Centering Innovation in Rural Communities, with Alycia Bayne

Organizations and resources mentioned in this episode:

• NORC Walsh Center for Rural Health Analysis
• Practical Guide to Supporting Innovation in Rural Health

Transcript

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'm talking to Alycia Bayne. Alycia is a researcher with the NORC Walsh Center for Rural Health Analysis. Alycia, you recently contributed to a resource entitled Practical Guide to Supporting Innovation in Rural Health, which was published on RHIhub's website in June. Can you tell us what inspired the development of the guide?

Alycia Bayne: In developing this guide, we wanted to shine a light on the innovative work happening every day in rural communities. We know that they are innovating in terms of using their unique assets, also while addressing some really complex challenges: workforce shortages, resource constraints, access issues. And so, the guide was developed to provide a practical resource and a roadmap that can help rural leaders move from a creative idea to implementation, using strategies that do fit rural context and realities.

Andrew Nelson: In the context of this guide, how is innovation defined?

Alycia Bayne: So, innovation takes many forms in rural communities, and so I think it's helpful to start with what innovation is, and what it's not. Rural innovation is thoughtful, purposeful change that's realistic in rural communities, and that can be sustained over time. It is adapting evidence-based and promising practices, and then also ensuring that they fit the context of the community. And it's incremental change. It's not always large-scale change. Sometimes it's small-scale improvements. What it's not is, rural innovation isn't limited to technology. It's not a one-off project that can't be sustained. It's not implementing an evidence-based practice without really giving thought to how to adapt it to the context of the community. I also think it's important to talk about some of the features of rural innovation. Rural innovation is very context-driven and place-based. It's focused on solving problems. It's adaptive. It's asset-focused, so assets-first. It's community-engaged, sustainable, and then also supportive of the workforce within rural communities.

Andrew Nelson: Yeah, it's important to have a framework that's tailored to the communities you're trying to serve. Why is it that innovation tends to look different in rural communities versus urban?

Alycia Bayne: Well, I think rural communities are different. So rural communities are not simply smaller versions of urban communities. They differ from other communities in many important ways. So, both population size and density, in terms of health status, economic conditions, and access to services. And so, while I think sometimes when we think about innovation as being a huge technology advancement, rural innovation is often driven by community relationships, partnerships, local assets, rather than a large tech budget or a new tech implementation.

Andrew Nelson: You mentioned community-centered design; could you go into a little more detail about why that specifically is so important?

Alycia Bayne: Sure. So successful innovations are designed with the communities at the center. Community-centered design really focuses on reflecting the local priorities, the culture, the values, the experiences that everyone brings to the project. And I think cross-sector community engagement is key to rural innovation. We want everyone to be at the table when talking about innovations. And this includes local residents, government partners, local service providers, faith communities are a big important partner in rural, payers, employers. So, bringing them all to the table, having everybody there builds trust, it improves the relevance of the innovation, and it also helps us to ensure that innovations are sustainable, if everybody buys in and is really engaged.

Andrew Nelson: When you were going through the process of contributing to this resource, what was the biggest misconception you encountered about rural innovation?

Alycia Bayne: The biggest misconception, I think, is that it's related to technology. So, innovation is not synonymous with technology, and I think sometimes that's right where our minds go. Many of the most impactful rural innovations that we see through our research are actually low-tech or even no-tech. In rural communities, those types of innovations are partnerships. They are workflow redesigns within health systems. They're integrating health and human services in new ways. They are community-based approaches. And so, I think we have to get beyond thinking about technology as the only form of innovation. And I think we see that in rural communities. Innovation is so much broader than that.

Andrew Nelson: We certainly heard a lot about telehealth in the last few years, but that's really just one tool that providers can use to improve outcomes for people in rural areas. What do you want rural leaders to be able to take away from this guide?

Alycia Bayne: I hope rural leaders and practitioners see themselves and their communities in this guide. I also want them to take away that innovation does not need to be large and expensive and disruptive. We don't want it to be disruptive, for innovation to make a meaningful impact. So, the best innovations start with what the local needs are, what problems do we need to solve, and how can we be creative about doing that? And then what kinds of strengths do we have at the community level that we can bring to bear? And how can we evolve over time, perhaps starting small and then adapting and learning and growing, and then hopefully sustaining new innovations? So, I hope rural leaders take away that process and also that it doesn't need to be this large undertaking.

