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Palliative care and hospice services have evolved and matured mostly in urban areas alongside robust health infrastructures, with highly trained specialists and teams and other needed resources. Yet, nearly half of the world’s population resides in rural locales and experiences marked health disparities. Rural areas, geographically isolated with large distances between established communities, often have small populations and struggle to maintain primary care clinicians with limited to no access to specialty care such as palliative care. Palliative care delivery models require interdisciplinary teams of physicians, nurses, pharmacists, social workers, chaplains, and many other health care professionals, who may be in short supply in rural health care systems. Contributing to and compounding this limited clinician access is the fact that rural regions often lack robust health infrastructure, resources, broadband connectivity, and capacity to effectively scale up many health care models adopted in urban settings.
Noted differences in the characteristics of urban and rural populations in the United States (U.S.) include a tendency for rural residents to be older, chronically ill, and living below the poverty line. They disproportionately experience poorer health outcomes, and their geographic disparities compound racial health inequities. Although many rural communities share similar outcomes, rural regions often differ in population, infrastructure, and culture, with each area facing a distinct combination of challenges to delivering high-quality specialty palliative care. All “rural” areas are not the same; rural communities represent a heterogeneous group of locales—some more remote than others—complicating systematic health care delivery to their residents. Terms such as “remote” and “frontier” may indicate more isolated geographical regions.
Table 71.1 lists the many issues and considerations to address when establishing rural palliative care services. Similar to their urban counterparts, rural patients and their family caregivers may have limited awareness and misconceptions of palliative care, often equating palliative care with end-of-life or hospice services. Compounding these misperceptions, local trusted clinicians may be reticent to refer to, recommend, or incorporate palliative care. Although not specific to rural settings, a recent systematic review indicated that clinicians hesitate to recommend palliative care due to concerns about alarming the patient and family or lack of consensus with timing and criteria for referrals. In many rural communities, acceptance may be dependent on the advice of a trusted local health care clinician or extended social support community. Rural patients may draw on prior experiences with specialty care outside their community where they might have dealt with fragmented care. While awareness and perceptions of palliative care are slowly changing, several studies identify misconceptions of palliative care as a major barrier to integration and widespread access. Additionally, many of the antecedents and triggers to palliative care referral, such as a serious illness diagnosis or worsening prognosis, may be considered “taboo” or not “in line” with established mores of rural or remote communities.
Considerations and Issues | Potential Considerations and Strategies |
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Community readiness |
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Site of care |
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Duration of care |
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Patient population |
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Care workflow, logistics, and policies |
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Pain management |
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Staffing |
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Finances |
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Competing urban-based health centers’ palliative care staffing demands for a limited palliative care workforce complicate delivery of high-quality palliative care in rural and remote areas. As the population ages, with older adults as the primary palliative care consumers, preexisting deficits of primary and palliative care clinicians are projected to balloon. Kamal and colleagues’ modeling of the U.S. palliative care physician workforce estimates a lack of specialty-trained clinicians by the 2030 s with potential ratios of more than 1,300 eligible Medicare beneficiaries to every physician. Rural communities, already experiencing clinician shortages, are likely to experience this burgeoning clinician drought more acutely as supportive health care infrastructure buckles under changing health care conditions. The recent Achieving Rural Health Equity report from the National Academy of Medicine highlighted some of the recent challenges of stabilizing health infrastructure, noting that since 2010 nearly 100 critical access hospitals have closed due to declining populations and changes in payer models. This combination of clinician shortage and lack of hospital beds limits the sustainability of palliative care models using inpatient consultative service in rural communities. The combination of the demand of an aging population plus ongoing unmet palliative care need merits the innovative strategies discussed throughout this chapter and highlighted in Table 71.1 .
Guidelines, policies, regulations, and reimbursement are highly variable across the globe. In countries with established rural palliative care outreach and robust nationally sponsored or supplemented health care, palliative care services are generally reimbursed with minimal cost to patients and their families. However, this type of reimbursement is not the norm worldwide, with reimbursement varying widely by country, payer system, and types of service. For example, rural residents within the U.S. often rely on Medicare and Medicaid, a fee-for-service model that pays for specific services such as advance care planning discussions and complex chronic care management only by approved clinicians, often excluding reimbursement of services provided by an interdisciplinary team. Furthermore, different regulations and reimbursement policies may limit the scope of practice for nurses or other health care members providing palliative care services and stipulate the timing of palliative care, often only paying for service once patients meet hospice criteria and waive the right to other Medicare-covered services, further limiting early outreach to rural residents.
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