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JANUARY / FEBRUARY 2015 :: 76(1)
Rural Health in North Carolina

This issue of the NCMJ discusses factors that influence the well-being of residents in rural communities in North Carolina. These include factors related to health care, such as physician recruitment and retention, the effects of hospital closures, and the need for behavioral health services, and factors beyond the health care sphere, such as child care, health behaviors, economic development, and access to health services.

INVITED COMMENTARY

Building Capacity to Improve Economic Health

Olivia Collier, Patricia Mitchell

N C Med J. 2015;76(1):46-49.PDF | TABLE OF CONTENTS



The economic health of a community is vitally important for attracting and retaining businesses and for creating an environment in which people want to live, work, and play. Rural communities in North Carolina rely on a variety of partners and programs to build local capacity for job creation and the development of quality-of-life amenities.

Improving the economic well-being and quality of life of the citizens of North Carolina is the mission of the North Carolina Department of Commerce [1]. Through a variety of partnerships and programs, this department helps communities build capacity, which not only enables business to succeed but also ensures that communities have access to the resources they need to provide a sustained quality of life for their residents. “If you don’t work for the economic health of your community, it won’t happen,” stated North Carolina Department of Commerce Secretary Sharon Decker when addressing a group of rural leaders (Sharon Decker, oral communication, July 2013). “To be a healthy economy, we must be a healthy people” (Sharon Decker, oral communication, October 2013).

The Department of Commerce recognizes that health related to economic development goes beyond employees having access to health care; it also includes jobs that are created by the health care sector. In many rural communities, health care providers (including small hospitals) are the largest employers. According to the National Center for Rural Health Works, high-quality health services are needed to attract businesses, industry, and retirees to rural communities. Thus, access to health care and the jobs created by health care can both drive the economy of a community [2]. The purpose of this commentary is to highlight selected capacity-building partnerships and programs that improve the economies of North Carolina’s rural communities.

Building Capacity Through Partnerships
The Department of Commerce makes targeted investments in workforce development and infrastructure—including water, sewer, broadband, bricks and mortar, gas, and roadway—as well as community projects that support local and regional economic development activities. These investments lead to creation and retention of jobs in communities across North Carolina. Creating communities with thriving businesses provides multiple opportunities for employees and their families to have access to resources such as high-quality affordable health care.

The Department of Commerce supports activities in rural communities that provide opportunities to improve quality of life, including access to health care, but the department does not work in isolation in helping communities to improve quality of life. Partnerships are vital to successful projects, and entities such as the Golden LEAF Foundation (GLF), the Kate B. Reynolds Charitable Trust (KBR), and The Duke Endowment (TDE) are significant partners. These organizations, along with many others across the state, strive to help create opportunities for communities to improve their economic well-being.

The mission of the GLF is to support the social welfare of North Carolina’s citizens. The GLF provides funding for projects that make a financial impact in economically affected or tobacco-dependent regions of the state. Grants may be awarded to 501(c)(3) nonprofit organizations and governmental entities across North Carolina [3]. In February 2011, the GLF awarded a $108,000 grant to the Halifax Regional Medical Center to support building renovations that resulted in the development of the Wound Care Center on the hospital’s Halifax County campus. The Wound Care Center, which offers hyperbaric oxygen therapy for treatment of wounds, addresses the critical need associated with the high incidence of diabetes in Halifax, Northampton, and Warren counties. As of May 2013, the project had resulted in the creation of 22 new positions with an average annual salary of approximately $65,000 (written communication from Terri Bryant Adou-Dy, Golden Leaf Foundation; October 2014).

The mission of KBR is to improve the quality of life and the quality of health for financially needy residents of North Carolina. KBR is committed to supporting organizations whose work is innovative and makes a difference, thus creating systemic change in a community. KBR grants may be awarded to 501(c)(3) nonprofit organizations [4]. Since 2008, KBR has awarded approximately $6 million to support the establishment of the Nurse Family Partnership program, including the creation of a state office. This funding has allowed the Nurse Family Partnership program to work in over 19 counties and has resulted in the creation of at least 50 jobs. The program works with first-time, low-income pregnant women and their children (up to age 2 years) to improve child and maternal outcomes (written communication from Allen Smart, Kate B. Reynolds Charitable Trust; October 2014).

