural Counties have fared well in other aspects of health insurance coverage and access to health care. Unlike other states, a variety of insurance plans are offered in every New Mexico county. The proportion of uninsured in our state was reduced to 12.9% in Urban counties, and to 13.6% in Rural counties. (See Health Insurance Coverage and New Enrollments, 2015

The Affordable Care Act also resulted in greater improvement in the number of rural patients able to access hospital services for the first time thanks to their Medicaid benefits:

Conversely, repeal of the ACA would negatively impact rural patients to a greater degree. For a more in-depth look at this issue see The Role of Medicaid in Rural America .

ALL HEALTHCARE FACILITIES, Interactive Map:

HOSPITALS AND CLINICS

HEALTH CARE FACILITIES

The 519 active Medicare service providers and 12,600 inpatient beds in New Mexico are distributed in an equitable manner across the rural-urban continuum. Rural counties contain 50% of facilities and 40% of inpatient beds. Click on the points on the above map to see information about each of them.

Explore Live Map of all Facilities: https://arcg.is/1XuD0P

HEALTHCARE WORKFORCE RESOURCES

MENTAL HEALTH PROFESSIONAL SHORTAGE AREAS, Interactive Map:

With the exception of parts of three urban counties, every county and census tract in the state of New Mexico is classified as a Mental Health Professional Shortage Area. Click on the map to see other health professional shortage classifications:

EXPLORE LIVE MAP: http://arcg.is/0z14vP

BEHAVIORAL HEALTH TREATMENT RESOURCES

Notably lacking in Rural counties of New Mexico are psychiatric hospitals or residential treatment centers: 

Statewide there are 13 facilities with 562 beds, but only 1 facility with 20 beds is located in a rural county.

BEHAVIORAL HEALTH TREATMENT FACILITIES and MENTAL HEALTH STATUS, Interactive Map:

(SAMHSA certified facilities, outpatient and inpatient. Click on a STAR to see info.)

Explore Live Map - http://arcg.is/CGyqr

Over the previous 10 years, the number of person over 18 reporting poor mental health has grown 3 1/2  times faster in rural counties:


BEHAVIORAL HEALTH CARE LICENSED PROVIDERS, Interactive Map:

Rural counties have 3.28 behavior health providers per 1000 population.  Urban counties have 5.05 per 1000, a 54% greater rate.

Explore Live Map - http://arcg.is/1Kui15

COMMUNITY HEALTH NEEDS ASSESSMENTS

The Patient Protection and Affordable Care Act requires hospitals claiming tax-exempt status conduct a community health needs assessment every three years and develop a strategy to address the needs identified. Hospital and their provider systems must report on what they are doing to address the needs identified in the community health needs assessment. In addition, they must  describe any needs not being addressed and explain why they are not being addressed.

The following documents are all examples of how this health assessment process has developed among healthcare provider systems in rural New Mexico.  The links are provided here for participants to explore and thereby further their understanding of the role of patient care systems in population health.

2015 Community Health Needs Assessment and Implementation Plan, Gerald Champion Regional Medical Center, Alamogordo, NM:   http://www.gcrmc.org/upload/docs/Community%20Needs%20Assessment%202015.pdf

2013 Community Health Needs Assessment and Implementation Plan, Holy Cross Hospital, Taos, NM:   http://taoshospital.org/uploads/files/HCH-CHNA_Report_5-15-13.pdf

2016 Community Health Needs Assessment and Implementation Strategy, Cibola General Hospital, Grants, NM:   http://www.cibolahospital.com/docs/6_21_2016_-_CHNA_FINAL_-_Cibola.pdf

Community Health Needs Assessment Collection, Presbyterian Healthcare Services, Multiple Sites, NM:  https://www.phs.org/community/committed-to-community-health/Pages/default.aspx

Nationwide, healthcare provider systems, insurance companies and service organizations are working to integrate population health concepts.

At times, the strategies promoted are more focused on improving care within a system of eligible patients, rather than across an entire population. AthenaHealth has developed the following  interactive to promote strategies related to the patient-centered medical home model: improving the patient experience, improving health-care outcomes, and reducing costs:  


Would you agree with definition of population health implied by this presentation from AthenaHealth? 

to be continued . . .



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