Providing Health Services in a Rural Community, Capstone Project Example

Introduction

Rural healthcare in the United States faces a number of serious concerns that require further investigation and evaluation. There are significant barriers to healthcare access for many people who live in rural areas; therefore, these individuals may possess weaknesses and challenges with respect to their health and wellbeing that impact their quality of life. This is due in large part to lack of resources and other concerns that impact health and wellbeing. These factors require nurses to give important and meaningful input regarding the role of healthcare in rural communities where the need is greatest. Most importantly, access to healthcare services for many rural children and adults is limited because there are fewer clinics and opportunities in these areas to provide care and treatment on a continuous basis. This is a difficult set of circumstances that requires an economic evaluation in order to determine how to acquire new types of resources in order to accomplish the desired objectives and improved access to care and treatment for patients across a variety of population groups.

The healthcare system must ultimately recognize the unmet needs of many rural communities and establish objectives to ensure that there are significant opportunities for growth and change within these environments, including improved health and wellbeing. This process requires a discussion of programmatic efforts and resources that are required to improve healthcare services to rural areas and to determine if these programs and the required costs are feasible and appropriate for the objectives that are sought. The following paragraphs will discuss these objectives in greater detail and will emphasize the importance of project development and its impact on local residents who will benefit from these services if they are available and access is granted to them on a regular basis to improve their health and wellbeing.

Discussion

In rural communities, access to healthcare services is often severely lacking; therefore, it is important to identify strategies that might be effective in addressing these concerns and in supporting the needs of patients across a variety of age groups. In these communities, there is a significant lack of focus and understanding regarding patient care and the level of services that many individuals require, due in large part to the limited number of healthcare clinics and hospitals that exist (Agiro, Wan, & Ortiz, 2012). In this context, it is particularly challenging to address the needs of patients in rural areas because there is a lack of resources and a subsequent ability to deliver high quality care to patients who require these services (Agiro et.al, 2012). Therefore, it is necessary to identify potential opportunities to improve outcomes and to reflect upon the needs of local residents through new ideas and approaches to manage care and treatment in a timely manner that is conducive to improvements in health and wellbeing (Agiro et.al, 2012).

In most communities, local health centers provide a means of accessing basic and preventative services and treatment to address a variety of current or potential health conditions that may arise throughout the life span, and these clinics support local residents who might require care of a minor urgent nature or other types of care (Adashi, Geiger, & Fine, 2010). In this context, it is evident that organizations must develop strategies that will encourage and facilitate support for a variety of objectives to manage populations more effectively over time (Adashi et.al, 2010). Nonetheless, access to community-based services is limited in some areas and therefore, requires further investigation and resources in order to address this problem more effectively (Adashi et.al, 2010). Community health centers are an important reminder that local residents, particularly those in rural areas, do not often possess the level of access to services that is most desirable, thereby creating a set of difficult challenges for these communities and the people who reside and require these services (Adashi et.al, 2010).

Assessment

Environmental Challenges, Access for Consumers, Technology Required

Many persons in rural areas possess limited access to resources that are likely to maintain and/or improve their health and wellbeing. This is a difficult premise and requires an awareness of unmet needs within these communities. For example, older adults typically require a higher level of services due to their often compromised health status; therefore, they must be provided with the tools and resources that are necessary to meet these needs effectively in the rural environment (Bacsu, Jeffery, Johnson, Martz, Novik, & Abonyi, 2012). It is the responsibility of the healthcare community to address the challenges related to the needs of different population groups, and in particular, older adults, in rural areas (Bacsu et.al, 2012). There are a number of particularly challenging issues that rural communities face in treating patients who require ongoing healthcare support and assistance to encourage older adults to age without significant health concerns (Bacsu et.al, 2012). Greater attention must be directed towards rural communities in an effort to better understand their challenges and to recognize the value of improving access to community-based healthcare services in these areas (Bacsu et.al, 2012).

