How often do you interview nurses for a health care story? If rarely or never, you’re not alone.

According to a 2018 study in the Journal of Nursing Scholarship, which reviewed and coded a random sample of 365 health care stories published September 2017, “Nurses were identified as sources in only 4% of all quotations or other sourcing in newspaper stories, and in 1% of those in stories from news magazines and industry publications. Physicians and dentists were sources in 43% of newspaper articles, 30% of news magazines, and 18% of industry articles.” Furthermore, nurses “were never sourced in stories on health policy,” the authors report.

Only 13% of the articles in the study sample mentioned nurses or the nursing profession, and nurses were identified in only 4% of photos, even though nurses are the largest group of health care professionals, according to the 2017 National Nursing Workforce Survey in the Journal of Nursing Regulation.

We spoke with one of the study’s authors, Diana Mason, about why journalists should interview and cite nurses in their health reporting. Mason is a nurse, a professor at the Center for Health Policy and Media Engagement at the George Washington University School of Nursing, and the former editor-in-chief of the American Journal of Nursing.

In Mason’s experience, journalists tend to talk to nurses if they’re writing a “nursing story,” but not when covering a broader health care story. Mason describes a journalist telling her that he didn’t do stories on nursing, that he did stories on the business of health care. What he missed, Mason points out, is that those aren’t mutually exclusive topics. “The chief nurse of the hospital is often the vice president of patient services and controls the largest portion of the hospital budget,” she says. “Who better to talk to about the impact of budget cuts on patient care?”

Mason says she also rarely sees health care journalists citing professional nursing journals, even though these journals publish evidence-based research.

So what’s keeping journalists from seeking out nurses as sources? To shed some light, Mason teamed up with nurses Barbara Glickstein and Kristi Westphaln on a qualitative study, published in the American Journal of Nursing, in which they interviewed 10 health journalists. The researchers asked pointed questions such as, “Why do you not use nurses more as sources in your health reporting?”

Mason and Glickstein summarized their findings in an article for the Center for Health Journalism. Among the key takeaways: Journalists often don’t really know what nurses do; public relations staff at hospitals and universities tend to offer up doctors rather than nurses in response to media requests; and journalists often have outdated and biased views on nursing, a majority-woman profession.

It’s worth noting that Americans widely trust nurses — a lot. Every year, Gallup conducts a poll of more than 1,000 randomly sampled adults, asking them how they rate various professions in terms of honesty and ethics. For 18 years in a row, respondents have rated nurses higher than all other professions that Gallup asks about. In the most recent poll, some 85% of respondents gave nurses a rating of “high” or “very high” on a range of “very low” to “very high” on the honesty and ethics scale. By comparison, 65% of respondents rated medical doctors “high” or “very high.” Journalists fared less well at 28%.

For reporters who cover any aspect of health care news, here are three reasons why you should be talking to and citing nurses – especially during the COVID-19 pandemic.

#1. Nurses can help you come up with excellent pitches for health care news stories.

Mason urges journalists to form relationships with nurses — especially acute care nurses, nurse administrators and public health nurses — and check in with them regularly, even if only for a background conversation. “If you have a relationship with nurses on the front lines of care and talk with them periodically, they can tell you what the issues are, they can tell you what you should be looking at, they can tell you what the stories ought to be,” Mason says.

Nurses are often among the first health care workers aware of a new development or problem, but it’s not always prudent for them to proactively alert media. As Vice reported in April, nurses have been fired for publicizing personal protection equipment (PPE) shortages during the COVID-19 pandemic. “If journalists had been in touch with nurses early on,” Mason says, “they would have known the PPE was not adequate.”

In another example, Mason describes how New York City public health nurses in the 1980s reported to the radio show Mason co-hosted with Glickstein that they were seeing an uptick in tuberculosis cases. Shortly after that, Mason says, “multi-drug-resistant tuberculosis cases officially surged.”

If you want to know how a policy (or a pandemic) is affecting how patients feel, what patients need, and what is unexpectedly arising in patient care, ask a nurse, she maintains.

#2. Nurses develop and disseminate evidence-based practices, conduct research and influence public policy.

Nurses have specific complementary skill sets, Mason explains, and their unique roles help them see problems and address them. Talk to nurses if you’re looking for information about patient-based or practice-based health care solutions. Mason points to Elaine Larson, a professor emerita of nursing research and epidemiology at Columbia University School of Nursing, who developed and published over 200 papers about the hand hygiene practices followed by hospitals — which audiences care a lot about in the time of COVID-19. Larson came to this research as a staff nurse in the 1980s, when she wondered why infection rates didn’t drop when patients were moved from large shared rooms to private rooms.

If you’re covering chronic health conditions like diabetes, nurses are the ones working with patients on self-health management. Other nurses are national leaders in new care models. For example, nurse Lauran Hardin is a leader in addressing “high utilizer” patients—frequent users of multiple health care resources. Hardin has designed and implemented models of complex care practices for these patients and was recently appointed to the U.S. Government Accountability Office’s Physician-Focused Payment Model Technical Advisory Committee. The current nursing workforce is “more educated than ever before,” Mason says. “We’ve got well prepared leaders.”

Fun fact: Nursing icon Florence Nightingale, widely known for her work treating soldiers during the Crimean war, also played an important role in health care policy and statistics gathering, such as advocating for health data collection in mid-19^th century Britain.

#3. Ignoring nurses reinforces gender bias and limits perspectives when reporting on health care.

In 2019 the American nursing workforce was about 88% women, according to the Bureau of Labor Statistics. In contrast, 40.8% of physicians and surgeons were women. These numbers are likely to shift, as the Association of American Medical Colleges reported that in 2019, for the first time, women made up the majority of enrolled medical students in the U.S. But for now, relying solely on physicians as sources for health care reporting maintains gender disparities and reinforces the perspective of a physician-centered hierarchy in a multidisciplinary field, according to Mason. “Nurses have a different perspective than physicians,” Mason says. While physicians are the experts in diagnosing and treating diseases, “nurses are the generalists in health care,” she adds.

In hospitals, “we are the ones with the patients 24/7,” Mason says. “If you’re not interviewing a nurse you may be missing the best part of the story.”

The post 3 reasons health care journalists should interview nurses more than they do appeared first on The Journalist's Resource.

Abuse of people age 60 and older is widespread, research shows. According to a 2017 study in The Lancet Global Health, “elder abuse seems to affect 1 in 6 older adults worldwide, which is roughly 141 million people.”

Elder abuse takes many forms. A 2015 review article in The New England Journal of Medicine explains that research on elder abuse generally addresses these five categories:  “physical abuse, or acts carried out with the intention to cause physical pain or injury; psychological or verbal abuse, defined as acts carried out with the aim of causing emotional pain or injury; sexual abuse, defined as nonconsensual sexual contact of any kind; financial exploitation, involving the misappropriation of an older person’s money or property; and neglect, or the failure of a designated caregiver to meet the needs of a dependent older person.”

