All North Carolinians should have the opportunity to be healthy, however far too often opportunities for health are not available in our rural communities. Although access to medical care is important, health begins long before medical care is needed. Health begins in families and communities, in the places where we live, learn, work, and play. Rural communities are often supportive communities with strong social networks and connections, however they often lack the resources needed to provide opportunities to support the health and well-being of residents.
One in five North Carolinians lives in a rural community. People living in rural North Carolina communities have poorer health outcomes than those living in urban areas [1]. Many of our rural communities, particularly those that are economically distressed, are resource poor and cannot offer the same choices for individuals to pursue health as are available in many more urban communities. Rural communities are often less likely to have jobs that pay adequate wages, places to buy healthy food, high-quality child care, well-resourced schools, higher education opportunities, and access to recreation spaces. Communities in rural North Carolina share risk factors that increase the likelihood of poor health outcomes including higher poverty rates, fewer health professionals and health care facilities, and isolation, all of which contribute to poorer health [1]. Residents in rural communities are older, poorer, sicker, and less likely to be insured than North Carolinians living in and around urban areas [1]. These factors lead to rural residents having higher rates of chronic disease, disability, and death [1].
In 2014, more than 300 North Carolinians including rural residents, representatives of state and local policymaking agencies, funders, health care professionals, community agencies and nonprofits, and other stakeholders contributed to the development of the North Carolina Rural Health Action Plan [2]. Development of the Rural Health Action Plan was led by the North Carolina Institute of Medicine (NCIOM) Task Force on Rural Health, which was convened in partnership with the Office of Rural Health within the North Carolina Department of Health and Human Services and the Kate B Reynolds Charitable Trust. The goal for the Rural Health Action Plan was to identify the areas in which investments over the next three to five years would yield a significant improvement in rural health outcomes.
The Rural Health Action Plan priority areas highlight that the health and well-being of rural communities relies on investments in economic development, early care and education, and healthy eating and active living, as well as health care services, access, and the health workforce. There are other areas that impact health as well, but these are the six selected as priority areas for the Rural Health Action Plan.
Since 2014, there have been many investments in the health and well-being of rural communities around the state. Full documentation of progress in fulfilling the recommendations from the Rural Health Action Plan can be found online at http://nciom.org/2018-update-to-the-rural-health-action-plan/. Below are highlights of progress made from each of the priority areas [2].
Invest in small business and entrepreneurship to grow local and regional industries
In 2014 the North Carolina General Assembly (NCGA) created eight prosperity zones, each with a central office where regional representatives of the Department of Commerce, Community College System, Department of Transportation, Economic Development Partnership of North Carolina, the Department of the Environment and Natural Resources, and others are co-located to help enhance collaboration and cooperation between state, local, and regional organizations working to support and improve local economies.
In 2018 the NCGA established the Growing Rural Economies with Access to Technology (GREAT) program, which facilitates the deployment of high-speed broadband to unserved areas of the state. GREAT also provided $10 million in state funding and allocated North Carolina's share of federal funds to expand broadband access.
Thread Capital, a new nonprofit subsidiary of the Rural Center that launched in May 2018, provides loans of up to $50,000 to entrepreneurs in all 100 counties.
Since 2015, the Carolina Farm Stewardship Association has been helping small- to mid-scale farmers implement Good Agricultural Practices for Small Diversified Farms food safety practices, which increase farmers' ability to market and sell their produce.
The North Carolina Community College System has grown many of its workforce and Career and College Promise programs at rural community colleges and implemented the NCWorks Career Coach program in many rural communities.
Ensure that all childhood settings (0-8) provide a high quality and nurturing environment and promote parenting supports
Child care subsidies have been increased in the last three budget cycles, with a focus on increasing rates in tier 1 and tier 2 counties.
Evidence-based parenting support programs, including Triple P, Child FIRST, Nurse-Family Partnership, Durham Connects, and others, have been expanded throughout the state. In July 2018, North Carolina Medicaid launched two pilot home visiting initiatives in Cleveland and Johnston counties.
Funding has been increased for evidence-based school readiness programs that distribute books to young children.
Support healthy eating and active living
Communities are increasing opportunities for healthy eating and active living in a variety of ways, often with support from philanthropy. This includes working on transportation, built environment, school policies, food deserts, and other strategies to improve nutrition and increase physical activity.
The Blue Cross and Blue Shield of North Carolina Foundation, The Duke Endowment, and the Kate B. Reynolds Charitable Trust have all invested significant funding to help address healthy eating and active living in communities across the state through evidence-based programs, supporting opportunities for recreation, supporting local health collaboratives, and other efforts.
In 2017, North Carolina adopted more rigorous nutrition, physical activity, and screen time standards for both center- and home-based early care and education providers.
The NCGA has provided $500,000 for the Healthy Corner Store Initiative to bring fresh produce and other healthy foods into small retail stores.
More than 50 farmers markets have opened in the last four years, bringing total to approximately 230 across the state. About half accept Supplemental Nutrition Assistance Program (SNAP) benefits.
Increase access to mental health and substance use treatment through integrated care
Community Care of North Carolina has created toolkits to inform providers about the screening and billing process for mild to moderate behavioral health conditions and promoted the implementation of evidence-based models of integrated care.
Under Medicaid transformation, Medicaid beneficiaries with lower-intensity behavioral health, intellectual, and developmental disabilities will receive integrated coverage for behavioral health and physical health services.
The Division of Mental Health, Developmental Disabilities, and Substance Abuse Services has sponsored many Mental Health First Aid trainings. Since 2014, more than 46,000 Mental Health First Aiders have been trained in North Carolina.
Educate and engage people in rural communities about new and emerging health insurance options as well as existing safety net resources
Over the past four years numerous organizations throughout the state have worked to educate and enroll North Carolinians in new health insurance options under the Affordable Care Act, leading North Carolina to have the third-largest enrollment among the 38 states using the federal exchange. More than 500,000 North Carolinians have enrolled in private plans through the federal exchange.
Recruit and retain health professionals to underserved areas of the state
Following in the footsteps of East Carolina University's Brody School of Medicine, the Campbell University School of Osteopathic Medicine and the University of North Carolina School of Medicine consider the geographic origins of applicants during the admissions process and in pipeline programs.
UNC has developed new programs meant to inspire students to pursue primary care practice in rural areas of the state.
Residency programs at rural health care facilities have been created and/or expanded.
Session Law 2018-88 directed the Department of Health and Human Services to study and report recommendations for creating incentives for medical education in rural areas, to assist rural hospitals in becoming designated teaching facilities, and to maximize federal funding programs that assist with placing health care providers in rural areas [3].
In addition to these changes, the Rural Health Action Plan has helped broaden the discussion about conditions that must be addressed to improve health and well-being. Along with many other efforts, the Rural Health Action Plan has helped spread the message that to truly improve the health and well-being of communities, action must be taken to address barriers to health. Long-term sustainable improvements in health outcomes will not occur without addressing the physical, social, and economic challenges that keep people from achieving optimal health in our rural communities. Four years after issuing the report, North Carolina has made significant progress toward implementation of recommendations from all six priority areas, including complete implementation of one priority area.
Acknowledgments
Potential conflicts of interest. A.J.Z. and B.Y. have no relevant conflicts of interest.
- ©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.