1. CU SOM Rural Track Mark Deutchman MD
What is Rural?
CU SOM Rural Track Mark Deutchman MD

2. Objectives
Understand the various definitions of “rural” and look at the Colorado map
Understand some of the parameters that are used to assess rural health and healthcare
Review how healthcare is organized and delivered in rural areas.
List resources for information about rural health and healthcare

3. Exercise # 1
Write down how you would answer a classmate who asks “what is rural”?

4. Sources of Definitions (and who cares?)
US Census Bureau
Office of Management and Budget
Economic Research Service of the U.S. Department of Agriculture (USDA)
Office of Rural Health Policy
Conventional wisdom
The ultimate answer about “who cares” lies in politics and money.
Good summary:

5. Urban is better defined than rural
US census bureau defines “urban” as “places of > 2500 people.
US OMB defines a “metropolitan area” as “core area containing a large population nucleus, together with adjacent communities having a high degree of economic and social integration with that core.”

6. Urbanized area (OMB)
“A central place and its “urban fringe”, or surrounding territory, which is populated by at least 50,000 people.”
Colorado’s UA’s:
Boulder, Colorado Springs, Denver, Fort Collins, Grand Junction, Greeley, Longmont, Louisville, and Pueblo.

7. Urban Cluster (OMB)
A core with a total land area of less than two square miles and a population density of 1,000 persons per square mile. They may contain adjoining territory with at minimum 500 persons per square mile and encompass a population of at least 2,500 but less than 50,000 persons. 

8. Micropolitan Statistical Area
Nonmetro county with an urban cluster of at least 10,000 persons or more. As with metro areas, outlying counties are included if commuting to the central county is 25 percent or higher, or if 25 percent of the employment in the outlying county is made up of commuters from the central county.

9. RUCA Codes Rural-Urban Commuting Area codes
Census tract-based classification
Use standard Bureau of Census urban area and place definitions in combination with commuting information to characterize all of the nation's census tracts regarding their rural and urban status and relationships.

10. RUCA Codes
Based on 2010 census and the American Community Survey.
Two levels:
Whole numbers (1-10) delineate metropolitan, micropolitan, small town, and rural commuting areas based on the size and direction of the primary (largest) commuting flows.
Further subdivided based on secondary commuting flows, providing flexibility in combining levels to meet varying definitional needs and preferences
RUCA codes are based on data from the 2010 decennial census and the American Community Survey. The classification contains two levels. Whole numbers (1-10) delineate metropolitan, micropolitan, small town, and rural commuting areas based on the size and direction of the primary (largest) commuting flows. These 10 codes are further subdivided based on secondary commuting flows, providing flexibility in combining levels to meet varying definitional needs and preferences

11. Codes 4-10 are generally considered “rural”
Primary RUCA Codes, 2010
Codes 4-10 are generally considered “rural” 1
Metropolitan area core: primary flow within an urbanized area (UA) 2
Metropolitan area high commuting: primary flow 30% or more to a UA 3
Metropolitan area low commuting: primary flow 10% to 30% to a UA 4
Micropolitan area core: primary flow within an Urban Cluster of 10,000 to 49,999 (large UC) 5
Micropolitan high commuting: primary flow 30% or more to a large UC 6
Micropolitan low commuting: primary flow 10% to 30% to a large UC 7
Small town core: primary flow within an Urban Cluster of 2,500 to 9,999 (small UC) 8
Small town high commuting: primary flow 30% or more to a small UC 9
Small town low commuting: primary flow 10% to 30% to a small UC
10  
Rural areas: primary flow to a tract outside a UA or UC 99
Not coded: Census tract has zero population and no rural-urban identifier information

12. Colorado county Ruca Codes in County Larimer and El Paso 1,2,7 Weld
1,2,3,4,10
Mesa and Pueblo
1,2,10
Montrose and La Plata
4,5,10
Garfield
4,5,7
Chaffee 7
Park
2,10
Gunnison
7,8,10
Alamosa
7,8
Morgan
4,7,10
Prowers
Broomfield
1,10
Baca, Lincoln RioBlanco, Washington, Dolores, Sedgwick 10

13. Colorado according to US Census Bureau:
Urban Population
Rural Population
Total Population
3,634,746
666,515
4,301,261
84.5%
15.5%
100%
Colorado according to US Office of Management and Budget (OMB):
Metropolitan Population
Non-metropolitan Population
Total Population
3,607,656
693,605
4,301,261
84%
16%
100%

14. Colorado counties: 17 urban 24 rural 23 frontier

15. Frontier “A county with six (6) or fewer people per square mile.
Based on whole counties.
23 of Colorado’s 64 counties:
43% of land mass
3% of population

