Dr. Christine Alarcon, left, and assistant Lisa Windsor treat a three-year-old patient at the Cambridge Dental Clinic, the only dental clinic for low-income children in Dorchester County, Maryland.
Frontier and rural health care providers looking for innovative ways to solve increasing workforce shortages are sometimes finding that help is as near as their own backyards: by recruiting and training local people to be health care professionals in their communities.
In Nevada, the Rural Family Medicine Consortium proposed what it termed "an aggressive rural community partnership" to recruit and retain health professionals for rural and frontier communities. In Alaska, the board of directors at a critical access frontier hospital picked up the bill for hospital employees to become registered nurses. In rural Maryland, a coalition paid all expenses for local residents to become dental hygienists if they would agree to return to the area to practice.
Communities like these that look within their ranks to fill health care professional needs are the most likely to succeed, according to Dr. Robert Bowman, past chairman of the Rural Medical Educators Group of the National Rural Health Association and Director of Rural Health Education and Research for the Department of Family Medicine at Nebraska Medical Center in Omaha.
"Rural areas should be recruiting people that grew up in their state," said Bowman, who has done extensive research on provider shortages. "Physicians, physician assistants, family nurse practitioners-we've found that these professionals who are working in underserved areas are more likely to also have been born in lower income and rural areas. And physicians who grew up in rural areas are most likely to return to that area."
Recognizing the need to supply their own practitioners, the University of Nevada began a pilot program to develop more training opportunities in the state, said Caroline Ford, assistant dean at the University of Nevada School of Medicine and director of the Nevada Office of Rural Health.
"We decided to look at how we could influence rural training opportunities for our medical students and simultaneously initiate educational and treatment programs in rural communities," Ford said.
The Rural Family Medicine Consortium-a partnership between the University of Nevada School of Medicine, a community-based hospital and a hospital-affiliated network-developed a medical student rotation program to introduce students to rural practice and, at the same time, provide more services to those communities. Fallon, a community of 13,000 about 63 miles from Reno, was selected for the first site. In 2006, the University began requiring students to do medical rotations in Fallon. By the time the program is in its third year, four residents will always be serving rotations at Fallon, Ford said.
In addition to seeing patients, medical residents provide outreach care such as prenatal exams, wellness education and chronic disease management programs. One of the most innovative aspects of the program is its attempt to also address specific health concerns. A cluster of people, primarily children in an agricultural region near Fallon, have an abnormally high rate of certain cancers. Fallon's medical residents are developing an occupational health and environmental program focused on needs of this cancer cluster.
"And as they (medical residents) see these patients, they are screening them more carefully for cancer risks than in other clinical situations," Ford said. "They're also providing cancer prevention and education outreach."
Ford said Fallon was selected for the first site because of the University's longstanding training relationship with the community. When the program is well underway, it will be evaluated and may be replicated in other rural areas of the state.
With assistance from the Nevada State Legislature, solutions are also being sought for the lack of obstetrics services in rural areas. Because the cost of malpractice insurance outweighs the number of obstetrics patients that rural family medicine physicians see, many of these physicians have dropped obstetrics, Ford said. The Nevada State Legislature has appropriated $150,000 a year to assist with insurance premiums for family medicine/obstetrics practitioners, which is available in a pool for qualifying rural physicians. The physicians must agree to certain terms, such as not denying access. The University also offers what Ford termed "mini-residency training" to help practitioners delivering babies maintain their skill levels.
Registered nurses are also in short supply nationwide. Weary of investing extensive funds in nurse recruitment programs, the board of directors at Petersburg Medical Center in Petersburg, Alaska, partnered with a college nursing program to train interested hospital employees as registered nurses.
Many in the community turned out when (from left) Elizabeth Hart, Angela Menish and Yvette Boggs graduated as registered nurses through a scholarship program established by Petersburg Medical Center. At the podium is clinical instructor Martha Smith, also a Petersburg employee.
Four students, handpicked by the board, completed the majority of their course work through a distance-learning program offered by Weber State University of Ogden, Utah. Then, a nurse instructor at the hospital oversaw the clinical portion of their education. The board borrowed money from the hospital's foundation to fund $10,000 a year in educational expenses for each student.
For Angela Menish, it was a dream come true. Menish graduated from high school in Petersburg, married a fisherman and was working at Petersburg Medical Center as a certified nursing assistant. "I wanted to go into nursing and I'd even looked into nursing school, but I didn't want to move," she said. "Having to be away from home so much would have really been a burden, for my family and financially. It was so convenient to be able to do it from here."
