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Rural Health Information Hub

NACRHHS Updates: PACE and Childcare Need in Rural Areas

Duration: approximately minutes

Featured Speakers

Jeff Colyer Jeff Colyer, MD, Chair, National Advisory Committee on Rural Health and Human Services; Former Governor of Kansas
Pat Schou Pat Schou, Executive Director, Illinois Critical Access Hospital Network (ICAHN)
Isabel Garcia-Vargas Isabel Garcia-Vargas, Executive Director, Redlands Christian Migrant Association

Members of the National Advisory Committee on Rural Health and Human Services recently explored two topics of importance to rural areas. The first was the use of the Programs of All-Inclusive Care for the Elderly (PACE) in rural areas. The second was childcare need and availability in rural areas. Please join us for a webinar that will highlight the rural context related to these two topics, and a discussion of the policy brief and recommendations submitted to the Secretary, HHS.

Additional Resources

From This Webinar


Kristine Sande: Good afternoon everyone. I'm Kristine Sande and I'm the program director of the Rural Health Information Hub. I'd like to welcome you to today's webinar with the National Advisory Committee on Rural Health and Human Services. They will be sharing updates on their recent work on PACE and childcare needs in rural areas. And before we begin, I'll quickly run through a few housekeeping items. We have provided a PDF copy of the presentation and that's on the RHIhub website, so you can either go to the URL that's on your screen or click the link in the chat function. And now, it's my pleasure to introduce our speakers for today's webinar.

Jeff Colyer is the Chair of the National Advisory Committee on Rural Health and Human Services. He is a physician and the former governor of Kansas. As governor, he made Kansas the first state to privatize its entire Medicaid program into KanCare saving $2.5 billion, expanding services, and acting as the basis of many other states' programs. A surgeon known for volunteering in 25 war zones from Rwanda to Syria, he provides trauma reconstruction in Kansas City. Originally from Hayes, Governor Colyer has degrees from Georgetown, Cambridge University and KU Med.

Pat Schou is the executive director of ICAHN, the first statewide critical access hospital network. She also manages the Medicare Rural Hospital Flexibility Grant, Small Hospital Improvement Program, and several other grant programs on behalf of the Illinois Department of Public Health. In addition, Pat is the executive director of the Illinois Rural Community Care Organization. Pat has more than 35 years of clinical and rural hospital administrative experience.

Our final speaker will be Isabel Garcia-Vargas. Working in early childhood education for over 30 years, Isabel is the executive director of the Redlands Christian Migrant Association. RCMA provides childcare and kindergarten through eighth grade dual language education to over 6,500 migrant and low income students and their families throughout the state of Florida. She is an accomplished early childhood educator and the leader within the world of Head Start. And with that, I'll pass it over to you, Governor Colyer for your opening remarks.

Jeff Colyer: Thank you, Kristine, and thank you to RHIhub for hosting this and putting this together. And thank you to the numerous staff and the committee members that have worked hundreds of hours to put these reports together. My name is Jeff Colyer and I was the former governor of Kansas, a lieutenant governor, and also a surgeon here. Rural health issues has really been something that's been in my blood and in my DNA from when I was born. So it is been a real honor to serve with this committee. The National Advisory Commission has been charged with a number of high level overviews on topics. Two of those topics that we're going to go through today are regarding the Program of All-Inclusive Care for the Elderly known as the PACE Program. And Pat is going to be discussing that. Then we'll have Isabelle Garcia-Vargas who will discuss childcare needs and availability in rural areas.

In other words, we're taking both ends of the age spectrum on two very important topics here. Before we hear from them, I want to provide you a little bit of background on the National Advisory Commission on Rural Health and Human Services. This is actually a federally chartered program that's actually instituted in law and is composed of 21 citizens from across the United States, and we have a variety of experience and expertise in health and human services. Typically, the committee meets twice a year to examine issues of importance and usually issues two or three different reports to the secretary and to the country. The committee has been quite busy over the last couple of years and has actually passed that on several different occasions. In the end, we provide a policy brief making recommendations to the secretary of HHS, and those policy briefs can be found on the committee website.