Take for example a 2014 study in the Journal of General Internal Medicine, in which researchers studied nearly 4,000 older residents of New York state. They found that financial abuse afflicted nearly 5% of them during their lifetime, with Black people at higher risk.  “If a new disease entity were discovered that afflicted nearly one in 20 adults over their older lifetimes and differentially struck our most vulnerable subpopulations, a public health crisis would likely be declared,” the authors write. “Our data suggest that financial exploitation of older adults is such a phenomenon.”

But as prevalent as elder abuse is, it also goes widely unreported.

A 2018 article in Clinics in Geriatric Medicine, citing research from a 2011 report from the New York City Department for Aging, suggests that about only 1 in 24 cases of elder abuse is identified and reported to social service or legal authorities. The recognition, identification and regulation of elder abuse is complicated by the self-determination granted adults; in other words, while children are mostly seen as a vulnerable population requiring protection, there’s less oversight with vulnerable older adults.

In the past few years federal legislation designed to protect older Americans has passed or been proposed. The Elder Abuse Prevention and Prosecution Act of 2017, signed into law in October of that year, increased data collection, information sharing, training for federal prosecutors and investigators and penalties for criminal acts for elder abuse. It also established coordinator positions at the Federal Trade Commission and the Department of Justice.

In recent months, the U.S. Senate’s Special Senate Committee on Aging has called attention to increased risk of elder abuse during the COVID-19 pandemic. In May, Sens. Susan Collins, R-Maine; Bob Menendez, D-NJ; and Chuck Grassley, R-Iowa, introduced the “Promoting Alzheimer’s Awareness to Prevent Elder Abuse Act.” That bill builds on the Elder Abuse Prevention and Prosecution Act of 2017 and is paired with companion legislation in the House. When introducing the bill, Sen. Collins said, “During the COVID-19 pandemic, there may be increased risk for elder abuse, including elder financial exploitation. Our bipartisan bill would help to ensure that the frontline professionals who are leading the charge against elder abuse have the training needed to respond to cases where the victim or a witness has Alzheimer’s disease or other forms of dementia.”

Health care providers who work with elderly patients also warn that the pandemic has exacerbated some of the risk factors for elder abuse, for both victims and perpetrators. The COVID-19 stay-at-home orders/recommendations that are meant to keep older people physically safe from the virus may create conditions for abuse. Older adults are now more likely to be isolated and out of sight, for example, making potential abuse harder to detect. Perpetrators, including family members, who experience increased personal or financial stress caused by the pandemic may be more likely to commit abuse.

In addition, there has been increasing ageism rhetoric in the United States during the COVID-19 pandemic, devaluing the lives of older adults, note the authors of a recent letter to the editor in the Journal of the American Geriatrics Society. To combat ageism in our culture, they suggest “increasing representation of older people with decision-making power in public and private sectors.”

To help journalists cover stories of elder abuse, we’ve gathered and summarized several relevant studies, including a recent article on abuse in the context of the COVID-19 pandemic. We also have compiled information on current and pending legislation on the topic, an introduction to a specific type of elder abuse called guardianship abuse, and additional resources for in-depth reporting.

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A note on the limitations of data in many studies of elder abuse:  Data is often self-reported, depending on the victim to divulge the abuse. Shame of abuse and/or the vulnerable position of older people who may rely on abusers for daily living needs often make older adults less likely to report abuse, leading to underreporting. And most studies exclude participants with dementia or cognitive impairment, even though older people with those issues experience abuse. According to Professor Pamela Teaster, director of the Center for Gerontology at Virginia Tech, these exclusions occur because self-reporting by people with dementia may be unreliable and because of protections for people with dementia regarding research. In an e-mail to Journalist’s Resource she explained, “We have to be very careful because, depending on the degree of the dementia, they may be unable to consent to participate in research.” 

Elder Abuse
Mark S. Lachs and Karl A. Pillemer. The New England Journal of Medicine, November 2015

The authors of this highly cited paper estimate that across the U.S., approximately 10% of older adults not living in care facilities are victims of abuse. “Thus, a busy physician caring for older adults will encounter a victim of such abuse on a frequent basis, regardless of whether the physician recognizes the abuse,” they write.

People with dementia are at especially high risk, and women are at higher risk than men, the authors note. Those at the younger end of the age group, the so-called “young old,” also have increased risks, as they more often live with the most likely abusers: a partner or adult children.

To help physicians identify elder abuse, the authors create a detailed breakdown of types of elder abuse (physical, verbal/psychological, sexual, financial, neglect) along with ways that abuse manifests itself during physical exams (for example, bone fractures may be a manifestation of physical abuse).

Assessment strategies for physicians include interviewing potential victims separately and alone and recognizing that mental illness resistant to treatment may have its source in emotional abuse. The authors also note that signs of neglect and financial abuse may be more subtle than those of physical abuse (e.g., weight loss and failure to keep appointments or fill prescriptions). Other assessments are specific to the abuse manifestations, such as determining if fractures are from abuse or falls/accidents. Physicians are cautioned that interviews with suspected perpetrators are best conducted by specifically trained professionals.

The authors note that successful treatment usually doesn’t involve just a single intervention of removing the victim from an abusive environment. Instead, successful interventions are typically “interprofessional, ongoing, community-based, and resource-intensive.” They write that the role for physicians is not to lead interventions, but rather to identify abuse, know the local organizations and services that provide resources to victims and refer patients to them, while coordinating care. These services can include Adult Protective Services, police and district attorneys, home health care organizations and appropriate nonprofits, and more.

Elder Abuse in the Time of COVID-19—Increased Risks for Older Adults and Their Caregivers
Lena K. Makaroun, Rachel L. Bacrach and Ann-Marie Rosland.  The American Journal of Geriatric Psychiatry, May 2020

The stay-at-home orders and recommendations intended to protect people, especially older people, from COVID-19 have created additional risks for elder abuse, note the authors of this perspective article. “Even in the best of times, elder abuse cases are rarely detected, with only 1 in 24 cases identified and reported to the appropriate authorities,” the authors write, citing a 2011 report of elder abuse in New York.

In the pandemic environment, older people and their family caregivers may be especially vulnerable to isolation, anxiety, financial stress and difficulty accessing healthcare and supplies, along with increased co-dependency brought on by the changing living conditions. These stressors increase risk factors for elder abuse.

Health care providers and outside caregivers are now less likely to have in-person contact with their patients, relying instead on technology-based communication; however, many older adults are not adept at technology, may not have the necessary hardware devices, and may not be able to speak privately if living with an abuser. And some elder care must be provided in person. The reduction or loss of this care could lead to neglect.

Existing abusive relationships may become more severe or lethal as mood disorders and substance abuse increase among caregivers. Additionally, during the pandemic, “there was a substantial increase in the purchase of firearms and ammunition.”

The pandemic does offer opportunities for positive change, the authors note. Providers who can contact elder patients via technology can now observe patients in their homes and can provide support for caregivers whom they may not typically see during in-person visits. Institutions and organizations are mobilizing programs and support for elders during the pandemic, including the Veterans Health Administration and local agencies on aging. The authors report that “the new challenges presented by the COVID-19 pandemic present an important opportunity to forge these new partnerships.”

