Reaching Rural America

UIC’s rural health professions program includes a “no harm on the farm” visit to a farm to allow students to discuss potential emergencies with first responders and farmers.

Many pharmacy schools offer rural health concentrations to train student pharmacists to care for underserved populations.

By Joseph A. Cantlupe

In the heart of Appalachia, better, more accessible healthcare is needed for populations beset by higher poverty and disease rates than in other parts of the country. The leaders of East Tennessee State University (ETSU) Bill Gatton College of Pharmacy say they embrace this evolving challenge and want to pursue a commitment in the place they call home. “We’re right in the thick of Appalachia, and we focus on the rural and undeserved and improve lives of people in this region,” said Dr. Debbie C. Byrd, dean of the college of pharmacy, which is located in the South Central Appalachian region.

“One of the things that is unique is that we are attracting students from this geographic region and students are committed to this community and want to go back to the community to study and serve,” said Dr. Ralph Lugo, founding chair of the Department of Pharmacy Practice. “At ETSU, there has been a long history with the medical school of a rural primary care track that trains healthcare providers in this region.”

Rural Americans, who make up at least 15 to 20 percent of the U.S. population, face inequities that result in worse healthcare outcomes than that of urban and suburban residents. The rural health disparities, reflected in Appalachia, “are rooted in economic, social, racial, ethnic, geographic and health workforce factors,” according to the university. The healthcare challenges include lack of access to care, with fewer local doctors, and more remote locations.

With these deficits in mind, pharmacy schools believe that they can help bridge those healthcare gaps, and universities such as ETSU are taking steps to broaden their academic reach to bring in student pharmacists to focus on the specific needs of the communities. Other pharmacy schools are also bolstering their educational programs, including those in bigger communities that border rural areas. The result has been a keen interest among students, more of whom are drawn to the rural healthcare offerings that are constantly expanding.

Filling a Need

While Chicago may be one of the biggest cities in America, its suburbs flow quickly into rural parts of Illinois. The University of Illinois Chicago (UIC) College of Pharmacy has embraced rural pharmacy education at its campus 90 miles away in Rockford with rural pharmacy education program (RPHARM), part of the University’s National Center for Rural Health. Student pharmacists complete a concentration in rural pharmacy services, said Dr. Kevin O. Rynn, clinical professor and vice dean at the College of Pharmacy. Twenty percent of the student body is enrolled and about 60 percent of graduates with the rural pharmacy concentration practice in a rural community. In many cases, “they may be the only healthcare provider in the community, so they have to be a healthcare leader and step up to the challenge,” he said.

In Des Moines, Drake University’s College of Pharmacy & Health Sciences offers a Rural Health Initiative Program, an interprofessional certificate program designed to enable students to understand the value of and nuances faced by healthcare practitioners in rural settings, said Dr. Renae Chesnut, dean and professor. The pharmacy program also continues to have students complete experiential rotations in rural settings. “The pandemic has changed a lot of things,” Chesnut said, “but our students are still going to rural settings for their experiential education, practicing in pharmacies and hospitals that are open to serve their communities.”

These programs are becoming more popular and are attracting more students, with a focus on interprofessional teams drawn from other health profession schools, specifically eyeing the gap in care that the pharmacists can fill in rural communities. Over the past two years, ETSU’s College of Pharmacy has expanded its rural curricula under a rural health initiative strategic plan that specifically targets improved coordination among the academic community, hospitals and healthcare providers in the area. The idea, according to the school’s educators, is to nurture progressive, team-oriented pharmacists while improving healthcare in rural and underserved communities.

Student Pharmacist administering COVID-19 vaccine
An ETSU student pharmacist administers the COVID-19 vaccine at Johnson City Medical Center, Ballad Health, in Tennessee.

One of the school’s top initiatives is a partnership with Remote Area Medical (RAM) that allows student pharmacists to work with other healthcare professionals to provide care for patients. This care includes documenting medical histories, performing health screenings, providing education and helping patients navigate vision or dental care needs that they may have neglected. “Ninety percent of the U.S. population lives within five miles of a pharmacy,” said Dr. Emily Flores, associate professor of pharmacy practice. “The accessibility of a pharmacist is there. We’re trying to get our pharmacy students to help bridge gaps in rural healthcare and the disparities that exist.”

Since ETSU initiated the program, students have increasingly served hundreds of hours in rural underserved areas, she said. Even dealing with COVID-19 this past year, “our students served over 900 hours—and that’s just what they logged, they probably did more,” Flores said. “We’re making strategic partnerships and more specialized opportunities for students. All of our students have a set of competencies that they should achieve for rural care.”

About 97 percent of the pharmacy school’s APPE students completed at least “one rural and/or underserved experience” in 2019-20, Flores and her colleagues wrote in a poster describing the program. Each student completes a rural service IPPE of at least two hours in each of the first three years. Through its diverse programs, which include 15 health professional degrees within the school’s Academic Health Sciences Center, “we have an environment that expects collaboration,” said Dr. Brian Cross, associate professor and vice chair in the Department of Pharmacy Practice and associate professor in the Department of Family Medicine at the James H. Quillen College of Medicine.


Despite COVID-19, “we’re still committed to the rural healthcare settings. ’The pharmacies and critical access hospitals in these rural areas are important partners for our educational programs.”

Dr. Renae Chesnut

We prepare the students to be service leaders in their communities. Some of these students want to return to their home communities. Others want to serve underserved populations and without this program they don’t really know how to get started—the program teaches them to make the connections possible.

