Background: Rural America is underserved by the nation’s healthcare system. There are fewer doctors—especially specialists—per capita, many rural hospitals are in danger of closing, incomes are lower and employers less likely to provide health insurance, distances to care are greater and there is less broadband access to medical information and virtual office visits. The rural population is older, less healthy, engages in more unhealthy behavior (e.g., smoking) and is less informed about healthcare issues. Older rural residents requiring surgery have less access to care and may be less informed on how to participate in their care and about treatment choices.
Proposed Solution to the Problem: The Grange, founded in 1867, is the largest, best-known community organization in rural America; it conducts a variety of social, service and educational programs and is a leading advocate for rural interests. It is a trusted messenger to rural America, providing information on many topics from agriculture to health.
The Grange will disseminate a pre-surgery QPL guide and a post-surgery guide generated from results of PCORI-funded research studies to optimize post-surgery discharge care, providing patients with actionable information enabling them to understand their conditions, to help them make more informed care decisions consistent with their personal goals and preferences, to facilitate shared decision making with clinicians and to better prepare for surgery. This increased patient engagement should increase their satisfaction with their care.
The Grange will develop the guides based on results from two key PCORI-funded research efforts to improve the lives of the older rural patient:
- Effectiveness of a Question Prompt List Intervention for Older Patients Considering Major Surgery
- Helping Seniors Plan for Posthospital Discharge Needs Before a Hospitalization Occurs: Results from the Randomized Control Trial of PlanYourLifespan
Dissemination will be conducted through multiple channels, including 1,500 Grange Halls, with 150,000 members located in 37 states, and at community events.
Objectives: Disseminating the guides should (i) empower rural surgery patients to become more engaged in their own care and to obtain care in line with their personal values and preferences and (ii) inform patients about what to expect after surgery, allowing them to do more advance planning and inform their family and other caretakers about “best practices” aftercare. This should lead to more satisfied patients, better aftercare and possibly better medical outcomes. It is also hoped patient and family stress will be reduced, clinicians will more effectively obtain and provide necessary information, and The Grange will improve its ability to conduct public health campaigns.
Activities: The guides will be adapted to be suitable for an older rural audience in consultation with Subject Matter Experts (SMEs), and “beta tested” at five local Grange Halls. The dissemination campaign will be designed and the guides and campaign introduced at regional Grange meetings and communication between the program team and state and local Grange leaders. The guides will be posted on The Grange’s website and distributed digitally and in hard copy at local Grange meetings and special events and at community events such as fairs and festivals to both 150,000 Grange members and to others in their rural communities.
Projected Outcomes and Outputs: The guides are to be disseminated to 1,500 local Grange Halls during the two-year funded period, reaching 100,000 and 150,000 Grangers, respectively. The guides should also reach increasing numbers of non-members during and after both periods. The outputs will be the guides themselves and an infrastructure and experience for future public health initiatives.
Short-term outcomes during the project period: Better prepared and more engaged older rural surgical patients capable of making care decisions based on a deeper understanding of their condition and choices that are in accordance with their personal goals, values and preferences and better-informed family members and other care partners who will be capable of providing better and more effective aftercare. These improvements in engaged and individualized decision making should improve patient satisfaction and reduce stress by both patients and care partners. The target is for 500 chapters to be included in the initial outreach, with a goal of 1,500 chapters to participate by the end of the project period.
Medium-term outcomes (0-2 years post-project period): While the primary goal is focused on the Grange chapter, as the level of participation increases Grange chapter members will disseminate the project through local community events such as farmers’ markets and through other partner organizations, such as Kiwanis and Rotary, with whom they have longstanding relationships.
Long-term outcomes (3+ years post-project period):
- To provide a paradigm for future health initiatives which can benefit rural America’s medically underserved population.
- To demonstrate the success of the Grange’s infrastructure to improve rural health through demonstrating the uptake of critical information about health and medical issues.
- To reduce the stress on both patients and their families and other caregivers leading to greater satisfaction for both patient and care partners alike, and ultimately resulting in rural seniors being able to remain safely in their homes following surgical procedures.
Patient and Stakeholder Engagement Plan: The primary stakeholders are older rural patients facing surgery. Grange members in five local Grange Halls will review the preliminary drafts of the guides to ensure they are clear and useful. After dissemination, patient and caregivers will be asked, via forms accompanying the guides and on the Grange website, to report on their experiences and offer suggestions for improvements; local Grange and civic leaders will be asked to evaluate the events under their purview where the guides are disseminated and to suggest improvements.
Project Collaborators: Laurie Anne Ferguson, DNP, APRN, FNP-BC, FAANP, an expert in rural public health and communication, will lead the project team with input from Grange stakeholders in five regions. Those collaborating member locations include regional representatives from:
- Northeast - Porter Grange #569, Porter, Maine.
- Southeast - St. Johns Grange, Mt Pleasant, North Carolina.
- Midwest - Turkey Hill Grange, Belleville, Illinois.
- Great Plains - Alamo Grange , San Antonio, Texas.
- Western - Walterville Grange, Springfield, Oregon 97478.
The beta test will include:
- Distribution of the guides in hard copy to local Granges which will disseminate them to appropriate members.
- Evaluation of the guides ease of use, choice of language and other relevant metrics to be determined by the project lead.
- Revision of the guides based on feedback from the initial effort and incorporation of changes as indicated.