Researchers study barriers and facilitators to accessing health care in rural Missouri

Rural Missourians often face more disparities in health outcomes than their urban and suburban counterparts, in part from challenges accessing health care—a problem amplified in recent years by a growing physician shortage. But a new study at the University of Missouri found that health and health care organizations are increasingly offering basic social services, such as transportation, housing, food, and mental health support, as they recognize these services contribute to a person's overall health.

In the study published in Professional Case Management, MU researchers interviewed various health care organizations serving rural Missouri about their care coordination; organizations included behavioral health, federally qualified health centers and hospitals. Researchers sought to better understand the challenges that rural Missourians face in accessing health care, as well as the innovative solutions care coordinators and social services implemented to help overcome them.

The findings shed light on new roles health care organizations must play to improve health outcomes of rural Americans by providing basic services.

"Transportation was the most commonly reported barrier addressed, particularly in rural areas where you have to travel farther distances, especially if you need specialized care, and the physician shortages in rural areas have made this barrier even worse," said Julie Kapp, an associate professor in the MU College of Health Sciences and lead author on the study. "Some families might just have one car that everyone shares, the car might not be reliable, or if families are working long hours while juggling household responsibilities, missing work to drive long distances might not be possible."

Additionally, Kapp said Uber and Lyft do not operate in some rural areas, where residents often don't have access to bus, train or subway systems.

The research team found that 100% of the organizations interviewed provided assistance with transportation, while 86% provided support or referrals for mental health care, 79% provided food assistance, 71% provided housing assistance, and 50% provided dental assistance.

Researchers also explored how these organizations were implementing the 10 essential characteristics of care coordination that were recommended five years ago by the Journal of American Medical Association. These recommendations emphasize patient-centered, team-based processes that incorporate comprehensive assessments of patients' health and psychosocial needs.

The most implemented recommendation among the interviewed organizations was proactively planning for transitions of care, while the least implemented recommendation was using an electronic health information system that facilitates communication. Collecting this information helps researchers identify both success stories that other organizations can learn from as well as areas for improvement.

"One of the main takeaways of this research is that health care is much more broad today than before, and it incorporates basic social services that are often not thought of as health care related," said Beau Underwood, a doctoral student in the MU College of Arts and Science's Truman School of Government and Public Affairs who collaborated with Kapp on the study. "We need to think beyond just what happens in the doctor's office, and part of that is thinking about if patients have transportation to get to the doctor's office in the first place, or if there is even a physician in the patient's area."

Kapp said food insecurity or lack of broadband internet can also serve as barriers in rural areas, particularly for lower-income families.

"Doctors often recommend prescription medications be taken on a full stomach, but for someone struggling with food insecurity, that might not always be an option," Kapp said. "Telehealth is often marketed as a possible solution in rural areas, and it can definitely be a convenient option, but lack of broadband internet access can be a challenge, although MU and the UM System have made great strides to help in this area."

While the COVID-19 pandemic intensified some of the barriers for rural Missourians accessing health care, the research team identified innovative solutions that could potentially be expanded in the future.

"One organization we interviewed talked about partnering with a local food bank and dropping off the food at the patients' door with contactless delivery," Kapp said. "Another created their own transportation system when the one in their area shut down during the beginning of the pandemic. There was also an organization that would proactively call patients in between appointments and ask how they were doing or if they needed anything, which decreased the likelihood of missed appointments."