Learning from international models for delivering quality care and support to older people living in rural communities

Background

Delivering care for our aging population is a growing challenge in the USA and internationally, especially for older adults living in rural communities. The adequacy of economic and human resources available to serve them is diminishing while the demographic and financial challenges of serving this population increase. Partnerships, although little researched, are often suggested as a way to address needs and pool resources; therefore, this collection of articles brings together interdisciplinary and cross-sectoral qualitative perspectives on new ways of viewing partnerships.

Lead authors in five disciplines from four different nations provide new insights about how to develop partnerships to bring forward more effective and efficient models of care for older adults in rural areas. Spelling and terminology in each article follows the conventions of the country of the lead author.

Each of the manuscripts uses a different lens to assess new approaches to developing and nurturing interdisciplinary and cross-sectoral partnerships, and offers information about how partnerships can be developed strategically to improve care for older rural adults. The foundation for this collaboration was a symposium convened by Lyn Holley and Roger O’Sullivan at the 69th (2016) Annual Scientific Meeting of the Gerontological Society of America; speakers; papers for the symposium were recruited intentionally to present the state of the art of scholarship and practice in this area.

These manuscripts will be of interest to practitioners in any aging-related field that serves rural older adults (e.g. public health, nursing, sociology, rural studies, kinesiology, social work, long-term care management, geriatric medicine and gerontology). Scholars in those fields may be especially intrigued by the article that considers a theoretical frame for practical assessment of these efforts. College students and other learners will find these are valuable supplements to texts about care for rural older adults. Citizen advocates and public administrators may be particularly interested in the optimization of resources enabled through the strategic approaches to partnership that are described.

Articles

The lead article “Research partnerships – embracing user involvement: practical considerations and reflections” by Roger O’Sullivan, PhD, applies research and fieldwork undertaken in Ireland, and practical reflections on designing partnerships to community-based partnerships, cross-sectoral and cross-country partnerships for research and practice. It expands understanding of the theoretical context in which partnerships are designed and operate, and provides insight into the practical questions and considerations that inform decision making on partnerships.

Intentional application of the CARDI model developed by Dr O’Sullivan and others is illustrated in the next article by a case report of development of a successful university program specifically designed to prepare nurse practitioners to provide interdisciplinary acute care to rural older adults. The program provides an important example of how an interdisciplinary partnership could be one answer to meeting the needs of rural older adults. “Interdisciplinary partnerships for rural older adults’ transitions of care” recounts conceptualization, funding, organization, methods, and evaluation of the program. The Principal Author Joyce Weil, PhD, MPH, notes that evaluation to date indicates that the program may be useful as a model for interdisciplinary partnerships to create new rural adult-gerontology acute care academic programs that prepare nurse practitioners to provide culturally and clinically competent care for rural older adults.

“Strategic partnerships enhance resources for care of rural-dwelling older adults” illustrates how university partnerships with practitioners can inform and improve both theory and practice to address the persistent problems of recruitment and retention of adequate staff in rural nursing homes. The article describes a case in which the CEO of a nursing home partnered with a university to apply demographic analysis and qualitative assessment to identify organizations that could as partners contribute resources critical to meeting staffing needs. Partnerships were developed with a variety of private charities and agencies of local, state and federal governments that provided social services meant to help unemployed persons. Partnerships provided resources that enabled creation of new training and promotion opportunities, and dramatically reduced expense of “temporary staff” that are typically used short-term by long-term care facilities to cover vacancies. The case is described through the lens of the experience of the CEO of a nursing home in rural Nebraska who collaborated with his “alma mater” to identify the potential for and develop strategic partnerships that enabled the nursing home to meet staffing challenges and which produced innovations, perhaps even a complete model worthy to be considered for replication.

Partnerships can be useful in designing and delivering interventions intended to reduce racial disparities in health risk among rural older adults. The article, “Assessment of metabolic syndrome risk factors among rural-dwelling older adults requires innovation: partnerships and a mobile unit can help” reports how Martha R. Crowther, PhD, MPH, Cassandra D. Ford, PhD, RN, FAHA and their community and academic partners collectively amassed and shared social capital to gain access to rural communities where residents are predominantly African Americans with lower social economic status (SES). That access was antecedent to the intervention, which was to use a mobile unit with an interdisciplinary healthcare team to assess risk of metabolic syndrome (MSX), and access to healthcare in rural West Alabama. The partners collaboratively assembled evidence of the racial disparity in health, also demonstrated the effectiveness of this approach (partnering to earn social capital and share information) and intervention (partnering to provide interdisciplinary care and information by way of a mobile unit) to address the disparity.

The Canadian Institutes of Health Research (Canada’s federal funding agency for health research) recognized the potential power of partnerships by funding a number of studies through a special program,“ Partnerships for Health System Improvement (PHSI) in 2013 (www.cihr-irsc.gc.ca/e/39315.html).” The study which is reported in “Impact of a home-based nutrition and exercise intervention in improving functional capacity associated with falls among rural seniors in Canada” describes conceptualization, organization implementation and evaluation of a home-based exercise intervention that is delivered thorough an urban and rural home care network. The goal of the intervention is to improve functional capacity and reduce falls among older adults. Falls are a leading cause and symptom of age-related functional decline. Smaller population and distance from services made rural recruitment initially difficult, but the researchers partnered with community organizations and individuals to utilize the connectedness typical of those small populations in which “everyone knows everyone” to disseminate positive reports about the intervention and develop trust. That experience and the positive evaluation of the reduction of frequency of falls strengthens other indications in the literature (e.g. the article above) that rural context and culture is important to consider in developing the partnership experiences and benefits.

Partnerships often increase resources both in volume and in content. Charles Musselwhite’s article, “The importance of a room with a view for older people with limited mobility” reports qualitative research findings that suggest immobile older adults enjoy watching a motion full, changing, world going on outside the reach of their own mobility, and that they interact with it reflectively to create meaning and sense, and relate themselves to the outside world. Findings suggest that those working in health and social care can utilize this inexpensive but powerful intervention by partnering across disciplines even potentially using technology to adjust the environment of the older person so the older person can observe the outdoors.

The US Government administers a nationwide healthcare system for military veterans, the Veterans Administration. The Veterans Health Administration operates a network of 170 hospitals and 1,061 Community-based Outpatient Clinics that provide a range of medical, surgical, psychiatric and rehabilitative care. However, healthcare for older veterans in rural situations poses particular challenges. The article, “Supporting older military veterans in the rural United States.” describes utilization of partnerships within the context of an overview of how the VA has dealt with the challenges of providing care for older rural veterans. VA healthcare is largely concentrated in urban areas, thus limiting rural Veterans’ access to VA benefits. These challenges have been addressed by establishing the national Veterans’ Health Administration Office of Rural Health to “refine, and promulgate policies, best practices, lessons learned, and innovative and successful programs to improve care and services for Veterans who reside in rural areas of the United States” (38 U.S. Code § 7308, 2006). Based on results of more than 1,700 local pilot projects, two strategic themes became unifying principles for practice in 2016, one theme highlights partnerships with public and private local providers and advocacy organizations as the recommended approach to enhancing services. VA guidance for these partnerships is discussed, and Table I provides the VA “Lessons for Rural Partnership.”

Finally, an article by Cassandra Ford describes how a professional association of scholars can be a vital and effective means for dissemination of new knowledge to both researchers and practitioners, who are in positions that permit them to translate knowledge into practical applications. This article discusses the challenges of providing care for older persons in rural circumstances and argues that such associations and their literature help improve the capacity of societies to serve rural-dwelling older adults.