The Management of Chronic Diseases in Rural Missouri Practices

Abstract

This qualitative study describes the challenges of managing chronic diseases in small, rural, health care practices in Missouri. Four recurrent themes were identified from each of the nine focus groups: the similarity of their patient population and community characteristics, their unfamiliarity with aspects of the chronic care model, the consistent problem of poverty as a barrier to health care access for patients, and the uncertainty about what health care reform will mean for rural practice settings.

Introduction

The Chronic Care Model,¹ the Patient Centered Medical Home,² and newer hybrids of these organized health care delivery systems have been developed to help consolidate fragmentation in the United States (US) medical care system with the goal of improving patient outcomes and lowering costs. Over 78% of the US health care budget is spent on people with chronic disease who need regular health care provider visits.³ To date the most successful chronic disease health outcomes have been achieved by large integrated delivery systems that have invested in electronic health records (EHR), organized care teams, used group visits, and made multiple other management changes to facilitate cost conscious care. Kaiser Permanente, Group Health Cooperative, and the Cleveland Clinic are some of the most illustrative examples. Our study was designed to hear from health care providers which features of these models might work in small, rural, practice settings. This challenge is formidable as this statement from the Center for Rural Affairs describes:

“Rural America presents a unique set of challenges for health care reform. Rural people have less access to health networks and health care providers, greater rates of disability and chronic diseases and higher use rates of all public health care programs. And largely as a result of higher rates of self-employment and small business employment, rural Americans have lower rates of employer-provided benefits and are more likely to be underinsured or uninsured for longer periods of time.”⁴

Given that over 60% of outpatient health care visits are made to solo or small provider groups,⁵ the views and opinions of small practice organizations are important. We conducted focus groups with rural practices in Missouri to ask whether these more organized models of care could be adapted to their settings and if so what assistance would they need to move in that direction of organized chronic care. We also solicited their opinions on the recently passed Patient Protection and Affordable Care Act (PPACA).⁶

Methods

Medical and social science researchers have successfully used telephone focus groups as a methodology to enhance recruitment for difficult to reach populations.^7,8 Phone access is of particular value when used with participants, such as busy rural health care providers, who are widely dispersed throughout a state and who have limited time to participate in research. This research method provides a means to create a geographically diverse sample and to enhance access to the target population. In addition, it is also an extremely cost-efficient method to use because participants, and researchers, do not need to travel to an interview venue.⁹

Setting

The target population for this study was small rural health care practices located in Western and Central Missouri. In Missouri 30.6% of the population lives in rural areas, and 103 of the 115 counties in the state do not contain urbanized areas. Of the 30 counties located in the northwest corner of Missouri, 27 have no urbanized areas. Rural Missouri residents experience a disproportionate rate of chronic diseases. For example, 88% of counties with rates of diabetes higher than the statewide rate were rural counties. Further, over 93% of the counties with rates of stroke that are higher the statewide rates are also rural counties.¹⁰

Sample

Over a ten-month period (September 2010 to June 2011) a three-prong strategy was used to recruit small rural health practices into the study. Because there are over nine definitions of rural that are used for different purposes, we chose to recruit practices located in towns with fewer than 10,000 residents. Invitation letters for participation in the study were mailed via the US Postal Service, emailed and/or faxed to physicians and nurse practitioners who had graduated from the University of Missouri-Kansas City Schools of Medicine or Nursing within the past 20 years. Graduates were targeted who had reported on alumni surveys that they were practicing in rural Missouri settings. In addition, letters of invitation were also sent to rural practices that were Blue Cross Blue Shield of Kansas City participants, a large health care insurance provider in Missouri. This purposeful sampling technique is a feature of qualitative research in which participants are selected that are experienced and knowledgeable about the phenomenon of interest, who are willing to participate, and that are able to speak articulately about the experience.¹¹

Data Collection

The telephone focus groups were facilitated using an interview guide that contained questions about the common chronic diseases seen in the patient population served, provider understanding of available resources, barriers and challenges faced by the practice and by patients, and about health care reform and other strategies that might be used to enhance chronic care management. Queries included both primary interview questions and follow-up probes to encourage additional discussion (see Table 1). A total of nine focus group interviews were conducted. By the seventh and eighth interviews, no new data were emerging during data collection. One additional interview revealed no new data. Saturation of data had been reached and no further interviews were conducted.

Table 1.

