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A proposal for the establishment of efficient, comprehensive preventive health and fitness centers in rural, under-served areas in the United States.

Luke Johnson

on 1 March 2016

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Transcript of Capstone

A healthy initiative for efficient, effective, and sustainable medicine for underserved populations.
Mr. Luke A. Johnson __, MPH, BSc
Social Determinants of Health
•Adults living in both rural and urban areas without adequate access to healthy living options on a daily basis.
Organizational Structure
(cc) photo by Jakob Montrasio
With special thanks to:

Dr. Emmanuel Keku MD, MA, MSPH, FAHA

Dr. John Morrow MD

November, 2, 2011
1. Cultural "status quo"
2. Inaccessible preventive therapies
3. Consequences
Benfits for Organization
1.Aiken, Linda H., Lewis, Charles E., Craig, John., Mendenhall, Robert C., Bledon, R. J., Rogers, D., The Contribution of Specialists to the Delivery of Primary Care. N Engl J Med. 300:1363-1370. June 14, 19792.Blair, S. N., Kampert, J. B., Kohl, H. W., Barlow, C. E., Macera, C. A., Paffenbarger, R. S., et al. (1996). Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA : the journal of the American Medical Association, 276(3), 205-10. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8667564.3.Blair, S. N., Kohl, H. W., Barlow, C. E., Paffenbarger, R. S., Gibbons, L. W., & Macera, C. A. (1995). Changes in physical fitness and all-cause mortality. A prospective study of healthy and unhealthy men. JAMA : the journal of the American Medical Association, 273(14), 1093-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/7707596.4.Blair, S. N., Kohl, H. W., Gordon, N. F., & Paffenbarger, R. S. (1992). How much physical activity is good for health? Annual review of public health, 13, 99-126. doi: 10.1146/annurev.pu.13.050192.000531.5.Blair, S. N., Kohl, H. W., Paffenbarger, R. S., Clark, D. G., Cooper, K. H., & Gibbons, L. W. (1989). Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA : the journal of the American Medical Association, 262(17), 2395-401. Retrieved, from http://www.ncbi.nlm.nih.gov/pubmed/2795824.6.BRFSS- CDCs Behavioral Risk Factor Surveillance System. (n.d.). . Retrieved from http://www.cdc.gov/brfss/index.htm.7.Casey, M. M., Thiede Call, K., & Klingner, J. M. (2001). Are rural residents less likely to obtain recommended preventive healthcare services? American journal of preventive medicine, 21(3), 182-8. Retrieved from http://www.ajpmonline.org/article/S0749-3797(01)00349-X/abstract.8.Clearinghouse, N., & Frontier, F. O. R. Frontier Communities : Leading the Way With Innovative Approaches to Behavioral Health. Education. February 2003.9.DiPietro, L. (2001). Physical activity in aging: changes in patterns and their relationship to health and function. The journals of gerontology. Series A, Biological sciences and medical sciences, 56 Spec No, 13-22. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11730234.10.Dunn, A. L., Marcus, B. H., Kampert, J. B., Garcia, M. E., Kohl, H. W., & Blair, S. N. (1999). Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: a randomized trial. JAMA : the journal of the American Medical Association, 281(4), 327-34. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9929085.11.Earle-Richardson, G. B., & Earle-Richardson, A. F. (1998). Commentary From the Front Lines: Improving the National Health Service Corps Use of Medical Providers. The Journal of Rural Health, 14(2), 91-97. doi: 10.1111/j.1748-0361.1998.tb00609.x.12.Eberhardt, M. S., & Pamuk, E. R. (2004). The importance of place of residence: examining health in rural and nonrural areas. American journal of public health, 94(10), 1682-6. American Public Health Association. Retrieved from /pmc/articles/PMC1448515/?report=abstract.
Target Population and Demographics
Benefits for community
SWOT Analysis
Create Alliances
Compress late-life morbidity (healthier glory years)
Lowered accumulated health costs
Cheaper insurance rates
Increases confidence that their health needs are understood
Easier and cheaper access to health care
Travel and office wait times slashed
Less congestion for GP office
Resources can be shared
Strength in numbers
Bargain for lower insurance
Bridge the Gap
13.Engelman, K. K., Hawley, D. B., Gazaway, R., Mosier, M. C., Ahluwalia, J. S., & Ellerbeck, E. F. (2002). Impact of Geographic Barriers on the Utilization of Mammograms by Older Rural Women. Journal of the American Geriatrics Society, 50(1), 62-68. doi: 10.1046/j.1532-5415.2002.50009.x.14.Hartley, D. (2004). Rural Health Disparities, Population Health, and Rural Culture. American Journal of Public Health, 94(10), 1675-1678. doi: 10.2105/AJPH.94.10.1675.15.Jochemsen-van der Leeuw, H. G. A., Dijk, N. van, & Wieringa-de Waard, M. (2011). Attitudes towards obesity treatment in GP training practices: a focus group study. Family practice, 28(4), 422-9. doi: 10.1093/fampra/cmq110.16.Litan, R. E. (2008). The Safety and Innovation Effects of U. S. Liability Law: The Evidence. American Economic Association. Retrieved October 29, 2011, from http://www.jstor.org/pss/2006826.17.Luft, H. S. (2007). Assessing the Evidence on HMO Performance. The Milbank Memorial Fund Quarterly. Health and Society. Vol. 58, No. 4, Special Issue: HMO Promise and Performance (Autumn, 1980), pp. 501-536. Published by: Blackwell Publishing on behalf of Milbank Memorial Fund Stable URL: http://www.jstor.org/stable/334980518.Noda, M., Saito, K., Nishizawa, Y., Tsushima, E., Kida, K., Sakano, S., et al. (2006). Comparison of activity level in daily life with heart rate: Application to elderly persons of different ambulatory abilities. Environmental health and preventive medicine, 11(5), 241-9. doi: 10.1007/BF02898013.19.OBrien Cousins, S. (2003). A Self-Referent Thinking Model: How Older Adults May Talk Themselves Out of Being Physically Active. Health Promotion Practice, 4(4), 439-448. doi: 10.1177/1524839903255417.20.Pate, R. R., Pratt, M., Blair, S. N., Haskell, W. L., Macera, C. A., Bouchard, C., et al. (1995). Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA : the journal of the American Medical Association, 273(5), 402-7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/7823386.21.Ricketts, T. C. (n.d.). RURAL HEALTH CARE IN THE UNITED STATES. Health (San Francisco).22.Rosenthal, T. C. (2000). Access to Health Care for the Rural Elderly. JAMA: The Journal of the American Medical Association, 284(16), 2034-2036. doi: 10.1001/jama.284.16.2034.23.Tai-seale, T., & Chandler, C. (n.d.). NUTRITION AND OVERWEIGHT CONCERNS IN RURAL AREAS : A LITERATURE REVIEW In the last 20 years , American children and Rural residents experience an to their urban United States , the problem may be. Children, 115-130.24.Turnock, Bernard J. (2009) Public Health: What it is and How it Works. Public health and the health system. 107-155. 4th ed. Sudbury, Ma: Jones and Bartlett Publishers LLC.25.Wei, M., Kampert, J. B., Barlow, C. E., Nichaman, M. Z., Gibbons, L. W., Paffenbarger, R. S., et al. (1999). Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men. JAMA : the journal of the American Medical Association, 282(16), 1547-53. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10546694.
Services Provided:
Integrated info system
Preliminary care
Healthy living services
Smoking Cessation clinics