The pandemic also presents opportunities for new research. The authors write, “Perhaps most understudied, and the area where new revelations could have the biggest impact, are caregiver-related risk factors. With many people experiencing caregiving stress and concern about whether loved ones’ needs will be met, caregivers may be more open to participating in research to share their experiences, even uncomfortable ones.”

Elder abuse prevalence in community settings: a systematic review and meta-analysis
Yongjie Yon, et al. The Lancet Global Health, February 2017

This meta-analysis of 52 international studies in 28 countries describes how prevention of elder abuse requires a better understanding of the breadth of the problem. The authors report that “elder abuse seems to affect 1 in 6 older adults worldwide, which is roughly 141 million people.” Psychological abuse was reported most often, at a 11.6% pooled prevalence estimate (pooled prevalence is a statistical technique for pooling results of many epidemiological studies), followed by financial abuse, neglect, physical abuse and sexual abuse.

The authors note that reported rates vary widely. “For example, national estimates of past-year abuse prevalence rate ranged between 2.6% in the UK and 4% in Canada to 18.4% in Israel and 29.3% in Spain,” they write. That’s due in part to a lack of consensus on how to define and measure different types of elder abuse, they note, making elder abuse a “neglected global health priority.”

The authors report that if the proportion of elder abuse cases remain constant through the aging global population, they expect elder abuse victims to number 330 million by 2050.

The National Elder Mistreatment Study: An 8-year longitudinal study of outcomes
Ron Acierno, et al. Journal of Elder Abuse & Neglect, 2017

This study is the 8-year follow-up to a 2011 study published in the American Journal of Public Health, “Prevalence and Correlates of Emotional, Physical, Sexual, and Financial Abuse and Potential Neglect in the United States: The National Elder Mistreatment Study.” The original study analyzed interviews (in English and Spanish) with over 5,500 respondents across the continental U.S., finding that 1 in 10 self-reported some type of elder abuse or neglect. The follow-up study attempted to contact all 752 original participants who reported mistreatment since age 60, of which they reached 183. They also interviewed 591 randomly selected non-mistreated participants from the original study.

The authors of the 2017 paper found that lack of social support increased the likelihood of all forms of abuse, while the presence of social support mitigated negative effects of abuse, particularly anxiety and poor health. Few instances of abuse were reported to authorities.

The authors describe how the 2017 follow-up study “represents the first longitudinal epidemiological study of elder mistreatment to date,” and focuses on how abuse affected victims’ health over time.

In the 2017 study, the authors look at the factors that exacerbated or mitigated the long-term effects of elder abuse. Variables of gender, income, and employment status were not as relevant as levels of social support. Further, beyond the effects on elder mistreatment, the researchers report that “low social support consistently predicted negative outcomes” in mental and physical health, even more consistently than did abuse.

“This is encouraging insofar as these findings speak directly to an actionable intervention to prevent both elder mistreatment and its negative effects,” they write.

They recommend that when family and friends can’t provide sufficient levels of social support, policies should further social support programs “in the form of education, volunteerism, or socialization” with examples including online and in-person classes, and social activities and meal programs through senior centers.

Limitations of both studies were that data was self-reported, respondents were all “community-residing” elders (not living in elder care facilities) who were “cognitively intact,” and the stigma of abuse and mental illness may have led to under-reporting. In the follow-up study a significant proportion of the original respondents were “not available for follow-up, either due to death, relocation, or inability to participate.”

Prevalence of elder abuse in institutional settings: systematic review and meta-analysis
Yongjie Yon, et al. The European Journal of Public Health, June 2018

This systematic review and meta-analysis, described by the authors as the “first rigorous quantitative synthesis of prevalence estimates for elder abuse in the institutions” estimates a high global prevalence of elder abuse for those living in elder care facilities during the 12 month period preceding this study.

Based on nine international studies that focused on staff-to-resident abuse in six countries, the authors report more than half of the staff interviewed for these studies admitted to elder abuse, with psychological abuse being most common, followed by physical abuse.

Among self-reporting victims, more than a third had experienced psychological abuse. Next-most common was physical abuse, followed by financial abuse, neglect and sexual abuse. While abuse in elder care facilities also occurs resident-to-resident and visitor-to-resident, the selected papers did not include these categories of data.

The main risk factors in an institutional setting are reported as “being female, presence of a cognitive impairment and disability, and being older than 74 years old,” with a “strong association between increasing dependency and elder abuse occurring” regardless of whether older adults live in an elder care facility or elsewhere.

Staff who self-reported committing abuse described stress from staff shortages and time pressure. The authors also cite staffing data from prior research in which staff who committed abuse described emotional exhaustion. In addition, higher ratios of patients to registered nurses correlated to higher levels of abuse, while “increased presence of qualified nurses” correlated with lower risk.

Comparing older adult and child protection policy in the United States of America
Peiyi Lu and Mack Shelley. Ageing & Society, September 2019

This study compares child and adult protection policies in the U.S., noting that by 2050 the U.S. is “expected to have 88.5 million older adults and 79.9 million children.” The authors describe an estimated prevalence of abuse as more than five times higher among older adults than children (10% vs 1.71%); however, they note that the data for elder abuse is not always available or comparable to the detailed data on child abuse.

Overall, U.S. adult protection policies were developed later and more slowly than those for children. The authors include comparisons across multiple factors including response services, post-response services, prevention services and allocation of resources and funding. “Compared to child protection policy, older adult protection policy lacked federal legislative and administrative direction, well-developed diagnosis and evaluation tools, a national data system, sufficient federal funds and a comprehensive response mechanism,” they write.

The autonomy of adults complicates some elements of adult protection. While children are viewed as a vulnerable population requiring protection, “older adults have lived independently for most of their lives and still expect to be independent in most periods of their late life. When abuse happens, especially for the self-neglect and financial exploitation cases, it is difficult to determine whether it is intentional.”

As one example, federal protection policies mandate reporting for both child and adult abuse. Child protection policies are more strictly implemented than those for adults.

“There is a trade-off,” the authors write, “between protecting older adults’ rights to be free from violence and exploitation, and maintaining their individual autonomy.” They cite other researchers who believe that a mandatory system not only interferes with the autonomy of older adults but presents ethical conflicts for physicians.

Financial Exploitation of Older Adults: A Population-Based Prevalence Study
Janey C. Peterson, et al. Journal of General Internal Medicine, July 2014

The authors conducted over 4,000 interviews in 2008–2009 with older adults in New York state not living in elder care facilities to identify those who had experienced financial exploitation, defined as: “improper use of funds, property or resources, coerced property transfers, denial of access to assets, fraud, false pretense, embezzlement, conspiracy, or falsifying records.” They found that almost 1 in 20 adults were victims of financial exploitation in their older years.

Older adults who self-reported financial abuse were more likely to already be economically, medically or otherwise demographically vulnerable. Poverty was an indicator for financial exploitation, possibly because individuals in poverty may be sharing homes with others. Family members are most often (57.9 % of the time) the ones financially exploiting victims, with adult children being the primary perpetrators. In addition, living with non-spousal family members put older adults at greater risk. Other perpetrators, in order of occurrence, were friends and neighbors, and home care aides.

