State’s ru­ral res­i­dents have less ac­cess to health ser­vices

New Haven Register (New Haven, CT) - - FRONT PAGE - By Jodie Mozdzer Gil

Con­necti­cut’s ru­ral res­i­dents die at higher rates than their city and sub­ur­ban coun­ter­parts and a large per­cent­age of those deaths may be pre­ventable if bet­ter pub­lic health pro­grams or bet­ter ac­cess to health care ser­vices were avail­able, ac­cord­ing to the lat­est data from the Na­tional Cen­ter for Health Statis­tics.

Doc­tor short­ages and long com­mutes make it harder for ru­ral res­i­dents to get health care. And some of­fi­cials worry that changes in hos­pi­tal own­er­ship and the Af­ford­able Care Act could am­plify ex­ist­ing prob­lems.

“We have ex­cel­lent med­i­cal care as a gen­eral rule in the state,” state Rep. Su­san John­son, D-Wind­ham, said. But ru­ral and other high­poverty ar­eas, where many res­i­dents are on Med­i­caid rather than pri­vate health in­sur­ance, re­main vul­ner­a­ble to hos­pi­tal ser­vice re­duc­tions and changes in el­i­gi­bil­ity for health care coverage, she said.

“My bat­tle is to make sure the ba­sic hos­pi­tal ser­vices, like crit­i­cal

care units, are main­tained in the small ru­ral hos­pi­tals,” John­son said. “If you take (hos­pi­tal con­sol­i­da­tion) in com­bi­na­tion with the pro­pos­als to change the Af­ford­able Care Act, that in com­bi­na­tion would def­i­nitely dec­i­mate not just Con­necti­cut, but most places around the coun­try, in terms of ac­cess to health care,” John­son said.

Of Con­necti­cut’s 169 mu­nic­i­pal­i­ties, 68 are clas­si­fied as ru­ral, based on pop­u­la­tion and num­ber of peo­ple per square mile. They’re home to about 9 per­cent of the state’s 3.57 mil­lion pop­u­la­tion, or about 320,000 res­i­dents. In New Haven County, the ru­ral des­ig­na­tion ap­plies to Bethany, Mid­dle­bury and Wood­bridge.

In Con­necti­cut, ru­ral res­i­dents were more likely than their city and sub­ur­ban coun­ter­parts to die from four of the top five causes of death: heart dis­ease, can­cer, chronic lower res­pi­ra­tory dis­ease and un­in­ten­tional in­jury. The state’s find­ings mir­ror na­tional trends, ac­cord­ing to a 2017 re­port pub­lished by the Cen­ters for Dis­ease Con­trol, which an­a­lyzed data across the coun­try from 1999 to 2014. Na­tion­ally, ru­ral res­i­dents re­port higher rates of ad­verse health fac­tors, such as smok­ing, obe­sity and lower use of seat­belts.

Con­necti­cut’s death rate from heart dis­ease in 2015 was about 60 per 100,000 peo­ple, but in ru­ral ar­eas, the rate was 72 per 100,000. The can­cer death rate was roughly 104 per 100,000 statewide but 127 per 100,000 in ru­ral ar­eas.

Ru­ral res­i­dents in Con­necti­cut were al­most twice as likely to die from chronic lower res­pi­ra­tory dis­ease, which in­cludes asthma, chronic bron­chi­tis and em­phy­sema. And their death rate as a re­sult of un­in­ten­tional ac­ci­dents was about 50 per 100,000 com­pared with a statewide rate of 38.

“The num­ber one is­sue is trans­porta­tion,” said Mary Wi­nar, man­ager of the state Of­fice of Ru­ral Health, which is based at Northwestern Con­necti­cut Com­mu­nity Col­lege in Win­sted.

Ru­ral ar­eas have fewer doc­tors, and they are more scat­tered. With pub­lic trans­porta­tion cen­tered in more ur­ban ar­eas, those liv­ing out­side of cities of­ten have to fend for them­selves to get to ap­point­ments.