Most importantly, much of the healthcare industry recognizes that there are significant issues in rural communities because there is a lack of access to care and treatment that is available for rural residents (Huttlinger, Schaller-Ayers, Lawson, & Ayers, 2012). It is very difficult to establish healthcare services in many rural communities because significant resources are required in order to accomplish these objectives and sustain them over the long term (Huttlinger et.al 2012). It is important for the healthcare industry to demonstrate their support of rural communities and in advancing their access to much needed care and treatment within their own neighborhoods (Huttlinger et.al, 2012). Many individuals do not have access to care either because they do not have health insurance, or they lack transportation and are unable to visit clinics and doctor’s offices because they are too far away; therefore, it is necessary to consider opportunities that may have a positive impact on these residents by bringing healthcare to them within their towns, particularly since they are often a far distance from these clinics and their offerings (Huttlinger et.al, 2012).

Many populations who are perceived as at-risk are likely to reside in rural areas, due in large part to lack of access to routine healthcare services, testing, and treatments that could improve behavioral outcomes and general quality of life (Jennette, Vupputuri, Hogan, Shoham, Falk, & Harward, 2010). From this perspective, it is evident that there are significant issues to consider that have an impact on local residents, such as limited health promotion activities that might have a positive influence on their lives (Jennette et.al, 2010). It is important to demonstrate the value of improving healthcare access for at-risk communities, particularly those in rural areas, so that these individuals have a chance to improve the quality of their lives and to understand the risks that are involved in the health-related decisions that they make, as well as the lack of access to services that could save their lives (Jennette et.al, 2010). These factors require an understanding of the specific risks that impact these populations and how they might be alleviated through activities that encourage the allocation of resources and the development of clinics in these areas to positively impact patients who reside there (Jennette et.al, 2010).

Issues regarding primary care are highly prevalent in many rural communities, due in large part to limited availability of clinics and doctor’s offices within close proximity to individual homes (Bodenheimer & Pham, 2010). These limitations prevent individuals across all age groups from obtaining the expertise and guidance of a physician and/or a nurse practitioner when these opportunities could improve their health and ultimately save their lives (Bodenheimer & Pham, 2010). Therefore, primary care access is a significant problem that requires greater attention and focus and also supports the development of new ideas and approaches that will likely have a positive impact on patient care outcomes (Bodenheimer & Pham, 2010). In this context, it is important to identify how to improve primary care access for individuals who require care and treatment in the rural environment (Bodenheimer & Pham, 2010). For individuals who live in these areas, it is necessary to consider their needs more fully and to determine how to best approach these needs with an expanded set of approaches that will expand access to areas where there is a high level of need and where access to physicians and other services is sorely lacking (Bodenheimer & Pham, 2010).

Mission, Values, and Goals

In rural areas, one of the key priorities is to develop a greater understanding of the needs of this population and the creation of new ideas that will support the growth of the practice environment, along with other factors that will demonstrate a high level understanding of the needs of patients and how to provide them with care and treatment that is consistent with their values and their desire to improve the management of their quality of life (Racher, Vollman, & Annis, 2012). Most notably, the exact identification of the circumstances involving rural residents must be determined, as this will support the development of new factors to facilitate growth for local residents, along with new ideas that will capture the interest of nurses and other healthcare providers who will advocate for these individuals and provide them with the tools and resources that are required to improve their overall health (Racher et.al, 2012). There are considerable issues to be addressed that require ongoing financial support from the healthcare community at large, and this reflects the challenges of developing new strategies to address outcomes for these individuals with respect to their overall health and wellbeing (Racher et.al, 2012). Healthcare leaders must demonstrate a high level commitment and stake in rural communities so that these individuals receive high quality care and treatment that will support their health and wellbeing, and this must occur within their own communities and neighborhoods (Racher et.al, 2012).