Being Black was associated with greater relative risk of being a victim of financial abuse. People who have trouble with the tasks of daily living (e.g. managing finances, shopping, cooking and cleaning, or taking medications) were also at higher risk, as people providing assistance have access to their finances. Other factors associated with financial exploitation were “non-use of social services, need for [assisted daily living] assistance, poor self-rated health, no spouse/partner and lower age.”

The authors conclude, “In addition to robbing older adults of resources, dignity, and quality of life, victims of [financial abuse] likely cost our society dearly in the form of increased entitlement encumbrances, health care, and other costs.”

As with other studies of elder abuse, the limitations are that data was self-reported, did not include participants with dementia, and that elder people are often less likely to report abuse, leading to underreporting.

Risk Factors for Elder abuse and Neglect: A Review of the Literature
Jennifer E. Story. Aggression and Violent Behavior, Jan-Feb 2020

To help health care providers identify older adults at risk for abuse, this literature review provides a summary of risk factors that increase the likelihood of becoming either an abuse victim or perpetrator. Many risk factor categories are similar for perpetrators and victims. For example, “dependency” is a risk for a perpetrator, particularly if they are financially dependent on the victim, possibly leading to anger and abuse. For victims, dependency creates a vulnerability because it increases isolation and makes it harder to seek help.

The paper includes a detailed chart with the categories of factors that can increase the likelihood of becoming either a victim or a perpetrator of elder abuse: physical and mental health problems; substance abuse; dependency; problems with stress, coping and attitudes; problems with relationships, and previous experience with or witness to abuse.

Screening for elder mistreatment in emergency departments: current progress and recommendations for next steps
Tony Rosen, Timothy F. Platts-Mills & Terry Fulmer. Journal of Elder Abuse & Neglect, June 2020

This paper advocates for universal screening for elder abuse in emergency departments. The authors describe the “dismally low rate at which emergency providers are currently recognizing or reporting abuse” even though, compared with other older adults, victims of elder abuse seek emergency care more frequently and primary care less frequently. They note that “annual rates of ED usage by elder abuse victims are 3 times greater than non-victims.”

Current screening tools, the authors argue, are either likely to miss incidents of elder abuse or are too long and complex for the busy, chaotic emergency department environment. Patients are often screened in the emergency department for safety issues such as domestic abuse with a single vague question: “Do you feel safe at home?”

Instead, the authors propose a two-step screening process: a brief universal screen followed by a comprehensive screen for those positively identified. The initial screen would be designed to more specifically detect elder abuse, with questions such as: “Has anyone close to you harmed you?” or “Has anyone close to you failed to give you the care that you need?” Another option for the initial screen would be to design the electronic health record system to identify at-risk patients. The second-step comprehensive screening would involve a brief cognitive assessment, questions for the patient and a physical exam.

To improve emergency department detection and intervention for elder abuse they also recommend stronger ties between emergency departments and Adult Protection Services, development of multi-disciplinary response teams modeled after similar teams for child protection, and involving emergency medical service providers in initial screenings.

A note on guardianship abuse

There’s a relative dearth of peer-reviewed research on a specific type of abuse called guardianship abuse. This occurs when a court-appointed guardian, who is typically granted control over an elder person’s financial and medical decisions, takes advantage of their position in an abusive way. As described in Rachel Aviv’s 2017 New Yorker article “How the Elderly Lose Their Rights,” abusive guardians overtly exploit the system to steal from those they’ve been entrusted to protect. Some guardians forge relationships with hospital personnel to help them identify potential vulnerable clients and then convince courts of the need for guardianship, even when family members object. These abusive guardians have convinced physicians to prescribe sedating medications and oftentimes isolate their clients from family or friends.

The scope of the problem and devising remedies has been hindered by lack of data. Testifying before the United States Senate Special Committee on Aging in April, 2018, Dr. Pamela Teaster, professor and director of the Center for Gerontology at Virginia Tech, said that “despite estimates that some 1.5 million adults are under guardianship, in 2018, not one single state in the country can identify its people under guardianship.”

No central national database exists to identify guardians and track potential abuse. Oversight of guardians varies by state. For example, only some states require background checks and few have safeguards to protect against abuse of the system.

In 2018 the U.S. Senate’s Special Senate Committee on Aging published a report on guardianship abuse, Ensuring Trust: Strengthening State Efforts to Overhaul the Guardianship Process and Protect Older Americans. While special committees have no legislative authority, they can study issues and make legislative recommendations. Committee Chairman Sen. Susan Collins and Ranking Member Sen. Bob Casey subsequently sponsored the “Guardianship Accountability Act of 2019,” which, in its most recent action, was sent to the Committee on the Judiciary in February 2019. The bill addresses many of the 2018 report’s recommendations, including the establishment of a National Online Resource Center on Guardianship.

Guardianship may not always be the best way to assist an older adult who needs assistance. As described in the 2018 Senate Ensuring Trust report, “a full guardianship order may remove more rights than necessary and may not be the best means of providing support and protection to an individual.” One relatively new alternative to guardianship is  called “supported decision-making. This concept, which first gained traction in the disability rights community, is now proposed as an option to guardianship for some older adults, including those with dementia, and is supported by the American Bar Association. Under supported decision-making the individual relies on support from family, friends, and/or service organizations to help make their own decisions, without having to relinquish legal autonomy. These arrangements can range from informal understandings to written agreements, which are recognized as legally enforceable in nine states.

In a recent issue of Generations, Erica F. Wood, who is the assistant director of the American Bar Association Commission on Law and Aging, provides information for those working with older populations on how to avoid guardianship or how to ensure a proper guardianship. She provides a practical information on how to manage a legal process that will potentially result in the appointment of a guardian.

She suggests obtaining legal representation, and describes possible actions to take before a hearing, including checking applicable laws, assessing for less-restrictive measures than guardianship, and collecting evidence. If the court does appoint a guardian the author describes which aspects of the guardianship to investigate (e.g. who’s the guardian; how will assets be protected), and how to monitor the guardian (e.g. reviewing reports and accounts) and to legally protect the adult under guardianship, by reporting abuse or exploitation or seeking a restoration of rights.

Wood also identifies six common scenarios that can lead to legal guardianship, including a medical crisis, a family feud, discharge from hospital to an elder facility, abuse, eviction and an unpaid care bill.

Additional Resources

Frequently Asked Questions by Guardians about the COVID-19 Pandemic

This COVID-19 resource document for professional and family guardians was jointly created by the American Bar Association, the National Center for State Courts and the National Guardianship Association (a professional association). It includes information on accessing and communicating with older adults living in facilities during the pandemic and protecting the legal, medical and financial rights of older adults under guardianship.

Restoration of Rights in Adult Guardianship: Research & Recommendations
American Bar Association Commission on Law and Aging with the Virginia Tech Center for Gerontology, 2017

This report describes that an “unknown number” of adults remain under guardianship longer than necessary or could have benefitted from less-restrictive support from the outset. The report focuses on guardianship for all ages, and includes legal research on restoration of rights by state, as well as court file research to extract data on guardianship.