Robert Pope, 49, of Sharon, uses a Dial-A-Ride ser­vice through Geer Vil­lage Se­nior Com­mu­nity in Canaan to get to his doc­tor ap­point­ments. Pope, who lives alone and has no car, has 4-hour-long dial­y­sis ap­point­ments three times a week in Tor­ring­ton, 45 min­utes away.

“I’ve tried us­ing other (ser­vices). They’re not al­ways re­li­able or de­pend­able,” said Pope. “With­out the Dial-A-Ride ser­vice from Geer, I would lit­er­ally have no de­pend­able way of get­ting to my dial­y­sis ap­point­ments.”

Nancy Heaton, CEO for the Foun­da­tion for Com­mu­nity Health in Sharon, said Litch­field County has stud­ied op­tions to im­prove trans­porta­tion. Loop tran­sit ser­vices aren’t prac­ti­cal in a ru­ral set­ting, she said, and on-de­mand ser­vices can be costly.

The foun­da­tion has given grants to add trips through Geer’s Dial-A-Ride ser­vice and oth­ers like it. Still, when the foun­da­tion sur­veyed res­i­dents in the Con­necti­cut and New York towns sur­round­ing Sharon Hos­pi­tal, 60 per­cent said trans­porta­tion was one of the main bar­ri­ers to ac­cess­ing health care.

“Peo­ple liv­ing here aren’t used to pub­lic trans­porta­tion, so it takes a lot for peo­ple to get used to think­ing about (it),” Heaton said. “They’re get­ting there through friends, and fam­ily, bor­row­ing cars, or they’re just not go­ing.”

The same is true in Wind­ham County. A sur­vey of 750 clients of the Gen­er­a­tions Fam­ily Health Cen­ter found 35 per­cent missed at least one health care ap­point­ment in 2016 be­cause of trans­porta­tion is­sues. About 67 per­cent re­ported a lack of re­li­able trans­porta­tion, ei­ther be­cause they didn’t own a car or couldn’t al­ways af­ford to use it.

Two Con­necti­cuts

Con­necti­cut is one of the top performers in the coun­try in pa­tient-to-doc­tor ra­tios, but its three pre­dom­i­nantly ru­ral coun­ties, Wind­ham, Tol­land and Litch­field, ranked the low­est in the state in this cat­e­gory, ac­cord­ing to 2017 County Health Rank­ings data pub­lished by the Robert Wood John­son Foun­da­tion and the Univer­sity of Wis­con­sin Pop­u­la­tion Health In­sti­tute.

Wind­ham County has 1,950 pa­tients per pri­mary care provider, com­pared with New Haven County, with 1,090. Mid­dle­sex County has 1,350 pa­tients per pri­mary care provider. The state av­er­age was 1,180.

Ru­ral ar­eas fare much worse in num­ber of den­tists, with Wind­ham County, for ex­am­ple, show­ing 2,380 pa­tients per den­tist, about half the state av­er­age of 1,230. New Haven County is slightly above the state av­er­age at 1,350 as is Mid­dle­sex County at 1,340.

For sev­eral years, not one den­tist in Litch­field County ac­cepted adults on Med­i­caid, Heaton said, forc­ing those pa­tients to travel to the UConn Health Cen­ter in Farm­ing­ton for den­tal care. The foun­da­tion gave money to help the Com­mu­nity Health and Well­ness Cen­ter in Tor­ring­ton add den­tal ser­vices in 2008.

“Why is there a short­age of physi­cians over here? They don’t want to work over here,” said Arvind Shaw, the CEO of Gen­er­a­tions Fam­ily Health Cen­ter. “That is not ac­cept­able.”

“When you look at all these things, you can see all these anom­alies,” Shaw said. “It’s be­cause the state of Con­necti­cut does not have a plan ... for health eq­uity. There is not a sys­tem that ac­tu­ally maps re­sources.”