One of the first things I asked the committee when I came on board was to develop an actual vision for what we wanted from our work. And that vision is that we want to focus on a rural America that is full of diverse citizens of healthy people and places and providers, a place where you can access world-class care and human services and see continued innovation and real rural values being played out in their health and human services. In short, we really want this to be a place where you have the greatest opportunity to live your American dream. And so we keep this vision on top of mind of all of our work and as we advance this vision, we're exploring a number of innovations in rural healthcare and human services. We're highlighting ways to integrate healthcare services and non-healthcare sectors as well as human services.

We are also recommending public policies that advance rural community diversity and resiliency. And of course, we rely on the science and the evidence and really working with large groups of advisors. And we advance this vision in a variety of ways. We're looking at a whole variety of different ways of helping our fellow citizens. One of them is the PACE program, which is the Program for All-Inclusive Care for the Elderly, and it's just really beginning to become available in rural areas. The committee had our last meeting in Lawrence, Kansas last fall, and we heard on the subject matter experts on PACE on aging and long-term care issues. Now as a governor, I was very much aware of the PACE program and saw how this began years ago and how it has expanded nationally.

Now here in Kansas, we are offering an innovative way to care for nursing home eligible seniors by keeping that at home. Now, I have to tell you the knowledge of the PACE program across the committee and kind of reflects the way it is across the country, not many people know about it. Many people were sort of generally aware of it but really hadn't taken an in-depth dive. And once we got to really dig into this, we've found that all of our committee members were very excited about the opportunities that the PACE programs provide. So I'd like to tell you some of the big picture takeaways and then we'll turn it over to Pat.

So part of the context of the PACE program is that it is a combined Medicare and Medicaid program. So it's a federal and a state option, what many people call dual eligibles. It's part of a group of care delivery focuses that the goal is to preserve the senior's ability to live at home, and that includes both their Medicare Advantage plans as well as their Medicaid HCBS waivers. They're focused on individuals over 55 and older. They live in a service area per a PACE organization and many of them need nursing level home care certified by their state, but we're able to actively provide them home care instead.

One of the important things the committee wanted to focus on was detailing important differences about implementing this in an urban environment versus our rural communities. We focused on PACE for this discussion because we saw a lot of potential issues where we can address some very significant problems in our rural environment, particularly in access to long-term care services and support. Two the issues that uniquely affect our broad expansion of PACE are transportation and staffing shortages, long distances to receive care, and inadequate transportation, as we all know, is a really major challenge in rural areas. And transportation is a central core provision of the service PACE programs. So it is a way that they can really help our rural elderly.

However, we have long drives for services in rural communities and can be difficult even for frail elders. So transportation is a very important consideration. Another really important consideration are ongoing staff shortages, which have actually gotten worse over the last couple of years since COVID. PACE has interdisciplinary team staffing requirements, and that requires a primary care advisor, or primary care physician who can work in an advisory role, a registered nurse, a master's level social worker, a physical therapist, occupational therapists, and a dietician. Now if a rural community has two of these, it's doing pretty well in most instances. But this is a way that we could actually bring telehealth to provide the full spectrum of services to reduce some of our staffing problems that we have in our rural areas.

So despite these and other challenges, the committee has been incredibly impressed by what we saw with the PACE program in eastern Kansas. It really seems to meet the full range of seniors' need. And as we heard from one PACE recipient, she talked at length about how the program was actually a game changer for her physical and her mental health. Prior to enrolling in PACE, she experienced social isolation and it took a serious toll on her mental and physical health. So PACE offered her social interaction, kept her in her home, got her the urgent medical care that she sorely needed and it really integrated her health and her social services together.

Another thing that stands out is the financing of these programs. Now, these programs normally have a very small number of enrollees, but the PACE program will actually assume full financial risk to make it worth because we're combining both Medicare and Medicaid funding. And what we're finding is that we're getting better results, and yes, actually saving money. By the end of our visits, the committee members are not only big fans of PACE, but they want to make some recommendations to the secretary that the program be expanded and targeted in rural areas. So, I want to turn this over to Pat who will explain some of our recommendations that committee submitted to the secretary.