Guardianship and Supported Decision Making

Among the resources on this American Bar Association page are yearly (2013–2019) summaries of state laws and policies regarding guardianship.

National Center for State Courts: Center for Elders

The National Center for State Courts is an independent, nonprofit “court improvement” organization that provides research, information services, education, and consulting to professionals involved in the workings of state courts. Its Center for Elders includes information on issues likely to concern state courts regarding aging, elder abuse and guardianship.

Government Resources

National Center on Elder Abuse

The National Center on Elder Abuse is a program of the U.S. Administration on Aging, which includes research, statistics and data, risk factors, and the multiple definitions of “How Is Elder Abuse Defined for Research Purposes,” among other resources. They’ve recently added a page on COVID-19 with resources for identifying and reporting abuse during the pandemic.

The Center also published a 2018 guide,  “Understanding and Working with Adult Protective Services.”

National Center on Law & Elder Rights

As part of the U.S. Department of Health & Human Services, NCLER has tools and resources for legal assistance regarding elder rights, particularly for those with the “greatest economic and social needs.”

The U.S. Department of Justice Elder Justice Initiative

This site has extensive resources regarding all types categories of elder abuse, focused on the justice system, with information for victim specialists, law enforcement and prosecutors, as well as specific rural and Tribal resources.

Centers for Disease Control and Prevention

The CDC published the report Elder Abuse Surveillance in 2016, which provides “uniform definitions and recommended core data elements for possible use in standardizing the collection of [elder abuse] data locally and nationally.”

United State Government Accountability Office
Elder Abuse, Report to Congressional Requesters, 2016

Focusing on the issue of guardianship for older adults, the report is based on research with federal agencies, relevant state court officials, and nongovernmental organizations with expertise in guardianship-related issues.

Academic Centers that Focus on Elder Abuse

Center of Excellence on Elder Abuse & Neglect, University of California, Irvine, School of Medicine

This center’s website has extensive information across multiple disciplines, including links to national resources and tools for promising practices, along with their own research publications.

Center for Gerontology at Virginia Tech

The center’s Resource page includes resources for preventing abuse, as well as specific information on intimate partner violence and violence against rural older women.

USC Center on Elder Mistreatment

The University of Southern California’s Center on Elder Mistreatment is a multi-disciplinary academic research center specializing on issues of elder mistreatment and includes publications on their research topics. One of their key projects is on the use of multi-disciplinary teams for elder abuse interventions.

For more help with reporting stories related to COVID-19, please visit our archive of resources for covering the coronavirus pandemic. 

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As COVID-19 cases continue to emerge in rural areas of the U.S., rural health care systems will need to respond to the crisis with fewer resources than urban-based hospitals, and for a population that is generally older and sicker than urban populations. Journalists will need to tell their stories.

While working on our research roundup on rural health care and COVID-19, Journalist’s Resource spoke with Carrie Henning-Smith, an assistant professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health, and deputy director of the University of Minnesota Rural Health Research Center.

Henning-Smith served as a panelist on a May 4 online SciLine media briefing titled COVID-19: Health Disparities and Vulnerable Populations. “Nearly 80% of rural areas are designated as medically underserved,” she said in the briefing. “Rural residents live farther, on average, from emergency rooms. And rural counties are also less likely to have ICU beds or ventilators available. When they do have them, they might just have one or two instead of enough to serve the population. Rural areas are also less likely to have access to reliable broadband internet and cellular connectivity. That’s really relevant in this current context. It makes it difficult to access health care and other services remotely.”

We asked Henning-Smith what she wants journalists to know when covering rural health and health care in the context of COVID-19. Below are four tips, based on our conversation.

 1. Seek out COVID-19 rates at the county and town level, not just at the state level.

As states report lowering rates of COVID-19 infections and related deaths, keep in mind that this data might be masking active hot spots of steady or rising infection rates in rural communities. Henning-Smith urges reporters not to forget about rural areas as statewide infection rates drop. The Centers for Disease Control and Prevention’s CDC COVID Data Tracker lists cases, rates and death numbers at the county level. According to the CDC, as of June 11, the county with the highest COVID-19 case rate in the U.S. is Trousdale County, Tennessee. The rural county is home to the Trousdale Turner Correctional Center, the site of a COVID-19 outbreak.

“We’re seeing hot spots in rural places where there are prisons, where there are meatpacking plants, where there is deep, deep and chronic poverty and structural racism—especially in places like the Navajo Nation,” she says. She also points to long-term care facilities as hot spots in rural areas.

Journalists can help thwart the notion that prisons are an urban issue. “They are disproportionately in rural areas, and any way we can shine a light on that is really useful,” Henning-Smith says.

2. Don’t cover rural areas as homogeneous.

 Racial and ethnic minorities make up 22% of the rural population, according to data from the U.S. Census Bureau. The healthcare and economic disparities experienced by black Americans in urban areas, which may be contributing to higher coronavirus infection and mortality rates, are also playing out in rural communities, she says.

Journalists also should pay attention to rural Latino communities, especially around agricultural sites, as well as Native American communities.

Henning-Smith adds that “in each of these situations, the one advantage that the rural communities have over urban is that you don’t have people living quite as close to one another.”

 3. Keep in mind that the small size of rural health care systems can sometimes be an advantage.

While rural health care systems may often have fewer resources and less financial stability than urban systems, many rural systems are still independent, and their small size allows them to be more nimble. Decisions can be made more quickly, with fewer layers of decision makers.

“In the best case scenarios, and I’ve seen this around the country, rural decision-makers are just more in touch with what it is that the community needs, what the threats might be, and also what the best way to respond in a community-appropriate way might be,” Henning-Smith says.

In a smaller community where residents tend to know each other, it can be easier to test a larger percentage of residents for COVID-19 and do contact tracing. As an example, Henning-Smith refers to Vashon, a rural island community of 11,000 near Seattle. Their community-based approach to testing and tracing coronavirus infections was profiled in The New York Times article “Remote and Ready to Fight Coronavirus’s Next Wave.”  Vashon Island residents hope their Rural Test & Trace Toolkit can be a model for other communities, and have published a downloadable guide to their strategy.

“There is so much hope in rural places,” Henning-Smith says. “There is so much flexibility, ingenuity, resourcefulness in many rural places.”

She encourages journalists to consider taking advantage of “any time that some light can be shone on that, and not just painting this as desolate and bleak.”

4. Look to a news outlet with the expertise on covering rural America.

Dr. Henning-Smith says her go-to source for rural health news is The Daily Yonder, a nonprofit news site published by the Center for Rural Strategies. She says they are a great source for “exactly what’s happening in rural [America] and why.”

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During the first few months of the coronavirus pandemic in the U.S., most outbreaks were centered in cities and their surrounding areas. Preparations for critically ill patients focused on the capacity and readiness of hospitals in high-population and high-density communities. As hot spots continue to emerge throughout the country, rural health care systems face challenges unlike those in urban areas. This research roundup focuses on the state of rural health care and its capacity to respond to a pandemic.

