Editor’s Note: This interview first appeared in Path Finders, an email newsletter from the Daily Yonder. Each week, Path Finders features a Q&A with a rural thinker, creator, or doer. Like what you see here? You can join the mailing list at the bottom of this article and receive more conversations like this in your inbox each week.

Kristine Sande works as the program director for the Rural Health Information Hub (RHIhub), a clearinghouse for information, opportunities and resources when it comes to rural health. The RHIhub is funded by the Federal Office of Rural Health Policy, a division of the U.S. Department of Health and Human Services’ Health Resources and Services Administration. On the RHIhub website, everyone from rural healthcare providers to rural community leaders to state and national policymakers can find information about rural health topics in order to make more informed decisions.

Initially called the Rural Assistance Center and led by Dr. Mary Wakefield, the center is now run by Sande, who also serves as the Associate Director of the University of North Dakota’s Center for Rural Health. December 2022 marked RHIhub’s 20th anniversary. We asked Sande what RHIhub has meant to rural health and what has changed since the organization began.

Liz Carey, The Daily Yonder: What has changed since RHIhub started? You’re celebrating 20 years. What is different now?

Kristine Sande: RHIhub has grown and evolved in our first 20 years, but what I consider our core services remain the same – our website, electronic newsletter, and resource and referral service. Our original website was much less extensive than our current one. At the beginning, we also received many more requests for customized assistance. That was great because those requests helped us to identify what type of information people needed and where the gaps were. Then we were able to create content for the website that addressed those needs and gaps.

Kristine Sande, program director for the Rural Health Information Hub. (Photo provided.)

The original website was pretty basic and focused on identifying information and opportunities that could help rural communities more easily stay up-to-date, make decisions, apply for funding, and otherwise work to improve health and healthcare. That work still makes up the backbone of RHIhub and now resides in the Online Library and Topic Guides sections of our website. We still have our staff scouring the internet and other sources every day looking for resources and opportunities that could be useful to rural stakeholders and then indexing those resources to the site.

Over the years, we’ve added a lot more content to the site, such as State Guides, data visualizations, evidence-based toolkits, and Models & Innovations. We’ve also adapted to the changing ways that people access information adding RSS feeds and social media channels; hosting webinars and podcasts; and providing custom alerts of new information.

DY: What was your first position with RHIhub, and how did you move into the position you’re in now?

KS: My first position with RHIhub was as project coordinator. I had been working at the Center for Rural Health at the University of North Dakota for about 10 months when RHIhub got started and I had helped to write the grant application, so I was very interested in being on the ground floor of building this new information center.

As the project coordinator, I was responsible for operations, so I supervised staff, worked with partners and our funder, and mostly tried to figure out how to operationalize the grand vision that Dr. Wakefield, the original PI (principal investigator) and program director, and our other partners had for the program. Luckily, I had the help of a really talented staff. Maren Niemeier, originally our lead information specialist and now our information resources manager, came to us from a digital librarian position at the university library. Her expertise was – and continues to be – critical to shaping the content and structure of our website.

In the early years of the project, I learned so much from Dr. Wakefield about running a program, understanding policy, strategy and more. Sometimes, it was like drinking from a firehose, but I was so lucky to have her to mentor me. In 2004, I became the program director, and in 2005, also took on the PI role.

DY: What is your take on the state of rural health and rural healthcare? Have things gotten better, worse, or are they the same?

KS: Oh, tough question! I hesitate to say that things are better or worse, but there have definitely been changes. In rural health, there are some persistent challenges and access barriers. For example, distance to care, workforce, and the unique challenges that come with having low volumes of patients are all persistent issues that are unlikely to be ‘fixed’ anytime soon. A bright spot is that rural rates of uninsurance are down over the last 10 years.

Two other significant and not unrelated changes that we’ve seen over the years are an increased focus on social determinants of health and the move towards value-based healthcare payment. There’s been an ever-growing awareness of how the social experiences and needs of a patient affect their health. For instance, it’s unlikely that a patient will have good health outcomes if you send them home from the hospital to a house with no heat and electricity. Some of the value-based payment models allow healthcare providers to be creative about addressing those social needs to, in turn, improve the outcomes of their patients.