Hospital administrator John Bringhurst said the hospital spent less money educating the nurses, who have all been working there for the last two years, than they would have spent on recruiting and training in that same time period.
Located on an island accessible only by boat or airplane, Petersburg Medical Center is a 27-bed acute and long-term care facility designated as a critical access hospital in frontier Alaska. Bringhurst said nurses they recruited from out of state came for what he terms the "Alaskan experience," but they generally stayed less than two years. Consequently, retention had become even more difficult than recruitment.
Oral health care is another arena where rural areas experience major shortages. Dorchester, Worcester and Somerset counties on Maryland's Eastern Shore are federally classified as areas with health care access and economic disparities. For several years, a dental hygienist shortage contributed to lack of access to oral health care, said Jacob Frego, executive director of the Eastern Shore Area Health Education Center in Maryland.
No dental training programs are located on Maryland's Eastern Shore, and there are only three statewide. A coalition of community resources concluded there were insufficient resources to develop their own program, so they negotiated a deal with Alleghany College in western Maryland to reserve two spots for Eastern Shore students in its dental hygiene program.
The Tri-County Council and the Three Lower Counties Community Health Center, a federally qualified health center, provided costs for student housing, tuition, books, labs and other fees, a total of about $13,000 a year. Students were required to commit to practicing at least two years on the Eastern Shore.
"This was a stopgap measure implemented to get some dental hygienists into this area as quickly as possible," Frego said. "Seven students were funded. Four have graduated and are working on the lower shore. Three are in the pipeline. Since that time, the University (University of Maryland Dental School) has stepped up to the plate and established a dental hygiene program with 10 slots per year for students enrolled in the community college programs."
The University's program, begun last year, allows students to train at a local community college for their first two years. They complete the last two years by participating in a distance-learning program offered by the university; they are required periodically to go to the campus. They complete clinicals locally.
Legislative support has also improved Maryland's oral health care situation. The Maryland State Legislature approved a law that goes into effect in October allowing hygienists to apply fluoride varnish in public health settings without a prescription or dentist's order.
"This law really contributes to a definite improvement in the public health service structure," Frego said. "The other area we addressed was getting services to children. There was no clinic or dentist in Dorchester County providing services to Medicaid children."
He credits a Health Resources and Services Administration (HRSA) grant for the seed money that established CROC (Children's Regional Oral Health Consortium). CROC is improving dental health care for children in low-income families through a variety of means, such as public oral health education, enhancement of inpatient hospital services and establishment of dental clinics.
"The HRSA grant helped us get an operational clinic to meet children's needs," Frego said. "Since last October, 663 children have been through Dorchester Clinic, and 91 percent of them were Medicaid patients. In that same time span, 28 children had dental surgery at Dorchester General Hospital. The majority of them were four and under. The grant stipulations are being fulfilled, and we've been able to provide a valuable service for children."
To learn more about these communities and their successes, contact Ford at 775-784-4841, Bringhurst at 907-772-4291 or Frego at 410-221-2600.
Health Care Challenges Abundant in the Alaskan Frontier
by Candi Helseth
Frontier communities like Petersburg, a fishing community in southeastern Alaska, offer pristine beauty but extreme isolation, which makes it difficult to retain health care professionals there. (Photo by Dave Berg).
Nestled on islands surrounded by majestic mountains in southeastern Alaska, Petersburg and Wrangell are frontier communities boasting abundant wildlife and reputations as breathtakingly beautiful wilderness vacation destinations. Both attract summer visitors eager to view glaciers and humpback whales. Fishing is a primary industry and pastime in both communities.
It may be a tourist's dream, but for hospital administrators it can be a nightmare. Hospitals in these areas struggle with acute workforce shortages. Recruitment is difficult; retention is even more of a challenge. Employees are expected to handle multiple roles, and the isolation and distance from major medical centers can be intimidating. Like many of Alaska's frontier communities, Wrangell (pop. 2,300) and Petersburg (pop. 3,100) are accessible only by water and air. No roads connect the islands to the mainland. Lifestyle amenities are minimal-malls and supercenters that many Americans take for granted don't exist here.