Overall, rural health care systems are not as robust as metropolitan area systems. They have fewer hospitals, fewer physicians specializing in critical care and fewer intensive care unit beds per capita. Non-metropolitan areas have about half the number of ICU beds as metropolitan areas after adjusting for population age, per an April brief from the Peterson-KFF Health System Tracker, a partnership between the Peterson Center on Healthcare and the Kaiser Family Foundation, which monitors various aspects of the health care system in terms of quality and cost. According to an April report from the Chartis Center for Rural Health — part of The Chartis Group, a private consulting firm for the health care industry — 63% of U.S. rural hospitals have no ICU beds.

Even before the pandemic, many rural hospitals were under financial strain. Since 2005, 171 rural hospitals have closed, according to data from the Cecil G. Sheps Center for Health Services Research at the University of North Carolina. Another 450 rural hospitals are vulnerable to closure, according to a February 2020 Chartis Center report. Hospitals in cities and rural areas have halted profitable elective procedures since the pandemic began, while taking on unexpected costs to prepare for and treat COVID-19 patients and protect staff.

The strain on rural health care infrastructure may carry into metro areas. For example, during a May 22 press conference, Steven Reed, mayor of Montgomery, Alabama, said his city had run out of ICU beds and not all patients were local: “Many people in Montgomery hospitals are not from Montgomery. They’re suffering because they don’t have the rural health care system in place that they need.”

Spreading to rural communities

As early as March, researchers from University of Chicago showed hot spots cropping up in rural areas. Many rural counties have had fewer deaths compared with large cities, but higher relative infection or death rates. On May 28, The New York Times reported that rural Trousdale County in Tennessee had the nation’s highest per capita infection rate, linking the spike to a local prison. The Times maintains a U.S. coronavirus map with infection, death and per capita rates by county.

Several factors are likely to increase infection rates in rural America. As reported in the Washington Post, people travelled farther in the past month, sometimes from hot spots to rural areas, for recreational opportunities or to access services that have been closed in their communities due to pandemic restrictions. Potential “super-spreader” environments can also create hot spots. Meat processing plants with large COVID-19 outbreaks are mostly in rural areas, the U.S. Centers for Disease Control and Prevention has documented. A May article in Wired describes why conditions in those plants facilitate infection transmission.

Prisons are also a risk as super-spreader environments, as explained by Vox, with potential for large outbreaks among the incarcerated population, as well as staff, who can infect their families and communities. As explained in The Conversation, of the over 1,000 prisons constructed from 1970 to 2000, about 70% were built in rural communities. Finally, nursing homes and other elder care facilities have also been hot spots of infection outbreaks in cities. Such facilities in rural areas also face similar problems, but with fewer critical care resources.

Rural residents at high risk

Rural areas are older, poorer and sicker than their urban counterparts, according to research from the Rural Health Research Gateway, funded by the Federal Office of Rural Health Policy. Older people and those with underlying chronic health conditions — such as hypertension, diabetes, obesity and coronary artery disease — have a higher risk of becoming seriously ill from COVID-19.

Roughly 23% of older Americans live in rural areas, according to a report from the U.S. Census Bureau covering 2012 to 2016. About 18% of the rural population was age 65 and older, compared with 14% in urban areas. In Vermont, Maine, Mississippi, West Virginia and Arkansas, more than half of people over age 65 are in rural areas, according to the Census report.

From 2010 to 2017, rural areas had a higher percentage of preventable deaths than metropolitan areas for the five leading causes of death, according to a 2019 CDC report. The gap in preventable deaths from cancer, heart disease and chronic lower respiratory disease widened between the most rural and most urban counties during the study period. The gap decreased for unintentional injury and remained steady for stroke.

Racial and ethnic minorities, who make up 22% of the rural population, are at an even higher risk. Non-Hispanic black and Indigenous rural residents have higher rates of chronic health conditions and poorer access to health care, placing them at higher risk for COVID-19, as noted in a May commentary in the Journal of Rural Health. Navajo Nation has suffered among the highest per capita case rates in the country. High Country News reports, “Decades of negligence and billions of dollars in unmet need from the federal government have left tribal nations without basic infrastructure like running water and sewage systems, along with sparse internet access and an underfunded Indian Health Service.”

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Policy and issue briefs

The policy and issue briefs highlighted in this section were written and developed by university-based researchers, typically for research centers. While usually not peer reviewed, such briefs often include useful statistics and contextual information for journalists and policy makers. For this research roundup we’ve sourced policy briefs on the rural impact of COVID-19 and other issues of risk from academics working at centers focused on health care or rural communities.

Many policy briefs, data visualizations, maps and other resources on rural health care are available through the Rural Health Information Hub and their ten rural health research centers at state universities across the country. These centers are a national clearinghouse of rural health issues. Each center focuses on areas of specialization by geography and topic. The Federal Office of Rural Health Policy under the U.S. Department of Health and Human Services funds the centers.

Why Coronavirus Could Hit Rural Areas Harder
Shannon Monnat. Lerner Center for Public Health Promotion at Syracuse University, March 2020

This brief summarizes many issues regarding rural health care during the pandemic, including that the overall health care infrastructure is less robust in rural than metropolitan areas. Rural areas tend to have fewer hospitals and limited availability of health care personnel, ventilators and personal protection equipment. As has happened in metro areas, cancelling elective surgeries and other procedures while increasing funds for COVID-19 planning has put enormous financial strain on urban hospitals, according to this brief. Many rural hospitals were already in financial peril pre-pandemic and on the verge of closing. In addition, rural populations are older than urban populations and the chronic health conditions that increase the risk of serious illness from the coronavirus are more prevalent in rural areas. Rural physicians are also older than those in metro areas, putting them at greater risk as well.

The report concludes by pointing out that “the impacts of the coronavirus epidemic on rural communities will also have major implications for urban populations. Rural America supplies disproportionate shares of the nation’s food, energy, military personnel, and natural amenity recreation.”

Metropolitan/Nonmetropolitan COVID-19 Confirmed Cases and General and ICU Beds
Fred Ullrich and Keith Mueller. Center for Rural Health Policy Analysis at the University of Iowa, Policy Brief, May 2020

One factor for measuring the availability of acute care and ICU beds is the historical occupancy rate: What percentage of ICU beds is typically available? Using historical occupancy rates of general and ICU hospital beds in rural hospitals, the authors find 56 rural counties at risk of having “more COVID-19 cases than ICU beds.”

Occupancy Rates in Rural and Urban Hospitals: Value and Limitations in Use as a Measure of Surge Capacity
North Carolina Rural Health Research Program at the University of North Carolina at Chapel Hill, March 2020

This policy brief also addresses rural hospital capacity based on historical occupancy rates, and includes additional variables that will affect capacity. Occupancy rates for acute care and intensive care units are lower in every state for rural hospitals compared with urban hospitals. The brief cautions that other factors will contribute to whether rural hospitals will exceed acute care and ICU surge capacity. Among these are:

• More beds will be freed up by cancelling nonessential procedures.
• Other sites, like dorms and military bases, may handle surge capacity; non-COVID-19 patients could be redirected to alternative sites.
• Rural hospitals have fewer ICU beds per capita compared with urban hospitals, making them less capable of handling a surge.
• Many rural hospitals historically have transferred severely ill patients to larger hospitals, which may not be able to accept more patients during a surge.
• Patients routinely bypass their local hospitals for others they consider as higher quality, affecting the distribution of patients among hospitals in a region.

