Dissertation
Strategies to improve health in rural areas: evaluating the implementation of community health programs, telehealth technology, and home health care
University of Iowa
Doctor of Philosophy (PhD), University of Iowa
Spring 2021
DOI: 10.17077/etd.006066
Abstract
Rural Americans face more health disadvantages than those living in urban and suburban areas. The literature on rural health has found that health inequalities between rural and urban populations continue to grow. Healthcare organizations in rural areas face constraints in improving their communities' health due to institutional barriers complicated by cultural and regulatory factors. Robust strategies are needed to strengthen rural health across the care continuum (prevention, treatment, and maintenance). Accordingly, this dissertation explores three potential strategies for improving rural health – community health programs, telehealth, and home health care. The first study examines rural hospitals' motivations to engage in community health programs and discusses their strategies to address community health issues. In rural communities, hospitals are frequently the primary organization with the resources and capabilities to address health issues. This characteristic highlights their potential to be a partner and leader for community health initiatives. We conducted semi-structured interviews with key leaders from four rural hospitals in a Midwest state in the U.S. These hospitals are located in rural counties that have demonstrated progress in creating healthier communities. On-site and telephone interviews were audio-recorded and transcribed. We applied the combination of inductive and deductive qualitative analysis to identify common themes and categories. We identified three categories of motivations that drove rural hospitals' community health improvement efforts: internal values, economic conditions, and social responsibilities. We also identified three categories of strategies that rural hospitals used to address community health issues: building capacity, building relationships, and building programs.
Studies have shown the benefits of telehealth service in rural areas. However, there is evidence of limited adoption and utilization. The second study investigates health systems' experience in implementing telehealth services in rural hospital emergency departments (TeleED) and by analyzing factors influencing its implementation and sustainability. We conducted semi-structured interviews with 18 key informants from six health systems (hub sites) that provided TeleED services to 65 rural emergency departments (spoke sites). All used synchronous high-definition video to provide the service. We applied an inductive qualitative analysis approach to identify relevant quotes and themes related to TeleED service uptake facilitators and barriers. We identified three stages of implementation: 1) the start-up stage; 2) the utilization stage; and 3) the sustainment stage. At each stage, we identified emerging factors that can facilitate or impede the process. We categorized these factors into eight domains: 1) strategies; 2) capability; 3) relationships; 4) financials; 5) protocols; 6) environment; 7) service characteristics; and 8) accountability.
The third study examines the impact of Certificate of Need (CON) laws on access to and quality of home health care. Home health care has a significant role in the care of Medicare beneficiaries. It can keep the patients at home while receiving efficient post-acute care services, potentially reducing Medicare expenditures. The CON laws can affect home health agencies' accessibility and quality by limiting their number in affected states. We compared the availability, utilization pattern, and quality performance of urban and rural home health agencies in CON states and non-CON states. Findings indicate that CON states have fewer urban and rural home health agencies available for their Medicare population than non-CON states.
Furthermore, the results suggest that urban and rural home health agencies in CON states have less utilization in terms of care episodes and visits. The findings also indicated that the CON laws have a mixed effect on home health agencies' quality in urban and rural areas of CON states. The results showed asymmetrical effects across different star-rating quality categories and locations. Also, there is evidence of some quality measures that home health agencies in CON states performed better and poorer than home health agencies in non-CON states.
Details
- Title: Subtitle
- Strategies to improve health in rural areas: evaluating the implementation of community health programs, telehealth technology, and home health care
- Creators
- Mochamad Muska Nataliansyah
- Contributors
- Xi Zhu (Advisor)Marcia Ward (Advisor)Thomas Vaughn (Committee Member)Keith Mueller (Committee Member)Amy Colbert (Committee Member)
- Resource Type
- Dissertation
- Degree Awarded
- Doctor of Philosophy (PhD), University of Iowa
- Degree in
- Health Services and Policy
- Date degree season
- Spring 2021
- DOI
- 10.17077/etd.006066
- Publisher
- University of Iowa
- Number of pages
- xiii, 94 pages
- Copyright
- Copyright 2021 Mochamad Muska Nataliansyah
- Language
- English
- Description bibliographic
- Includes bibliographical references (pages 79-94).
- Public Abstract (ETD)
Rural Americans face more health disadvantages than those living in urban and suburban areas. The literature on rural health has found that health inequalities between rural and urban populations continue to grow. Providers in rural areas have limited resources to improve their communities' health due to institutional barriers complicated by cultural and regulatory factors.
There is a need to assess strategies that include community engagement, aspects of the care continuum, and enhanced policy solutions. This dissertation examines three strategies for improving rural health – community health programs, telehealth, and home health care. The first study explores rural hospitals' engagement in community health programs and concludes that rural hospitals can successfully conduct community-oriented programs despite the challenges. Our findings extended the literature on how rural hospitals may strategize to improve rural health by engaging their communities and conduct activities beyond patient care. The second study evaluates health systems' experience in providing telehealth services in rural emergency departments and finds that multiple factors can influence health innovation implementation. Our study contributes to the field by highlighting key elements and domains that play roles in specific stages of telehealth operation in rural hospitals. Moreover, we recommend strategies to motivate the diffusion of promising innovations such as telehealth. Lastly, the third study examines the impact of Certificate of Need laws on access to and quality of home health care and finds evidence to understand the phenomenon better and make future improvements.
This dissertation's findings highlight different strategies to enhance rural health through community engagement, telehealth implementation, and home health care improvement. By appreciating and responding to this dissertation's results, relevant healthcare stakeholders may achieve more favorable outcomes in improving health in rural and isolated areas.
- Academic Unit
- Health Management and Policy
- Record Identifier
- 9984097170202771
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