Rural Navigation: Breaking Down Barriers to Care

May 2020 Vol 11, No 5


Rural Navigation

Health disparities are differences in health status compared with the population overall, but rural health disparities are unique to the people living in these less densely populated areas. These disparities can create significant barriers to care, but according to Katelyn Mosshart, RN, BSN, a Breast Health Nurse Navigator at HaysMed, part of The University of Kansas Health System, navigators are in a unique position to address them and ease the burden of patients living in rural areas.

Risk factors for rural health disparities include geographic isolation, lower socioeconomic status, higher rates of health risk behavior (heavy drinking, smoking, lack of sleep), limited access to healthcare specialists and subspecialists, limited job opportunities, and lack of reliable transportation.

“We’re not just dealing with their cancer when we see these patients; we’re dealing with everything else they bring with them,” she said at the AONN+ 10th Annual Navigation & Survivorship Conference. “In our rural populations, they might have a little bit more baggage.”

Rural areas have high rates of self-employment (eg, farming, mom-and-pop shops), leading to higher rates of uninsured individuals. When health insurance is not provided by an employer, many people find the cost of private insurance prohibitive.

Ms Mosshart says transportation is the number 1 barrier her patients face. Many patients live more than an hour from a treatment facility (particularly a problem when radiation is recommended), and even if they have a reliable vehicle, this adds up to significant cost and wear and tear on their vehicle. Further, people in rural America often have less job flexibility than those in urban areas.

“We’ve got some hard workers in rural America, and they don’t want to—or simply can’t—take off work to come into these appointments,” she said.

She urges navigators to personalize care to each patient. “As nurse navigators we are advocates for our patients. Fight for them and make their care personalized to them. Know if they have a farm to take care of or a company to run themselves,” she said. “Understanding and assessing these things can help to ease some of their burden.”

Grant money from organizations like Susan G. Komen can be put into a transportation fund and used to pay for gas cards and hotel vouchers. For patients to qualify for these resources at her institution, their trip to the cancer center must be at least 100 miles roundtrip, but a substantial number of her patients meet that criterion. Patients often won’t ask for these resources, she added, but are grateful when they’re offered.

“Finding out about these resources is part of our job,” she said. “If I’m coming from a medical background and I didn’t know a resource existed, how would the community know?”

Utilizing outreach physicians and conducting research on what other resources are available, then connecting patients to these outside organizations (eg, local cancer councils), can also help to ease a patient’s burden.

Another common barrier in rural western Kansas is the lack of specialty care. Ms Mosshart’s hospital only has general practitioners, with no breast oncologists, breast surgeons, or genetic counselors, but navigators are in a unique position to connect patients to those specialists and help them make the transition to other providers.

“You’re going to have patients who only want to deal with a breast specialist, or a female doctor, and they reserve the right to want that,” she said. “I can tell them the resources we have available, but if that’s not what they’re looking for, I’m going to connect them to someone they’ll feel comfortable with.”

Ms Mosshart pointed out that navigators shouldn’t overlook themselves as a valuable resource, as they can take steps to make sure their patients feel recognized and cared for. She may not be a breast surgeon, but she is a breast specialist, she said, and can uniquely tailor each patient’s materials to their particular malignancy. They can also connect with other navigators and case managers in larger facilities to offer patients more resources when necessary.

Yet another major barrier she sees in her patients is the financial burden of cancer. Patients are concerned about healthcare costs even prior to a cancer diagnosis, so she meets with her patients before a recommended biopsy.

“Before they even know if they have cancer, they ask how much it’s going to cost,” she said. “The financial part can be incredibly scary.”

She connects them with appropriate resources (billing department, etc) right away, and encourages them to advocate for themselves and ask questions about things like out-of-pocket costs and insurance deductibles. The fear of the unknown can be more upsetting to patients than the reality, she says.

She also connects her patients to state resources— such as Early Detection Works in Kansas, which provides cervical and breast cancer screening, diagnostic imaging, and biopsy—and assists them in gathering the correct documents for Medicaid applications and other financial resources.

Helping patients with cancer in rural areas is about knowing what resources are available and putting patients in touch with these resources, and she encourages navigators in rural areas to have pride in where they work and in what they can offer. Finally, having a strong working relationship with physician colleagues can help navigators to advocate for their patients and make their wishes known.

“The AONN+ conference is also a great opportunity to network and advocate for your patients,” she said. “We need to work together. Reach out to see what resources are out there, and find out if you can collaborate.”

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Last modified: August 10, 2023

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