Strategies for Managing Chronic Conditions in Rural Areas

Organizational Support

Gaining institutional support for a new program can be one of the biggest challenges to starting a program, particularly if that program has lower reimbursement rates than others.

Allison Cihla, MD, Medical Director of Intensive Care and Cardiopulmonary Services, is the consulting pulmonologist for the Appalachian Pulmonary Health Project. The project is a regional collaboration of all the Grace Anne Dorney Pulmonary Rehabilitation Centers throughout West Virginia, Kentucky, and North Carolina. They aim to deliver community-based pulmonary rehabilitation to individuals in rural areas.

Typically, though, pulmonary rehabilitation programs are do not receive high levels of reimbursement like their cardiac counterparts do.

“Pulmonary rehab is reimbursed at less than 50 percent of what cardiac rehab is. Hospitals and FQHCs find it very hard to sustain these programs,” Cihla noted.

To ensure the program’s success, then, her group needed to gain organizational support from key stakeholders who understood the importance of pulmonary rehabilitation services and how these practices could help individuals with chronic lung disease stay out of the hospital. These aspects combined would ultimately lead to better health outcomes and lower costs for hospitals.

“It takes a lot of effort and backing from administration, hospitals, and clinics to continue to provide funding for a program that doesn’t reimburse as well as other programs would,” Cihla explained.

One way to persuade stakeholders, Cihla suggested, was to point to the implications of not providing high-quality rehabilitation to patients with COPD.

"COPD exacerbations take up a lot of clinic time and resources. From that aspect, looking at the overall larger picture with patients is one way to present it to decision-makers," Cihla explained. "My administration at the hospital understands the need for this program. We know that it's not going to be our moneymaker, but looking at things from a larger standpoint, we can keep patients out of the hospital, which is a huge deal for reimbursement."

Think Outside the Box

Entering a new area to provide care and interventions can be challenging. There might be pushback from community members for an outsider telling them what to do, challenges around policies that do not allow programs to thrive, and unwillingness from key stakeholders to engage in the initiative.

Shelia Plogger, the Appalachian Diabetes Coalition Project Coordinator, said thinking outside the box allowed the programs they support to thrive. The Appalachian Diabetes Coalition supports community-based organizations through seed funding for diabetes prevention programs and works with them to generate strategic and sustainable goals.  

One of the most successful initiatives was a Walk to Disney World program, where students would walk every day at recess and compete with other classrooms to see who could walk the equivalent distance it would take to get to Disney first.

“It’s thinking outside the box and finding what works. Everybody’s got a competitiveness about them, so one school might compete against a school on the other side of the mountain,” Plogger noted.

She also explained that when putting these community-based coalitions together in different communities, diversity is essential because it helps the program developers think in new ways.

"We have found, in trial and error, that if people come together at a table and there are only two or three people, it's not really a diverse group. One of our requirements is that a coalition needs to have a minimum of five organizations present,” Plogger said. “Those typically look like the extension office, the health department, faith-based communities, and city government. That group then pulls folks from other sectors of the community to get them engaged and mobilized."

What one person may not have thought of, someone else might have experienced, thus promoting an environment of collaboration and creative thinking.

"You can't just throw money at people and expect something to be sustainable. You have to engage people,” Plogger continued. “The resources in people's communities are already there. They need the tools to help them along."

Build in Sustainability

For programs to maintain their work after initial funding, organizations need to build sustainability into their regular activities. “Team Up. Pressure Down.” was originally a grant-funded project to help patients with blood pressure medication adherence. Crystelle Fogle, MBA, MS, RD program manager for the cardiovascular health program and Carrie Oser, MPH, epidemiologist and evaluator for the same program discussed how they built sustainability into the Montana Department of Public Health and Human Services' program. 

“Team Up. Pressure Down.” worked with community pharmacies to promote medication adherence among patients with hypertension.

“We tried to build sustainability into the program from day one,” said Fogle. “By the end of the project year, we were asking partners how they planned on sustaining the project. We found that many of them still would, and many had the ‘Team Up. Pressure Down.’ materials on hand, so they were still going to distribute them.”

The program offered several ways to improve adherence, particularly among patients taking multiple medications in a day. The bubble pack allowed the patient's medication to be pre-packaged for them by day, and medication reviews ensured refill dates for multiple prescriptions lined up, so patients did not need to make several trips to the pharmacy.

These practices proved effective at helping patients adhere to their hypertension medications, which allowed the program to expand to other chronic conditions.

“Pharmacies started with blood pressure and were willing to move into working with the diabetes programs to extend this even further,” noted Oser. “They were able to use what they learned with our project and progress it with different conditions.”

“Our state health department expanded this to diabetes, asthma, and cholesterol control. Some of the same pharmacies that did ‘Team Up, Pressure Down.’ are now working on these new projects with us,” continued Fogle. “We know that they already have the background, know how to do the consults, and distribute educational materials. It’s nice to see them come back and want to do something additional for chronic disease.”

Adapting the physical program materials to include other chronic conditions was not a challenge.

“The ‘Team Up, Pressure Down.’ materials were focused on blood pressure, but it was a very simple edit to add ‘and diabetes,’” said Fogle.

Building in sustainability and growth into the program allowed what began as a hypertension intervention to grow to help patients with various chronic conditions adhere to their medications and promote better health outcomes overall.

Collaborate with the Community

All three programs emphasized the importance of collaboration across sectors with the community.

The Appalachian Pulmonary Health Project holds regular collaborative conferences between all their community partners as a way for individuals across the care continuum to discuss continuing education, reimbursement strategies, and updates on best practices.

“This collaborative model of medical education and peer management allows people from all over the country to come together and offer different solutions and ideas for patient care,” said Cihla.

A collaborative care model is not just successful for traditional care, but Oser noted it was helpful for “Team Up, Pressure Down.” as well.

"The team-based care approach involved the pharmacists as part of a care team in the community setting," she said.

However, one of the most challenging aspects of beginning a new program is being an outsider coming into a community or a care team.

“You cannot have outsiders coming in and telling you how to solve your problems,” Plogger stressed. “People have to be on board within the community. I think you see all too often grants that come by and tell you the objectives. It doesn’t always work that way. You have to give them the tools and resources.”

Communities are the best suited to explain their needs.

"I think communities have their own champions. They know what to do. They need the tools and resources to do it and someone to help them along their journey," continued Plogger.

Understanding who these champions are within a community, partnering with them, and supporting them in their work will ultimately lead to a program’s success.

“It’s all about building relationships,” Plogger concluded. “It’s just getting down to the basics. We build trust with our funders and the community.”