Market Analysis

In many areas of the rural United States, there are significant gaps in the availability of and access to healthcare services that are essential to meet the needs of local residents. Therefore, there is a high market demand for services in these areas and for the development of new clinics to accommodate this type of patient population. Modern healthcare systems must embrace rural communities because these individuals possess many unmet needs that must be addressed in a timely manner (Fortney, Burgess, Bosworth, Booth, & Kaboli, 2011). In rural areas, many residents are of retirement age or older, as younger populations are moving away from these areas and into urban communities, and furthermore, many of the workers in rural healthcare facilities are also older, including physicians (American Hospital Association, 2011). This reflects a lack of younger workers to fulfill the needs of existing hospitals and clinics, as well as new facilities, thereby increasing an already challenged rural environment (American Hospital Association, 2011). Many rural hospitals have less than 25 beds, but they are required to provide the desired levels of service that emphasize a variety of areas (American Hospital Association, 2011). Rural areas do not often provide optimal reimbursement levels for physicians; however, this is changing for the better due to the opportunity for physicians to practice in these Health Professional Shortage Areas (HPSA) over the next five years (American Hospital Association, 2011). In some areas, there is a single primary care practitioner for every, 3,500 residents, while some areas have one for every 2,500 residents; furthermore, only 10 percent of these physicians actually live in rural areas (American Hospital Association, 2011). Also, specialists are largely unavailable, with 54 specialists per every 100,000 residents, which is extremely low; therefore, it is important to aim to recruit physicians to these areas to practice medicine through a variety of initiatives to increase the number of physicians that are available to residents in these areas (American Hospital Association, 2011).

The primary stakeholders in rural clinics are the patients who are served and who require adequate care and treatment to meet their needs. The secondary stakeholders are community-based leaders and policymakers who establish the agendas to setup and operate these organizations over time. Furthermore, physicians have a key stake in these developments because they administer the care and treatment that patients require. These factors have a significant impact on patient care quality and the overall clinic environment. The competition within these markets is less substantial than in urban areas; nonetheless, the quality of care that is provided requires a high level of consideration and focus because patients rely on this care to achieve greater health-related outcomes.

SWOT Analysis

In order to determine the potential feasibility of community clinics in many rural areas, it is important to identify some of the business practices and principles that exist in these areas and to be cognizant of the challenges that also exist. Most importantly, the following SWOT analysis will summarize these challenges:

• Strengths: Healthcare practices in other communities may serve as a guide in creating new clinics that will have an impact on healthcare in rural areas. Furthermore, healthcare providers may exercise their knowledge and expertise in advancing the potential for new clinics in these areas.
• Weaknesses: It is evident that lack of resources and lack of proximity to other communities that lead to isolation and a limited ability to obtain the necessary economic support to establish new clinics in areas where healthcare needs are largely unmet.

Opportunities: Community clinics in rural areas will be able to treat many patients who otherwise lack access to healthcare services. In addition, these clinics will provide new jobs to clinicians and physicians and encourage them to take risks and to challenge themselves in communities where they possess a high level of unfamiliarity.
Threats: There is a potential risk of being unable to attract and recruit the appropriate professionals for the positions that will become available, particularly if they are not interested in relocating to rural areas. In addition, transportation may remain an issue for some individuals in these areas in their aim to access the clinic setting.

Recommendations

In rural communities, it is important and necessary to improve access to healthcare services because those residing in these areas do not have the care and treatment that is necessary to improve their quality of life. This is an essential reminder to develop a strategy that will encompass the development of new factors and approaches to improve healthcare outcomes and to recognize the importance of developing opportunities to improve the lives of people living in rural areas. It is necessary to establish an environment that supports the development of factors to encourage the growth of rural clinics because those living in these areas lack many important resources that might have a positive impact on their lives over the long term. Therefore, it is important to identify how to best approach a strategy that will encourage expansion into rural areas where many healthcare needs are largely unmet and to recognize the importance of evaluating the financial options that are available to support these clinics, as well as personnel and other resources that are required to conduct operations in an efficient and productive manner. In this context, it is important to identify specific challenges that must be addressed that support the development programs to construct new facilities or refurbish existing facilities in areas where there are a clear lack of healthcare resources.