Andrew Nelson: You mentioned a couple of minutes ago how when people think about innovation, often their mind just immediately goes to technology, and that's often kind of presented as a silver bullet for rural health challenges. So that's part of the picture, absolutely. What have you identified as guidelines for when technology can be useful related to innovations and when caution should be used?

Alycia Bayne: I think technology can be really important, but only when it's fit for purpose. Meaning that it's capable of doing what we want it to do. And so, technology can support innovation in rural if the infrastructure is there to support it. So, if a technology requires infrastructure that doesn't exist, if it adds to the workload that people already have, and if people are already very stretched, or if it's difficult for patients to use, or perhaps they don't trust it, then technology can create new and different barriers and challenges. So, I think successful rural innovation really does start with the problem, and then whether the technology is the right solution, and not the other way around.

Andrew Nelson: And I guess to look at it another way, you just want to make sure you don't want to have systems of care that are dependent on some form of technology, that not everybody is going to have access to. Another form of technology that we hear a lot about every day is AI, of course. In the paper, you briefly mentioned AI as an emerging tool for rural providers, but you don't spend a lot of time on it. What's your assessment of where AI and similar technologies could genuinely benefit rural health, and where might it actually cause harm?

Alycia Bayne: This is a really interesting question, and we do touch on it in the innovations guide, but we're also working on a toolkit focused on AI in rural healthcare. And so, what we've learned through both of these projects is that rural leaders should actually start by saying, "What problem are we trying to solve?" rather than, "How can we use AI? How should we implement AI? Where should we bring in AI?" Starting with a clearly defined problem is where to begin, and that might be a workforce shortage, or clinician burnout is an issue, or perhaps there's long wait times, and there aren't enough people to schedule, limited access to specialty care. There's so many different problems that might exist, and then determining, "Is AI actually the right tool? Is AI where we want to begin?"

So, I think when we look at rural, there are a lot of opportunities with AI, and there's also so many different tools and use cases. Some of the really interesting examples that we've seen through our research are using AI to reduce documentation burden, to support care coordination, to identify patients who may need earlier intervention. They're using AI with medical image interpretation, in some ways with telehealth and remote patient monitoring to make that faster and more efficient. And I think what we see in rural is using AI to try to help clinicians spend less time doing administratively burdensome things and more time actually caring for their patients. But AI isn't going to solve every problem that we have, especially if it's a problem where technology isn't the issue, it's actually a training issue, or the best solution is a new partnership, or a redesigned care model.

So I think we always need to start with the problem and then figure out if AI is the right solution. You are right to think about the risks. AI can introduce bias. We have concerns about privacy, and of course, the need for governance councils. Some rural communities lack broadband access, which may create issues. There's the need for training and technical assistance, so not just bringing AI in, but how do you maintain it? How do you sustain it and ensure people know how to use it? There's the importance of patient trust. And then certainly, the concerns around AI may not adequately reflect rural populations depending on how the tools are trained and what kind of data they're trained on. So, I think rural leaders should approach AI, with a careful assessment of whether it's truly the best solution and how it can support them.

Andrew Nelson: There's this recurring idea that I see popping up that if you're not shoehorning AI into every facet of your organization, then you're going to be left behind. Sometimes it seems like people might be using AI as a solution in search of a problem, and that's just not always going to be appropriate or the best way to accomplish a goal. I really like the framework you've provided on how to evaluate when AI can be useful and effective. What are some other examples of rural innovation that you highlight in the guide?

Alycia Bayne: There's so many great examples that are highlighted in the guide. There are some workforce pipeline programs that get at that recruitment and retention challenge that we see in rural communities. So, bringing local students in for rural health careers and trying to retain them. There are great examples of community health worker programs that expand access to care for community residents and really do bring that trust. There's Project ECHO, which is telementoring to connect specialists with rural providers, mobile clinics and home-based models that bring services to patients, and integrated care models where we see the combination of primary care, behavioral health, oral health, and social services, really looking at the person and their health as a whole. So, there are many different examples, and many of these don't have anything to do with technology. I think it's important to just see the vast array of examples of innovation that are happening.

Andrew Nelson: Something else you identify in the guide is the role of community health workers as crucial partners. What role or roles do you see CHWs playing in the next decade of rural health innovation? And what kind of support do they need in order to thrive?

