Cover Story

Drive about 25 miles in any direction outside Tuscaloosa, Ala., and you won't find much in the way of primary health or dental care, and nary a place to turn for specialized mental health services.

In fact, until University of Alabama psychologist Forrest Scogin, PhD, and his colleagues began to study the feasibility of providing home-delivered interventions to older adults in the area, many of his study participants' mental health symptoms went untreated, says Scogin.

"There's a scarcity of services available [to rural older adults], and the services that are available are difficult to access," he says, noting that for many, transportation to and from health-care services poses a significant burden.

Like most rural areas in the United States, this region of Alabama has a higher proportion of adults 55 and older than do metropolitan communities, and that population has less access to health care than their more urban counterparts: Although 25 percent of Americans live in rural areas, less than 9 percent of the nation's health-care providers practice there, according to the University of Montana Rural Training Institute.

Adding to the problem is that approximately 20 percent of people age 55 and older have some type of anxiety or mood disorder, phobia, obsessive-compulsive disorder, Alzheimer's or other dementia, according to a 2001 U.S. Department of Health and Human Services report.

The situation may quickly become a crisis as the older adult population grows, says psychologist Beth Hudnall Stamm, PhD, director of telehealth at the Idaho State University (ISU) Institute of Rural Health.

But there is hope: Stamm and Scogin are among a number of psychologists and other mental health professionals working to develop and test programs that improve the well-being and quality of life of older adults in rural communities. Some, like Scogin, are providing interdisciplinary home-delivered care, while others are exploring the potential of telehealth care.

Home-based treatment

In Scogin's project, he and his colleagues are studying the efficacy of a five-year program that provides cognitive behavioral therapy to frail but cognitively intact rural Alabamans age 65 and older.

The study tests the effects of 16 to 20 treatment sessions provided by trained clinical social workers--the providers most likely to be available in a rural setting, according to Scogin--in consumers' homes for no cost.

Before the intervention began, the Scogin team had participants complete a variety of emotional well-being and quality-of-life measures. And in an upcoming article in the Journal of Gerontological Social Work, Scogin's preliminary data suggest that the program, known as the Project to Enhance Aged Rural Living, induces positive benefits for both measures.

One of the keys to the program's success was heeding the participants' rural culture, which includes a more casual, less precise conception of time. The cultural differences forced the social workers to adapt. For instance, they found that it was not unusual to travel more than an hour to a participant's house for a scheduled appointment only to find no one home, or the older person too ill to participate in a session. To counteract the missed appointments, they repeatedly discussed with participants and their caregivers the importance of keeping scheduled appointments, or contacting the staff person if the appointment needed to be changed, as well as providing participants with written appointment notes to serve as a reminder.

The social workers also adapted to the participants' religiosity, which at times made participants reluctant to express and work on relieving their worry, anxiety, despair and other negative emotions, because expressing such emotions might be seen as a "lack of faith," according to Scogin. As such, the social workers encouraged the participants to integrate their traditional coping tools, like their faith, with cognitive-behavioral processes.

"As providers we need to develop sensitivity to different types of people," he says. "There are differences in terms of being rural that we need to be aware of."

Telehealth care and other methods

With physical access to care the greatest challenge that many rural patients face, Stamm has developed TeleHealth Idaho, an Idaho State University research and service project that offers physical, dental and mental health care via telehealth. By serving as a telehealth hub, the project aims to improve access to health care to rural Idahoans throughout the state--an acute problem in Idaho because the state's "rural health professionals are thinly spread, with little time or access to continuing-education opportunities," according to a 2004 Idaho Department of Health and Welfare report.

To fix the problem, TeleHealth Idaho offers both new and continuing educational training programs that allow providers to continue career training while remaining in their rural home communities. For example, the program conducts "virtual grand rounds" that bring current, evidence-based practices to rural professionals via a statewide interactive videoconference presented by specialists.

Other educational programs allow providers to remotely draw on ISU's resources to continue their career training online. For instance, a nurse's aide could continue training to an associate-level nursing degree, then to a bachelor's degree--or even an advanced-practice degree without having to devote substantial time to travel.

TeleHealth Idaho also offers providers technical support and the Tel Ida Toolbox--a medical and health policy online information resource and digital medical library.

The net result is better qualityof care for more Idahoans, says Stamm. For instance, in a little more than a year the North Idaho Rural Health Consortium used TeleHealth Idaho to find ways to use Medicaid reimbursements to conduct 30 psychiatric consults with consumers who otherwise would not have received care.

"It's absolutely critical that we reach this population--and telehealth allows us to do that," she says.

However, telehealth care is also not without its costs--or limits in its applicability, she adds.

In a 2000 article in Professional Psychology: Research and Practice (Vol. 31, No. 2, pages 184-189), she suggests that some older adults find the technology intimidating. Counteracting such apprehension often requires providers to make their initial contact face-to-face, with follow-up visits done via videoconferencing.

Attracting a rural work force

Ultimately, improving rural older adults' care depends on developing a larger, more active rural workforce, according to Stamm. "Providing care to older adults in rural settings is more difficult than other situations," she says. "[Providers] have less support and there's more risk for burnout. And if they burnout or are traumatized, there's nobody else there to step in."

The shortage of providers in rural areas is receiving some attention. In the past year, for example, APA's Committee on Rural Health embarked on a campaign to highlight the National Health Service Corps--a U.S. Department of Health and Human Services program that offers loan forgiveness to psychologists and other providers offering services in rural and urban areas with provider shortages. Like the Tel Ida Toolbox, the APA committee's Web site aims to serve as a guide for locating training and funding opportunities in rural areas, as well as to provide rural health-related papers and presentations. (For more on the committee's work, see the upcoming January Monitor.)

Despite the progress, more work needs to be done, says Kathleen Buckwalter, PhD, RN, director of the University of Iowa's John A. Hartford Center of Geriatric Nursing Excellence.

"We don't need to throw up our hands and gnash our teeth just because the situation is difficult," she says. "We need more education, training and support for those who choose to practice in rural settings."