Another recommendation to consider in expanding clinics in rural areas is to emphasize the importance of mental health and the issues that many people face in this area. Mental health in rural areas is a largely ignored problem; therefore, it must be addressed in a timely manner and must demonstrate a high level of support and understanding of the issues that are most likely to occur with the patients who are seen in the rural clinic environment (Gamm, Stone, & Pittman, 2010). In this capacity, organizations must be prepared to manage the mental health issues that their patients might present with and determine how to best manage these issues in an effective manner, including the ability to reflect upon the needs of patients and to understand how to approach mental health with the appropriately qualified experts in place (Gamm et.al, 2010). This is an important requirement for these individuals and must reflect the challenges of developing a strategy that supports the creation of programs and support systems to encourage mental health to be discussed and evaluated in an open and honest manner to accommodate patients (Gamm et.al, 2010). It is important to consider the resources that are required to manage mental health in rural communities and to also recognize the importance of developing strategies to specifically accommodate these practices in a timely manner to improve patients’ quality of life (Gamm et.al, 2010).

Strategies for Attracting Healthcare Professionals

Based upon the information that has been obtained, it is important to develop a strategy and focus that will facilitate a gathering of resources and an opportunity to examine which rural areas have the greatest unmet needs and that require a clinic setting in order to optimize these improvements. Although the clinic location is an essential component of the strategy, there is also a potential lack of staffing in many areas and this may contribute to negative outcomes because many professionals may not be willing to relocate to rural areas in which to practice and to conduct their lives (MacDowell, Glasser, Fitts, Neilsen, & Hunsaker, 2010). It is necessary to evaluate the potential opportunities to recruit employees to work in rural communities and to determine how to best approach these issues to improve recruitment and retention rates (MacDowell et.al, 2010). There are considerable factors related to the development of new strategies to attract employees, including compensation and benefits, as well as recruitment packages, and these factors must be considered in an attempt to identify new possibilities for growth and change (MacDowell et.al, 2010). It is critical that clinic environments possess an adequate number of employees and also a means of aiming to retain high quality employees in these areas for as long as possible (MacDowell et.al, 2010). It is imperative to evaluate these conditions and to reflect upon the needs of local communities in determining how to recruit employees and entice them to work in rural areas to treat populations with highly specific needs (MacDowell et.al, 2010). The ability to attract employees to work in these areas requires a high level effort to determine which resources and benefits are required to expand access to these services and to recognize the importance of resource allocation to attract high quality employees to work in these clinic environments.

Strategic Initiatives

From a strategic perspective, it is important to identify the specific tools and resources that are required to ensure that organizational needs are met and that clinics are able to accommodate patients form rural areas. Therefore, it is expected that these efforts will require a high level of support in order to facilitate greater performance and the delivery of high quality services to patients (MacKinney, Mueller, Coburn, Lundblad, McBride, & Watson, 2012). In this context, the allocation of sufficient resources and the acquisition of employees to fill the required positions must serve as key priorities, along with other factors that will encourage and support the development of new ideas and approaches to support employee growth and development within these environments (MacKinney et.al, 2012). High quality performance is dependent upon a number of factors, all of which must contribute to the development of new ideas that might be effective in supporting the growth of clinics in areas which have been identified as having the greatest level of need with respect to healthcare services (MacKinney et.al, 2012). It is important to identify the issues that might emerge in this context and to evaluate the conditions under which there is a great need to allocate resources and to recognize technology and innovation as critical to this process (MacKinney et.al, 2012). Most importantly, the allocation of resources requires a high level of understanding of economic conditions and how to improve achieve profitability for the clinics that are developed (MacKinney et.al, 2012).

It is also important to address education in rural areas in order to improve the quality of care that is provided to patients, and this may be accomplished through the recruitment of qualified professionals who will also receive specific training and education in order to better understand the needs of rural patients (Soliman, MacDowell, Schriever, Glasser, & Schoen, 2012). These factors will support the demands of rural residents and also enable healthcare workers to provide specialized forms of care and treatment that will accommodate these populations in an effective manner (Soliman et.al, 2012). These factors require a formalized education program that will encourage healthcare workers to gain adequate training and resources to work effectively in rural environments on a long-term basis (Soliman et.al, 2012).