At a recent National Rural Health Association (NRHA) meeting in Alaska, conference attendees were able to get a look at this extreme version of "rural" in site visits to 27 remote locations all over Alaska, said Rod Betit, president of the Alaska State Hospital and Nursing Home Association (ASHNHA).
"We took them by bus and plane to these frontier communities. We heard over and over from many of them that there's a dimension even beyond what they knew that we have to deal with here in Alaska. Frontier communities like ours face similar barriers as rural communities, but on a larger scale."
Alaska has 25 hospitals-with only one accredited as a Level I trauma center-providing care for patients spread across 600,000 square miles. The state faces major health care workforce shortages; for instance, currently 370 additional physicians are needed. Frontier hospitals like those in Wrangell and Petersburg are coping by working smart: developing innovative approaches to stretch their workforce and maximize their strengths.
Workforce shortages plague health care facilities nationwide. But in frontier areas, pay is often lower, ongoing staff shortages contribute to increased workloads and stress, and families don't want to move from more convenient, urban areas, said Carol Miller, executive director of the National Center for Frontier Communities.
"Recruiting and retaining people is probably our biggest challenge because they tend not to stay lifelong in these really remote areas," Betit said. "Workload demand is also a factor because of the chronic people shortage."
Retaining and maximizing staff
Nurses Diana Nore, left, and Kathy Blackburn prepare a patient in the Operating Room at Wrangell Hospital. Employees are cross-trained to work in different areas in this frontier hospital in Alaska.
At Wrangell Medical Center, cross-training staff and stabilizing patient loads have improved workforce issues, according to administrator Brian Gilbert. The medical center, which includes a 23-bed critical access hospital (CAH) and a nursing home, has developed contractual arrangements with larger hospitals to transfer swing bed patients to the hospital.
"Big hospitals mostly don't want to deal with swing beds, and CAH offers Medicare reimbursement for swing bed status," Gilbert explained. "We had to figure out a way to improve our patient load. It's unusual for patients to be moved from a big hospital to a small one, but the patients are loving it."
Gilbert said most swing bed patients are recuperating from surgeries, such as joint replacements, and stays are relatively short-term. The arrangement generates steadier business for Wrangell's physical therapy staff, as well as other staff.
"We're also cross-training staff wherever we can," Gilbert said. "Housekeeping and dietary can fill each other's shoes and you don't need one person doing coding, another doing billing, especially in small facilities like ours. We've pared down staff without compromising service."
Frontier facilities also have heavy investments in staff training, Gilbert said, because universities are graduating physicians and nurses in specialty areas.
"We need generalists who are willing to cover ER, work nights, help deliver a baby if necessary, and it's hard to find nurses and doctors willing to take it all on," Gilbert said. "They never know what's going to walk into that ER. We don't have a CT scanner-no radiologist, no surgeon on staff."
Petersburg Medical Center, a 27-bed acute and long-term care facility also designated as a CAH, found its solution by paying for nursing training for four hospital staff members. They hand selected people who knew the expectations and were committed to staying in the community. (See previous story, "Recruiting Local People to Fill Health Care Needs").
"We all knew the hospital, knew the patients, knew how the facility ran and understood what we'd be expected to do," said Angela Menish, who worked as a certified nursing assistant prior to becoming a registered nurse through Petersburg's scholarship program. "We all cover the ER, work both sides (acute and long-term care) and continue to train in special areas. We're always researching, always trying to be ready for whatever might happen."
Training community providers
Recruiting community members committed to the area has worked well for Alaska's Community Health Aide Program (CHAP), which began in the late 1960s to serve the state's Native population. More than 550 Community Health Aides/Practitioners (CHA/Ps), employed by 27 tribal health organizations, practice in more than 180 rural villages in the state's most remote areas known as the bush; some villages are as far as 1,300 miles from the nearest regional center. Mountains, glaciers, impassable rivers or other barriers separate 90 percent of these villages. Most are not connected by a road system.
CHA/Ps see patients, provide assessments and perform approved treatments relying on the Alaska Community Health Aide/Practitioner Manual. The manual outlines protocols for patient histories, exams and treatments. Approved health aides can also proceed with standing orders listed in the manual.
Generally selected from within their own villages, CHA/Ps progress through four levels of training. Following the first level, they are eligible to be certified by a federal certification board for the level of training they have attained. They work in community clinics. Some clinic settings include physicians or midlevel providers, and in some, the CHA/P works alone. Providers periodically rotate to these clinics.