Focus Group Interview Questions and Probes

QUESTIONS	PROBES
Tell us about your practice setting/your community.	What is the size of the community you serve? What are the demographic characteristics of the patient population you serve? What is the mix of providers/staff in your practice/clinic? What are the common types of patient problems/chronic diseases seen in your practice?
What are your thoughts about small rural primary care practices collaborating in an exchange of ideas with an academic medical center about chronic care management?	How do you feel this type of collaboration might help you enhance the chronic care management of your patients?
Do you (as physician/NP/nurse/medical assistant/clinic manager, etc) think it is feasible to adapt the chronic care/patient-centered medical home models to your clinical practice settings?	Are you familiar with the Chronic Care Model/patient centered medical home model?
Are you receptive to a multi-condition chronic disease approach?	Do you use a multi-condition approach now with your patients?
What barriers/challenges do your patients/your practice face with regard to chronic care management?	What changes do you feel need to be made?
What interventions/changes/strategies do you feel would help your patients/your practice overcome the barriers/challenges you currently face?	Do you feel that an academic medical center could help facilitate these interventions?
What health policy changes do you feel need to be made to help your patients/your practice overcome the barriers/challenges you currently face?	How do you feel health care reform will impact your practice/your patients? Do you feel health care reform is a step forward?

Procedures

Permission to conduct the study was obtained from the Social Sciences Institutional Review Board of the University of Missouri-Kansas City. Verbal consent to participate was obtained at the beginning of each telephone focus group via a script. Participants were informed that they could hang up or stop participation at anytime during the focus group call and that stopping participation would not impact their receipt of a gift card. Every participant completed the entire focus group. Each participant received a $50 bookstore gift card for his/her time. The same researcher facilitated all of the telephone focus groups.

Data Analysis

Focus groups were audio-taped and transcribed verbatim; then characteristics of voice and emotion were added to the transcriptions. Three investigators performed the data analysis: one was the nurse researcher who performed the focus groups and the other two were physician researchers who had no contact with study participants. Transcripts were analyzed using content analysis ¹² to identify themes that were discussed by the focus group participants. The three researchers coded the data independently and then came together to discuss results, themes and categories that emerged from their independent coding. As a group, independent coding was reviewed and then discrepancies in coding were discussed until there was unanimous agreement among the investigators.

Respondents

Nine practices and twenty-nine health care providers (See Table 2) volunteered to participate in this study. Participants included physicians, nurse practitioners, nurses, and office staff. Of the four physicians who participated in this study, each had his/her own individual practice. All of the eight nurse practitioners were in collaborative practices with physicians as required by state law. All of their practice settings were located in similar geographical and community venues. This is partly due to the fact that the practices were purposefully recruited from the 30 county Western Missouri Blue Cross Blue Shield catchment area. The number of individuals who participated in the phone interviews ranged from one to six individuals with a mean of three participants per interview. All individuals on each phone interview were encouraged to participate. The facilitator took a role call at the beginning of the interview and took an active role to assure each participant was encouraged to comment.

Table 2.

Characteristics of the Participating Practices (n=9) and Their Communities

Population of town served by practice	# of practices	%
<1,000	1	11%
1,000 to 2,000	6	67%
>2,000 to 10,000	2	22%
Driving time to nearest city with >/200,000 population
< 1 hour	3	33%
> / = 1 hour	6	67%
Age of patient population served
All ages	9	100%
Note: most practices reported that at least half of their patient population was >50 years of age
Type of insurance accepted by practice and percent of patients with each type of insurance
Medicare/Medicaid	9	40–50%
Commercial Insurance	9	30–40%
Uninsured/Self-Pay	9	20+%
Role of focus group participants (n=29)
Nurse Practitioner	8	28%
RN/LPN	5	17%
Medical/Lab Assistant	5	17%
Physician	4	14%
Office Manager/Office Staff	7	24%

Findings

We identified four major themes that were recurrent in each of the focus groups: the similarity of patient and community characteristics, unfamiliarity with the Chronic Care Model, poverty as a consistent problem, and uncertainty about health care reform.

