:: TBI and Resources in Rural America A Supplement to the “Quick Guide” Census data in the last decade indicates that over 60 million people, or approximately 21% of Americans, live in rural areas.Schopp, Johnstone, and Reid-Arndt (2005) People in rural areas have been found to be more likely to have difficulty obtaining medical and psychological resources than members of urban societies. Over half of counties in the U.S. do not have psychologists, social workers, or psychiatrists and over 70% of shortages in federal mental health services are found in rural areas.WHY IS THIS PRODUCT IMPORTANT (THE PROBLEM OF ABI INTHIS POPULATION, CURRENT GAPS, AND THE PURPOSE OF THEPRODUCT)? As seen below, it is evident that rural areas experience deficits in treatment resources, including those for TBI. The related product sheds light on these concerns and offers ideas for change. Practices within rural communities and urban-centered options are proposed.
THE SCOPE OF THE PROBLEM Traumatic brain injury (TBI) itself has 1.5 to 2 Johnstone, million sufferers a year, nationally. The cost forNossaman, Schopp, TBI treatment ranges from $9 to $10 billion for Holmquist, and Rupright (2002) emergency and rehabilitative care, however, persons with TBI in rural areas tend to have the most difficulty a receiving such treatment. Among Americans ages one to fifty-three, accidental injury is a leading cause of death. Typically, members of rural populations incur an atypically high number of such fatal injuries. As a rule of thumb, accident rates increase the Coben, Tiesman, more rural (sparse) the area. For injuries that Bossarte, and can result in TBI, rural areas attribute their Furbee (2009) fatal accidents to motor vehicle incidents, falls and poisonings, unlike urban areas, whose high accident rates align with assaults. Per capita, hospital costs for accidental injuries are highest for rural areas. The high rate of injury in these regions has drawn attention to needed prevention and intervention programs there. Stallones, Gibbs- In Colorado, for example, incidence of TBI isLong, Gabella, and Kakefuda (2008) higher in rural counties than in urban counties, and, in Iowa, vehicular accidents and falls have Schootman and a higher incident rate in rural counties. Fuortes (1999)
Traumatic brain injuries that result in death often occur in the workplace. Following construction workers, employees in the Tiesman, Konda, agriculture, forestry, and fishing industries are and Bell (2011) most likely to incur fatal TBIs. A call for care has been made for members of these groups, likely to reside in rural areas, seeking preventative measures on these work sites. WHAT ARE THE COMMON SHORT AND LONG TERM DIFFICULTIES THAT THIS GROUP MAY EXPERIENCE? Trauma care systems exist in the US for the sake of transporting injured persons to the most accessible facility providing services for a Tiesman et al. designated injury. Unfortunately, greatest (2007) accessibility is in urban areas. In rural areas, travel is less efficient (longer, farther) between patient retrieval and appropriate facilities. Because immediate care of TBI contributes to a more positive prognosis, speedy hospital arrival is key. In the long-term, delays in urgent care can contribute to patient death following TBI. In rural areas, such as regions of Missouri, where a third of the population lives outside of metropolitan areas, a common obstacle to care for TBI is a lack of resources. Necessary practitioners for care, such as Johnstone, neuropsychologists and rehabilitationNossaman, Schopp, psychologists with training in brain injury, are Holmquist, and Rupright (2002)
not accessible. Fewer rehabilitation sites, psychologists, physiatrists, and support groups are found in rural areas than in cities. Less than a fifth of a state’s licensed practitioners may be found in a rural region. Typically, clients have to receive urgent care in an urban setting then return to the city for ongoing treatment, see a general practitioner in their rural community or terminate care altogether. As of a year to year-and-a-half following TBI, survivors in rural areas are more likely to be dependent on others and less advanced in Schootman and recovery than those in urban areas. Reasons for Fuortes (1999) this difference include cause of injury, care immediately following injury, long-term/rehab care, and community supports. Notably, quality and quantity of care is notably different between urban and rural populations. Specifically, in Iowa, a structured trauma care system is not available. WHAT ARE RISK AND PROTECTIVE FACTORS AFFECTING REHABILITATION? Low economic status impedes participation inSchopp, Johnstone, urgent or long-term care following TBI. Twenty- and Reid-Arndt five percent of rural employees earn less than (2005) minimum wage and lives below the poverty line, compared to sixteen percent of employees in urban areas.