Overall, I would say that we have seen a lot of ebb and flow in what are critical rural health issues over these 20 years. When we started RHIhub, we were indexing lots of resources related to hospital and services closures. But the Critical Access Hospital designation had really seen good uptake and we started to see fewer and fewer publications about closures, to the point where we discussed whether there was still enough volume of resources on that topic to keep that taxonomy term in our system. We decided it was an important concept and we should keep it. Boy, did we make the right decision because that issue came back with a vengeance.

When it comes to rural health, there are always many different factors at play, some of which stabilize rural health and others that have a destabilizing effect. Even in the best of times, the rural health environment needs our constant vigilance to make sure that our issues are understood and monitored to avoid poor outcomes or unintended consequences.

DY: Where will RHIhub go in the future? What do you see for RHIhub 5 years from now, 20 years from now, and at 50 years old?

KS: For all of those time frames, I would say that RHIhub will be working to respond to information needs of our rural users, and we’ll do that using the channels they use and the technology that’s available to make that information access as easy as possible. We pride ourselves on our ability to be responsive to those factors, as well as the needs and priorities of Federal Office of Rural Health Policy.

At the beginning, we were very concerned about making sure that our resources were easy to access for rural people, and we continue to carry that in mind. In 2002, we had users who were still using dial-up internet services. While that’s improved, we still have rural users who have much slower connection speeds than average, so their needs for fast loading times trump our desire to add bells and whistles to the site.

DY: Why do we need something like RHIhub?

KS: RHIhub exists because rural communities and healthcare providers do not have the same resources that exist in urban areas. Staff in rural healthcare facilities are often stretched thin and have to ‘wear many hats.’ For instance, they probably aren’t going to have a dedicated grant writer who can spend a lot of time researching available grant opportunities and writing for multiple opportunities each year, which puts them at a disadvantage when trying to compete for resources with hospitals in urban areas. So, RHIhub works to ‘level the playing field’ for rural facilities by making information and opportunities easier to find and access.

In addition, RHIhub helps people learn about rural health issues. That may be at the local level, like new Critical Access Hospital board members who need to understand the nuances of Critical Access Hospital status, or it might be policymakers who are considering ways to improve healthcare delivery and payment. Having a go-to starting point for that information can be really helpful when trying to learn and understand the issues. A key point about RHIhub is that we know there are a multitude of sources that produce information about rural health – we don’t try to replace those sources, but rather we help our users find that information that already exists.

We also help rural communities share ‘what works’ when it comes to rural health. Over the last decade, we’ve worked to develop evidence-based toolkits with our partner, the NORC Walsh Center for Rural Health Analysis. These toolkits can help rural communities develop and implement new health initiatives. We’ve also created a Models & Innovations section that shares the successes and lessons learned of rural programs so that other communities can learn from them. Our Rural Monitor also shares the experiences of rural programs and facilities. This sharing of what works is one of my greatest passions in the work that we do.

When it comes down to it, there are so many different use cases for the RHIhub website that we’re sometimes surprised when people tell us how they’ve been using it.

DY: What impact do you think RHIhub has had on the rural healthcare landscape?

KS: I think RHIhub has become an important piece of the infrastructure supporting rural health. We hear constantly from our users about how much they rely on RHIhub to help them do their job better. And that’s why we do what we do.

We collaborate enthusiastically with other key pieces of the rural health support infrastructure, like the Federal Office of Rural Health Policy, as well as state offices of rural health, technical assistance providers, research centers, and membership organizations. We support them and they support us so that we don’t have to duplicate each other’s work — that allows us to maximize our collective impact for rural health stakeholders.

This interview first appeared in Path Finders, a weekly email newsletter from the Daily Yonder. Each Monday, Path Finders features a Q&A with a rural thinker, creator, or doer. Join the mailing list today, to have these illuminating conversations delivered straight to your inbox.

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