Custom workout regimens
Professional supervision
Health education classes
Healthy meal plans
Complimentary Supplements
(at gym only)
Establish an efficient, comprehensive preventive health and fitness centers in rural, under-served areas of the United States.
How much?
Cross sectional survey
Define purpose
Drs: MDs and DOs
Social worker
Allied Health Inc.
Purpose shapes an understanding of what you want to do.
A road map to national healthcare recovery
Student training
3rd party vendors
Restaurant, Barber, Realtor office, Car wash, Coffee shop
Where are you?
Where are you going?
How are you getting there?
Establish Goals
Short term

Long term
Undoubtedly, a business venture such as this is not for the weak of heart, nor to those looking to make a quick buck. Dedication, commitment, and an understanding in the core values in public health are a necessity. The current state of health across our nation demands an alternative plan of action. The traditional system of trying to maintain the status quo and treating individual battles as they present themselves is failing, and quite frankly, bankrupting us. By introducing efficient, comprehensive preventive medicine and fitness centers in rural, under-served areas in the United States, as proposed, significant gains in health and wealth will be achieved.
Lack of consistent physical fitness needs to be at the same public awareness level as tobacco and alcohol consumption in order to stigmatize unhealthy behaviors.
The two “factions”, public health and primary medical care, that have jurisdiction over preventing serious maladies from materializing in the public sector, have polar opposite world views on how health care should be implemented and distributed.

