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Rural Health Information Hub

Rural Age-Friendly Health Systems, with Alan Morgan, Rani Snyder, and Jed Hansen

Date: April 2, 2024
Duration: 35 minutes

Alan Morgan Rani Snyder Jed Hansen
An interview with Alan Morgan, CEO of the National Rural Health Association, along with Rani Snyder, Vice President for Program at John A. Hartford Foundation, and Jed Hansen, Executive Director of the Nebraska Rural Health Association. We discuss the National Rural Age-Friendly Initiative, the importance of ensuring rural health systems maintain accessibility for patients of all ages, the “Four Ms” of an age-friendly health system, and the vital role of direct care workers.

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Organizations and resources mentioned in this episode:


Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved.

Today I am speaking with Alan Morgan, CEO of the National Rural Health Association, along with Rani Snyder, Vice President for Program at John A. Hartford Foundation. Also joining us is Jed Hansen, Executive Director of the Nebraska Rural Health Association. Thank you all for joining us today.

Jed Hansen: Yeah, thanks Andrew.

Rani Snyder: So glad to be here.

Andrew Nelson: I appreciate you taking some time to talk to us. To get started here, and each of you can answer this in turn from your different perspectives, why do we need to be paying attention to the health and care of older adults in rural communities?

Alan Morgan: Oh, I think I can take the lead on that one. In addition to the right thing to do, first and foremost, from a rural perspective, there is a disproportionate percentage of elderly in rural communities, number one. Number two, they utilize a disproportionate share of healthcare services in rural communities. And these are communities that have workforce shortages and are operating in lean margins. So, just for being able to maintain access to healthcare, you've got to make sure that you have a good, focused policy when it comes to seniors. So, for all the right reasons, it makes perfect sense to focus on this.

Rani Snyder: And I'll follow on if I can. So, I'm just going to state what I think is obvious to all of us here, given the rural focus of so much of our work, which is that rural areas are not just urban areas with fewer people. There are structural, cultural differences. And rural America faces a really unique combination of factors that do create some disparities. Those include economic and cultural and social, as well as sometimes educational, differences. But many of these really come down to access. So, we think about large geographic distances and the higher rates of poverty and underinsurance. Those can compound older adults' ability to maintain health. But they also, along with some of the rural hospital closures and healthcare professional shortages that Alan referenced, hinder access to necessary care, screenings, chronic disease management. And then there's long travel distances that can create some barriers to access. So I would just say that Alan referenced that the older population in rural America continues to grow in size. It's culturally diverse, and these communities have really heterogeneous attributes, including strengths, though — I want to note that there can be very close-knit community ties. These are assets and they can be leveraged to improve care for older adults.

Jed Hansen: And I'll just continue to add to that narrative with what Alan and Rani have mentioned, and I do believe that this is an access issue. And over the next 30 to 40 years, we're going to see an increase in our rural aging adults, and we need to do what we can now through policy and through infrastructure to make sure that we can hold to those promises of taking care of everyone in our rural communities over that time period.

Andrew Nelson: In terms of working in that direction, Rani, maybe you could take this. Why is an age-friendly health system important, and what does it look like?

Rani Snyder: I love this question. Thank you, Andrew. We think a lot about age-friendly health systems at our foundation. An age-friendly health system entails reliably providing a set of four evidence-based elements of what is high quality, best quality care for older people. They're known as “The Four Ms.”. And they include first and foremost, what Matters to the older adult and his or her caregiver. Medication, Mentation, which is anything cognitive, anything of the mind. And then Mobility, and mobility's very much about function. So, age-friendly health systems are really essential elements of the best care for older people; quite frankly, they're best care for everybody. They're just more important for older people. And there are now over 3,800 evidence-based care sites, reducing harm and focusing on what matters to older adults in our country. And the last point I'll make about age-friendly health systems is that they also support family caregivers who are really the backbone of support for so many older adults aging in place in rural communities.

Andrew Nelson: Alan, can you tell us a little bit about the Rural Age-Friendly Initiative and how it originated, and what its goals are?

Alan Morgan: Oh, absolutely. I'm just so very excited with this new initiative that we have at the National Rural Health Association. Rani opened with the fact that rural is not just a small version of urban, it's a unique healthcare delivery environment. And the John A. Hartford Foundation has been working in this space for many years now, looking at how we build these systems and programs at the national level. And what we want to do is bring this into rural communities across the U.S. now. What we do at the organization is identify best practices; we share best practices for replication. And what people really need to understand is what we have out there are literally hundreds of small communities that are serving as innovation hubs. And there are a lot of great practices out there that are trying to bring in this concept of a rural age-friendly approach. We want to collate and share the best of these and raise them up. And so hopefully we can develop a rural context for rural age-friendly programs.

