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Collaboration is key for rural challenges.

Rural communities face significant challenges, and they face them with fewer and different kinds of resources. Compared with metropolitan residents, rural Americans earn less, have higher poverty rates overall and for children, have higher rates of working poverty, attain lower education levels and are older. Rural citizens are also less likely to have health insurance and have lower access to specialists of all kinds (doctors, social workers, psychiatrists and psychologists). At the same time, they report poorer overall health, have higher rates of chronic illness, and higher rates of manufacture and usage of methamphetamines.



Rural people and places are creative, resilient and build their communities upon the strength of their relationships, but sometimes those strengths cannot overcome the reality of how challenging it can be to deliver social and human services in rural communities.

The reality of a vast geographic landscape with sparse population density create a unique rural differential to service delivery. However, not all of the challenges are solely rural challenges. The rural differential is often a matter of degree from suburban and urban communities.

Rural people in need confront the question of whether a social service is even available to them in their county or even region, and if it is, worry about how many hours out of their day they will spend traveling to the service location, if they even have transportation available. The reality is that it costs more to deliver services per capita in rural areas. What this means practically is that the staff in social service offices have to wear many different hats for many different safety net programs. Specialization, therefore, is rare. However, perhaps silos do not exist in rural as they do in metropolitan areas? Due to the lack of rural-specific, human service research, this is an unanswered question that, regardless of the answer, does not make it any easier to find and deliver services in rural areas. The depth and breadth of nongovernmental, philanthropic and private-sector organizations is much less developed in rural areas, resulting in a much greater reliance on public-sector services. And with fewer philanthropic and nonprofit providers in rural areas, there are fewer advocates available to give voice to rural-specific needs. Population-driven funding formulas are never going to adequately benefit rural areas without a rural-specific carve-out in funding requirements. But rural communities don't want their needs to be considered "carve-outs." All of these rural challenges are confronted while dealing with the very significant issue of the unintended rural consequences of program rules written for urban situations.

What rural people have in spades, though, are the strong relationships that build the foundation of their communities. And they know how to utilize this network of relationships in creative ways to "get things done," a common refrain in rural areas, because often they do not have any other choice despite having fewer tools to get things done than their urban counterparts. But if local control of scarce human resources has been eroding because of the need to ensure that the most bang for the buck is being achieved, it is hard to tap into the inherent rural strengths of creative collaboration to provide services in a manner consistent with the rural reality.

Collaboration Rural Realities

When flexibility is allowed in both funding allocations and program design, however, rural relationships can be tapped for collaboration. And when rural service providers can step out of their very comfortable local relationships and think more regionally about their collaboration, new service opportunities open up and more "bang for the buck" truly can occur in rural areas. In 2006, Deep East Texas, a 12-county area in the state, was presented with the opportunity to develop a collaborative Rural East Texas Health Network through a flexible funding stream from the Federal Office of Rural Health Policy. The Network Development Grants provide opportunities for rural providers to work together in formal networks, alliances or coalitions, to integrate services and functions across their organizations through rural health networks. The goal of this integration is to help overcome fragmentation of health and human services in rural areas and achieve economies of scale.

A needs assessment confirmed the Deep East Texas region's lack of sufficient mental health resources at the community, regional and state levels to prevent crises, treat crises at the inpatient and outpatient levels, and to provide adequate community-level aftercare to prevent further crises. This lack of resources placed a significant financial and workload burden on local community agencies, particularly law enforcement. Patients in need were sent either to the hospital emergency room or the county jail because there were no other safe alternatives. The distances to appropriate mental health services were so great that local law enforcement often spent more than two days transporting each patient needing mental health evaluation and services the long-distances to the closest available clinic. The needs assessment also highlighted confusion, misunderstandings, attempts at cost shifting, and constant policy revisions as community and agency coping strategies.

The Rural East Texas Health Network was formed to help overcome this confusion, misunderstanding and provider burden through both communications and collaboration. By almost all accounts, the collaboration was a success in many different respects. The collaboration of the RETHN enabled the opening of a regional Psychiatric Emergency Service Center to provide client-centered residential assessment and emergency care much closer to the patients' homes. Even before the opening of the center, a Mobile Crisis Outreach Team of mental health professions was established to provide 24-hour linkage to psychiatric services and necessary medicine prescriptions through telehealth. Just as important, the RETHN, through its dedicated program director, took unnecessary burden off of law enforcement, judges and medical personnel.

While the RETHN certainly did not alleviate all challenges with providing mental and behavioral health services--more resources are needed for youth services and treatment of substance abuse, for example--it does provide some useful lessons specific to rural communities. The opportunities available to expand health and human service delivery in rural areas through technology have vast untapped potential and are still their infancy stages. Of course, a key prerequisite is having high-speed broadband coverage in all rural areas. Those most remote areas that may have the most need for telemedicine services may be the least likely to obtain adequate broadband in the near future. And it goes without saying that nothing can truly replace the reassurance of face-to-face contact with a service provider for people in need.

What the RETHN also reinforced is that having a common rural understanding and culture was instrumental in enabling the very fast formation and strengthening of the program and the relationships of those involved in the network. Just as critical for the future of rural health and human service delivery was the ability of this common identity to be expanded more widely to regional relationships. Understandably, rural people would like to obtain all of their needed personal and professional services in their own communities. While this ability has slowly been eroding for decades, however, the acknowledgment that services might need to be obtained outside your community's boundaries is slower to transpire. Rural-centric regional relationships in service provision are a necessary transition that rural areas must undertake. But this is not to be thought of as regional offices in mid-size metropolitan communities, but regional services in communities that are well-positioned to be natural growth hubs in nonmetropolitan counties. Regional, and ideally integrated, service provision can provide a level of economies of scale and economies of function in rural areas that is hoped will be sufficiently cost-effective in times of tightening budgets. Regional health hubs are becoming more common and allow a level of specialization not achievable in smaller hospital and clinic settings. States that have eliminated county- level human service provision in favor of central state operations may find an ideal balance in regional rural offices that provide a level of cost effectiveness while bringing services back to the local level.


Livable Countryside

The collaboration achieved within the RETHN is not the only way that we need to develop our understanding about collaboration and integration to create better outcomes for people across the entire geographical landscape. Federal agencies have a wealth of opportunities to collaborate, integrate services and enable creative new combinations of services, both within agencies and across the federal government. Rural community leaders (and urban and suburban as well) see multiple ways they could more effectively combine federal funds in their communities to achieve creative, locally determined solutions to their needs. In rural communities, leaders interact daily with every aspect of their community and probably can name numerous ways that a tweak here and a little flexibility there would improve their community more appropriately and cost effectively.

The upcoming reauthorization of the child nutrition legislation at the federal level provides many such opportunities for interdepartmental collaboration to create regional food systems, overcome hunger and provide more consistent access to highly nutritious foods in rural communities. It is hard to imagine that in a country with the most productive farmland in the entire world, rural neighbors would go hungry and not have access to an abundance of nutritious, fresh food. But rural areas experience the same challenges with accessing food as their fellow citizens in urban city centers. For example, with a small collaborative fund from the U.S. Department Health and Human Services and the U.S. Department of Agriculture, rural areas could obtain local demonstration projects for regional food systems and child nutrition. This is just one small step in creating a livable countryside where services operate in a way that provides locally appropriate solutions and enables healthy and productive livelihoods for all people.

Jocelyn Richgels is program director and Christine Sande is project director, respectively, at the Rural Assistance Center.
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Author:Richgels, Jocelyn; Sande, Christine
Publication:Policy & Practice
Geographic Code:1USA
Date:Oct 1, 2009
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