Dr. Kevin O. Rynn

Cross also helped establish a program with his wife, Dr. Patricia Amadio, a professor at the medical school, to carry out a “grassroots initiative from the students” to help the homeless population get flu shots and clothing, as well as prepare for COVID-19 vaccinations as they become available. “We need to be on the front line with our team. That’s not to say we are cavalier and do not protect our students and ourselves,” Cross added. “For us to go into a bunker and wait for COVID-19 to be over would mean that we had an opportunity to help and we did not.”

Dr. Jessica Robinson, assistant professor, pharmacy practice, a member of the college’s community pharmacy initiative, said she knows firsthand the contributions that ETSU is delivering to the rural environment and the potential it offers students. “I was a student here and I was from a rural area,” Robinson said. “I don’t know if I would have gone to pharmacy school if this college wasn’t here for me at the time. I couldn’t imagine practicing anywhere else other than with the folks who got me where I am today.”

While more highly populated areas have seen more chains, South Central Appalachia has a greater concentration of independent pharmacies, which offers additional opportunities for community-based innovations as well as hands-on learning. Through the college’s participation in the Flip the Pharmacy grant program (Community Pharmacy Foundation, 2019), Robinson and other faculty, along with students, work with more than 120 pharmacies to evaluate their business and clinical workflow and provide ongoing support to help pharmacies meet their unique business, social and demographic needs, she said.

As part of their pharmacy education, students participate in nine monthlong rotations during their APPE year, many of which are in rural communities, “which gives them the skills they need to jump into that environment when they graduate,” said Dr. Susie Crowe, director of experiential education. That experience not only encompasses the work of community pharmacies, but also in hospitals, ambulatory care settings and primary care, all within the rural environment, Crowe said. “If a career in a rural setting is something [students] want to pursue, then they have plenty of opportunities to develop and practice those skills while on APPEs.”

As the school develops its programs, it also is focusing on research to evaluate how patients are impacted by rural healthcare teams, said Dr. Karilynn Dowling-McClay, assistant professor of pharmacy practice. A major multidisciplinary effort is examining “the intersection of health policy and care, including pharmacy-based care, through the newly formed Rural Health Equity Research Center, a collaboration among the ETSU Addiction Science Center, the ETSU Center for Rural Health Research and the NORC Walsh Center for Rural Health Analysis,” she said.

It Takes a Team

Having academic programs that involve pharmacy practice along with other professions is standard in much of the work at ETSU and also is reflected in programs at the University of Illinois Chicago and Drake University. Giving student pharmacists the opportunity to work interprofessionally with medical and nursing students is paramount in UIC’s rural health professions program, said Rynn, the vice dean. During their four years in the program, they complete a rural community capstone project with a medical student partner. In early years pharmacy, nursing and medical students learn together how to conduct a needs assessment and work with local community organizations, hospitals, clinicians and community leaders to develop their project. The RPHARM program culminates with students spending 18 weeks on three APPE rotations in a rural community. During this time, they work with their medical student partner to implement and measure the outcomes of their project, later presenting results at the campuses research day.

“We prepare the students to be service leaders in their communities,” Rynn said. “Some of these students want to return to their home communities. Others want to serve underserved populations and without this program they don’t really know how to get started—the program teaches them to make the connections possible.” Part of UIC’s program includes a “no harm on the farm” visit to a farm where students discuss with first responders and farmers potential emergency situations that pharmacists and other health professionals may encounter, whether it’s “a pesticide exposure, tractor rollovers or grain bin entrapment,” Rynn said.

Even though Drake University doesn’t have its own medical school, the school partners with other institutions in the area so student pharmacists and occupational therapy students can work with doctors of osteopathic medicine, in addition to physician assistants, and physical therapy students through the Rural Health Initiative Program. Students can complete one year of the program or continue to a second year to earn the Rural Health Initiative Program Certificate. The program includes didactic coursework with hands-on interactive group work and site visits to healthcare practices in rural communities.

Student pharmacist with patient
Student pharmacists at UIC spend 18 weeks on three APPE rotations in a rural community.

The Rural Health Initiative Program has been an option available to student pharmacists at Drake for the past five years. More than 30 students have finished the program, and the school expects even more interest. Despite COVID-19, “we’re still committed to the rural healthcare settings,” Chesnut said. ’’The pharmacies and critical access hospitals in these rural areas are important partners for our educational programs.” Drake is expanding its rural healthcare education opportunities in the pharmacy program, she said. Among those is “Cultivate,” a high school internship program that seeks to heighten interest in the pharmacy field.

At ETSU, the community expressed a need and desire for a pharmacy school more than 15 years ago, said Byrd. In 2004, the nearest pharmacy school in the state was more than 500 miles away and there were calls in the community to have its own. The state wasn’t willing to fund one—but then-Gov. Phil Bredesen offered a challenge. He said if the community and region could raise $5 million in 90 days, they could have their school. “I think it was meant to be the end of the story, but this is a group of people up for a challenge,” Byrd recalled. With many people just donating dollar bills at local grocery store collections, the community raised more than $5 million in 58 days, setting the stage for the Gatton College of Pharmacy. “We feel a sense of responsibility to this community,” Byrd said. “We wouldn’t be here without them.”

Joseph A. Cantlupe is a freelance writer based in Washington, D.C.