17. Exercise # 2
Write down some adjectives that you think apply to the demographics and health of rural people.

18. People & Health in Rural CO
Parameter
Rural V. Urban
Median Age
Median Household Income
Children in poverty
Un-insurance
Suicide rates
MVA deaths/100,000
Births to teens
Monthly health insurance

19. People & Health in Rural CO
Parameter
Rural V. Urban
Median Age
45-64, versus 18-44
Median Household Income
$45,307 compared to $61,642
Children in poverty
24.5% compared to 15.8%
Un-insurance
20.6% compared to 15.1%
Suicide rates
Higher in rural
MVA deaths/100,000
20 v. 12.3
Births to teens
1.6 times higher in rural
Monthly health insurance
$ 532 V. $352

20. Rural Alphabet Soup
HPSA
MUA
MUP
CAH
RHC
FQHC

21. HPSA
Health Professional Shortage Areas may be designated as having a shortage of primary medical care, dental or mental health providers. They may be urban or rural areas, population groups or medical or other public facilities.
Primary Care: population to practitioner ratio of > 2,000:1
Dental : a population to practitioner ratio of > 3,000:1
Mental Health: a population to practitioner ratio of 10,000:1
What is a Health Professional Shortage Area (HPSA)? A HPSA is a geographic area, population group, or health care facility that has been designated by the Federal government as having a shortage of health professionals. There are three categories of HPSAs: primary care (shortage of primary care clinicians), dental (shortage of oral health professionals), and mental health (shortage of mental health professionals). HPSAs are designated using several criteria, including population-to-clinician ratios. This ratio is usually 3,500 to 1 for primary care, 5,000 to 1 for dental health care, and 30,000 to 1 for mental health care

22. MUA
Medically Underserved Areas/Populations Medically Underserved Areas (MUA) may be a whole county or a group of contiguous counties, a group of county or civil divisions or a group of urban census tracts in which residents have a shortage of personal health services

23. MUP
Medically Underserved Populations (MUPs) may include groups of persons who face economic, cultural or linguistic barriers to health care.

24. HPSA score
HPSA Scores are developed for use by the National Health Service Corps in determining priorities for assignment of clinicians. Scores range from 1 to 25 for primary care and mental health, 1 to 26 for dental. The higher the score, the greater the priority.
All Federally Qualified Health Centers and those Rural Health Clinics that provide access to care regardless of ability to pay receive automatic facility HPSA designation. These facilities may have a HPSA score of 0

25. HPSA score calculator: http://bhpr. hrsa
Scoring for primary care includes four factors:
Population-to-Primary Care Physician Ratio,
Percent of the Population with Incomes below 100% of the Poverty level,
Infant Mortality Rate or Low Birth Weight Rate (whichever scores more highly)
Travel Time or Distance to nearest available source of care (whichever scores more highly)

26. Colorado’s HPSAs

27. Exercise # 3
List some of the types of healthcare organizations that are important to rural healthcare delivery.

28. Critical Access Hospital
Must be or have been a licensed hospital in the past 10 years
Must be located in a rural area.
Must have no more than 25 beds; any combination of swing beds or acute.
Must maintain an average length of stay of no more than 4 days, or 96 hours annually.
Must have written agreements with another, larger hospital(s) for appropriate transfer and communication about patients.

29. Certified Rural Health Clinic
A Rural Health Clinic (RHC) is a primary healthcare clinic located in a non-urbanized area that has been shown to have a shortage of healthcare services or healthcare providers, and has been certified as a Rural Health Clinic under Medicare.
The greatest benefit of the program is cost-based (enhanced) reimbursement from Medicare and Medicaid.
There are about 44 RHCs in Colorado.

30. What is required to become a certified RHC?
• Be located in a non-urbanized area;
• Be located in a MUA or HPSA that was designated within the past 3 years
• Provide outpatient primary care services;
• Utilize the services of at least one mid-level practitioner at least 50% of the time the clinic is open
• Have a physician to provide medical direction
• Meet health and safety requirements set by Medicare and/or Medicaid.
Have a physician to provide medical direction who is present for sufficient periods of time, at least once in every 2-week period to oversee patient care services, provide consultation and supervision, and be available through direct telecommunication; and

31. Colorado’s Rural Health Facilities

32. What is a FQHC ?

33. FQHC Required Services

34. Cost-based reimbursement

36. Access to care
“Access” and “Coverage” are two distinctly different things that are often confused.
“Coverage” refers to a payment system and the services that are included in that payment
“Access” refers to how readily available services are.

37. Percent of Colorado Population without Health Insurance and Below 200% FPL, 2000

38. Exercise # 4
Write down some questions that you would like to answer for yourself about your future in healthcare.