GLEN ULLIN, N.D. — When small rural towns get smaller, the challenges for those who remain get bigger.
It's especially true for older residents and those who care for them in this shrinking North Dakota town.
Adults age 65 and older make up a third of Glen Ullin's roughly 700 residents. The town's retired teachers, accountants and health care workers are making every effort to age at home, but one big obstacle for them is the ability to access medical care — without it, they are often forced to move to a larger city.
Rural health care has been facing a crisis for years. But in rural towns such as Glen Ullin, older adults are getting help to manage, thanks to the handful of community members working to fill the gaps.
Each person plays a separate role — from keeping lonely older adults company to springing into action when a health emergency arises. In rural towns experiencing a loss of people, jobs and resources, this network of support can make a big difference.
NPR visited some of them to see what obstacles they encounter when trying to make sure the community's older adults have the care they need.
The program coordinator, a jack-of-all-trades
It typically starts with a concerned neighbor.
"They'll say, 'I haven't seen him outside for six weeks,' or something like that, and I'll go tap on their door," said Kyla Sanders, a coordinator for the Aging in Community program in western Morton County, where Glen Ullin is located.
It's a pilot program at North Dakota State University Extension to support older people living alone in rural areas. The idea behind the initiative is that older adults living alone are at the greatest risk of struggling under the radar. They are also the most likely to move out of town to be closer to resources.
There's no catch-all term for the work Sanders does. A former nurse and lifelong farmer, Sanders has the official title "program coordinator," but her list of responsibilities changes every day — from setting up internet at an older person's home to leading a flower arrangement class for a group of seniors to helping an older adult apply for Medicaid.
She's a firm believer that there are small, affordable ways to keep older people aging at home and that they don't have to relocate to a large town or city to thrive.
There are about 150 older adults whom Sanders visits or talks with regularly on the phone. According to Sanders, more than half the program's participants don't have family members living nearby or able to help. She suspects even more seniors are living alone in the greater region, and she hopes to expand the program out to 200 miles — about five times more than the distance she typically travels now.
"I think it's such a treasure to be able to have older adults stay in place and that it just can't be overlooked," she said.
The nurse practitioner, aka the primary care provider
Rhonda Schmidt's official title is "nurse practitioner." But like in many small rural communities, she's Glen Ullin's main primary care provider.
On a regular day, Schmidt sees somewhere between 15 and 20 patients. Her core staff is made up of two other people — a nurse's aide and a receptionist. Another nurse practitioner fills in once a week. Together, they handle medication refills and acute infections. But the clinic could do so much more if it had the staff, Schmidt said.
For instance, X-ray tests can help identify pneumonia, a disease common in adults over 65. The clinic has the X-ray equipment but no technician to run the machine, according to Schmidt. A doctor from an affiliated hospital used to help fill that gap, but that is no longer the case.
CT scans are another service that's limited at the clinic. Staff members who operated a mobile CT scanner used to visit once a week, according to Schmidt. Now, they come once a month.
In North Dakota, only six out of 53 counties are considered to have enough health care workers, according to the Rural Health Information Hub.
Schmidt was born and raised in Glen Ullin. Of her four siblings, she's the only one still in town, and she lives on the same dairy farm that she grew up on.
"I just feel it's my job to make sure they get what they need," she said of her patients. "If I can't figure out how to see them, they're going to have to drive or find a driver."
The volunteer EMT crew
Lori Kottre may work 9 to 5 as the office manager at Glen Ullin's nursing home, but she serves around the clock as the town's emergency responder.
"I have my pager on 24/7," she said. "And if I'm gone from the office three or six hours a day, I make up my time here so that my job here isn't neglected."
Kottre has worked as a volunteer EMT for nearly 30 years, alongside her son, daughter, daughter-in-law and five others. Like Kottre, all of them have day jobs. In the U.S., more than half of rural EMS agencies are staffed by volunteers, compared with 14% in urban areas.
The ambulance squad receives 120 to 150 calls a year — a majority of which involve older adults, Kottre said. This means that the calls the EMTs receive are almost always serious, such as cardiac arrest and strokes. But they are limited in how they can help.
The ambulance carries aspirin, EpiPens and medications to help treat chest pain and asthma. But with no paramedic on the squad, there is no one certified to insert an IV or place a breathing tube. In those cases, the EMT crew calls the ambulance service in Bismarck, North Dakota's capital, to meet on the highway, typically about 17 miles out of town, and take over.
According to Kottre, the EMT crew wouldn't be able to afford a paramedic. Many rural communities face that challenge as a result of a national paramedic shortage.
"They don't stick around the small towns," she said.
Still, Kottre tries to do the best with what she has.
"I feel more responsible for trying to take care of the patients as good I can, because we know all of them — we know all of their children, all of their grandchildren," she said.
The priest making home visits
When he's not at church, the Rev. Gary Benz spends his weekdays traveling to the homes of his aging parishioners who are too ill or weak to attend services. He makes about seven to nine trips a week. Initially, the purpose was to bring them Holy Communion, but he quickly learned that they needed something else — connection.
"They say, 'Father, this illness or condition is weighing on me and it just takes away my joy,' or 'It gets lonely being alone here all day,'" he said. "Some of them have family and friends who come visit, which is good, but some, they're the only person in their house."
Rural towns are often celebrated for their tight-knit communities and close bonds between neighbors. But even in areas where that holds true — like Glen Ullin — they face unique barriers to social connection, like distance, neighbors moving away and few opportunities to gather. According to the University of Minnesota Rural Health Research Center, older adults in rural areas report being lonelier than their counterparts in urban areas.
Loneliness can have detrimental effects on physical health, including increased risk of heart disease, stroke and dementia, according to a report from the U.S. surgeon general.
Benz, who leads three congregations in neighboring counties, sees the need firsthand. It's why home visits are important to him. On top of daily Mass and confessionals and leading the youth ministry, Benz rarely misses a home visit or room visits with nursing home residents.
"These people — it's not just a euphemism — they become part of my family," he said.
This story was supported by the Pulitzer Center on Crisis Reporting.
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