Theme 1: Similarity of Patient and Community Characteristics

The practices were located in towns that ranged from 450 people to 6,000 with the most common size of the towns being around a population of 1,500 to 2,000. Practices saw between 20 to 50 patients per day. Participants reported that most (over 90%) of their patients were white and at least half of their patient population was over the age of 50 years. Diabetes, hypertension, and hyperlipidemia were noted by every practice as the most common chronic conditions they treated. Heart disease, chronic obstructive pulmonary disease (COPD), depression, and asthma were mentioned by a majority of practices as conditions they frequently managed. Managing patients with multiple chronic conditions was the norm not the exception. Obesity complicated the management of many conditions. Community-based services were usually absent, especially resources for weight loss and health education. Most of the towns were approximately a one-hour drive from a major urban center.

This quote, from a nurse practitioner participant, illustrates the typical setting for the practices in this study:

“We are small rural clinic. Population of our town is about 1,200 and we probably (provide) service another 10 or 12 miles past the clinic. I’m the full-time provider, we have a physician that comes in two days a week; on the two days that I’m not here. We’ve been here 15 years in the town. We see all ages except we do not do any kind of pregnancy care. Otherwise, we take care of birth to death.”

Theme 2: Chronic Care Model

All practices varied in their use of concepts from the Chronic Care Model but needs related to various components of the model were common. Most practices were unfamiliar with the term “Chronic Care Model” as a specific set of interventions. So a brief description was developed to start the focus group sessions. A diagram used to develop the description is shown in Figure 1.

Figure 1.

The Chronic Care Model

Used with permission from the American College of Physicians

Only three practices had electronic health records (EHRs); all the other practices expressed the need to convert from paper charts to electronic systems. The cost of conversion to such systems was the major barrier. The EHR systems that did exist could not communicate with other systems. Thus the concept of “meaningful use” and community health information exchanges in the PPACA will take many attempts before a somewhat standardized system emerges that is used in rural practices. On the lower technology front, practices needed up-to-date, easy to read patient education materials and they considered this a barrier to having informed and activated patients. All practices identified one need that they considered most important. A diabetes educator was their biggest need and to have this service available on site they would be willing to set up group appointments. Face-to-face education was felt to be far superior to webinars or other electronic training methods. Most practices had care teams that almost always included a nurse practitioner. Because in many cases there were no other provider groups in the county, these offices coordinated care and acted as de facto medical homes.

These two quotes illustrate the need for increased resources and more access to technology, both for record keeping and for patient education, among the practices in this study:

“The benefits of electronic medical records…. we cannot participate in that.”

“We communicate with other health care providers mostly by fax and phone calls.”

“We have handouts (for patient education). We have two file cabinets of paper handouts that we’ve collected over the years.”

Theme 3: Poverty Was a Consistent Problem

All of the practices that participated in this study relied on public programs such as Medicare and Medicaid for most of their revenue with private insurance a third source. The practice managers estimated that 20% of patients were self-pay because they had no health insurance. This high number of self-pay patients was due to rising unemployment. One practice offered a 33% discount if the patient’s bill was paid at the time of service. Economic factors made it difficult to recruit physicians and several expressed a desire to retire but could not find a replacement. A universal concern was the shortage of primary care providers, particularly those who are willing to practice in a rural setting. Most practices tried to adhere to the Walmart $4 pharmacy list but certain items such as glucose test strips and steroid inhalers were noted to be unaffordable for their patients. A frequently reported problem was medication management such as having an up-to-date list of what the patient was actually taking. This issue was often mentioned by the practices that were using paper records. Patients often told providers that Medicare Part D was unnecessarily complicated. None of the practices were closed to Medicaid patients and there were very few complaints about Medicaid administration. The lack of coverage of preventive care by some private insurance plans was noted as a barrier to quality care.

These two quotes were typical of the statements made by participants about their reliance on discounted prescription formularies and their inability to engage their patients in prevention due to poverty:

“The best thing that happened to us down here was the Walmart $4 prescription list. I do a lot of prescribing from that $4 list because people either don’t have insurance or if they do, their prescription deductibles are really high and they can’t afford to pay their (prescription) co-pays.”

“They (patients) are not getting screenings, they’re not getting immunizations, they’re not getting a mammogram done … say they find something, well, where you going to go? – say you have breast cancer, who’s going to take care of that if you don’t have insurance?”

Theme 4: Uncertainty About What Health Care Reform Would Accomplish

When asked about the Patient Protection Affordable Care Act (PPACA) specifically, providers did not believe they knew enough to evaluate the changes however there were exceptions. The elimination of pre-existing condition medical exclusions for insurance and allowing children to stay on their parent’s policy through the age of 26 years were seen as good things. Otherwise opinions varied. One participant felt that the law did not go far enough towards a national health system and other participants felt the government plan was “going to do more harm than good.” None of the practices were receiving any incentives to develop EHRs yet. While there are at least 20 interventions in PPACA that have the potential to specifically address the rural health needs and augment primary care they must be funded and implemented and participants by nature were suspicious of government interventions.

