Helping close the health care gap in rural North Carolina

Dr. Lisa Shock is Chief Population Health Officer with United Healthcare Community Plan of North Carolina.

Corinna Miller is Director of Community Involvement at UnitedHealthcare.

About 15% of the U.S. population lives in a rural location.¹ Residents in these less populated areas often face additional barriers that limit their access to health care services. Necessary services are not always available and other issues such as internet access, transportation, financial limitations, health care literacy and a lack of trust can widen the gap. 

A U.S. Census Bureau report found that 9.1% of the population living outside metropolitan statistical areas (MSAs) did not have any type of health insurance in 2018, compared with 8.4% of the population within MSAs.¹ Infants in rural households were also less likely to have health insurance, compared with those in urban households. Of rural residents who were uninsured, 43.4% did not have a usual source of care and 26.5% delayed receiving care in the past year, due to cost.¹

Residents in rural areas face limited primary care and specialty health care resources

People living in rural locations often times have limited availability to some physicians, specialty providers and services. On average, rural counties have four times fewer specialists per capita than urban areas.² Other services such as behavioral health, maternity care, substance use disorder treatment, oral health, hospice and palliative care may also be reduced as compared to urban and suburban areas.

Three types of health care facilities help to provide primary care services to rural communities: Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and acute care hospital outpatient departments. There are 660,893 U.S. residents living in rural counties without an FQHC, an RHC, or an acute care hospital.¹

Pregnant individuals are also at risk. Only 27% of rural counties had hospital-based obstetric services as of 2018.¹ Many pregnant individuals must travel more than 30 minutes to reach a hospital with obstetric services which increases the risks of infant mortality and pregnancy complications.³

Behavioral care is also limited in rural areas. As of March 2021, 58% of Mental Health Professional Shortage Areas were located in rural areas. Individuals in rural areas seeking treatment for substance use disorder may have fewer wraparound services. Eighty-two percent of rural residents live in a county without a detox provider.¹

Traveling to receive care is a barrier and telehealth Is also a challenge

Traveling to health care providers can be costly, especially with specialty providers being located even farther away. This may cause people living in these areas to skip seeing specialists or see primary care physicians for specialty care. This is often true with pregnant individuals who cannot access obstetrics and instead receive care from a family physician or general provider.

Accessing telehealth or mobile apps is not always an option for residents in rural locations as technology and high-speed access to the internet may not be available. People in nonmetropolitan locations are almost twice as likely as those in metropolitan areas to lack internet access at home.¹ There are also fewer people who own a smartphone or access the internet frequently.⁴

Bridging the health gap for individuals in rural locations

UnitedHealthcare Community Plan of North Carolina is helping rural residents improve their health by removing some of these barriers. We are studying the needs of the community and looking at ways to maximize care where people live, work, play and pray. We are also looking at how we can help residents in rural areas with needs related to social determinants of health, such as lack of nutritional food and housing, find solutions.

We are able to support some of this work in rural communities as part of the Healthy Opportunities Pilot (HOP). HOP is a new approach being developed by the North Carolina Department of Health and Human Services that is addressing whole person care with Medicaid in select qualifying counties. HOP addresses services for social determinants of health such as transportation, housing and food. Thirty-three of North Carolina’s 100 counties participate in HOP even though 80% of our population lives in unincorporated areas.⁵ We are working to reach out to all residents in rural areas across the state and are measuring our efforts to ensure these areas can meet their health needs.  

To overcome the limited availability of health care services and digital access barriers, we will soon be providing primary care physicians and clinics with digital tools. Some of our digital application-based resources will enable video visits to improve access and address chronic conditions.

We will also be holding health fairs and community events to supply needed items such as diapers, car seats and other resources. To support equitable access to care, we are connecting with faith-based organizations in historically marginalized communities.

Supporting pregnant individuals in rural North Carolina

North Carolina OB/GYN clinics are bringing pregnant individuals in rural locations together in group prenatal programs. CenteringPregnancy groups meet at clinic locations to bring together those who are expecting. During meetings, pregnant individuals take their own vitals, have one-on-one time with a provider and share helpful information about pregnancy, birth and caring for infants. Pregnant individuals are paired with another person who is due the same month as they are and go through their whole pregnancy together, creating a bond and support system.

UnitedHealthcare provided a $175,000 grant to support implementation of CenteringPregnancy, an evidence-based model. It aims to improve a wide range of birth outcomes, including lowering the risk of preterm births, reducing low birth weights, increasing rates of breastfeeding, promoting postpartum depression screenings and healthier pregnancy spacing.

The Maternal Outreach Through Telehealth for Rural Sites (MOTHeRS) Project is another program that is working to increase access to health care and improve health outcomes for mothers and babies in rural North Carolina. The MOTHeRS Project provides face-to-face care at community-based primary care obstetric clinics, health departments, and other regional clinics. Expectant individuals are also able to access telehealth services at home via tablet, computer, or phone, if clinically indicated. 

The primary care provider remains the driver of the individual’s care with the assistance of any needed specialists. The MOTHeRS Project also provides for other important needs for pregnant individuals, such as mental health care, food and clothing. Pregnant people are also connected with additional resources in their community as needed.

Both programs are supporting pregnant individuals by making support and specialized care available in a way that works for rural locations. This is important to improving the health of all rural residents, since everyone should have an opportunity to experience health and well-being, no matter where they live.