Strategies for Financial Management

One area to consider with respect to financial management is the ability to provide primary care services to those living in rural communities, as this reflects the importance of new ideas to address the needs of local residents with respect to primary care (Glynn, Valderas, Healy, Burke, Newell, Gillespie, & Murphy, 2011). From this perspective, it is likely that there will continue to be an examination of tools and resources to accommodate the needs of patients that include primary care objectives, along with preventative measures and health promotion activities (Glynn et.al, 2011). Each of these areas requires further consideration because they must facilitate the growth of the practice environment and also demonstrate a high level understanding of organizational needs and expectations for local residents (Glynn et.al, 2011). The services that are provided to residents must include a specific focus on primary care and on the ability of individual patients to obtain preventative services, such as vaccinations, along with nutritional guidance and chronic illness management (Glynn et.al, 2011). These factors contribute to the overall direction of the clinic environment and how it should be structured to accommodate the patients who will be seen (Glynn et.al, 2011).

The ability to finance new clinics in rural areas requires significant capital and resources in order to improve access to care for residents living these areas. Therefore, it is necessary to acquire financial support and backing from a variety of areas so that these programs are successful in meeting the required objectives (Kumar, Chen, Choudhury, Ganju, Mahajan, Sinha, & Sen, 2011). From this perspective, it is important to demonstrate a high level understanding of the financial challenges that are likely to occur and to examine the different issues that may arise with respect to these complications, given the complexities of the healthcare system and how they are impacted by the need for sufficient resources to construct clinics in rural areas (Kumar et.al, 2011). From this perspective, it is likely that organizations will experience different challenges in their efforts to finance new clinics in rural areas, largely because they are unproven and are difficult to sustain with respect to financial stability (Kumar et.al, 2011). Therefore, other factors must be considered that will aim to accomplish the desired objectives and to reflect upon the needs of these clinics to achieve sustainability over the long term (Kumar et.al, 2011).

Annotated Bibliography

Adashi, E. Y., Geiger, H. J., & Fine, M. D. (2010). Health care reform and primary care—the growing importance of the community health center. New England Journal of Medicine, 362(22), 2047-2050.

This article addresses the importance of community health centers and their impact on improving quality of care for patients who require primary care services, including the expansion of services to accommodate individuals across many different types of communities.

Agiro, A., Wan, T. T., & Ortiz, J. (2012). Organizational and Environmental Correlates to Preventive Quality of Care in US Rural Health Clinics. Journal of primary care & community health, 3(4), 264-271.

This article addresses the issues that are most prevalent to organizations in their efforts to improve preventative care and treatment for patients in rural health clinics, where there are significant challenges to consider in achieving optimal quality of care.

Bacsu, J. R., Jeffery, B., Johnson, S., Martz, D., Novik, N., & Abonyi, S. (2012). Healthy aging in place: Supporting rural seniors’ health needs. Online Journal of Rural Nursing and Health Care, 12(2), 77-87.

This article addresses the importance of senior health in rural communities, particularly when there are challenges in accessing healthcare services and in supporting older adults within these population groups to achieve optimal health and wellbeing.

Bodenheimer, T., & Pham, H. H. (2010). Primary care: current problems and proposed solutions. Health Affairs, 29(5), 799-805.d

This article considers the challenges associated with supporting primary care for patients, including access to care and treatment, along with other factors that impact the ability to receive routine care that will improve overall health.

Burton, L. M., Lichter, D. T., Baker, R. S., & Eason, J. M. (2013). Inequality, Family Processes, and Health in the “New” Rural America. American Behavioral Scientist, 0002764213487348.

This article addresses the importance of understanding the impact of healthcare inequalit In rural communities where there is a general lack of access to care and treatment across many patient population groups and supports the development of new strategies that are designed to address rural communities and the populations that must be served in these areas.

Fortney, J. C., Burgess Jr, J. F., Bosworth, H. B., Booth, B. M., & Kaboli, P. J. (2011). A re-conceptualization of access for 21st century healthcare. Journal of general internal medicine, 26(2), 639-647.

This article addresses the importance of improvements in 21^st Century healthcare, including expanded access for those in need and the development of factors that will have a positive impact on patient care outcomes, including routine access to care and the availability of services to meet patient needs.