TDE endeavors to assist people and strengthen communities across both North Carolina and South Carolina by supporting efforts that nurture children, promote health, and support education. TDE also supports rural churches in their efforts to assist communities. TDE provides grant resources to select 501(c)(3) organizations [5]. In 2014, TDE awarded $500,000 to the Southeastern Regional Medical Center in Lumberton. As part of a collaboration with Campbell University School of Osteopathic Medicine, this grant will support the development of a residency program for primary care physicians. Funding will support the renovation of existing space in Southeastern Regional Medical Center, which will be used for clinical education of over 100 primary care residents (written communication from Lin B. Hollowell III, The Duke Endowment; October 2014).

Capacity Building Through Programs
Rural communities across the state benefit from a variety of programs from the North Carolina Department of Commerce. These programs, which support community health improvement and development of economic potential, include Community Development Block Grants (CDBGs), rural grants, Main Street Solutions Grants, and the Appalachian Regional Commission (ARC).

The CDBG program assists communities with projects that offer opportunities for low- and moderate-income (LMI) residents. The majority of funding is provided for water and sewer infrastructure projects in which at least 70% of the grant funding supports the LMI population. Funded by the US Department of Housing and Urban Development, the program provides grants to local governments for projects that support the creation or retention of jobs. The funds can be used to support building renovations, infrastructure development, shell building construction, or site development [6]. In 2012, the program provided a grant of $338,175 to the city of Cherryville to construct a water line that would allow the opening of a 65,000-square-foot assisted living/skilled nursing facility. Peak Resources operates 7 similar facilities across North Carolina, and the company will create 43 new jobs and invest over $10 million in private funds at their new Cherryville facility.

Administered by the Rural Development Division of the North Carolina Department of Commerce, the Building Reuse Program provides funding to local governments to renovate vacant buildings and to expand or construct health care facilities that lead to the creation of new full-time jobs. Grantees must be a unit of local government, and the grants require a match equal to the amount of the grant awarded. Priority is given to projects with resident companies and projects in towns and communities with populations of fewer than 5,000 residents [7]. In 2011, the program awarded $80,000 to Brunswick County to support the construction of the Lower Cape Fear Hospice and LifeCare Center (LCFHC). The LCFHC provides professional health care and support to people with life-limiting illness, and it focuses on the emotional and spiritual needs of patients and their families during illness, death, and bereavement. This project created 10 new full-time jobs with an average annual salary of $38,355 (written commination from Hazel Edmond, Rural Grants/Programs Section; October 2014).

Another program administered by the Rural Development Division is the Economic Infrastructure Program, which provides grant funding to assist local governments with infrastructure projects that will lead to the creation of new full-time jobs. Grants are made to units of local governments, and priority is given to the 80 most distressed counties in the state as defined by the 3-tiered ranking system of the Department of Commerce. Project examples include public water and/or sewer infrastructure, public broadband infrastructure, construction of public rail spurs, and construction of publicly owned access roads [8]. The program awarded $585,495 to the town of Blowing Rock in 2012 to support the construction of water and wastewater infrastructure that would assist the Appalachian Regional Healthcare System in opening a new post-acute care medical facility. This project will create 59 new jobs (written communication from George Collier, Rural Grants/Programs Division; October 2014).

The Main Street Solutions Fund is a reimbursable, matching-grant program that was created by the North Carolina General Assembly to spur economic development activity in downtown business districts. The program provides direct financial benefit to small businesses, supports the retention and creation of jobs, and assists in spurring private investment in association with small businesses.