Quality of Care in Rural Hospitals
Rural Health Research Recap, Rural Health Research Gateway, January 2019

The Centers for Medicare & Medicaid Services rate hospitals nationwide using the Star Quality Ratings for Hospitals, which is based on self-reported data. Among the measured areas where rural hospitals received worse scores on the one- to five-star scale in 2017, “Emergency rooms in small rural or isolated small rural area hospitals saw a higher percentage (67%) of patients with non-emergent conditions compared to urban hospitals (62.2%),” this research recap reports.

If emergency departments in rural hospitals experience a COVID-19 surge, it could affect rural residents who typically seek their non-emergent care at emergency departments.

Rural hospitals also had lower overall star ratings compared with urban hospitals, and also lower ratings for preventable hospitalizations, post-hospital discharge follow-up care among Medicare beneficiaries, and certain screenings. However, rural hospitals did have fewer adverse drug events.

The recap notes there’s “no consensus on which measures are clear indication of quality health care.” It also cautions that due to their small size and sometimes limited services, 34% of rural hospitals did not receive a star rating compared with 12% of urban hospitals in 2017 and so “some stakeholders argue that [the CMS Star Quality Rating] is not an effective quality measure for hospitals and excludes many small rural hospitals.”

Most Rural Hospitals Have Little Cash Going Into COVID-19
North Carolina Rural Health Research Program at the University of North Carolina at Chapel Hill, March 2020

Metro-area hospitals have been losing money on cancelled non-essential procedures while incurring unexpected costs for supplies, equipment and staffing for pandemic response. This paper uses something called median cash days on hand — the number of days the hospital could operate without receiving additional cash — and Medicare data to determine which rural hospitals may face financial struggles.

“Based on recent cost report data, rural Prospective Payment System (PPS) 26-50 bed hospitals had a median of only 21.3 days cash on hand and rural Medicare Dependent Hospitals (MDH) hospitals had a median of only 28.4 days cash on hand prior to the onset of COVID-19 in the United States,” the brief states. “These hospitals are the most likely to be the first to have a cash crunch.”

The brief notes that once hospitals run through their cash on hand they may not be able to make payroll unless they can “borrow money, sell assets, or seek emergency funding.”

Trends in Risk of Financial Distress among Rural Hospitals from 2015 to 2019
Sharita R. Thomas, George H. Pink, Kristin Reiter. NC Rural Health Research Program, Findings Brief, April 2019

This brief tracks the predicted proportion of financially high-risk hospitals from 2015 to 2019 by geographic census region and by Centers for Medicaid & Medicare Services reimbursement type. The authors report that the proportion of rural hospitals at high risk increased from 7.1% in 2015 to 9.2% in 2019. Further, states in the South had large increases in the percentage of financially at-risk hospitals.

Relevant academic journal articles

Exposing Some Important Barriers to Health Care Access in the Rural USA
Douthit, S. Kiv, T. Dwolatzky, S. Biswas. Public Health, May 2015

The authors of this literature review look at research published before and after the passage of the Patient Protection and Affordable Care Act of 2010. They detail multiple barriers to health care access in rural America. The barriers they address that may be relevant to rural health during the COVID-19 pandemic include:

• Obstacles to getting to a doctor.
• Lack of access to hospitals or specific health care specialties and services.
• Financial burden.
• Lack of access to broadband for telemedicine, or even to the Internet for health information, especially for those over 65.

“Significant differences in health care access between rural and urban areas exist,” they write. “Reluctance to seek health care in rural areas was based on cultural and financial constraints, often compounded by a scarcity of services, a lack of trained physicians, insufficient public transport, and poor availability of broadband internet services. Rural residents were found to have poorer health, with rural areas having difficulty in attracting and retaining physicians, and maintaining health services on a par with their urban counterparts.”

Trends in Emergency Department Use by Rural and Urban Populations in the United States
Margaret Greenwood-Ericksen and Keith Kocher. JAMA Network Open, April 2019

If more rural than urban residents use emergency departments for non-emergent health care needs, what might this reveal about the rural health care system? Since emergency departments are designed to treat acute, not chronic, conditions, increased emergency department visits for non-emergent care means rural patients may be receiving fragmented, inconsistent care for chronic conditions.

The authors of this paper write that rural emergency departments (ED) are “increasingly serving a larger proportion of traditionally disadvantaged groups and with greater pressure as safety-net hospitals.”

Using a data set from the National Hospital Ambulatory Medical Care Survey, they determine that from January 2005 to December 2016, “Rural ED visit rates increased by more than 50%, from 36.5 to 64.5 per 100 persons, outpacing urban ED visit rates, which increased from 40.2 to 42.8 visits per 100 persons. Rural ED use increased for those aged 18 to 64 years, non-Hispanic white patients, Medicaid beneficiaries, and patients without insurance, with a larger proportion of rural EDs categorized as safety-net EDs.”

Rural risk: Geographic Disparities in Trauma Mortality
Molly Jarman, et al. Surgery, December 2016

The authors of this paper examined rural trauma mortalities based on data from the 2009–2010 Nationwide Emergency Department Sample. They find rural residents are 14% more likely than nonrural residents to die after traumatic injury. “This disparity varies by trauma center designation, injury severity, and U.S. Census region,” they note.

This study may be relevant to COVID-19 because, as the authors write, “Distance and time to treatment likely play a role in rural injury outcomes, along with regional differences in prehospital care and trauma system organization.”

Predictors of Primary Care Physician Practice Location in Underserved Urban and Rural Areas in the United States: A Systematic Literature Review
Amelia Goodfellow, et al. Academic Medicine, September, 2016

The authors of this literature review recommend strategies of financial incentives and training programs to increase the number of primary care physicians in underserved areas. In prefacing their findings, they describe the lower distribution of primary care physicians in rural areas:

“Although there are approximately 80 primary care physicians per 100,000 people in the United States, there are only 68 per 100,000 practicing in rural areas compared with 84 per 100,000 in urban areas,” they report.

Describing the importance of primary care physicians, they write: “Prior research has shown that higher concentrations of primary care physicians are independently associated with better health outcomes in multiple domains, including cancer, management of chronic disease, self-rated health, and overall mortality.”

Strategies for increasing the number of primary care physicians in underserved communities include:

• Identifying and supporting medical students who enter training interested in underserved communities.
• Increasing graduate medical education training in underserved areas, since physicians typically end up practicing near the geographical area of their training.
• Increasing funding support, because physicians who received support or were without debt were more likely to practice in underserved areas.
• Increasing placement in rural medicine programs and rural practice locations.

Will Community Health Centers Survive Covid-19?
Brad Wright, et al. The Journal of Rural Health, May 2020.

Community health centers are an integral part of health care services in underserved communities, including rural areas. The authors of this commentary report that CHCs are currently experiencing a 70% to 80% drop in net revenue as residents stay home fearing exposure to the new coronavirus. Staffing is also reduced as CHC providers step in to relieve hospital staff.

