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Advancing rural health

The O’Connor Office of Rural Health is proud to highlight the incredible work of our faculty members. Through research, education and advocacy, they significantly impact rural health in New York state, driving change and enhancing health outcomes for rural communities.

Faculty spotlight: Ann Fronczek

Ann Fronczek, associate professor of nursing and director of undergraduate and doctoral nursing programs, has played a vital role in advancing rural health initiatives that focus on innovative healthcare delivery and workforce development. Her commitment to enhancing patient outcomes and supporting rural healthcare professionals has significantly affected the field.

• Q&A with Ann Fronczek

  How can telehealth technologies help bridge the gap in healthcare access for rural populations like in Delaware County?

  Telehealth technologies help bridge the gap by giving patients and families additional ways of accessing providers in their home communities or in larger healthcare systems. In one project I was working on, it allowed Delaware County providers and patients access to specialty providers in more urban areas. This access was especially important when making decisions as to whether a patient could stay in their local community or if they would require transport to a higher level of care or specialty. It also allows providers in rural areas to reach more patients through technology rather than a provider having to travel great distances to meet patient needs. Telehealth technology offers the capability of maximizing specialty care within an organization as well, for example pediatric, mental health and maternity services.  

  What inspired you to pursue a career in healthcare, particularly in serving rural populations?

  I always wanted to work in a hospital, but only realized I wanted to be a nurse after a year of college and being introduced to nurses working in the profession. I didn’t seek out a first position in a rural area. The job market for new graduate nurses was very tough when I graduated, but when I did find a position, I relocated to a rural area to take the first steps in my nursing career away from the pressures of large, urban institutions. It was a great start to my professional career. 

  Can you share a personal experience or moment that ignited your passion for working in rural healthcare?

  When working as a new graduate nurse, I was able to see the art and science of nursing come together in very creative ways. In a rural facility, your colleagues quickly become your second family. I also had the opportunity to care for patients with unique challenges due to their place of residence, it sparked more interest.  

  How does addressing health challenges in rural areas differ from urban areas?

  Rural communities often have a strong “insider/outsider” culture, it takes more time to establish trust with individuals and communities. It may be harder to recruit healthcare professionals to these areas who want to live, work and stay in these communities long term. Many rural communities are also health professions shortage areas. These shortages mean that there is a very high patient:provider ratio. There are simply too many people who may need access to care who face long wait times to see a provider, especially for primary care. Specialty care is also a problem in rural areas -- those areas need partnerships with their urban counterparts to provide services to their communities. Rural areas also have issues with geography and landscape, some areas are not easily accessible -- physical infrastructure like roads and issues like weather are more likely to impact travel to and from appointments and specialty care. 

  In your opinion, what are the three most significant challenges facing rural healthcare providers today?

  • Patient to available provider ratios are very high. 
  • Rural providers need to be nimble and knowledgeable about a lot of healthcare issues to serve the needs of a community. “Jack of all trades, but only master of a few.”
  • Finding healthcare providers that want to live, work and stay in a rural community long-term. 
  • Providers wanting to advance their education may not have time or resources needed to do additional schooling. 

  As the co-project director of the Rural Telehealth Educational Consortium, what specific goals or objectives are you aiming to achieve in addressing healthcare disparities in rural areas?

  As a school, we have done a lot of work to make sure our new graduates are knowledgeable about rural health and healthcare and telehealth technologies. We initiated multiple workforce development initiatives to support rural healthcare, the RTEC membership was used as a consultant to share what might be needed to prepare future practitioners but also to establish academic-clinical partnerships to facilitate care in rural areas. 

  Example goals of the RTEC were to: 

  • Convene rural health partners to discuss the promotion of telehealth initiatives through innovative educational models
  • Increase the number of highly skilled healthcare professionals/educators trained in the use of telehealth and telemedicine modalities through healthcare programs in college and university settings and within the healthcare community
  • Strengthen the capacity for healthcare education and workforce training using telehealth technology in rural and underserved areas
  • Partner with national and regional stakeholders to generate data related to telehealth and remote monitoring to contribute to the improvement of healthcare outcomes        

  How do you balance the demands of providing quality healthcare in rural settings with the challenges posed by geographic isolation?

  I think one way of trying to overcome some of these issues is working with the local community stakeholders: healthcare delivery systems, nonprofits, patient populations to see how they are already coping with the geographic isolation. The rural residents would be the expert on potential strategies to manage  or minimize the isolation. We need to work with the “insiders.” Quality healthcare can exist in rural communities, but you need to capitalize on current strengths and work on the continuing needs. 

  What motivates you to continue serving rural populations despite the obstacles you may encounter?