Jed Hansen: And I can speak from a Nebraska perspective, just how lucky we are to have the partnership between the John A. Hartford Foundation and the National Rural Health Association, and how we've been able to be a recipient of that partnership at the state level. We are working through a partnership with our hospital association, our rural health association, and then our state Department of Health and Human Services, to really bolster the dollars that are available through the John A. Hartford/NRHA partnership and take it a step further from age-friendly facilities to age-friendly communities. And so we're going to be piloting five age-friendly communities, where we're going to take some of the expertise from the different organizations and see what we can do to really promote rural aging and aging dignity in our communities. [We're] really excited. And it just shows where partnerships can go when we start to work together in our rural communities, when we stay focused on the things that matter like rural aging.

Rani Snyder: I love the comments that both Alan and Jed just made, because we're super excited also about the National [Rural] Age-Friendly Initiative. Lots of rural health partners and advocates have attempted to address challenges through research, through collaborations, educational sessions, and community outreach at a variety of levels, including federal and state and regional. And you just heard about some of those. There has not yet been an aging-focused initiative that's really thinking about this across the board, centered on combining these components under one umbrella. And that's why I want to give huge props to NRHA. They're doing this work with us. They're developing resources, partnerships across many of these areas that I just mentioned, and a strategy for the implementation of that National Rural Age-Friendly Initiative to ultimately build age-friendly care for the one in five older adults who are living in rural geographies. That's what really matters to us.

Andrew Nelson: Alan, can you give us a little bit of a rundown on the shortages that face the rural healthcare workforce and how those shortages might especially affect older adults in rural communities?

Alan Morgan: Absolutely. I think it's a well-known fact that rural health policy is the study of workforce shortages, unfortunately. Now, the good side of that is because of that challenge, it drives innovation. And when it comes to seniors' health, most notable are the dramatic shortages of behavioral health specialists in a rural context. And for rural seniors facing feelings of isolation and loneliness in many cases and transitioning within their life, it's just so very important to be able to have professional resources there to utilize. And the question is, how do we utilize technology? How do we utilize broadband and other activities to be able to address these needs, number one. And then once you get past the specialists, which we always see dramatic shortages of, primary care as well too, and that focus on how do we keep seniors healthy and in their homes, how do we move healthcare outside the walls of the hospital to be able to treat them where they want to be treated and maintain these healthy lifestyles; still very, very important. So, again it is a shortage, but this innovative approach and how do we restructure our healthcare system, I think is a real takeaway lesson here.

Rani Snyder: I just would love to add to a couple of the comments that Alan mentioned. You know, we are seeing shortages, and we can't ignore the fact that the pandemic exacerbated those. So, there's even higher staff burnout, and therefore higher turnover, that we've seen and heard about across the states. Given that 20% — one in five Americans — live in rural communities, this is a really significant issue that can't be ignored. And I just want to highlight that we've seen lots of surveys that indicate that rural areas struggle to recruit and retain healthcare providers, and this is really critically important. I'm excited to hear what Jed has to add to that from his perspective in community.

Jed Hansen: Rani, you gave me the perfect segue. Just a couple weeks ago in a couple of our local papers in western Nebraska, which tends to be more rural than the eastern half of our state, we had a story that was highlighting five rural women that were working at a nursing home that closed about a year ago. And these women could have done any number of things. They could have just folded it in, found a different career path than the one that they're working in long-term care. But they had decided to band together, and they commute over 90 miles one-way daily to the next closest long-term care facility. And so it speaks to some of the shortages and some of the infrastructure challenges that we have, but it also speaks to the tenacity that we have in rural America, that we really want to take care of those around us and those in our community.

You know, Nebraska has approximately 135 long-term care facilities in our state. And we did a pulse survey just a couple weeks ago. In that pulse survey we asked, “Is your facility rural-age-friendly?” And of those respondents it was great to see that about two-thirds were, but we also asked about some of those challenges that they're seeing. And unfortunately just under half — 45% — stated that a long-term care facility closed in their community over the past five years. But we also asked what other resources are available and things like Meals on Wheels, assisted living, senior transportation, and senior centers. And so we are seeing some of those assets that are percolating through, and that mixture of those challenges, and then those assets that are in place in those communities, really speaks to the importance of age-friendly initiatives and making sure that we're keeping our older adults healthier, independent longer, so that they can remain in their communities in a vibrant way.

Andrew Nelson: Rani, I know that there are also shortages of direct care workers. Can you tell me a little bit about who they are, and what role they play in helping to support rural older adults?