The Main Street Solutions Fund has supported several projects that have improved access to health care in communities [9]. In 2014, the town of Williamston was awarded $100,000 to help with the renovation of an abandoned downtown building that was converted into a primary care medical office. The facility, called AccessMedicine, uses a business model based on a structure of differentiated payments that include a monthly membership, an annual membership, or a-la-carte payments. This business model will better serve the needs of patients without the restrictions and bureaucracy of insurance, and it provides an opportunity for businesses to contract with AccessMedicine for medical insurance at greatly reduced costs. The AccessMedicine project leveraged over $400,000 in private investments and will create 4 jobs (written communication from Liz Parham, director of the NC Main Street Program; September 2014).

The ARC was established by Congress in 1965 to address economic and quality-of-life issues in the 13 states in the Appalachian region. The program is a federal-state partnership that works to create opportunities for self-sustaining economic development and improved quality of life. Twenty-nine counties in North Carolina are eligible for assistance from the ARC [10]. The program has supported a number of projects that have assisted in the creation of health care jobs and have provided increased access to health care. In 2011, the Mountain Area Health Education Center received $200,000 to expand in response to the growing demand for services for uninsured, at-risk pregnant women in Western North Carolina. ARC funding covered the cost of equipment for a new facility, which expanded access to quality obstetrical and specialized gynecological services for high-risk patients. The project resulted in the creation of 10 jobs and the retention of 96 jobs.

Capacity Building Through Planning
The recently reorganized Division of Community Assistance—which is now a part of the Rural Development Division within the North Carolina Department of Commerce—provides a variety of targeted planning services to units of local governments. Land use planning, training, meeting facilitation, economic development studies, and strategic planning are but a few of the services offered. Specific to supporting healthy communities, the Office of Community Planning sponsored preparation of a guidebook on integrating healthy planning principles into local comprehensive plans. The document has statewide applicability and provides technical assistance in addressing local planning needs for municipalities and counties. With a focus on the multiple dimensions of healthy community planning, the Guidebook on Local Planning for Healthy Communities is a resource guide for towns, cities, and counties that are interested in offering and promoting safe environments for people to be more physically active in their communities—whether walking or bicycling [11].

Partners Working to Build Capacity and Support Communities
The Innovative Readiness Training (IRT) program, administered through the United States Department of Defense, routinely conducts medical missions in medically underserved communities throughout the United States. Medical services are provided free of charge for community members while providing a training opportunity for military reservists [12].

In August 2012, Murphy Medical Center partnered with the North Carolina Department of Health and Human Services and the North Carolina Department of Commerce’s ARC program, and together they applied to bring an IRT medical mission to southwestern North Carolina and northern Georgia. In November 2012, the Department of Defense approved the North Carolina–Georgia IRT proposal. To support the Appalachian Care Medical Mission and coordinate follow-up care for patients, the mission leveraged the resources of the ARC and 135 health care organizations, educational institutions, civic organizations, and faith-based agencies from both North Carolina and Georgia. This was the first project jointly organized by 2 states that the Department of Defense has supported. The project service area (15 counties in North Carolina and Georgia) is designated as a health professional shortage area and a medically underserved area. As in most rural areas, there is a lack of medical services because of the shortage of medical, dental, and vision providers. Coupled with the lack of transportation and the high cost of medical care, this results in poor health for many individuals in these communities, which in turn affects the region’s quality of life and economic potential.

The Appalachian Care Medical Mission was located in Cherokee County (town of Murphy) and Swain County (Bryson City) for the 2-week period from June 2 to June 12, 2014. The mission allowed patients to access primary care, dental services, optometric care (including glasses made on site), behavioral health care, and veterinary care (vaccinations). Services were provided by 138 Army reservists from various locations in the United States, 17 active duty soldiers from Fort Bragg, and 7 members of the North Carolina National Guard. The military personnel were supported by 302 volunteers from North Carolina, Alabama, and Florida. More than 8,000 patients and 2,600 animals from communities in Western North Carolina and neighboring states were provided with medical services. The known economic impact of this mission was over $1.5 million [13]. The mission was supported by a $50,000 grant from the ARC.