"The CHAs are on call all the time, they're usually the primary care contact for the area," said Steve Gage, CHAP director for Southeast Alaska Regional Health Consortium. "For the past 35 years, this program in Alaska has been making a positive difference for people living in the bush."
Technology and education
Technological advances and distance learning are improving Alaskan facilities' abilities to meet demands. Twelve small hospitals formed a consortium, the Alaska Small Hospital Performance Improvement Network (ASHPIN). One of its successes has been securing $4.4 million in grants from various agencies to build the Alaska Rural Telehealth Network (ARTN). ARTN connects these hospitals electronically with high-speed capability. Hospitals can transmit radiologic images to other hospitals and physicians can consult with other professionals in real time. Patient response time improves and the need to transport patients by air to distant medical centers has decreased. Medical professionals also use the system to network with peers.
The telemedicine equipment, scheduled to arrive in August at Wrangell, will relieve pressures on Wrangell's three physicians, who may wait for several days before they receive x-ray results from a distant radiologist, Gilbert said. "Most of the time, they've had to move long before the radiologist reads the x-ray. Now they'll be able to get solid answers fast."
ASHNHA is working with the University of Alaska to create more distance-learning programs in areas identified as workforce gaps. For instance, a nursing program will allow students to complete academic components online from wherever they live and do clinicals in abbreviated time periods. A preceptor program in the works will provide community nurses with training that they take back to their facilities to train in-house staff.
"When you have no road system, it's a real challenge to stay current in your profession unless you have a distance-learning opportunity to do that," Betit said.
Betit served on a Physician Supply Task Force, which concluded that the ratio of physicians to population in Alaska is below the national average and that Alaska needs 10 percent more physicians per population than other states because of its rural nature, great distances and severe weather. Strategies already in place that are producing physicians include the Alaska Family Medicine Residency Program, which places 70 percent of its graduates in Alaska, and favorable loan repayment programs for physicians locating in Alaska.
Alaska is one of four states training medical students through the University of Washington in Seattle. The graduating physicians will receive financial subsidies approved by the Alaskan legislature if they return to Alaska to practice for a specified time. To encourage physicians to choose rural areas, the repayment period is shorter for rural placements.
ASHNHA successfully lobbied the state legislature this year to increase funding in support of the program. Beginning with the fall class, Alaska will subsidize 20 medical students a year, up from the previous 10 a year.
Cooperation, not competition
In Alaska's frontier territory, these administrators say there's no room for competition. By using a broker to negotiate a contract using collective bargaining power, ASHPIN saved $800,000 in Workmen's Compensation expenses alone last year. Because they were able to work together like a "large employer," said ASHPIN Director Randall Burns, they obtained the same amount of coverage at a much lower rate.
Alaska's Native tribes, even though they have a separate health system, have joined ASHPIN. Historically, Native hospitals served Alaskan Natives only, but the federal government has given them flexibility to serve non-Natives living in their service areas, Betit said. Consortium hospitals treat Alaskan Natives and non-Native patients at the hospital closest to a patient's home.
The University of Alaska and a number of other partners have developed a single Internet portal for applicants, Health Careers in Alaska, to access information on internships and job openings, major health care employers, and job forecasts and average wages in the state.
"We try to work cooperatively together to maximize what we offer," Betit said. "Cooperation and collaboration have been essential in making progress and we're continuing to look at programs and services that will help improve workforce needs throughout the state."
Workforce shortages plague health care facilities nationwide. But recruiting staff is more difficult in frontier and rural areas. Pay is often lower, ongoing staff shortages contribute to increased workloads and stress, and isolation and lack of amenities often make urban practices seem more appealing, according to Carol Miller, executive director of the National Center for Frontier Communities.
While Alaska has developed several programs that work for its frontier needs, Miller warns that other frontier communities have very different needs. She said they can range from extremely isolated, poverty-stricken areas to high-amenity, high-income communities with an excess of providers in some specialties. That doesn't necessarily improve health care access, though.
"In a high income frontier area-a Colorado ski resort, for instance-you'll have more orthopedic surgeons than the population would suggest, creating overservice," she explained. "The low-wage workers and service industries personnel don't generally need orthopedic surgeons; they need access to preventive and primary health care. Yet, there is often an undersupply of primary care, and service isn't equitably available to everyone. Clinics may refuse to accept Medicaid patients or uninsured people. Many of these low-income workers don't get health insurance coverage with their jobs."