This quote illustrates the uncertainty that many participants had about health care reform:

“Well I hope, I hope it (health care reform) helps. I think that we just have to have national health care. But I’m pretty discouraged that it (health care reform legislation) didn’t get any further than it did. I heard somebody saying, some health consultant, that they think that it (health care reform) will have to come on a state-by-state basis.”

Discussion

White race and a high prevalence of poverty were typical characteristics of patients seen by the practices in this study. The small town Missouri practices that we interviewed estimated that at least 50% of their patient population had one or more chronic diseases, especially among older patients. Patients with multiple chronic conditions were the norm. Every practice reported that diabetes, hypertension, and hyperlipidemia were the most common chronic diseases that they treated. Heart disease, asthma, COPD, and depression were also common conditions in their patient populations. Several practices mentioned that smoking cessation counseling was important. This is not surprisingfitur given that Missouri is a tobacco state, has the lowest tobacco tax in the U.S., and over 23% of the population smokes.¹³

Elements of the Chronic Care Model and the Patient Centered Medical Home were only partially in place but were very relevant to the rural setting. Providers felt that due to the small size of their practices they operated as care teams. The most common organizational model was physician-nurse practitioner dyads supported by several other office staff members resembling the practice care teams described in the model. Although patients had to drive to bigger towns for specialty care, in general, access to specialists was felt to be good. This is not surprising because two-thirds of US practitioners are specialists.¹⁴ Only three practices had EHRs and their systems did not communicate with other EHR systems outside of the office making telephones and fax machines typical tools for referral. The money to convert to an EHR was the biggest obstacle to its use. The heavy reliance on Medicaid and the increasing number of uninsured makes it unlikely that small rural practices will automate anytime soon without economic help. The PPACA contains some economic incentives for this but how far the money will go is unknown.

The primary care practice coordinated most specialty care since there were usually no other providers in the counties. Rural primary care provider shortages have been previously described. Both the University of Kansas¹⁵ and the University of Missouri - Kansas City¹⁶ have innovative rural-based medical and nursing school training programs that are attempting to fill this void.

Providers described scheduling regular appointments with their chronic care patients, another part of the model. Absent were electronic records with patient reminders for visits and most communications were by telephone or facsimile. Health services issues were reported by every practice. Cost of care was a major problem for at least the estimated 20% of patients who were uninsured because rising rates of unemployment resulted in a loss of private health insurance coverage.

Medicaid and Medicare were the most common payers with private insurance usually third. Practices coped with these economic issues with a variety of strategies. One practice had a discount program for self-pay patients. The lack of coverage of preventive care by some private insurance plans was noted a barrier to quality care. This problem should be resolved by PPACA which eliminates the co-payments for preventive care that receive an A or B rating by the U.S. Preventive Services Task Force.

There are at least 20 interventions in PPACA that have the potential to specifically address the rural health needs and augment primary care we but they must be funded and implemented. This will not be simple. New programs such as the Community Transformation Grants will go to state and local governments for evidence-based community preventive care programs. The Primary Care Extension program will provide health extension agents that have the task of bringing preventive services such as diabetes counseling to rural communities. Covering the uninsured and raising physician Medicaid payment rates would be a boon to small town practices.

Progress is beginning on initiatives such as the Health Information Technology Extension Program and meaningful use payments for electronic health records. It remains to be seen how much of PPACA will actually be implemented. Future research should follow the outcomes of successful interventions so they can be widely replicated.

Of the four themes we identified, none of them are amenable to a quick fix. Pro-active patients will always want current information and all health care providers find it challenging to find the best materials. Comprehensive electronic medical records will take years to implement. The health care professions and industry have no control over the current state of the economy. Whether the PPACA fulfills its promise to remove many access barriers to medical care and how it will benefit people who live in rural Missouri is not clear at this time.

Biography

Maithe Enriquez, APRN, PhD, is in the School of Nursing, and Jill Moormeier, MD, and William Lafferty, MD, (above) MSMA member since 2011, are in the School of Medicine, at the University of Missouri - Kansas City.

Contact: laffertyw@umkc.edu