Limited access to intervention is a marked barrier for proper recovery. Facilities and trained practitioners are limited, notably for financial reasons. Physicians and therapists are Johnstone, not attracted to working in rural areas becauseNossaman, Schopp, they may spend up to 16% more time in the Holmquist, and office and have 38% more patients than Rupright (2002) clinicians in urban areas and this does not correlate with higher earnings, unfortunately. Medical care is usually covered by Medicare or Medicaid programs, which reimburse at a much lower rate than private insurance companies. Essentially, practitioners in rural areas work harder than those in the city but earn less for it. An advantage toward recovery is community support. The traditionally close-knit Johnstone, environment of rural areas corresponds withNossaman, Schopp, stronger emotional and psychological health Holmquist, and following injury. As well, the slower pace in Rupright (2002) those regions reduces risk of physiological or mental stress on the patient, advancing recovery.WHAT ARE YOUR SUGGESTED RECOMMENDATIONS ANDRESOURCES AND WHY DID YOU SELECT THEM? Mainly, the options available to patients in rural areas are located in urban settings. This requires long-distance travel that can be time-consuming and expensive, so patients have to turn to local, less-skilled practitioners or not receive care. Community-based programs for injury prevention and telehealth systems have been shown to be useful for rural healthcare.
WHAT SYSTEMS ARE INVOLVED IN THE CARE, REHABILITATION OF THIS GROUP? When available, urgent and long-term care provided by specialty physicians, nurses/physician assistants, occupational therapists, physical therapists, speech-language pathologists, neuropsychologists, rehabilitation Johnstone, specialists, counselors, psychiatrists and social Nossaman, Schopp, workers contributes to care of TBI patients. As Holmquist, and well, community services, such as Rupright (2002) transportation for the disabled, state disability programs and TBI support groups, are useful resources. Typically, care systems of this magnitude are more common to urban areas, so patient travel is required. Commonly, regular care must be provided through a rural general practitioner and community supports occur in a less structured form, as the help of family and neighbors. WHAT ARE SOME APPROPRIATE INTERVENTIONS/APPROACHES THAT LEAD TO POSITIVE OUTCOMES? Telehealth technology (telecommunication within a health and rehabilitation system) has been of focus, providing persons with TBI in rural areas long-distance connections to care. Evaluation interviews for rehabilitationSchopp, Johnstone, recommendations can be performed in spite ofand Merrell (2000) geographical obstacles, relieving obligations to
spend time and money on travel to regional urban facilities. It has been indicated that patients preferred long-distance contact from a clinician for these reasons, and that this technology also allows for communication with needed psychologists and rehabilitation programs funded by the state. Telecommunication technology is also being encouraged for training purposes, allowing physicians local to rural areas with a suitableSchopp, Johnstone, background in diagnosing and treating TBI. and Merveille (2000) Such telehealth training programs have already been implemented so members of rural populations can receive appropriate care from practitioners local to their areas. Preventative measures against brain injury are being undertaken within communities. Stallones, Gibbs- Community-wide prevention programs promoteLong, Gabella, and regular health maintenance and safety Kakefuda (2008) guidelines to build resilience against injury. The more support from the community, the more effective these initiatives. Improved statewide trauma care systems have been installed to reduce post-injury deaths due to sparseness of resources. For example, Iowa instated a Trauma System Development Act in 1995 to enact a statewide trauma care system; the program went into full effect in 2001. The
Tiesman et al., (2007) system included a hospital classification system (Level 1/State or Level 2/Regional), provided Advanced Trauma Life Support training and determined a triage protocol. Level 1 and 2 hospitals were required to have coverage for TBI, including neurosurgery. Tracking data revealed that the Trauma System successfully transported injured patients to Level I and II hospitals as needed, resulting in a significant decrease in risk of death within the first 72 hours following injury and in the long term. Also, diagnostic accuracy and treatment recommendations for TBI cases improved significantly. WHAT RESOURCES ARE AVAILABLE FOR ADDITIONAL INFORMATION AND/OR SUPPORT, SPECIFIC TO A GEOGRAPHIC AREA? Because support for community health and safety initiatives can vary according to culture, it is important to assess the readiness of a community before implementing such programs. It is possible that issues receiving widespread attention at the federal or state level are not considered important in the household because local issues or perspectives take priority. This is especially the case in rural counties. Colorado State University developed a Community Readiness Model and accompanying evaluation system to lay the groundwork for community- based programs. Through Community
Stallones, Gibbs-Long, Gabella, and Kakefuda (2008) Readiness Interviews (semi-structured, open- ended questionnaires), the model takes into account individual attitudes toward readiness (e.g. awareness of the problem at hand, dedication to care within their households) and community commitment (e.g. steps taken within local healthcare systems, leadership involvement). These assessments have proven to provide more information about community perspectives than typical statewide data acquired through medical, insurance and government databases and surveys. The Community Readiness Model and Interviews have been shown to help communities implement change, including in the area of injury prevention. Such a tool would be useful for starting programs in communities elsewhere. For more information, http://triethniccenter.colostate.edu/communityR eadiness_home.htm The National Institute on Disability and Rehabilitation Research has developed a model for telehealth training programs. Trial runs of the program have been implemented in the Midwest to evaluate its efficacy in providing treatment to rural residents with brain injuries. Simply, the design involves two to three online training sessions that last 1 to 2 hours. Lessons are facilitated by a board-certified neuropsychologist at an urban facility and a general practitioner with experience treating