•Physicians seek to produce the best possible outcome through the development and execution of individualized treatment plans (Turnock, 2009).
PCPs and PH officials are fighting the same war on two separate battlefields, where each campaign is vastly outnumber and under-resourced.
PCPs and PH officials are fighting the same war on two separate battlefields, where each campaign is vastly outnumber and under-resourced.
Private, primary care physicians have the relative luxury of greater resource availability. Overall costs are typically secondary considerations, especially with defensive medicine practices becoming more prevalent.

•Mostly due to combat rising insurance premiums, especially “high risk” specialties.

In part, this has led to the widely publicized financial woes of our national healthcare system that is currently draining our economy more so than any other developed nation in the world with virtually nothing to show for it (Litan, 2008).

**INSERT** graph of international health rankings

On the contrary, public health officials must deploy limited resources, which are even less available in rural regions, to avoid the worst outcomes at the group and community level via prevention strategies.
•Their work go largely unnoticed, excluding catastrophic events with subsequent failures (See: Hurricane Katrina, food contaminate outbreaks, etc) with the actual catastrophe typically getting the most documented attention and the “mundane” yet necessary day-to-day services are barely noticed.

Unity is needed.

Traditionally, the hurdle addressing rural health disparities is establishing long-term programs to run within their means efficiently, as clientele demand can be sporadic, while also retaining personnel, which can pose a challenge within itself.
(Earle-Richardson, G. B. and Earle-Richardson, A. F. 1998)

..or set up a stepping stone/pipeline for many young physicians..

Countless peer reviewed research articles have documented a wide disparity between the relatively high levels of morbidity and premature mortality rates found in rural areas across the nation compared, to that of metropolitan areas.
•Many attribute this scenario to multiple factors, notably
• poor access to adequate medical care
• high rates of obesity
• lower socio-economic status and average level of academic completion
• higher population percentage of elderly
(Eberhardt, Pamuk. 2004).

Another aspect to this problem is, from a cultural standpoint, most rural societies do not have a strong foundation, or awareness, in the medical importance of physical activity for adults.
Physical activity, especially when you remove outside, manual-labor jobs from the equation, is essentially non-existent for a fraction of the population.

The Center for Disease Control and Prevention (CDC) has documented epidemiological data not only backing these claims, but also illustrates that this trend is growing at an alarming rate. (BRFSS 2008).

Compounding this issue, as found in their 1996 study, Blair and his colleagues equated statistical evidence that there is a direct correlation between lack of fitness and the likelihood of late-life morbidity and disease, as well as a link with premature mortality (Blair et al,. 1996)

Previous (bad) solutions bolster the resources in the area by attempting to recruit more personnel at all levels of healthcare to the region.

•However, most rural practitioners know from experience that this in only half the battle, retaining personnel long term can be the Achilles heel.

Schools could lower admission requirements to increase matriculation rates and overall numbers of health professionals.
But such a strategy could potentially create deleterious side effects.
Apart from compromising the quality of care provided to the public by lowering standards, more doctors have been choosing to specialize rather than enter primary care for decades

…which arguably has led to an increase in the number of tertiary care procedures that “fix” individual problems and further fuel the exponentially growing health care cost (Aiken et al. 1979).

This traditional philosophy is backwards.
Rather than trying to treat problems at later, more expensive stages of disease progression, an alternative strategy is prevention.

Viewed at the long-term impact, this is by far the more economically feasible route.
When all resources and staffing obstacles are considered.

Also, this poses to make the greatest impact at the community level, which is one of the core goals of public health.

By introducing strategically placed comprehensive preventive health and fitness centers, the root of these problems could be faced head on.

By establishing that the core purpose of all health care practitioners is to improve health, from the individual to community level, avenues for reaching this goal can be constructed.

The present, fragmented structure of health care in the United States is ill-equipped to combat such a crisis
Unique and innovative to draw consumer focus on health maintenance.
Goal oriented
Start up financial risk
Changing health care policies allow for new strategies
Uncertainty in health market
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