Pat Schou: Well thank you Governor, you did a great job of giving the framework for this wonderful program that very few of us on the committee knew about. I go back to my days as a young nursing student and it was just starting in San Francisco and was impressed at how it all came together for seniors. And just think how long it's taken to roll out to our rural communities. And so I hope by the end of this program today you'll have a greater appreciation for this wonderful program that the governor talked about and about perhaps some takeaways about how we can really move into this program and either use it, get into the program of PACE, or maybe learn from some of the wonderful programs it's put together. I want to start building the background more about our recommendations and really start with rural demographics. And I'm not going to tell you anything new that you don't already know; that we have one in five that are older adults and they live in rural areas similar to how rural is compared to the urban population.

We have a higher poverty rate, we have a greater concentration. 17.5% of Americans live in rural areas over 65 compared to 14.5 that live in urban areas. So you can see if you go and look from state to state as well as from national perspective, there really is a greater concentration of rural elderly in our communities. And it presents a problem because we don't have a lot of the conveniences and transportation there. We also know that there's a higher prevalence of adults with multiple chronic health conditions and it may be a lifestyle, it may be just that we have older adults. But regardless of it, we do have a greater percentage of it and we want to make sure that we have a way of managing that and provide work for.

There's a higher percentage of people with disability. And as the governor mentioned, and Kristine, I work with Accountable Care organization in Illinois as a statewide organization that's a Medicare shared savings program. And what we have learned in our rural area is that their cost of providing care for dual eligible is much higher, $5,000-$7,000 per individual, higher than an urban areas. And so the programs like PACE, which is an all-inclusive program perhaps is a way that that can help build on it. However, we need to be able to expand it to our rural areas so that we can cover. And there's approximately 2.6 million people in our rural areas, so it's really important that we begin to address, look at our rural demographics, and what can we do for that population that really needs our attention, not only for increasing the value of their life and their family members, but also controlling costs.

So the committee recommended, and as the governor pointed out, the continuation of this program, we were very much impressed with it. So I'm just going to walk through these recommendations just to emphasize how important they are, support a pilot program for Medicare only to see if there's a difference between the Medicare beneficiaries as the dual eligible, more use of telehealth. And we learned through COVID how that really has changed. You still have to have that one-on-one contact and build that relationship, but telehealth can fill in those gaps. The development of more rural resources, we talked a lot about rural areas and including tribal areas which could be very, very important to the Indian areas. Supporting guidance to clarify the range of allowable shared spaces for critical access, and I work with critical access hospital, how can we build that relationship with these communities and can we find some partnerships there?

Allow sites to be eligible for the loan repayment program, National Health Service Corps and Nursing Corps, and that enrollment actually is going on now. So that's my pitch to get into the National Health Service Corps. It's great for providers as well as people wanting to go into the profession. I encourage students to be trained as health professionals both on site and in tribal areas, and then encourage some of the residencies or at least some types of experiences in the PACE setting so they see that comprehensive care. That's really what we're seeing with the PACE is that comprehensive care, which we don't have in our rural areas, it's very fragmented. And so maybe that will help with improving that concept. Allow PACE organizations submit multiple applications, that's one thing the governor talked about. They can only do one a year and it's hard to get that startup.

And if somebody knows how to do that well, how can we work and build and provide some collaboration among organization? And existing pay sites to have expedited approval, often it takes months and months to get that approved and that makes it very, very difficult. So let's delve into a little bit more detail about that with really going into low patient volume. That's been some of the challenges for our rural areas because you really want to... Some synergies are there from transportation and cost and everything by having volume there. So how can we build on it? Could you have rural communities come together and so forth? And so how can we expand that and perhaps just look at Medicare? Do they all have to be dual eligible and how can we enhance those resources in long-term care areas that really would make a difference?

The other thing with this, we found that there were a lot of high cost of the prescription program and that made people nervous about it with startup costs because it's an all-inclusive program. So maybe with just Medicare only, we might be able to reduce the cost and still provide that opportunity. And we're looking at this pilot and how could they encompass that? Could we look at being creative in a pilot that would really work through that and the importance of having some seed funding. We really want to promote other groups looking at how can we encourage rural startups in our rural community? Can we look at different population sets? Can we look at how people can maybe partner together to do it? And really that's what the committee wanted to do is how can we address the low volume? Which sometimes people are reluctant to do. If you only have dual eligible, that really makes a small subset.