Rani Snyder: Absolutely. This is something we think a lot about, and when we talk about healthcare, I think most people tend to pull to the clinicians that you think of, the doctors and the nurses who are in the rural healthcare settings. But I have to say, direct care workers are workers who are really, really important in the healthcare system and too frequently overlooked. So they are people who provide home care services, like certified nursing assistants, home health aides. They've got lots of names — personal care aides, caregivers, paid caregivers — sometimes we use that term to differentiate them from family caregivers, because they're two sides of the same coin, supporting people where they live. So, the services that they provide include a variety of tasks, things like dressing, walking, or feeding, and even more personal care like bathing or medical-related tasks like medications.

They really are a lifeline for the people they care for and for the family and friends who are also frequently struggling to provide highest quality of care. So we were talking about shortages. There is a shortage across the country in all areas of direct care workers, which does cause a further strain on the overall healthcare system and decreases that access we were talking about earlier, to quality care for people who have long-term care needs. Considering the rate at which our population is aging, the supply of direct care workers, which is already short, will fall shorter. We think about that not only in communities, but also in nursing homes, which exist in rural areas. 54% of nursing home surveys in 2023 said that they had to limit their admissions of new patients. And home care providers have said they turned away 25% of referred patients because of these shortages of direct care workers. So they cause delays in all kinds of places, including hospitals. And it's really important that we work on this, that we improve the conditions so that we can bring in an additional direct care workforce.

Jed Hansen: From a state perspective, I don't know that I have much to add. Rani said it so eloquently, but we are concerned about the workforce across the state and across the spectrum, and we're doing what we can to look at policy and to look at funding that can support that entire continuum of care. We know that if we can engage individuals at the beginning of their career at the entry-level spaces as medical assistants, as nursing assistants, then we can help them develop their career and develop their passions along the way into other programs like nursing and medicine. And that pipeline, that's how we're going to win the workforce battle in rural America, is through pipelining and looking at non-traditional pathways into careers. So, it's helping people find their passions and then aligning their passions with ways to express that.

Andrew Nelson: Alan, I know that the NRHA is working on developing training for community health workers [CHWs] based on the Age-Friendly Health System's “Four Ms” network. Can you tell me some more about that, and how you envision CHWs being able to support the aging population in rural communities?

Alan Morgan: Now we get to the exciting part of this presentation for me, and I'll tell you why. When I talk with people about the future of healthcare, everyone gravitates towards technology and telehealth because it's exciting, and it is a part of it. But I've got to tell you, the really exciting part of where we're headed as a healthcare system involves community health workers. And a lot of your listeners are well aware, these are nonclinical trusted voices within the community that receive additional training to be able to be that bridge between community members and the healthcare system. And since 2012, the National Rural Health Association has trained more than 2,000 community health workers in a rural context, understanding scarce resources, small communities, a healthcare system that's under siege and underfunded, to be able to be that bridge and to improve healthcare status.

Now, what we're excited about is through this partnership with the John A. Hartford Foundation, we've been able to work directly with Dr. Denise Hernandez, [at] the University of Texas, who in partnership with the Institute of Healthcare Improvement, has been able to develop an age-friendly curriculum for these community health workers. In particular, being able to do role-playing directly to the community health workers of how to engage and communicate with our rural seniors in an appropriate and respectful manner. Being able to be that connection, whether it's getting them to their appointment, checking on their pharmaceuticals, and do they have their medicines that they need, basic transportation issues, and also making sure that they get to see their clinician when they need to see their clinician. And when we talk so much about workforce shortages, this is a low cost, high impact improvement, which hopefully will empower these seniors to take control of their own healthcare status. And the potential impact of this just can't be understated. And so it's really one of the more exciting aspects of this partnership and what this will mean, not just for seniors, but also for the entire healthcare status of these small communities.

Rani Snyder: Alan, I love your excitement because we really share your enthusiasm. We're super excited about the potential for community health workers to help older adults understand, and then also act on, the “Four Ms” of age-friendly care in rural areas that we talked about. I think you can't underscore enough that community health workers are trusted by the communities they serve. They're of that community. Because they're of the community, they share culture, they share language, they share a sense of the opportunities and also the challenges facing community members. And that allows them to do better work for the people that we're talking about, the older adults in these communities. And so we're really excited about that and what NRHA is doing to build that. Alan mentioned Texas, which is where we're starting, and we are eager to move that out well beyond Texas, as well. We are a national funder, and so we fund beyond an individual area, but we're happy to start in one area to test it out so that we can show what we've got and bring that out more broadly. And so, I'll say one last thing, which is that the Institute for Healthcare Improvement, which leads the Age-Friendly Health Systems Initiative, and the “Four Ms” that we're talking about, is now adding training for healthcare teams, for community health workers as well. So it's a great addition to the overall work.