Gamm, L., Stone, S., & Pittman, S. (2010). Mental health and mental disorders—A rural challenge: A literature review. Rural healthy people, 1, 97-114.

This article addresses the significance of mental health challenges in rural communities where there are significant barriers to access and other issues that impact quality of life within these areas, thereby creating a difficult set of challenges that require further evaluation.

Glynn, L. G., Valderas, J. M., Healy, P., Burke, E., Newell, J., Gillespie, P., & Murphy, A. W. (2011). The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Family practice, 28(5), 516-523.

This article addresses the importance of multiple morbidities in primary care and how they impact individuals and the cost of healthcare services across different population groups.

Huttlinger, K., Schaller-Ayers, J., Lawson, T., & Ayers, J. (2012). Suffering it out: Meeting the needs of health care delivery in a rural area. Online Journal of Rural Nursing and Health Care, 3(2), 17-28.

This article addresses the challenges of achieving healthcare delivery and quality within rural communities where there is limited access to these services in order to meet the needs of the public in these areas.

Jennette, C. E., Vupputuri, S., Hogan, S. L., Shoham, D. A., Falk, R. J., & Harward, D. H. (2010). Community perspectives on kidney disease and health promotion from at-risk populations in rural North Carolina, USA. Rural Remote Health, 10(2), 1388.

This article addresses the importance of health promotion activities and the issues that are related to kidney disease for populations who are classified as high risk and how these issues impact their health and wellbeing, particularly if access to healthcare is an issue within specific communities.

Kumar, A. K., Chen, L. C., Choudhury, M., Ganju, S., Mahajan, V., Sinha, A., & Sen, A. (2011). Financing health care for all: challenges and opportunities. The Lancet, 377(9766), 668-679.

This article considers the importance of healthcare access for all persons, including the development of strategies that support improved and expanded financing for these services across a variety of areas, including rural communities.

MacDowell, M., Glasser, M., Fitts, M., Nielsen, K., & Hunsaker, M. (2010). A national view of rural health workforce issues in the USA. Rural and remote health, 10(3), 1531.

This article aims to identify some of the most prominent issues that impact rural healthcare in the United States, including workforce issues and staffing that often contribute to poor outcomes for many residents, particularly when they are unable to access care and treatment in a timely manner.

MacKinney, A. C., Mueller, K. J., Coburn, A. F., Lundblad, J. P., McBride, T. D., & Watson, S. (2012). Pursuing High Performance in Rural Health Care.

This article addresses the significance of achieving a high performance healthcare environment in the rural setting, particularly since this is often difficult to achieve in the context of an environment that often lacks sufficient resources and staffing to meet these needs.

Racher, F. E., Vollman, A. R., & Annis, R. C. (2012). Conceptualizations of” rural”: challenges and implications for nursing research. Online Journal of Rural Nursing and Health Care, 4(2), 61-77.

This article addresses the importance of defining the term “rural” in order to determine How to best approach nursing practice within communities where access to healthcare services is limited, thereby increasing the health risks for these populations.

Soliman, S. R., MacDowell, M., Schriever, A. E., Glasser, M., & Schoen, M. D. (2012). An Interprofessional Rural Health Education Program. American journal of pharmaceutical education, 76(10).

This article addresses the importance of health education as part of a larger rural Healthcare program and how this is likely to have a positive impact on local residents who do not have routine access to healthcare services to meet their needs effectively.