But if it was Medicare only or you could combine two communities, maybe there's a way that we can work through it. And I think that's just a challenge of a program. It starts out in a very urban area, very concentrated area, and now you move to a broader area, how can we make that work? And so that's really what the committee looked at. The second recommendation regarding broadband and telehealth, and like I said, we've all felt the experience of telehealth the last couple of years, and how can we extend it to the PACE organization and have that authority not just through the end of the public health and it's extension there, but shift to more of it on an ongoing basis? And we had these temporary flexibilities. How can we really enhance that and build on that? And how can we build on the telemedicine? It's important to have one-on-one and we want to be able to do that, but how can we expand it to fill the gaps?

There are some challenges in rural areas when you think of broadband. Now I think we've come a long way over the last 10 years of getting broadband in our rural areas, but we still have areas where it's very poor broadband and maybe they might have some coverage. It may be some bar, one bar. But often you need three or four bars for telehealth and more ongoing use of telemedicine. So we have to look at, if you're going to look at setting up a program in a rural area, how can that broadband coverage be enough to include telemedicine? And then of course, provide flexibility for the use of telehealth with their providers.

Looking at number three, the recommendation on limited awareness came up as a real concern is that many of us really had limited knowledge. I said I remembered, like I said in my early nursing career, that was a new program starting up and people were watching it, but it does have a long history and it's done well. So obviously there are values to that program, and how do we match the value with the opportunity and the cost and really look at what we can do to improve? They're really primarily in our urban areas. And we were in Kansas and the two sites that the governor talked about, they did cover rural, but they were still inside the city. So how do we take a smaller rural urban kind of community and really build on that?

So we really need some type of a kit and a promotion and really increase the awareness of how you build a program that's all-inclusive. As we learned it, and the governor talked about how these patients, or I should say beneficiaries, in the PACE program, they just thought it was wonderful. Ordinarily they would've had to go to a nursing home, and here they can live in their own home, their own home, and they can go and transportation brings them into the center. They can have primary care that day. They can have activities, somebody can deal with them on their emotional issues. They have companionship and it's really a way of doing.

Otherwise, they're in a nursing home and may not have that quality of life that they need. They're mentally alert, but they just don't have the resources to support them in their own home. And something like this becomes an option. If you look at the high cost, now PACE programs, they're given a capped payment for each beneficiary and they have to be able to provide the care for all of them. And that's why sometimes the challenge of the prescription. But the make a long story short though, if they can find a way of bringing them into the program and taking care of some of those costs, then it might makes it more feasible for them to do that.

So we're looking at ways of being creative and moving into our rural areas. But having a guide to cut through the bureaucracy and somehow being able to do it is really wonderful. So let's talk a little bit about the rural health landscape. And of course, that's where I come from, the rural hospital landscape. I live in Princeton, Illinois, which is a town of about 8,000 and it's a very rural area. Grew up on a farm. But I work with critical access in small rural hospitals. Maybe there's a way that we can build on our critical access because that program is designed for Medicare patients in that capacity, even though it covers the full spectrum, it still deals with Medicare patients. And could we work it some way that we can build on the synergy between a community-based program such as PACE and a critical access hospital, keep people in their homes?

And because we know the high cost of being in a nursing home compared to somebody living in their home and having those resources, which I was alluding to in the last comments, but sharing those efficiencies could be some advantages for critical access hospitals. They could build on some... Keep more patients locally for them. So it's a win-win if we start looking at the landscape. And we know over the last, what is it, almost 13 years, we've had close to 150 rural hospitals close, 147 exactly. And we know this is going to be a tough year moving forward as we look at coming out of the pandemic, some of the recession topics we hear about and we know the challenge of the high cost of healthcare. But here's a way that we can help providers keep patients locally and really reduce the overall cost to the taxpayers.

In your packet of slides, there's resources that you can connect and read more about it. Let's talk about workforce shortages. And I know that this is really close and dear to everybody's heart, the challenges that we're experiencing not only in rural areas but urban areas, but if you're trying to set up a new program that presents even more of a challenge. And we know that as far as physician per capital, you have 10.8% per 10,000 people versus 30.8% in urban areas. So we really are behind the eight-ball so to speak in our rural areas. We don't have enough providers.