Most frontier communities have a single economic engine, and some health care services may not be available to people outside that industry, she added. She noted that some Nevada mines have helicopters to provide emergency transport for employees, but air service isn't available to other area residents.
"The workforce issue is actually very complex, particularly in frontier areas," Miller said. "The one thing we do know about frontier communities is how different they are."
Alaska is the first and only state to have dental health aides that fill cavities and extract teeth. Their practice is limited to Alaska Native patients in extremely remote areas, where the rate of tooth decay is more than twice the national average.
In June, a Superior Court judge ruled in favor of the Native-run dental therapist program, after it was challenged in a lawsuit filed by the American Dental Association, which cited concern about safety and standards. At least eight dental therapists are currently doing fillings, simple tooth extractions and other procedures in villages where there are few dentists. The therapists receive narrower training than dentists and do not perform complex procedures, such as root canals. The Alaska Dental Health Aide program is part of the state's Community Health Aide Program.
For more on the J-1 Visa program, which allows rural areas to recruit foreign doctors to fill workforce gaps, see the RAC’s J-1 Visa Waiver Topic Guide.
Pine City EMS providers George Germann, top, and George Castonguay, practice transporting a "patient" (EMS provider Sandy Wilkening) using this stair chair, purchased through the North Central EMS Cooperative.
When the Balanced Budget Act passed in 1997, Gary Wingrove, an emergency medical services provider in Minnesota, worried that the new Medicare payment system it established would put small emergency providers out of business in his state and elsewhere.
"We were surrounded by rural, volunteer EMT services in Minnesota, and if they went out of business, their communities would be asking us (Mayo) for services," said Wingrove, a 25-year EMS provider with Mayo Clinic Medical Transport in St. Cloud, Minn.
So, in December 1997, Wingrove and three other Minnesota providers gathered around his kitchen table to hammer out plans for an EMS cooperative to serve Minnesota and surrounding states. The result was the North Central EMS Cooperative (NCEMSC), which got off the ground with the help of a two-year Kellogg Grant. Through the grant, the group was given the help of co-op development specialists from the University of Wisconsin-River Falls for three years to lead the group through strategic planning.
Observing its 10th anniversary this year, NCEMSC has grown to include 984 ambulance services in 29 states, said Wingrove, who is currently the co-op's president. About one-half of its membership serves rural areas.
Using the power of group purchasing within the cooperative structure, members save money on everything from daily office supplies to major purchases such as ambulances. Members that have purchased major items such as ambulances report saving $20,000 or more in one year, Wingrove said.
The co-op also researches products and prepares bids for members, provides services such as information on governmental and regulatory practices, certifications and safety standards, and keeps members updated on legislation that may affect the industry.
For two small EMS providers in Minnesota, where reducing costs and maximizing staff resources are constant challenges, membership in NCEMSC has breathed new life into their operations.
Pine Medical Center Hospital in Sandstone, Minn., owns an ambulance service centered in Pine City and covering a three-county rural area.
"It's a no brainer," Pine City Medical Manager Margery Fagerstrom said. "By joining North Central, we've definitely saved money on supplies we purchase, plus we get other substantial benefits. They help us tremendously by finding the best prices for what we need, and even helping with delivery of larger items."
In tiny Milan, Minn., First Responders is a group of volunteer EMS providers that provides care until an ambulance arrives. Operating on a shoestring budget supported by private donations, the group is always looking for ways to save money. First Responders saved $75 on their first order when they joined the co-op through the Minnesota Ambulance Association, said First Responders President Gwen Kleven Olson.
In 2001, the NCEMSC board of directors opened membership to all interested ambulance services; then two years ago, the board opened membership to state ambulance associations. Associations pay annual dues, and their members can access cooperative benefits. Wingrove said 17 state associations have joined so far, "which really helps out these very small, rural providers with limited resources."
Since the new Medicare payment system went into effect, three volunteer ambulance services in Minnesota have closed, and about 50 ambulance services have closed in Oklahoma alone, Wingrove said. He explained that the Balanced Budget Act (BBA) nationalized Medicare's ambulance fee schedule, with the fee schedule rewarding volume and rural ambulances obviously have much lower volume than their urban counterparts. In addition to the new fee schedule, the BBA established mandatory Medicare assignment, which means that the provider must accept the Medicare-allowed payment as payment in full and cannot collect the remainder of the cost from the patient as they could have in the past, only an established co-pay.