Conclusion

Rural areas throughout the United States possess significant healthcare challenges that have a direct impact on quality of life and wellbeing for these persons. It is important to identify the tools and resources that are required to address the substantial gaps in access to healthcare in communities where there are limited physicians, clinics, and hospitals. It is important to identify potential strategies that might be effective in advancing these agendas and in supporting the development of new ideas to expand healthcare services and access for residents in rural communities. The costs of expansion are significant; however, with the appropriate allocation of resources and a commitment from healthcare and financial experts, there is a greater potential to realize these objectives and to provide rural communities with clinics and doctor’s offices that will meet their healthcare needs and accommodate patients in a variety of areas, from preventative medicine to health promotion and treatment. These activities require a longstanding commitment from the healthcare community and from other areas regarding the development of new strategies to accommodate the lack of healthcare services for many rural residents. These opportunities will support and expand the alternatives that are available to enable these residents to visit healthcare clinics within their communities and to be proactive in taking the steps that are required to ensure that healthcare in these areas is of the highest possible quality and is provided at a consistent level at all times. Therefore, the costs of expanding and clinics in rural communities must be considered in order to determine the options that are available to improve healthcare access to rural residents who currently do not have these resources within close proximity of their homes. In addition, staffing for these clinics must also be in place in order to accommodate visiting patients and the issues that they experience.

References

Adashi, E. Y., Geiger, H. J., & Fine, M. D. (2010). Health care reform and primary care—the growing importance of the community health center. New England Journal of Medicine, 362(22), 2047-2050.

Agiro, A., Wan, T. T., & Ortiz, J. (2012). Organizational and Environmental Correlates to Preventive Quality of Care in US Rural Health Clinics. Journal of primary care & community health, 3(4), 264-271.

American Hospital Association (2011). The opportunities and challenges for rural hospitals in An era of health reform. Pp. 1-16.

Bacsu, J. R., Jeffery, B., Johnson, S., Martz, D., Novik, N., & Abonyi, S. (2012). Healthy aging in place: Supporting rural seniors’ health needs. Online Journal of Rural Nursing and Health Care, 12(2), 77-87.

Bodenheimer, T., & Pham, H. H. (2010). Primary care: current problems and proposed solutions. Health Affairs, 29(5), 799-805.

Burton, L. M., Lichter, D. T., Baker, R. S., & Eason, J. M. (2013). Inequality, Family Processes, and Health in the “New” Rural America. American Behavioral Scientist, 0002764213487348.

Fortney, J. C., Burgess Jr, J. F., Bosworth, H. B., Booth, B. M., & Kaboli, P. J. (2011). A re- conceptualization of access for 21st century healthcare. Journal of general internal medicine, 26(2), 639-647.

Gamm, L., Stone, S., & Pittman, S. (2010). Mental health and mental disorders—A rural challenge: A literature review. Rural healthy people, 1, 97-114.

Glynn, L. G., Valderas, J. M., Healy, P., Burke, E., Newell, J., Gillespie, P., & Murphy, A. W. (2011). The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Family practice, 28(5), 516-523.

Huttlinger, K., Schaller-Ayers, J., Lawson, T., & Ayers, J. (2012). Suffering it out: Meeting the needs of health care delivery in a rural area. Online Journal of Rural Nursing and Health Care, 3(2), 17-28.

Jennette, C. E., Vupputuri, S., Hogan, S. L., Shoham, D. A., Falk, R. J., & Harward, D. H. (2010). Community perspectives on kidney disease and health promotion from at-risk populations in rural North Carolina, USA. Rural Remote Health, 10(2), 1388. Kumar, A. K., Chen, L. C., Choudhury, M., Ganju, S., Mahajan, V., Sinha, A., & Sen, A. (2011).

Financing health care for all: challenges and opportunities. The Lancet, 377(9766), 668-679.

MacDowell, M., Glasser, M., Fitts, M., Nielsen, K., & Hunsaker, M. (2010). A national view of rural health workforce issues in the USA. Rural and remote health, 10(3), 1531.

MacKinney, A. C., Mueller, K. J., Coburn, A. F., Lundblad, J. P., McBride, T. D., & Watson, S. (2012). Pursuing High Performance in Rural Health Care.

Racher, F. E., Vollman, A. R., & Annis, R. C. (2012). Conceptualizations of” rural”: challenges and implications for nursing research. Online Journal of Rural Nursing and Health Care, 4(2), 61-77.

Soliman, S. R., MacDowell, M., Schriever, A. E., Glasser, M., & Schoen, M. D. (2012). An Interprofessional Rural Health Education Program. American journal of pharmaceutical education, 76(10).