Alycia Bayne: Community health workers are among some of the most important drivers of rural health innovation, and I think that will continue to be the case. They are the trusted connectors between healthcare systems and communities. They know the community, and so they are able to work really effectively with partners in the community to break down barriers that would otherwise not be possible to address. They help people address social needs, get access to social services. They help to focus on care coordination, health education. To thrive in the future, community health workers need sustainable financing and reimbursement pathways. I think they also need training programs, career advancement opportunities, and support in their careers. And that's something we've seen through our research on community health workers.

Too often, what we see are community health worker programs that depend on short-term grant funding. And then, when that grant funding disappears or ends, then the program is over, and we lose that part of the infrastructure. So, if we want community health workers to be a permanent part of the rural health infrastructure in communities, then programs need to consider policy and payment methods that recognize and support their value so that they can keep doing that work.

Andrew Nelson: In rural areas, maybe to a much greater extent than in urban areas, partnerships are an important thing to consider. What role do partnerships play in rural innovation?

Alycia Bayne: Partnerships are central to rural innovation. What we find is that no single organization in any community has all the resources that it needs to address the very complex challenges that exist. Innovation often depends on those partnerships among providers, schools, public health agencies, businesses, faith organizations, and others. And it really needs to be a cross-sectorial group. One theme that emerged repeatedly in our guide is that successful innovation really does depend on those trusted relationships and partnerships, having an alignment of priorities and shared goals, and consistent coordination and action across sectors. And we want those partnerships to be sustainable, because that does help to sustain innovation.

Andrew Nelson: In another section of the guide, you talk about ethical considerations that can emerge in various contexts, including digital divides and staff burnout and so forth. How can rural leaders balance the pressure to innovate with the risk of overwhelming teams that are already being pushed to their limit?

Alycia Bayne: This is an important question. I think the guide really encourages leaders to pursue innovations that are supportive of the workforce, rather than creating more work for everyone. Innovation should be focused on reducing extra work. So, it should be about improving efficiency or addressing a clearly defined challenge and supporting folks. I think to balance that pressure of wanting to do so much at once, rural leaders can start small with some creative ideas, pilot those ideas, collect feedback, make sure it's not putting too much burden on specific groups that are already stretched, and adapting. A successful innovation is not about doing more; it's about doing things differently, and hopefully more effectively.

Andrew Nelson: Rural innovation involves coming up with new and exciting ideas to improve outcomes for folks, but those new and exciting ideas need to be sustainable as well. Can you talk about the importance of focusing on sustainability in rural environments?

Alycia Bayne: Absolutely. Sustainability is so important, and it's important to think about it right at the beginning of the project. When everybody's at the table, how are we going to sustain this work? Unfortunately, many promising innovations disappear when the funding ends. And if we don't think about sustainability until after implementation of a new idea or project, it often is at risk of going away. So, I think rural communities should think about what types of sustainability strategies or approaches make sense for the work they're doing. Perhaps it's reimbursement. Perhaps it's partnerships, sharing the burden or sharing resources for the program. Perhaps it's staffing. But if an innovation can't be maintained, then it's unlikely to create lasting changes within the health system or the community. So, we really do want folks to think about sustainability upfront.

Andrew Nelson: Imagine it's 10 years from now, and the rural health landscape looks radically better than it does today. What specific changes do you think would need to happen for us to get there? And what gives you hope that we're on that path?

Alycia Bayne: Well, I think through this work, we've heard directly from rural communities, and I think several things would help. Certainly, reimbursement models that support innovation. New models of payment for many of our rural hospitals, particularly our low-volume rural hospitals. You get paid less and have less volume, which doesn't cover fixed costs, and then you end up with other challenges. So, thinking about payment, stronger rural broadband infrastructure helps us get to the next decade. Sustainable investment in workforce. How do we recruit and retain people in careers to help rural communities continue to flourish and to be vibrant? Continued efforts to align healthcare, public health, and social services around shared priorities. I think all of these things help to get us there, to that next version of rural communities and rural community health.

What gives me hope is that rural communities are innovation incubators.They are already doing many of these things in their unique ways within their own communities. And across the country, we're seeing so many examples of innovative partnerships, like hospitals partnering with different organizations or community programs building workforce pipelines, or investing in transformation initiatives, or telehealth being thought of in new ways. So, I think there's a lot of hope here, and there's a lot of promise. And I think we just need to continue to support innovation and to support rural communities and helping their efforts to succeed and to spread and to watch and evaluate and explore how they are innovating.