"Based on what we hear now, the cooperative has had a significant impact in keeping our members operating," he added. "That's pretty rewarding."
IPAC: Integrated Health Services for Appalachian Children
by Candi Helseth
Jane Hamel-Lambert, a member of the IPAC Executive Board, explains that the organization looks at children's broad developmental needs in order to offer them coordinated, comprehensive health care. (Photo by John Sattler).
By the time Andrew Williams was two, Brenda Williams knew something was seriously wrong with her son. He was diagnosed with a heart murmur, partial hearing loss and allergies, but Brenda felt Andrew's problems went even deeper. Andrew vomited several times a day and struggled to communicate, often collapsing in tears or erupting in anger. His anger spilled out in extreme behaviors.
"I had five years of frustration looking for answers in different places and feeling like I wasn't being listened to as a parent," Brenda said. "I knew Andrew needed more help than he was getting."
Finally, Brenda took Andrew to a new pediatrician, who subsequently referred him to IPAC (Interprofessional Partners for Appalachian Children). "IPAC is what I had been looking for all these years," Brenda said. "That was when we finally started getting some real help."
Focused on the assessment and comprehensive treatment of behavioral and developmental needs of children ages six and under, IPAC blends 19 university and community health care organizations in Appalachian Ohio in a partnership that provides "one-stop shopping for families." (For a complete list of partners, see http://www.oucom.ohiou.edu/ipac/partners.html).
"The idea is that no matter what door you enter, someone is going to take a look at your child's broad developmental needs," said Jane Hamel-Lambert, a member of IPAC's Executive Board as its ex-officio president and a faculty member in the Department of Family Medicine at the Ohio University College of Osteopathic Medicine in Athens. "We are trying to address mental health needs in early childhood, and help these families access the help they need before those behaviors and problems become entrenched."
IPAC frontline providers are a family's first point of contact. These specialists develop a comprehensive care plan that can include the expertise of primary physicians, psychologists, counselors, early child mental health professionals, nurses, educators, and hearing and speech-language pathologists from within the partnership.
"Sue did a complete evaluation that addressed every part of Andrew's body," Brenda said of IPAC frontline provider Sue Meeks, a well-child nurse coordinator at Ohio University's Community Health Programs. In addition to his physical problems, Andrew, who is now eight, was diagnosed with anxiety and bipolar disorder, both mental health conditions.
"We're trying to bring families to one person who helps them access all the help they need," said John Borchard, IPAC board chairman. "When you have a client being referred to five or six different providers who may not be communicating with one another, there's a lot of money being spent for incomplete service that will be marginally effective. It's not just the cost of the service; even getting there can be a hardship for these families. There are no services in some areas of these counties."
Funded by a three-year, $540,000 grant awarded to Ohio University by the federal Health Resources and Services Administration's Office of Rural Health Policy, IPAC serves Athens, Meigs, Hocking and Vinton counties in southeastern Ohio. Poverty rates and unemployment are high, and all four counties are federally designated as medically underserved areas. More than 7,000 children under age six live in these counties.
IPAC doesn't wait for families to find them, Hamel-Lambert said. IPAC is integrating mental health services into settings where young children already are: preschools, childcare centers and primary care offices. Frontline providers regularly do screenings at these sites, and last year IPAC partners trained county daycare providers to identify and screen children. Future goals include additional training sessions for early childhood providers.
For the Williams family, IPAC opened new doors. Andrew had speech and hearing evaluations and a psychological evaluation that resulted in his bipolar diagnosis. He received therapy for his anxiety, and was referred to a specialist in Columbus, Ohio, for the gastric problems. The Williams live in Nelsonville, about 30 minutes from Athens where most IPAC services are located and about two hours from Columbus.
Family education is a key component in IPAC's success. "Sue has done a lot of things that have helped me learn more and be able to help Andrew better," Brenda said. "She arranged for a professional from the college to go with me and tell school officials how they needed to handle Andrew's problems. Andrew used to fight and scream all the way to school. Now he loves school. And I feel like I can go in and talk to them and they listen to me."
For example, she explained, school officials decided not to require Andrew to learn to read because he became so frustrated. Brenda - supported by the IPAC professional - disagreed, believing that Andrew still needed to be challenged. "They weren't going to give him books. How do you learn to ride a bike if you don't have a bike?" Brenda asked. "I felt like they were just writing him off, and letting him pass through."
