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Rural Health Care: Challenges & Opportunities

Strengthening the Infrastructure


Daniel M. Campion, M.B.A., Senior Program Manager and Co-Project Director, Networking for Rural Health, Alpha Center, Washington, DC.

Luisa Buada, R.N., M.P.H., Executive Director, California Institute for Rural Health Management, Oakland, CA.

The purpose of this session was to describe how health care providers and other stakeholders can come together and improve the delivery of health care services to rural populations over the long term. Speakers discussed the development of rural health care networks and integrated delivery systems as platforms for change and mechanisms for strengthening the overall health care infrastructure. Background information was provided about several technical assistance projects/resources available to States, communities, and providers in developing such partnerships.

A rural health network is defined as an organizational arrangement among rural health care providers (and possibly insurers, social service agencies, public health departments, or other entities) that uses the resources of more than one existing organization and specifies the objectives and methods by which various collaborative functions are achieved. Rural health networks can vary considerably based on their membership, environment, age/experience, and joint activities.

Examples of substantive activities conducted by rural health networks include:

  • Increasing access to care or providing new services through organizing emergency medical services on a regional basis.
  • Improving availability of specialty mental health or substance abuse treatment services.
  • Improving ability of network members to recruit and retain health care professionals.
  • Improving the quality of health services through developing disease management programs to improve care for persons with chronic conditions (e.g., diabetes and asthma).
  • Improving peer review by the increasing the number of reviewers and reducing professional isolation.
  • Establishing a shared quality assurance program, involving a shared computer system and database management.
  • Establishing and improving community health promotion and disease prevention programs.
  • Improving the ability of the network members to participate in managed care by developing administrative services capacity for contracting with self-insured employers in rural communities.
  • Establishing a utilization review process for a network that contracts with a managed care organization or self-insured group.
  • Developing a networkwide management information system that allows providers to monitor services provided.
  • Improving member efficiency by reducing costs (e.g., group purchasing) and obtaining resources (e.g., staff sharing).

Mr. Campion described several initiatives designed to support rural health networks:

Networking for Rural Health—Academy for Health Services Research and Health Policy

Supported by a grant through The Robert Wood Johnson Foundation, Networking for Rural Health provides technical assistance resources that promote the development of rural health networks. Technical assistance tools include:

  • Primers and technical reports.
  • Network "profile" self-assessment tools.
  • Invitational workshops.
  • Network assessment site visits.
  • Targeted consultations.

For more information contact Daniel Campion, Co-project Director, or Katherine Browne, Senior Associate, at (202) 292-6700 or visit the Academy Web site at

Technical Assistance and Services Center (TASC) for the Rural Hospital Flexibility Program—National Rural Health Resource Center

Funded through the Office of Rural Health Policy, the goal of TASC is to aid States in their efforts to implement the Rural Hospital Flexibility Program, including the development of State rural health plans and the designation of critical access hospitals. For further information, contact Terry Hill, Project Director, at 218-720-0700 or

Managed Care Technical Assistance Center (MCTAC)—Health Resources and Services Administration's (HRSA) Center for Managed Care

Established by HRSA in May 1999, the goal of MCTAC is to assist HRSA grantees in obtaining managed care technical assistance and training. This program is administered by John Snow, Inc., in Arlington, Virginia. For further information contact Jacqueline Kelly, Project Director, at 877-832-8635.

Networks for Rural Health—Georgia Health Policy Center, Georgia State University

The goal of Networks for Rural Health is to produce stable community health care systems by engaging community leaders to assemble leadership to ensure accountability of local activities, complete core business evaluation, and envision and implement future health care systems. For further information, contact Karen Minyard, Project Director, at 404-651-3137.

Developing Rural Integrated Systems Initiative (DRIS)

Luisa Buada stated that the California Institute for Rural Health Management has provided project direction for the Developing Rural Integrated Systems Initiative (DRIS). Funded by The James Irvine Foundation, DRIS was established in 1997 as a 4-year, $6 million initiative whose goal is the creation and development of integrated health systems in rural areas of California that can effectively operate in the changing health care marketplace. Participating rural communities include Humboldt-Del Norte Counties, Indian Wells Valley/Ridgecrest, Lompoc Valley, and Imperial County.

Ms. Buada described some of the benefits of DRIS, including:

  • Better coordination of care.
  • Focus on health promotion and disease prevention.
  • Improved access to specialty services and relevant technologies.
  • Reduction in unnecessary duplication in clinical and management capacity.
  • Increased retention of health care expenditures.
  • Community collaboration on health planning.
  • Grant dollars to support community benefit goals.

Ms. Buada explained that a major goal of DRIS has been to develop mechanisms for rural providers to participate in managed care and for these managed care systems to be sensitive to community needs. She noted that in some communities, managed care is not an easy fit and offered the following lessons about community readiness to enter into such partnerships:

  • Committed, planned leadership is essential.
  • Perception of environmental threat can be an important motivator for action.
  • Involved community leaders can help leverage change in health care systems.
  • Negotiating effective compromise involves finding common ground among the various stakeholders in any partnership.

Ms. Buada offered several lessons for policymakers based on the DRIS experience:

  • Incremental integration efforts build relationships and trust.
  • Network building can improve health access.
  • Strengthening local health systems is an important approach to rural economic development.
  • Provider networks can be assisted through State action immunity from antitrust.
  • It is important to prevent health plans from passing too much financial risk to rural providers.
  • Have Medicaid follow Medicare in the critical access hospital program, especially regarding cost-based payments.
  • Strengthening rural integrated systems requires long-term financial investment.


Bonk G. Networking for rural health: principles of rural health network development and management. Washington, DC: Alpha Center, 2000 Jan.

Teevans JW. Networking for rural health: forming rural health networks. Washington, DC: Alpha Center; 1999 Oct.

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