The advanced practice nurses and physician assistants have done a great job of filling those gaps. However, it's still not enough to coverage, and setting up a new program we have to think about can we look at community health workers? Are there other ways that we can build from our National Health Service Corp and nurse programs and getting them into the program. And are really important that if we move forward and expand this to our rural areas through our encouragement, can the door be open that some of those recipients of the National Health Service Corps, can they come to our communities that have PACE programs?

So startup application, and this is what I was surprised at when we looked at the program, talked to the administrators of the PACE program, was that they're only allowed one application per year. Which surprised me. And if you are a capital startup organization and you see the potential to help a community out, could you not do two applications at the same time, and maybe there's some value of working together. And it takes months to go through that and there's more cost in weighting it. So I really think that there should be some streamlining considered, and that was one of our recommendations. How do we look at the PACE program, look at how could we streamline the application and provide some flexibility so that organizations can partner and do several applications? Because maybe there's some sharing of transportation costs and some other things, or primary care providers to go from one area to the other if they're somewhat close together.

So I think we have to be creative. And if they're working at tribal areas, how can we support that expansion? So that's something that we feel that we can make those recommendations to the general administrators of the programs. Additional consideration, and we talked about the broadband, we talk about making the PACE sites automatic, HPSA designation, so that moves their application along. Some startup grant funds for rural PACE sites through the administration. Maybe there's a way in rural areas that we can look at rural development and some other programs that might specifically address the rural areas, and can we amend the regulations to create travel and work with payment? Because when you get into childcare and travel some of those costs, it's no different for childcare as it is for elderly, the cost of transportation in rural areas because of the travel distance. So we need to really think about how we can work with our Medicaid state directors. Can we have some conversation with them to seeing what can we do for long-term care providers and then make them aware of our program?

I think just recently there's been some discussion in Illinois. And so I'm anxious at some point to follow up with the state Medicaid director to see what opportunities. So, a healthy aging, that includes aging in places not currently a feasible option in many communities. The community believes that the PACE exemplifies integrated care and the expansion of the model in rural America, which is historically fragmented. And the committee is impressed with what we saw and it really seems like that's a way of providing a full range of services. And how do we expand and see the capacity of an all-inclusive program and how can we do that to make it more viable for people to live in their homes and really improve the quality of their life and also support our rural community providers in keeping people locally?

So thank you for the opportunity and like I said, we weren't really all that aware of PACE, but I'm a real pro for it now and look forward to see how it might roll out in our Illinois and others. So I would like to turn it back to the governor and I think we're going to talk about the other spectrum of healthcare and ages. So, Governor, thank you.

Jeff Colyer: Thank you, Pat, and we really appreciate the enthusiasm because it's true blue, you're really there and we appreciate all the things that we've learned from this program and we look forward to seeing it take up in rural areas. We're also going to now transition to the other end of the spectrum, which is childcare need and availability in rural areas. It's a really crucial part of childhood learning and development. It's an important part of economic development as well. But helping children develop their social, emotional and cognitive skills are needed, and being able to have appropriate childcare services can benefit children and benefit their parents and their families.

Now many communities across the U.S. face difficulties in providing childcare, but when you put this in a rural saying, the geographic and demographic characteristics of rural areas make this an even greater and more unique challenge for childcare. There are challenges that rural families grapple with when seeking childcare and there are unique issues that providers face when providing that care. So the committee was motivated to explore these challenges.

On this slide is a summary of some of the key issues the committee really dove into on things that we researched while putting together our policy brief. Isabel will explain more about this in a second. In addition, the committee met with representatives from the Rural Policy Research Institute, the Administration for Community Living and the Administration for Children and Families. And the committee members also attend several presentations on some preliminary findings on human service programs. So we put many of those together and we have crafted a number of recommendations to be sent to the HHS secretary. Isabel will now explain a little these in a little more in depth. Thank you, Isabel.

Isabel Garcia-Vargas: Oh, thank you Governor Colyer. So I want to start out by providing a little bit more background and context on the current state of childcare in rural America. As Governor Colyer mentioned, in many rural areas, childcare is either limited or non-existent due to a variety of challenges, including difficulties with recruiting and retaining a qualified workforce, maintaining overhead costs associated with building and renovating facilities, and also low enrollment. An emerging term used to describe these areas is childcare deserts.