Importance of Capacity Building
The partnerships mentioned above provide human resources as well as financial capacity to our rural communities. Through the various grant programs, financial and infrastructure capacity is developed that aids not only job creation but also improvement in quality of life. The various partners working together provide leadership capacity to help ensure that our most distressed rural communities obtain needed services and programs. The North Carolina Department of Commerce will continue to focus on ensuring that communities have access to the resources they need to support the creation and retention of jobs, while also providing opportunities to improve quality of life. This work is not done alone, but through continued collaboration with many partners in many programs. By working together to help communities build capacity, businesses have a greater chance to thrive, communities have a greater opportunity to prosper, and citizens have access to the quality-of-life amenities that all North Carolinians deserve.

Acknowledgements
Potential conflicts of interest. O.C. and P.M. have no relevant conflicts of interest.

References
1. North Carolina Department of Commerce. About our department. North Carolina Department of Commerce website. http://nccommerce.com/about-our-department. Accessed September 5, 2014.

2. Doeksen GA, St Clair CF, Eilrich FC; National Center for Rural Health Works. Economic Impact of Rural Health Care. Stillwater, OK: National Center for Rural Health Works; 2012. http://ruralhealthworks.org/wp-content/files/Economic-Impact-of-Rural-Health-for-NOSORH-for-Natl-Rural-Hlth-Day.pdf. Accessed September 5, 2014.

3. Golden LEAF Foundation. http://www.goldenleaf.org/. Accessed September 5, 2014.

4. Kate B. Reynolds Charitable Trust. http://www.kbr.org/content/about-us-overview; http://www.kbr.org/content/faqs. Accessed September 5, 2014.

5. The Duke Endowment. http://dukeendowment.org/about/about-the-endowment. Accessed September 5, 2014.

6. North Carolina Department of Commerce. Community Development Block Grants. North Carolina Department of Commerce website. http://www.nccommerce.com/rd/community-assistance/investment-assistance. Accessed September 5, 2014.

7. North Carolina Department of Commerce. Building Reuse Grants. North Carolina Department of Commerce website. http://www.nccommerce.com/rd/rural-grants-programs/building-reuse. Accessed September 5, 2014.

8. North Carolina Department of Commerce. Economic Infrastructure Program. North Carolina Department of Commerce website. http://www.nccommerce.com/rd/rural-grants-programs/economic-infrastructure. Accessed September 5, 2014.

9. North Carolina Department of Commerce. Main Street Solutions Fund. North Carolina Department of Commerce website. http://www.nccommerce.com/rd/main-street/main-street-solutions-fund. Accessed September 5, 2014.

10. North Carolina Department of Commerce. Appalachian Regional Commission. North Carolina Department of Commerce website. http://www.nccommerce.com/rd/arc. Accessed September 5, 2014.

11. Weitz J. Guidebook on Local Planning for Healthy Communities. Raleigh, NC: North Carolina Department of Commerce; 2013. http://www.nccommerce.com/Portals/2/Documents/CommunityDevelopment/RegionalOffice/WRO/Local%20Planning/Healthy%20Communities%20Planning%20Guidebook%20Final.pdf. Accessed October 13, 2014.

12. Innovative Readiness Training website. http://irt.defense.gov/. Accessed September 5, 2014.

13. Gardner C. Military recognizes Office of Rural Health and Community Care for role in 2014 Appalachian Care Medical Mission. North Carolina Department of Health and Human Services website. http://blog.ncdhhs.gov/post/91156062478/military-recognizes-office-of-rural-health-and. Accessed December 15, 2014.


Olivia Collier, MPA Appalachian Regional Commission program manager, North Carolina Department of Commerce, Raleigh, North Carolina.
Patricia Mitchell, CEcD assistant secretary, North Carolina Department of Commerce, Raleigh, North Carolina.

Address correspondence to Ms. Olivia Collier, North Carolina Department of Commerce, 4313 Mail Service Ctr, Raleigh, NC 27699 (ocollier@nccommerce.com).