Andrew Nelson: The age-friendly health systems we've been talking about are just one part of the entire age-friendly ecosystem. Rani, can you tell us about its other parts?

Rani Snyder: Thanks, Andrew. Because this does not exist in a vacuum, and that's really important in terms of thinking about the fabric of society. So other parts of the age-friendly ecosystem include public health, and with a national organization called Trust For America's Health, or TFAH, it goes by, we support the Age-Friendly Public Health Systems Initiative. So it's really closely aligned with age-friendly health systems. There are also age-friendly cities and communities and states, and AARP is the lead for that, this particular global effort to make communities more livable for all ages. And just like I said about age-friendly health systems, the age-friendly public health systems and age-friendly cities and communities…These are really the best setups for all of our communities. Again, it's just that they can be more important for older adults. Similarly, education and research is another sector where there exist age-friendly universities. This is a movement that's spreading not just nationally, but globally. And we also need age-friendly workplaces that support older workers, as well, as many people want to work into their older years and remain healthy both in rural areas and elsewhere. So ultimately, all parts of society need to be age-friendly. And as I said, this is a sort of a fabric, if you will, that we can and are weaving together.

Andrew Nelson: Partnerships are a crucial part of any rural healthcare system. Jed, how do you see the Rural Age-Friendly Initiative's work helping to provide comprehensive services for older adults?

Jed Hansen: I really appreciate you asking that question, Andrew. You know, one of the challenges that we have in healthcare, and one of the things that we need to get a little bit better about is removing the silos that we exist in. And the age-friendly project in partnership — and I'm saying in partnership, because it really is a partnership between the John A. Hartford Foundation, the National Rural Health Association, and then other state agencies like the Nebraska Rural Health Association — and really, we are at a space in healthcare where we need partnerships to be able to tackle the complex needs that we see across this country. And in Nebraska, we're extending that out where, as I'd mentioned earlier, we're working with our hospital association, with a couple of our state agencies, with our local hospitals, and then with our local community partners. And so what we can do with that is we can build data around some of these projects. We can extend community relationships so that we make sure that we understand the gaps that are in a community and bring in and mobilize assets at the state level and at the federal level to be able to fill those gaps and provide quality care, and to have a platform such as the Rural Age-Friendly Initiative, and to have such high-value partners like the John A. Hartford Foundation, and like the National Rural Health Association. I can't speak highly enough about just how those partnerships really allow us to amplify what we're doing at the state and local level. So these partnerships are, to summarize, crucial to being able to help our rural aging individuals.

Andrew Nelson: Can each of you tell me about some ways in which reframing the narrative around aging in rural communities helps to create more inclusive communities?

Rani Snyder: I would love to start that one. Thanks, Andrew. The Reframing Aging Initiative works to really counter some of the very pervasive negative beliefs about aging that can frankly be barriers to improving care for older people. So when many people in this country think about aging, people automatically pull to sort of decline or disability or death. We don't frequently enough think about the positive aspects of aging, and about the ways that older people contribute to our communities, and they really do, everywhere. So, the National Center to Reframe Aging, which is based at the Gerontological Society of America, GSA, is busy disseminating lots of resources to combat ageism by helping us change the way we talk about aging in older adults. And that changes the way we think about aging and older adults. So, for example, let's not talk about older adults as others, because honestly, in reality, we're all aging. They're in all our communities and all our families. You've seen some of the logos that I love to quote, like, you know, “Aging is so cool. We're all doing it.” Ultimately, it's what we're doing all day, every day. And we should celebrate that for our loved ones, our communities, ourselves, our families. And so that simple reframe from “them,” to “us,” as the beneficiaries of our work, can make an enormous difference in the way it feels, and therefore in the buy-in that we get, more broadly.

Jed Hansen: Of the “Four Ms,” what Matters is probably my favorite “M.” Rani's really touching on that. And I think as we look at how we continue to focus on aging in rural America, and really engaging our seniors, we're going to find that we gain just as much from helping them through the aging process as they are with us helping them. And it's going to be a fun process to see.