While childcare deserts don't have an official designation, they can be thought of as a conceptually similar to the term food deserts. The Center for American Progress and Childcare Aware describe childcare deserts as areas that either have no childcare providers or have so few childcare slots that there are more than three children for every open spot. These deserts are most likely to be found in low income rural census tracts.

In the U.S., rural children under the age of 5, 24% of these children are eligible for childcare services, yet 55% over half of these children live in a childcare desert. For context, urban and suburban children represent 77% of the population of the children under 5 who are in need of childcare. Yet, 33% live in childcare deserts. Childcare shortages are a pressing issue for rural communities given that they undermined a family's ability to find childcare that is both affordable and physically accessible. A survey was conducted in 2019 by the Morning Consult on behalf of the Bipartisan Policy Center, and it states that only 38% of rural parents could easily find childcare that fit within their budget.

By contrast, over 50% of urban parents were able to find affordable childcare. As a result when compared to urban families, more rural families either depend on the family member or a friend for childcare, or even relocate in hopes of finding childcare elsewhere. Childcare shortages can also undermine the economic autonomy of a family. For example, a 2021 Bipartisan Policy Center survey reports that 86% of rural parents who weren't working cited childcare responsibilities as influencing their decision to be unemployed.

Now I'm going to discuss the impact of COVID-19 pandemic, which posed caused new challenges to the rural childcare industry. During the early stages of pandemic, 46% of the rural parents reported that their provider had closed provisionally, and over 90% of those Head Start programs across the U.S. ended up pausing their operations. Providers that continued to provide services actually lost revenue and they experienced employee shortages, changes in classroom size and regulations, and costs that were associated with the PPE equipment among other difficulties. Over the course of the pandemic, relief grants and loans were allocated to the childcare sector. Namely, three pieces of legislation, the Coronavirus Aid Relief and Economic Security or CARES Act, the Coronavirus Response & Relief Supplemental Appropriations Act, also known as the CRRSA, and the American Rescue Plan Act, known as ARPA, were appropriated over 50 billion of childcare relief funds.

This was provided through the Administration on Children and Families and it was allocated through various rounds of supplemental funding. In October of 2022, the Health and Human Services released an analysis of the American Rescue Plan's childcare stabilization program and the extent to which the program supported childcare providers in each state. The analysis reports that in rural counties, approximately 30,000 childcare programs received assistance. Providers in 97% of the rural counties in most states received support. Yet, the committee recognizes that rural providers may have not been able to access the entirety of these relief funds made available to them due to longstanding challenges that rural organizations face when attempting to access federal grant and loans.

Examples of these challenges include lack of organizational capacity to apply and lack of awareness of available funds in the first place. In this way, the COVID-19 pandemic represented a particularly tumultuous period of time for the rural childcare industry characterized by economic disruption as well as economic relief through influxes of public funding. The pandemic also drew attention to the longstanding difficulties both providing and accessing childcare in rural areas. These realities motivated the committee to provide recommendations to the HHS Secretary on ways to improve ability and access to childcare in rural America.

The committee met with representatives from the Rural Policy Research Institute, the Administration for Community Living, and the Administration for Children and Families. Committee members also attended a presentation regarding the preliminary findings of an analysis on the human services programs in rural context. It was conducted by the Administration for Children and Families and the Health Resources and Services Administration. After exploring these issues, the committee crafted recommendations that were sent to the HHS Secretary. We came up with seven recommendations which are listed on this slide, and these recommendations can naturally be grouped into three areas, and I will go through those areas one by one.

So, the first bucket of recommendations that we'll discuss has to do with the Public Health Emergency waivers and learned practices. As previously mentioned, during the Public Health Emergency, rural childcare providers faced considerable challenges while providing services. And some of these challenges were alleviated by the temporary waivers made available to childcare providers, which in turn allowed for the innovation and the delivery of childcare services. Anecdotally, committee members that oversee rural health Head Start programs know that the flexibilities allowed during the Public Health Emergency proved useful.

For example, the Office of Head Start provided a fiscal and administrative flexibilities waiver that offered relief from various fiscal and administrative requirements. This led the committee to recommend that the secretary assess which Public Health Emergency waiver should be extended to expand access to childcare services in rural areas. And I would just like to add also that not only this recommendation, but it's taken even rural areas longer to come back from the COVID experience. And so extending these waivers is even much more critical, we believe, in rural communities, which is already troubled with resources and access for families.