While Brenda Williams was proactive in finding help for her child, many families are forced into mental health counseling by a caseworker, said IPAC board member Kendall Brown-Clovis, a human resources director at Tri-County Mental Health and Counseling Services, Inc. "We want to get them in the door before things get that bad. When an early childhood provider the family trusts recommends us, they're much more likely to seek help."
"We've seen a 180-degree turnaround since we started with IPAC," Brenda said. "There were so many things wrong that I didn't even know where to go anymore. IPAC's team approach really makes a difference."
In my recent focus on poverty in the United States, I have noted that our national poverty rate has been disproportionately higher than other countries with advanced economies. As we entered the 21st century, the U.S. ranked 24th out of 25 peer countries when measuring the proportion of families with incomes below the 50-percent-of-median figure.
Similarly, the United States has a disturbing level of income inequality. In 2005, the richest 1 percent of all Americans had access to 19 percent of the nation's income while the poorest 20 percent (the bottom quintile) captured only 3.4 percent of the nation's income. We have not seen this level of income inequality since just before the onset of the Great Depression in the late 1920s.
For many, a key national challenge remains-what can be done about our high levels of economic vulnerability and inequality of opportunity?
Let's start this discussion with some evidence of relatively recent successes. Over the past decade and a half or so we have engaged in a period of reform of our policies directed at low-income families.
For example, the Aid to Families with Dependent Children (AFDC) program that once guaranteed cash support for impoverished families was replaced by a more work-oriented program called Temporary Assistance to Needy Families (TANF). A variety of other reforms included expanded tax-based benefits for low-income working families, more public investments in child care for low-income working parents, improvements in health care coverage for poor children and their families, and better child support enforcement. All have had salubrious effects on poverty and have made work preferable to receiving cash welfare.
A report issued in May 2007 by the Congressional Budget Office, Changes in the Economic Resources of Low-Income Households with Children, outlines some of the progress made in recent years. Between 1991 and 2005, the bottom fifth of all families with children (what we call the lowest quintile) saw a 35 percent increase in income after adjusting for inflation. This improvement was better than any other quintile except for those at the top of the income distribution.
Improvements in income among poorer families were not due to more cash welfare. In fact, just the opposite occurred. In 1991, more than 30 percent of all income for low-income families with kids came from cash welfare payments. By 2005, that proportion had fallen to 4 percent. Earnings on the market place, on the other hand, had jumped by 80 percent.
With earnings up and welfare dependency down, it would appear that we are on our way to solving the poverty problem. Unfortunately, there is evidence that such a happy ending is not quite the case. Most of the measured progress occurred in the late 1990s. More ominously, we have seen child poverty inch higher once again while the labor market participation by adults in low-income families stagnate and even decline.
In response to the continuing challenge, the Center for American Progress convened a Task Force on Poverty in 2006. Its charge was to come up with a plan to cut poverty in half over the next decade. It was motivated, in part, by a sobering estimate that persistent child poverty costs the nation some $500 billion dollars per year in lost productivity and direct public outlays-the equivalent of 4 percent of the Gross Domestic Product (GDP).
Raise and index the national minimum wage to half the average hourly wage.
Expand the Earned Income Tax Credit (EITC) and other child-focused tax credits.
Guarantee childcare assistance to low-income families and promote early education for all.
Create two million new "opportunity" housing vouchers and redistribute low-income housing opportunities in a more balanced geographical manner.
Restore Youth Opportunity Grants to connect youth with school and work.
Simplify and expand Pell Grants and make higher education accessible to low-income youth.
Make special efforts to help former prisoners reintegrate into the labor market and their communities.
Reform the Unemployment Insurance system to broaden coverage and to use periods of unemployment as opportunities to upgrade skills.
Expand and simplify the Saver's Credit to encourage savings for education, homeownership and retirement.
Modernize means-tested benefits to develop a coordinated system that helps workers and families.
The authors of the report estimate that four recommendations alone-increasing the minimum wage, increasing the EITC and child tax credits, and investing more in child care-would reduce poverty by over one quarter. There would be some nine million fewer people in poverty and the rate would be the lowest in recorded history.