  All of my interactions with rural providers and healthcare delivery systems have been relatively positive and welcoming. Most rural institutions are happy to work together for a common purpose and recognize that the University can provide additional resources at times as well. I  have come to appreciate the collaboration and the creativity for brainstorming solutions to issues. 

Faculty spotlight: Pamela Stewart Fahs 

Pamela Stewart Fahs, Bartle professor of nursing, is a leading advocate for rural health and editor-in-chief of the Online Journal of Rural Nursing and Health Care. She specializes in nursing and healthcare access for underserved populations. Her research and leadership continue to shape policies and programs that address critical challenges in rural healthcare systems.

• Q&A with Pam Stewart Fahs

  What inspired you to pursue a career in healthcare, particularly in serving rural populations?

  I was raised in southeastern Kentucky in a coal mining community. Dorothy Marrow, RN, was my first role model. She was the nurse for the health clinic when I was growing up. As a child what captured my attention was her blue cape, starched white uniform, nursing cap and shoes. She always looked cool and competent, and indeed that was her persona. She eventually became the manager of that clinic, quite an accomplishment for an African American woman in the 1960s in rural southeastern KY. I had other role models including two aunts who were nurses and Mrs. Schroder, the public health nurse in the region.

  Can you share a personal experience or moment that ignited your passion for working in rural healthcare? 

  I do not know if there was a specific moment. I loved working with the people of that area; it was home. I can tell you it was one of the most challenging experiences of my life! The Appalachian Regional Miners Hospitals, now the Appalachian Regional Hospitals (ARH), was the site of my first job as an RN. When I was hired I was a graduate nurse. Although I had taken my NCLEX exam, I did not yet have the results (at the time it took months, not hours, to get the results). I was the only RN on the unit of 58 patients, half pediatrics and half medical, surgical and primarily geriatric patients. I worked with two very accomplished LPNs and an aide on night shift. The nursing supervisor and nurse manager were only available during the day. So those on the night shift were expected to be self-sufficient. Although, most rural nurses must be fairly self-sufficient. The rest of the hospital consisted of an emergency room, a small ICU and the maternity and newborn unit. I learned how to prioritize, deal with multiple issues and handle a lot of client needs at once. The positive side was, it was a cohesive group to work with. There were no in-house physicians and if needed, it often took an MD 30 or more minutes to reach the hospital. If there was a code usually any EMTs in the ER at the time would respond to take over CPR while I was on the phone with the physician (a phone with a very long cord) giving ordered IV drugs and noting what was happening in the code to write up in the chart later.

  Nurses also had a long list of “telephone order” drugs that I could give as needed and the physicians would co-sign on their morning rounds. I could give everything from an aspirin to morphine based on these telephone orders. The physicians typically saw patients all day in their private offices or the clinic at the hospital and did not particularly appreciate being woken up at 2 a.m. The situation gave a lot of responsibility to the nurse and required a lot of interprofessional trust. It certainly honed my assessment capabilities. 

  One of the reasons I left that job was to gain more skill and education. From ARH, I went to the University of Kentucky (UK) Chandler Medical Center. The nursing model at UK was primary nursing. All RNs, so we took turns being the night supervisor and again the head nurse was there during the day. At UK, I worked on a surgical floor with three units, a surgical, medical and burn unit. We also had a “dirty” surgical ICU. It was great to go from 58 to eight patients per shift. However, it was usually two RNs on each unit with a round desk with the “ward secretary” in the middle. And you relied on each other.

  What unique aspects of rural healthcare drew you to this field, particularly at Appalachian Regional Miner’s Hospital?

  Initially, it was the pay differential. Appalachian Regional Hospitals (ARH) was advertising for RNs at $10 per hour while hospitals in Lexington and Richmond, KY, were paying RNs $2.50 per hour. Lexington was a big city that contained many of my early educational clinical sites and a very vibrant community. About the time I was getting ready to graduate, I also remember noticing how flat the landscape was compared to the area where I grew up and where I wound up with my first nursing job. I missed home, back in the mountains.

  How does your role in rural healthcare positively impact the community? 

  I think my biggest impact is from my faculty role in the education of nurses, and other healthcare providers about rural (a) health, (b) nursing and (c) culture. I understand the culture, since I have lived it as well as studied it for many years. I think my research, primarily on rural women and cardiovascular risks, from the past, continues to have meaning. I know that many past students went on to seek master or doctoral degrees and often noted their research experiences on our research team as part of their decision to continue for graduate education. I have also been told by some people who were in one or more of the studies I led, that those intervention studies helped improve their health and ability to be successful in behavioral changes that may influence cardiovascular risks. 

  What are the three most significant challenges facing rural healthcare providers today? 