Schopp, Johnstone, rural patients. In addition to medical and Reid-Arndt interventions, the training highlighted family (2005) involvement in patient care and TBI resources at the state and community levels (e.g. state TBI service coordinators, vocational rehabilitation counselors, the state Brain Injury Association, and TBI support groups). Ratings following these trial runs indicated that trained practitioners improved significantly between pre- and post-tests on TBI. Also, patient surveys were compared between those who had received care from trainees and those who did not; patients of trainees reported higher confidence in their physicians and greater satisfaction and guidance. Among these benefits, telehealth has also been considered efficient, customizable, convenient, as interactive as a classroom setting, more engaging than self-education via lectures or reading, requiring only limited technological awareness, and less expensive than a traditional training setting. Residents of Iowa, Minnesota and Wisconsin can refer to the National Institute for Disability and Rehabilitation Research (NIDRR)/Midwest Advocacy Project (MAP) website to participate in advocacy research http://mayoresearch.mayo.edu/mayo/research/tb ims/midwest.cfm
Resources and contacts by state are available through Brainline.org: preventing, treating and living with traumatic brain injury (TBI) http://www.brainline.org/resources/site_map.ph p News regarding research into using telecommunication networks to facilitate TBI treatment in rural areas is available through the Mayo Clinic website http://www.mayoclinic.org/news2012- rst/7151.htmlWHAT AUDIENCE WAS THIS PRODUCT DESIGNED FOR? This product was designed for advocate organizations for TBI, medical and psychological training programs, families and patients. This information is beneficial not only for understanding limitations in resources for TBI care but also to draw attention to these deficits, for the sake of improvement. This information can be taken to legislators to install regulations and supports such as those in Iowa. Training programs can look into telehealth education to generate more practitioners capable of assisting rural patients.WHY WAS THE FORMAT FOR THE PRODUCT CHOSEN? The product was placed in a quick guide format to be easily distributed within hospitals, from advocacy groups and for other interested parties. It should be a quick and easy read, with not too many words and just enough information to make readers aware of the situation. Placing only key information that stands out should pique interest, and if anyone wants more information, they can refer to the webpage.
HOW WAS THE PRODUCT DEVELOPED? Data related to the topic was compiled in full for the guide, then, the most salient and interesting points were placed into the quick guide for fast reading. A note is present at the bottom of the guide referring readers to the website if they desire more information.PRODUCT PREVIEW The quick guide can be accessed at the following website: http://www.slideshare.net/RuralTBIData/a-quick-guide-to-tbi-in- rural-america-15321364. Simply go to the link and scroll down the slideshow. The quick guide can also be downloaded and printed through this setup.LIMITATIONS TO USING THE PRODUCT The only caution for readers is to acknowledge that the information and research on rural populations does not account for all situations and just provides an overall picture. As well, data for individual states can suggest potential scenarios for similar regions but does not actually indicate sameness between the areas.
REFERENCES1. Coben, J. H., Tiesman, H. M., Bossarte, R. M., & Furbee, P. M. (2009). Rural-urban differences in injury hospitalizations in the U.S., 2004.American Journal of Preventive Medicine, 36(1), 49-55.2. Johnstone, B., Nossaman, L. D., Schopp, L. H., Holmquist, L., & Rupright, S. J. (2002). Distribution of services and supports for people with traumatic brain injury in rural and urban Missouri. The Journal of Rural Health, 18(1), 109-117.3. Schootman, M., & Fuortes, L. (1999). Functional status following traumatic brain injuries: Population-based rural-urban differences. Brain Injury: [BI], 13(12), 995-1004.4. Schopp, L. H., Johnstone, B. J., & Merrell, D. (2000). Telehealth and neuropsychological assessment: New opportunities for psychologists. Professional Psychology: Research and Practice, 31, 179-183.5. Schopp, L. H., Johnstone, B., & Merveille, O. C. (2000). Multidimensional telehealth care strategies for rural residents with brain injury. Journal of Telemedicine and Telecare, 6 (Suppl. l), 146–149.6. Schopp, L. H., Johnstone, B., & Reid-Arndt, S. (2005). Telehealth brain injury training for rural behavioral health generalists: Supporting
and enhancing rural service delivery networks. Professional Psychology: Research and Practice, 36(2), 158-163.7. Stallones, L., Gibbs-Long, J., Gabella, B., & Kakefuda, I. (2008). Community readiness and prevention of traumatic brain injury. Brain Injury, 22(7-8), 555-564.8. Tiesman, H. M., Konda, S., & Bell, J. L. (2011). The epidemiology of fatal occupational traumatic brain injury in the U.S. American Journal of Preventive Medicine, 41(1), 61-67.9. Tiesman, H., Young, T., Torner, J. C., McMahon, M., Peek-Asa, C., & Fiedler, J. (2007). Effects of a rural trauma system on traumatic brain injuries. Journal of Neurotrauma, 24(7), 1189-1197.