The authors write, “Federally qualified community health centers (CHCs) are the nation’s primary care safety net, serving a patient population of whom 68% have incomes below the poverty level, 63% identify as racial/ethnic minorities, and 82% are uninsured or publicly insured. Today nearly 1,400 CHCs operate some 13,000 health care delivery sites nationwide.”

CHCs have already received and continue to request emergency funding during the pandemic. The paper’s authors argue that maintaining the CHCs will be “critical to our nation’s ability to respond to COVID-19 in rural and underserved communities.”

Socioeconomic and Geographic Disparities in Accessing Nursing Homes With High Star Ratings
Yiyang Yuan, et al. Journal of Post-Acute and Long-Term Care Medicine, October 2018

The authors of this paper reviewed 15,090 Medicaid/Medicare-certified nursing homes and found that “those located in nonmetropolitan counties received significantly fewer stars on the quality measure ratings.”

(Nursing homes and other elder care facilities have emerged as hot spots in the COVID-19 pandemic. According to a June 1 press release from Centers for Medicare & Medicaid Services, of the 80 percent of the 15,400 Medicare and Medicaid nursing homes reporting data, there were 60,000 confirmed COVID-19 cases and almost 26,000 deaths: “Early analysis shows that facilities with a one-star quality rating were more likely to have large numbers of COVID-19 cases than facilities with a five-star quality rating.”)

Unequal Distribution of Covid-19 Risk Among Rural Residents by Race and Ethnicity
Carrie Henning-Smith, Mariana Tuttle, Katy B Kozhimannil. The Journal of Rural Health, May 2020.

Rural America is not as monolithically white as often imagined, note the authors of this commentary.

“Approximately 1 in 5 rural residents is a person of color or Indigenous and 11% of rural US counties are majority non-white,” the authors write, explaining that race and ethnicity-based disparities that existed in rural health care before the pandemic are ones that could adversely affect COVID-19 patient outcomes in these communities. The authors describe “non-Hispanic black and Indigenous rural residents facing higher rates of mortality and Hispanic rural residents facing poorer access to care relative to their non-Hispanic white counterparts.”

They argue, “Differences in health and health care access by race and ethnicity among rural residents are direct results of historical and current structural racism.” To address these disparities, they recommend both media attention and health care resources should be directed to those communities.

Regarding media coverage: “Without deliberately centering on their voices, there is a risk of portraying rural areas as monolithically white, which they are not, or losing sight of the deepest tragedies because averages can mask disparities, especially for minority populations.”

Regarding resources: “Policy intervention to address COVID-related suffering in rural America should prioritize those places that already have the fewest resources and the poorest health outcomes, namely black and Indigenous rural residents and racially diverse rural communities.”

Regional Strategies for Academic Health Centers to Support Primary Care During the COVID-19 Pandemic: A Plea from the Front Lines
Jennifer E. DeVoe, Anthony Cheng and Alex Krist. JAMA Insights, April 2020

The authors describe an approach of health care practices partnering with academic health centers at universities to help rural regions, among other communities, address overwhelmed primary care systems during the COVID-19 pandemic. The reasons they offer for supporting primary care are threefold:

1. Primary care teams are the often the first health care providers patients contact, and can divert patients from emergency departments who don’t require emergency care.
2. They are also managing moderately ill patients who remain home and those who have been released from hospitals.
3. Primary care physicians are among those providers covering shifts at overwhelmed hospitals and as ill staff are quarantined.

The authors point to the example of  Oregon Health & Science University, which has established the COVID-19 Connected Care Center, a service staffed by university clinicians.

In the first two phases of this three-phase model, hotlines staffed by medical students, residents and faculty shared real-time information — first to patients and then to primary care practices. “This hotline mirrors an existing OHSU specialty consult line, which serves the primary care community in rural and frontier counties,” the authors explain.

Phase III will expand the service “to the 25% of Oregonians without access to primary care and patients of small practices that lack the resources of larger health care systems, offering them nursing advice and video visits, if needed.”

Additional resources

What is rural?

What is the definition of “rural?” The Rural Health Information Hub lays out the official government definitions, and their uses and parameters, from the three federal agencies whose definitions are most widely used: The U.S. Census Bureau, The Office of Management and Budget and The Economic Research Service of the U.S. Department of Agriculture.

The Rural Health Information Hub has an “Am I Rural?” tool to determine if a location is rural.

What is a community health center?

Community health centers were first created in 1965 and are meant to serve vulnerable populations. As described by the CDC, “Community health centers are community-based and patient-directed organizations that serve populations with limited access to health care.”

Operating as private non-profits, and governed by a community board, CHCs provide primary health care, but also related services including translation, education, transportation, nutrition, care management and pharmacy services.

Updated rural COVID research and figures

The Cecil G. Sheps Center for Health Services Research at the University of North Carolina has created the resource Rural COVID Research and Figures. This resource includes continually updated maps and graphs of “Rural and Urban COVID-19 Hot Spots” and “COVID-19 Growth in Rural Counties” as well as the occupancy rates and vulnerability ratings of rural hospitals as relates to COVID-19. The Sheps Center also documents causes of rural hospital closures and updates a Rural Hospital Closure Page that tracks the number of closed hospitals.

Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020
Kathleen Hartnett, et al. Morbidity and Mortality Weekly Report, June 2020

On June 3, 2020, the CDC released a Morbidity and Mortality Weekly Report that reports emergency department visits from March 29 to April 25 declined 42% compared with the same time period in 2019. These declines were highest in areas with the largest pandemic outbreaks.

While some patients may have been treated by primary care physicians, and injuries may have been fewer due to changed behaviors during the pandemic, emergency department visits for nonspecific chest pain and acute myocardial infarction decreased during the studied period.

Racial/Ethnic Health Disparities Among Rural Adults – United States, 2012-2015
Cara James, et al. Morbidity and Mortality Weekly Report – Surveillance Summaries, November 2017

Nationwide self-reported data from the CDC’s Behavioral Risk Factor Surveillance System was analyzed for this report that describes racial/ethnic disparities including “health-related quality of life, health care access and use, health-related behaviors, and chronic health conditions.”

The authors of this summary report write that one of the limitations of the report is that the BRFSS data is self-reported. While this is most recent multi-year summary, the CDC’s more recent BRFSS data is published at the BRFSS site.

Solution-based information
The Rural Health Information Hub has a section on Rural Health Models and Innovations. Projects are organized by topic, state, and by levels of evidence. They’ve also created a page documenting COVID-19 innovations. It includes crowdsourced examples of how rural communities have been addressing the pandemic.

Rural news coverage
Who knows how to cover rural stories? We asked for recommendations from Dr. Carrie Henning-Smith, an assistant professor in the Division of Health Policy and Management, University of Minnesota School of Public Health and deputy director of the University of Minnesota Rural Health Research Center. She recommends The Daily Yonder.

For more information, check out these 4 tips for covering rural health care amid COVID-19 and these other 3 tips for reporting on rural health.

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