Rural: What does it mean for HIV providers in Wyoming?

Project Director, Wyoming AETC Regional Program Manager, Mountain Plains AETC

Limited medical and social services in rural settings make treating HIV more difficult, especially when the stigma remains and local healthcare providers do not see HIV as a problem that deserves real attention.  Vast distances to cover and limited logistical resources are a few more of the obstacles rural HIV providers face, compared with their colleagues in traditional urban areas. For more transparency on what life is like for HIV providers in the rural setting, we asked Anna Kinder, M.S.OTR/L, to tell us more about her experience as a healthcare professional and trainer in rural Wyoming. Anna Kinder is the Project Director of the Wyoming AETC, and Regional Program Manager of the Mountain Plains AETC. She is an occupational therapist by training and has been with the AETCs for more than 11 years.

What is your definition of rural, and how does it compare to other interpretations you have heard?

Anna:  I am a girl from a small town in Wyoming of 70,000 people, and although I understand there are rural parts in every state, I’m inclined to believe that rural areas in the more populated states have very different challenges than the rural areas I’m familiar with, i.e., smaller towns with fewer services for fewer people living vast distances from one another. The word “frontier” comes to mind, but we don’t qualify for that, even though it sometimes feels that way.

What are some advantages to being a healthcare professional in rural Wyoming, compared to more populated areas?

Anna:  We can be a little more flexible in finding ways to meet the needs of our patients. Because we are in small towns, we can reach out to who we know locally to assist us with our needs; relationships with those groups and organizations have already been established. We see this a great deal with our case managers who often have to go the extra mile to get what they need. Another advantage to providing healthcare in rural areas is that we’re usually the first to develop unique programs to address special needs, and therefore we have fewer obstacles to hurdle.  

What are some of the disadvantages?

Anna:  In Wyoming we have two active practices that provide HIV care for the entire state, but because of extenuating circumstances (lack of funds and transportation, no provider in their area etc.) approximately half of the patients go outside of the state to get care, which further complicates things. Vast distance between places makes it more difficult for both patients and providers. Often the directives we receive consider large populated areas with many resources that can meet the needs of their patients. Our resources are fewer and our needs are different so we have to be creative in figuring out how to make things work.

Can you give us examples of the unique challenges some of the HIV healthcare professionals in your region face?

Anna:  One of our HIV providers is inundated because he is the ONLY infectious disease specialist for the ENTIRE state who sees patients that come to him with ANY infectious disease, while our other HIV provider has a full primary care practice and is very busy as well. Although they see about the same amount of people infected with HIV, it’s a difficult situation because the infectious disease doctor is spread so thin, while the primary care doctor does everything she can to stay up-to-date with HIV. 

Our Native areas are difficult to reach. The reservations are in very remote locations and often when we identify contacts we can work with, they subsequently get transferred to different jobs, and later we discover that programs we were working with are no longer in existence.  Another example is in South Dakota where the reservations and the closest AETC are located on opposite sides of the state. Serving these areas involves a lot of windshield time. For further context, some of the reservations do not have lodging located in their cities or even close by.

As a trainer, if I want to offer training in another city, I have to travel over 150 miles at the minimum, and I’m lucky if I get 10 participants to attend. In rural areas, HIV is not seen as a priority, but rather as something that doesn’t really exist or that they won’t have to deal with it. 

Lastly, our case managers are not limited to just facilitating health care. There’s a need for them to become more familiar with all the resources in large geographical areas just so they can meet the basic needs of their patients’ care by teaching them to utilize the services that are available, even though they may be limited.

Tell us more about the work of your region’s case managers.

Anna:  Wyoming case managers are primarily nurses. We asked a few case managers from the surrounding areas to collaborate and present their best practices and challenges on a webinar for the Wyoming group. Many of their challenges were the same, but one thing that stood out most was that the case managers were ALL their patients had as a source for help. In addition to HIV care and management, the case manager provides assistance with financial planning, finding housing and job opportunities, filling out and filing necessary applications, finding transportation, grocery shopping and nutritional management. In essence, the case manager becomes the healthcare provider, accountant, lawyer, psychologist, nutritionist, driver, personal assistant and teacher. We try to give them as many tools as we can, but there needs to be more discussion around this. We only scratched the surface of this topic and we’re still working out how to address these issues.

What do you think is the best way to provide optimal care for patients in rural settings?

Anna:  This is difficult to answer because access to care is not optimal. We’re doing what we can with the limited services we have, however with the AETCs support I’ve always been able to get the information, training and clinical consultations we need to try and make it work for our region.

What are you doing at the Wyoming AETC to assist the healthcare professionals treating people who are infected with HIV?

Anna:  Getting providers to come out for HIV training in Wyoming has been challenging because most of our region’s providers do not recognize HIV as anything that should be on the radar. We offer an ID update webinar once a month called The Wyoming ID Network Webinar Series, and we make a point to include HIV information so providers are exposed to some HIV training each time. We’ve been doing this now for 3 years and it’s been very successful. Our providers, most of whom are nurses, have embraced the program. Unfortunately, technology is still slow here, so we have not been able so successfully record webinars and make them available for additional educational training. This is another challenge for our rural area.

We’ve also been able to provide training to healthcare providers through an annual conference called Extreme ID, where we bring in experts from across the country to talk about the latest trends in infectious disease. We cover a variety of topics that providers might encounter, including HIV, thus making it a win-win for everyone. 

Are there any other steps in place to address some of these challenges?

Anna:  We’re taking webinars to the next level with the telehealth program. A nurse in a remote section of Jackson, Wyoming, told us how connected she feels with the rest of the state through webinars. She’s able to ask questions and chat with other providers, which brings up another challenge. Some of our providers feel isolated and need community in order to provide the best care they can. We offer a resource book that helps them connect with other providers in the state for support, but sometimes it’s not enough.

Are there medical schools or residency programs in your area? If so, what advice can you offer medical students or young healthcare professionals who have chosen to focus on HIV in the rural setting?

Anna:  We spend a lot of time on this regionally because we recognize the workforce is going away. We utilize mentoring programs to help providers in the field in Wyoming. We do not have a medical school, so residents are coming from all different states. We expose them to our ID specialist so they can get current information, and we’d like to implement universal HIV testing in residency programs but there are many hurdles, one of which is dealing with electronic health records - a priority for residents right now. In 2005 we were the first to implement HIV testing in a community health center dental clinic. Just this year, a dental hygienist and faculty member for the Sheridan College Dental Hygiene Program in Sheridan, Wyoming, completed a mini sabbatical with Mountain Plains AETC in Denver, and found a way to implement HIV testing into this dental hygiene school. Note the amount of time it took for this to happen-seven years later-yet another challenge for us.  But, dedicated people who see the benefits persevere and the end result is a new and unique program.  

What questions do you have for other rural healthcare professionals?

Anna:  My experience of living and working in a rural area may be very different than that of people from rural areas near big cities. For the AETC faculty in those parts, what challenges do you face and how do they compare to our experiences in at the Wyoming AETC?

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