Mau­rice Mad­dox, 60, of Canaan, said it took him more than a month to find a doc­tor who would take Med­i­caid and help him with de­pres­sion and sui­ci­dal thoughts. He de­pends on Geer’s Dial-A-Ride and state con­trac­tor Lo­gis­tiCare’s trans­porta­tion ser­vices to travel to psy­chi­a­trist ap­point­ments at UConn Health cen­ter and to his ther­a­pist in Sal­is­bury.

“It’s im­por­tant for me to see them,” Mad­dox said. “Not be­ing able to talk about it, keep­ing it bot­tled up in­side, I think it would be pretty bad for me.”

Hos­pi­tal Changes

Hart­ford Health­Care has ac­quired two hos­pi­tals that serve largely ru­ral pop­u­la­tions: Wind­ham and Wil­liam W. Backus in Nor­wich. The sys­tem is work­ing to­ward af­fil­i­at­ing with Charlotte Hunger­ford Hos­pi­tal in Tor­ring­ton.

Be­ing part of a larger health net­work could help ru­ral hos­pi­tals at­tract new doc­tors, said Shawn Mawhiney, di­rec­tor of com­mu­ni­ca­tions for Hart­ford Health­Care.

Wind­ham re­cently re­cruited four new or­tho­pe­dic sur­geons and con­ducted its first spinal surgery in a decade, Mawhiney said. “That would have been nearly im­pos­si­ble if Wind­ham wasn’t part of the Hart­ford Health­care sys­tem,” he said.

Oth­ers see hos­pi­tal con­sol­i­da­tion as prob­lem­atic for ru­ral pa­tients.

Two years ago, Hart­ford Health­Care re­duced the num­ber of beds in Wind­ham’s crit­i­cal care unit, a change Mawhiney said was based on pa­tient vol­ume. Some worry that fewer beds could lead to pa­tients’ hav­ing to be trans­ferred to an­other hos­pi­tal for more se­ri­ous emer­gen­cies, but Mawhiney said this was hap­pen­ing even be­fore the change.

“If they’re not ad­mit­ted and have to go home, it’s that much far­ther of a dis­tance from Backus back to Wil­li­man­tic,” Wi­nar, of the state’s Of­fice of Ru­ral Health, said. “What if you don’t drive your­self or don’t have a fam­ily mem­ber who can eas­ily help you out? If it’s at night, there are no buses run­ning.”

John­son, the state rep­re­sen­ta­tive, said the Wind­ham com­mu­nity fought changes to Wind­ham Hos­pi­tal’s crit­i­cal care cen­ter in 2015, and said many be­lieve the hos­pi­tal can’t help them as much as it used to.

“It’s sad and dev­as­tat­ing,” John­son said.

But Mawhiney said the goal is to keep the hos­pi­tal open, which re­quires be­ing smarter about how to al­lo­cate re­sources. With a higher per­cent­age of Med­i­caid and Medi­care pa­tients in ru­ral ar­eas, hos­pi­tals there don’t al­ways get fully re­im­bursed for their ser­vices, he said.

“It’s not a Wind­ham Hos­pi­tal is­sue. It’s a com­mu­nity hos­pi­tal is­sue,” Mawhiney said. “There are very few stand-alone com­mu­nity hos­pi­tals left, es­pe­cially in ru­ral ar­eas. Those hos­pi­tals are strug­gling.” Jodie Mozdzer Gil is a Conn. Health I-Team writer. Carl Jor­dan Cas­tro con­trib­uted re­port­ing to this story. This story was re­ported un­der a part­ner­ship with the Con­necti­cut Health I-Team (www.c-hit.org )

Carl Jor­dan Cas­tro photo

Mau­rice Mad­dox, 60, of Canaan, said he had trou­ble find­ing a doc­tor who took Med­i­caid in ru­ral Litch­field County.

Carl Jor­dan Cas­tro photo /

Robert Pope, 49, of Sharon, waits as the Geer Vil­lage Se­nior Cen­ter Dial-A-Ride bus brings him to a med­i­cal ap­point­ment in June.

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