LEBANON — Dartmouth Health and the Dartmouth College Geisel School of Medicine will use millions of dollars to study rural health-care access for older adults.
“When we look at older patients, especially older patients with serious illness, and we look at what medicine has studied, we find that most of the research is on urban populations,” said Dr. Angelo Volandes, interim chief research officer at Dartmouth Health and senior associate dean for clinical and translational research at Geisel. “We know very little about how older people with serious illness age in rural America.”
Last month, the health system announced it would use an $11.8 million federal grant to establish a research program called the Center for Aging with Serious Illness at Dartmouth Health and the Geisel School. The hope is that the center — CASI for short — will help fill a national gap in rural health-care research.
“We cannot force solutions and models that work in urban America to attempt to put them in rural America,” Volandes said.
Volandes and Dr. Nathan Goldstein, chair of the Department of Medicine at DH and a Geisel professor of geriatrics, are the principal investigators for CASI.
Goldstein said he expects the institute will help put formal data to work that, in many cases, is already underway at Dartmouth. The money will be used to fund research, and also to build curriculum for researching older adults and assessing the results.
The research is especially relevant in rural Vermont and New Hampshire, the second- and third-oldest states in the country behind Maine, according to U.S. Census Data.
“Given that Dartmouth Health is the most rural academic medical center in America, it’s the perfect place,” Volandes said. “Many of our patients are older; many of our patients have serious illnesses. Most of our patients live in rural parts of the country, so there’s no better place in America to study this.”
Rurality and age both create barriers to health-care access, Goldstein said. Living in a rural area comes with challenges like distance to health care, drive time, weather and infrastructure issues, such as internet access and stable electricity, that all make it more difficult to obtain health care.
Aging also makes health care more complicated because diseases affect older patients differently, and challenges such as cognitive impairment can make it more difficult for patients to diagnose or describe their own symptoms, Goldstein said. The institute will look at the intersection of those challenges.
“CASI, in many ways, is one-stop shopping for rural America,” Volandes said. He envisions “a really unique research portfolio that meets the needs of rural communities, which is one aspect that the (National Institutes of Health) needs a lot more research toward.”
The grant will help establish “research infrastructure” for a series of projects looking at adults aging with serious illness, Goldstein said. In the first year, the institute will pursue three projects that are already underway at Dartmouth.
One will look at keeping older adults with arthritis and other diseases active with home-based physical therapy, so patients do not have to travel to Lebanon for every appointment. A second physician is studying patients with breast cancer and how to monitor and care for them remotely, including at home and different times of day. The third project underway is looking at how to help patients with vascular problems to make medical decisions.
“We’re trying to do work to really prove that these interventions that we’re doing actually improve care within a very rigorous, scientifically sound research context,” Goldstein said.
Just last week, DH and Geisel received an additional $13.82 million to lead a National Institutes on Aging study on how older Americans with serious illnesses make decisions about their care.
“In medicine, a lot of decisions that we make aren’t black and white,” said Volandes, who has researched medical decision-making throughout his career.
When making choices about their health care, patients often have multiple options that each come with their own complications, especially older patients, Volandes said. For example, if a 92-year-old patient has cholesterol problems, they might choose to watch the situation and wait to intervene, or they could opt for surgery. Each option has its own set of benefits and challenges
“When it comes to quality of life, quantity of life, prolongation of life, these are different values that people hold differently, depending on their age and their preferences,” Volandes said. “And so, a decision aid is a tool that helps you clarify what’s important to you.”
Decision aids might take the form of an interactive video, a graph for a patient to look through, or even the way a physician communicates with a patient.
Volandes and Goldstein hope that the research done at DH and Geisel can help serve not only patients in the Upper Valley, but farther afield.
While urban solutions might not serve rural populations well, Goldstein said there are vulnerable people living in urban areas who struggle with similar challenges and could also benefit from the work.
In rural New Hampshire, patients might not have the time or ability to drive 90 miles to a hospital, and might not have access to electricity or internet, for example. In the inner city of Manhattan, patients might also be living in unhealthy conditions, be unable to afford the subway to reach a hospital and have no access to internet or healthy water, Goldstein said.
“It’s actually all about people not having access to care, not feeling embraced by the medical system, and having very true barriers,” Goldstein said.
In addition, underserved rural populations around the country contending with the same challenges.
“Whether you’re living in the north country, or you’re living in rural Montana, the barriers are the same,” Goldstein said. “(…) If we can fix it here, we can fix it anywhere.”