The second bucket of recommendations revolves around the strategies to address access to care and financing. The committee recognizes that various intercepting reasons contribute to shortages in childcare and difficulties in accessing care in rural areas. Thus, it will be necessary to use a multi-pronged approach to improve access to childcare for rural families. One major issue facing rural communities is a significant shortage of childcare providers. And as I discussed earlier, there's a growing recognition that many communities can be classified as childcare deserts. And moving forward it will be necessary to better understand what incentives are needed to retain existing providers and to attract new providers in areas with extreme shortages, enable higher salaries for staff, and reduce the effects of low consumer volume on program sustainability.

Therefore, the committee recommends that the Secretary consider creating a childcare shortage area designation, similar to the health profession's shortage area designation to inform future policymaking about childcare supply, access, and affordability. Furthermore, rural communities face difficulties while accessing childcare services. In order to improve accessibility for all rural subpopulations, it will be essential for all levels of government to reach out to minority, racial ethnic communities, and tribal nations to increase their participation in early education efforts.

For example, for the tribes, there are currently no public data sources that indicate the number of childcare and early education programs serving Native American children. Thus, there is much more work to be done to learn more about their capacity to meet childcare needs. These realities also led the committee to recommend that the secretary support organizations that serve minority and rural populations such as historically black colleges and university tribal colleges, community colleges, community health workers, colonials, community leaders, and tribal leaders by funding them too, one, help increase the recruitment to early childhood education programs among rural African-American, Hispanic, American Indian, Alaska Native residents. And two, expand outreach and programmatic elements in the early childhood education.

Additionally, to the extent possible, the Office of Childcare in ACF should work with tribal leaders to collect data on tribal childcare capacity and need. At this time, I'd like to return to discussing the topic that has been mentioned a few times now, and that is pertinent when it comes to rural childcare. Head Start committee members who oversee Head Start programs note that the Office of Head Start has emphasized the expansion of early Head Start programs. While a committee member support such an expansion, it is important to keep in mind that without a simultaneous expansion of local Head Start program capacity, graduates of a Early Head Start program may be left without a quality Head Start provider. As a result, these graduates won't have a continuity of education through entry into kindergarten. Therefore, the committee recommends that when possible the Secretary allow for expansion of Head Start capacity in communities with newly created or expanded Head Start programs to allow for continuity of education and early Head Start through entry into kindergarten.

I'd like to enter discussion of this bucket of recommendations strategies to address access to care and financing by discussing a strategy that can help ease the challenges that is being faced through offering childcare in rural areas while increasing access to professional development programs for providers. Specifically, the strategy is ensuring to access high speed, low cost broadband services for childcare providers in rural areas, given that a higher proportion of rural families receive childcare through a home base institution when compared to their urban counterparts. This disparity represents a major gap in provider development specifically given that teacher trainees have been associated with increased cognitive test scores for the children in the subsequent year.

Making training more accessible to rural providers may improve the quality that the children receive. In addition, adequate broadband service could potentially also reduce social isolation often experienced by rural providers. And for these reasons, the committee recommends that the Secretary work with the U.S. Department of Agriculture, the Commerce Department, and the Federal Communications Commission to help rural home-based childcare providers gain access to high speed, low cost, broadband services for training and education.

And our final bucket that we would like to discuss in our recommendations relates to workforce. In the rural childcare industry, workforce recruitment and retention are major issues in part because of low salaries. In 2021, the average childcare provider salary nationally amounted to approximately $24,000 a year, or little over $11 an hour. Evidence suggests that wages are lower in rural areas than in urban areas, and the recruitment of personnel into childhood education areas have become more insufficient with qualified applicants. There's various licensed childcare positions that require associate's degrees or higher early education, or a related field. And what we're seeing is that 25% of rural adults have a bachelor's degree or higher compared to 37% of adults in suburbs and cities. And this is relatively lower level of post-secondary degrees among rural adults, which represents a potential mismatch between the availability of qualified applicants and staffing needs at rural health Head Start providers and other childcare centers.

