1. RURAL DISPARITIES

2. RURAL VS. URBAN

3. RURAL SERVICES COMMISSION Role of the Commission  Core entity charged with examining the challenges of low- to moderate-income individuals living in rural areas  Developing recommendations for strengthening services and service delivery to rural residents.  Met weekly to:  Identify the key issues in rural areas  Share experiences  Gather input from other states’ experiences  Discuss the changes needed to strengthen services in Massachusetts

5. Rural Communities For the purpose of this study, the definition of rural areas is communities that have population densities of less than 500 people per square mile (MacDougall and Campbell, 1995). There are 14 counties in Massachusetts, consisting of 351 communities total, of which 172 can be classified as rural.

6. FOOD DESERTS

8. THE OPIATE CRISIS  1) greater opioid prescription in rural areas, creating availability from which illegal markets can arise  (2) an out-migration of young adults  (3) greater rural social and kinship network connections, which may facilitate drug diversion and distribution  (4) economic stressors that may create vulnerability to drug use more generally.

9. RURAL DOMESTIC AND SEXUAL VIOLENCE In rural Massachusetts, domestic and sexual violence continue to be leading health problems exacerbated by social and geographic isolation and the lack of public transportation, housing, employment, child care, anonymity and accessible health and human services. Although domestic and sexual violence crosses all socioeconomic lines, the overwhelming poverty of many rural communities in Massachusetts further limits the choices of victims there, preventing escape and access to assistance.

10.  Only about ten percent of physicians practice in rural America despite the fact that nearly one-fourth of the population lives in these areas.  There are 60 dentists per 100,000 population in urban areas versus 40 per 100,000 in rural areas**  Hypertension was also higher in rural than urban areas (101 in metro areas vs. 129 in rural areas)  Medicare payments to rural hospitals and physicians are dramatically less than those to their urban counterparts for equivalent services. This correlates closely with the fact that more than 470 rural hospitals have closed in the past 25 years.

11. WHAT’S DIFFERENT ABOUT RURAL HEALTH?  The suicide rate among rural men is significantly higher than in urban areas, particularly among adult men and youth.  The suicide rate among rural women is escalating rapidly and is approaching that of men.

12. WHAT’S DIFFERENT ABOUT RURAL HEALTH?  Although only one-third of all motor vehicle accidents occur in rural areas, two-thirds of the deaths attributed to these accidents occur on rural roads.  Anywhere from 57 to 90 percent of first responders in rural areas are volunteers.

13. WHAT’S DIFFERENT ABOUT RURAL HEALTH?  Medicare payments to rural hospitals and physicians are dramatically less than those to their urban counterparts for equivalent services. This correlates closely with the fact that more than 470 rural hospitals have closed in the past 25 years.  From RAC

15. On average, rural populations are older than populations in other parts of the country. Populations of older adults increase by level of rurality:

21. TRENDS IN SUBSTANCE ABUSE  Heroin use in the United States increased 63% from 2002 through 2013. This increase occurred among a broad range of demographics, including men and women, most age groups, and all income levels. The highest rate of growth has been in rural areas.

22. TRENDS IN SUBSTANCE ABUSE  As heroin use, abuse, and dependence have increased, so have heroin- related overdose deaths. From 2002 through 2013, the rate of heroin- related overdose deaths nearly quadrupled.  Persons often use heroin with other substances, including marijuana, cocaine, alcohol, and opioid pain relievers. This practice is especially dangerous.

23. TRENDS IN SUBSTANCE ABUSE  Groups with an increased risk for heroin abuse or dependence include men, persons aged 18–25 years, non-Hispanic whites, persons with annual household income less than $20,000, Medicaid recipients, and the uninsured

24. GOALS FOR “RURAL” MASSACHUSETTS The Rural Access Commission identified and constructed goals for the commission to guide its study and the recommendations set forth in this report. The goals of the commission’s recommendations intend to: Strengthen the overall infrastructure of the service delivery system in rural areas; Engage and support rural service providers through improved policy and planning on rural services delivery; Align access policies across state agencies; Support workforce planning; Improve access to services and improve service coordination; Support improvements to information availability; Strengthen the state’s options for responding to housing issues and homelessness; and Leverage best practices from other jurisdictions regarding servicing rural communities.

25. RECOMMENDATIONS FOR IMPROVEMENT Recommendations for improvement were centered on five priority areas: Access, Policy, Workforce Planning, Technology, and Service Delivery.

26. Access Expand transportation options for rural residents Strengthen Information and Referral services available Increase access to subsidized child care KEY RECOMMENDATIONS ARE AS FOLLOWS:

27. Policy Review agency polices that require clients to travel to agencies Review rate models for rural providers Support rural appropriate models of health care Establish ongoing Commission on Rural Services Improve the ability of state agencies to reach and serve those in rural communities

28. Workforce Planning Develop an enhanced and coordinated state infrastructure that identify and address rural workforce needs Implement data-driven and evidenced based strategies to address health care worker shortage in rural communities Address Family Child Care Provider shortage for children in state funded slots

29. Technology Expand broadband access to rural communities and service providers Strengthen communications options Improve outreach and service delivery through use of smart phone technology Support data-sharing Expand the use of telemedicine and health information technology

30. Service Delivery Integrate eligibility processes Support service availability and a more comprehensive service experience in rural areas Establish service access centers

31. THE GOOD NEWS….  Quality of life  Outdoor and environmental resources  Increased interpersonal connections  Supportive infrastructure for advocacy

32. BE PART OF THE SOLUTION….  Every voice makes a difference  Neighbors helping neighbors  See something, say something  Stop the stigma