  There are multiple issues and it is hard to narrow it down to three. If you look at one issue as access, there are many factors that fit within that realm. As in most healthcare arenas today, one of the biggest issues is that of the workforce. Without adequate numbers and a well-trained workforce, access to care becomes more of an issue, and it is already a huge issue. We continue to see the need for nurses, particularly advanced practice nurses increasing. The Bureau of Labor projects job growth for nurse practitioners to increase by 46% (2021-2031). Another issue is the closing of rural hospitals, a pattern that stabilized during COVID; however, we saw a slight increase again in 2022 and 2023. Racial and ethnic divides in healthcare outcomes continues to be an issue in rural health. And, of course, the issues of mental health and healthcare in rural areas continues to be an issue. However, as I try to impress on my students, there are also positives for rural living. Recognizing some of those positive aspects is important. 

  What future initiatives or programs do you envision to further enhance cardiovascular care delivery in rural regions? 

  I believe telehealth will continue to be a much-needed resource in rural areas. The COVID-19 pandemic helped ease some of the barriers to practice of telehealth issues (treating people across state lines, etc.). Hopefully those barriers will not go back up. Some rural facilities now have the ability to communicate with their more urban specialty facilities such as stroke units via telehealth so that life-saving interventions can take place immediately prior or while individuals are being transferred. There are programs now where there is monitoring of EKG (heart rhythm, rate and patterns of electrical impulses) for individuals in a rural hospital by staff in larger or specialized centers to pick up on changes or abnormalities. I imagine in the future there will be AI capabilities for treatment decisions. There are also amazing wearable technological advances in body systems monitoring. Healthcare has just begun to scratch the surface of the possibilities. Wearable technology will not only give the individual insight and control of their own health, but will also improve diagnostic abilities as well as allow healthcare providers to monitor the effects of treatment in real time or over a period of time. 

  What strategies do you employ to overcome barriers to accessing healthcare in rural areas? 

  One strategy that has helped to some degree is the Patient and Affordable Care Act passed in 2010. The literature reflects the effect of differences between states that had expanded Medicaid coverage and those that had not allowed the expansion. By 2018, non-expansion states had shown 18% fewer covered people than those with Medicaid expansion. The ACA is not perfect. In rural areas there are often fewer choices and plan prices can fluctuate greatly; however, it has shown that this option can expand coverage, which is one factor in lack of access. Additionally, rural hospitals in states with Medicaid expansion saw very thin, but positive operating margins, while the margins were more likely to be negative in rural hospitals in states that blocked Medicaid expansion. Rural populations are often under-insured or uninsured. Their coverage may vary due to seasonal work. These fluctuations can be very detrimental to getting healthcare when needed.  

  Regionally, a successful strategy has been to set up transportation systems for those who cannot get to their appointments. The lack of public transportation in most rural areas is another factor in lack of access. If you do not have reliable transportation or have to rely on friends and family or on what limited public or government funded transportation there is, it is very difficult to get to appointments in a timely manner and be able to get home afterward. The system I saw grow and developed started in the Newark Valley area of upstate NY. What began as a volunteer program was eventually rolled into the Rural Health Network, serving South Central New York and is now called GetThere (https://gettherescny.org/home).

  How do you balance the demands of providing quality healthcare in rural settings with the challenges posed by geographic isolation? 

  Depending on where you are, and your access to reliable transportation, as a rural individual you might not see driving long distances as a problem. This phenomenon has been reported in Montana, where 100 miles is often not a particular problem. In southeastern Kentucky, in the Appalachian Mountains, topology plays a factor in where you decide to get healthcare as well as ease getting to these sources. I grew up in the shadow of the highest peak in Kentucky (5000 feet) and surrounded on three sides with smaller but still challenging mountains, with twisting and steep mountain roads. Some of the road systems have been upgraded, so in places there are straight stretches with passing lanes, which are particularly helpful when you get behind a coal truck or truck loaded with logs. Keeping mountain roads clear of ice and snow is a challenge in many rural areas and may be the last to be cleared, particularly if industry has died out in the area. 

  What motivates you to continue serving rural populations despite the obstacles? 

  I can see the need for competent rural healthcare providers, better access to healthcare, and how important it is to not only identify the issues and concerns, but to be part of the solution. To that end I hope I am having an impact in preparing nurses of various education levels to have rural cultural competence or at least heightened cultural awareness. Nurses can do so much to provide care in rural populations, from direct patient care in acute care to community health. Nurses can be advanced practice nurses who see patients in the clinics and emergency departments, of critical access hospitals or work with elder care or hospice. Nurses at the baccalaureate level and beyond can be involved in influencing healthcare policy or write grants to support the community. In my opinion, rural nurses are the consummate generalist and I am proud to have been among their number.