So far, various methods have been employed to tackle workforce issues. For instance, in an effort to recruit more qualified staff, the Office of Head Start offers a qualification waiver for Head Start preschool teachers. And this waiver is for program that have not yet been able to recruit a qualified teacher for their Head Start preschool room. Among other requirements, the program needs to demonstrate that the teacher is enrolled in a program that grants a qualified degree such as an associate's degree. However, this waiver doesn't apply to early Head Start programs which require teachers to have a child development associate, a CDA, or equivalent certification.

As a result, efforts to expand early Head Start programs in rural areas could be impeded. Therefore, the committee recommends that the secretary is in the qualification waiver for the Head Start preschool teachers to early Head Start programs who face similar difficulties with recruiting qualified teachers as it applies to waiving the CDA or equivalent to a CDA certification requirement. Extending this waiver would allow early Head Start programs to immediately enroll infant and toddler teachers in a program and provide initial training prior to entering the classroom. And to tackle the workforce issues, rural Head Start programs have also striven to hire parents as staff.

As of 2016, 29% of non-metropolitan area Head Start program employees were either current or former parents. Given that parents have a vested interest in the success of these programs moving forward, the committee recommends that the Secretary ensure both ACF's, Office of Head Start and Office of Childcare provide the necessary flexibility and support for rural providers that allow them to develop programs to train parents and community members and provide support to obtain required childcare licenses and degrees.

In summary, the committee felt it was an opportune time to explore the topic of childcare need and availability in rural areas. While conducting the research for the policy brief, it became clear to the committee that the rural childcare industry does face many longstanding challenges that make it difficult for families to access affordable quality childcare. And addressing these challenges will require a multi-pronged approach, which the committee sought to embrace as it prepared its recommendations. And at this time, I like to thank you all for engaging with me on this topic.

Kristine Sande: So, the question was, I'm a registered dietician working in PACE in California, having access to healthy nutritious food support is extremely important. How will the rural area execute procurement of healthy food and deliver the meals?

Meredith Anderson: Thanks Kristine. Hi, everyone. My name's Meredith Anderson. I'm a public health analyst at the Federal Office of Rural Health Policy, and I helped the committee put together the policy brief and was with them at the September meeting. So this is a great question. Thanks, Jenny. And yes, the nutrition piece is definitely a big component of PACE along with meal delivery as a component as well. So I did respond to Jenny here, but I wanted to talk a little bit more about this.

I would just say that from what we learned at the September meeting, from hearing from PACE experts and programs that the rural PACE programs that thrive do so because they're able to be dynamic and creative and really utilize existing resources and infrastructure. So that certainly applies here to the nutrition and really to all components of PACE. And something else we heard about as well was a hub and spoke model where an existing urban or suburban PACE organization expands into rural, and that rural component of the program is able to utilize some of the resources from that urban or suburban hub piece. So it's definitely not a one size fits all approach, since as we know, every rural community is different. It has varying levels of existing resources and infrastructure. Thanks.

Pat Schou: Meredith, that was a great response for it. I would just like to add that if we're able to partner in the PACE community with the rural hospital, they have a cafeteria. They generally have a dietician on staff and could potentially take advantage of providing that nutritional component that would maybe help with the community-based organization. So that might be an option to consider because nutrition is very important. And I think we saw that from the people in the community that were doing the PACE program. They got their meals there, or they could take their meals home with them, and it was really very, very important. Because that's what we see often with elderly, they don't eat well and then they get, as Governor Colyer is smiling, he knows that well when he sees them in the office that they're eating is not there. So nutrition is very important. I thought it was a great question. I just could say partnership with the hospital might be an answer.

Meredith Anderson: Yeah, great point. Pat. I think, too, that builds on our recommendation and the brief about partnering with critical access hospitals. Thanks.

Jeff Colyer: I want to thank everybody for joining us this afternoon. I'm excited about the PACE program and see this as a great opportunity. The childcare issues are so critical to the quality of life in our rural communities and for the long-term care of our kids. So we're excited by all of the work that everyone has done. But I want to thank our staff. I want to thank Pat, Isabel. I want to thank all of our team members on the commission and also want to thank our hosts, the RHIhub friends. They've done an outstanding job once again, and we want to thank you for sharing lots of information with everyone. Thank you very much.