Alan Morgan: What I've enjoyed about this initiative is really a new look at what it means to be a rural American. And since 1978, the National Rural Health Association has highlighted obstacles and challenges facing our healthcare system in a rural context. And we highlight these shortcomings so that way we can push policies to improve healthcare access and delivery in rural communities. This has actually allowed us to back up and look at the data, and what does the data show? And the data shows that people are actually choosing rural, as opposed to this concept of leaving small towns and fleeing from bad situations. Our nation's elderly are actually choosing to live in rural and enjoying the connectivity, enjoying the sense of community, enjoying the open spaces, and the ability to just be outside and the slower pace of life. There's just so many positives that we've overlooked in our effort towards trying to improve the current status and this concept of choosing rural. I think it has great benefits also as we move forward in attracting new workforce clinicians into these small towns as well, too. So reframing has just been a tremendous outcome of this project.

Jed Hansen: This is one that I can speak to personally in watching my own parents and their aging process. I'm from a small community in south-central Nebraska, about 3,000 people, and my parents both still live there. And they are choosing rural, and it's one of my drivers to make sure that everything that I can do can benefit my parents and can benefit my family members that stay in rural. But my parents are active in their church. They volunteer with the local schools. They coach, they're involved in youth activities, and that sense of community is so vital to them. Again, to a point that I made earlier, they're giving back and they're giving just as much as they're receiving in in those areas. And we are seeing trends where people are choosing rural. And for many, it's our aging adults that are doing so.

Andrew Nelson: Today we've been kind of just talking about approaches and solutions that are currently in place. What are some ways in which we can continue to innovate and expand availability of services for older adults?

Alan Morgan: That's such a good question, Andrew. And we've only been in this partnership with the John A. Hartford Foundation for one year, and we've already had so many great outcomes of it. It's nice to take a step back and realize the question you're asking is what we hope to define and identify as we move forward. Coming up in the future years, we hope to be able to identify, “what are these innovations?” And I think for anyone listening to this program, get involved with your state rural health associations with the National Rural Health Association, join this movement to identify best practices, what works, and how do we build better rural communities for our nation's seniors as we move forward.

Jed Hansen: One of the things that we're doing at the state level, and probably one of the projects that I'm the most proud of is our “I Love Rural Health Campaign.” And the campaign itself we began about three years ago, and we take out a comms and video crew, and we highlight communities and healthcare teams where there are traditional pinch points and barriers in rural healthcare delivery. And they're blowing past those barriers. And it's really fun to be able to highlight the tremendous work that's taking place for transportation, for senior care, for aging initiatives. And one of the videos that is through the John A. Hartford partnership with NRHA is that we're going to be going out and highlighting one of our champion age-friendly communities. And so we're really excited about that project and being able to highlight some of the great work we're doing. And to Alan's point, and to Rani's point, we're at the infancy of these partnerships and these initiatives, and it's going to be fun to see what this looks like a couple years from now and the lessons learned and really bringing everyone together and being able to coalesce those really great ideas and projects and give them a platform to be able to shine.

Rani Snyder: I love both of those responses. And I've got three words for you: stories, convenings, and resources. So starting with stories, more of us telling the story about the need for rural age-friendly care, like we're doing today, is part of what we need, because people need to hear about it. Choosing rural, that's part of the story, right? That's a really great encapsulation of what some of these stories are. It's a way to start. It may be a way to finish as well.

Convenings are another really key component, and that's something that philanthropy can do well. That's actually how our work started with us, the John A. Hartford Foundation, holding a convening with HRSA, the Health Resources and Services Administration, and their Federal Office of Rural Health Policy. We did this a year or two ago. We brought together a bunch of the big agencies that have an interest in this area to understand what they're doing, what they're interested in, and how we could bring that together. So it included organizations like the CDC [Centers for Disease Control and Prevention], Centers for Medicare [and] Medicaid Services, certainly HRSA, as I mentioned, the Agency for Healthcare Research and Quality, the Administration for Community Living, which is really focused on people who are older and people who have disabilities as well, the Veterans Administration. And then with organizations like NRHA, as well as others like Leading Age, that it really is focused on nursing homes and USAging, which is about what's happening in communities to support older adults, so major national organizations. And we came up with this particular initiative.

And so that brings me to the last word I mentioned, which is resources. So through this initiative, through our grant with NRHA, and you just heard Jed talk about some of the deployment of that, we're going to have more resources compiled that can be easily shared across communities, across states, and also importantly with policy makers. And we'll be working with the National Organization for State Offices of Rural Health and the Federal Office of Rural Health Policy to highly encourage these priorities and the solutions and resources that can be shared.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke with Alan Morgan, CEO of the National Rural Health Association, along with Rani Snyder, Vice President for Program at John A. Hartford Foundation, and Jed Hansen, Executive Director of the Nebraska Rural Health Association. Look in our show notes for more information about their work and visit for all things pertaining to rural health.