Of course, there is no free lunch as economists repeatedly point out. The price tag of the proposed reforms is estimated at $90 billion per year to start. While a large number, this amount is less than the projected costs of tax breaks to households earning over $200,000 in 2008. Still, it is a considerable investment of resources in tight fiscal times. And for many, it would represent yet another increase of government in our daily lives absent any reasonable guarantee of success.
So, do these kinds of recommendations constitute a reasonable core strategy for the future? What other tactics or approaches might be considered? Should government even consider another War on Poverty? If so, how should we even think about such a war, particularly in the context of rural America? We leave some of these tantalizing questions for future articles.
1 For brevity's sake, I am highlighting selected recommendations here; see the report for a full list of recommendations.
Tom Corbett has emeritus status at the University of Wisconsin-Madison and is an active affiliate with the Institute for Research on Poverty where he served as Associate Director. He has worked on welfare reform issues at all levels of government and continues to work with a number of states on issues of program and systems integration.
Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Assistance Center.
Professor Corbett welcomes your feedback. Comments and reactions can be sent to: Corbett@ssc.wisc.edu.
The ongoing title of this series, "Look What's Coming," reflects my interest in how our health care may evolve. We usually make projections by extending the trends we're familiar with. That's called extrapolation. That works best for things with lots of momentum and constant external forces-things like planets. The growth of our health spending seems to have almost as much momentum as a planet. It doubles its bite of our economy every 30-35 years and has been doing so since World War II. Various efforts to reduce the growth of health spending have produced, at most, pauses followed by catch-up growth. This trend alone suggests that health spending will consume one-third of our economy by 2040.
The factors most obviously bearing on health spending growth are (1) the aging of the baby boomers and (2) the demand for safer, higher quality care.
The "baby boom" in births following World War II started in 1946 and peaked around 1960. These "boomers" are expected to live a bit over 70 years. The increase in health care spending attributable to the aging and death of baby boomers will begin soon, and will peak around 2030. Therefore, health spending will grow even more rapidly in the future than in the past.
The Institute of Medicine has sponsored a very effective series of reports on problems with the quality of our care. The first report, and the one gaining the most widespread attention, was To Err is Human, published in 1998. It focused on patient safety, particularly in acute care hospitals. The report quoted two studies of patient deaths attributable to accidents and mistakes in hospitals. One estimated that such errors cause 44,000 deaths per year; the other, 98,000. Very few of these deaths are currently being recognized as due to hospital error. If each of these deaths were recognized and litigated, hospitals would see their operating costs rise by $50 billion to $200 billion per year. Medicare and accrediting agencies are pressing hospitals to institute programs to reduce the accidental death rate. These programs are less expensive than liability settlements but, nonetheless, add significant and highly appropriate new costs. This may further shorten the doubling time for health care's share of the economy, pulling the next doubling, when health will consume a third of the economy, even closer than 2040.
The IOM reports also call for changes to make health care more safe, timely, efficient, effective, equal and patient-centered. The insurance industry likes the idea of promoting efficiency and effectiveness by requiring the use of evidence-based practice protocols. Eventually this may save some money, and bring better health outcomes. Some argue that investing more in prevention and health promotion will save money in the long run. Perhaps, but my guess is that we'll save quality of life but not much money. The most obvious way to make care more financially efficient, and affordable, would be to reduce the high costs to all parties of passing money through our adversarial payment system, but hundreds of billions of dollars, and millions of jobs, are at stake, and won't be relinquished without great struggle.
In summary the primary forces acting on health care seem likely to accelerate, rather than slow, cost growth. At the same time pressure for change seems to be building, though much of it is misdirected. State legislators complain mightily about the growth of Medicaid costs, feeling there must be something terribly wrong with Medicaid. The problem, of course, is that health costs are growing two to three times as fast as the tax base. As I write this a similar battle is going on in Congress over reauthorization of SCHIP, the State Children's Health Insurance Program. It was a congressional favorite until underlying costs grew, as was inevitable. Now the program is regarded as problematic. (In fairness, "mission creep" through the addition of adults is also a factor).
The Fiscal Wake-Up Tour, sponsored by the Concord Coalition, points out that the combination of rising Medicare costs and national debt will destroy the financial underpinnings of our government. The speakers recommend, among other things, shedding government's responsibility for Medicare entitlement. If those costs are so high as to crash the government, how will handing them back to individual premium payers help? If I am faced with an astronomic bill, I don't much care whether it comes from the government as a tax bill, or an insurance company. Arguing about who pays is not the answer. There simply is no alternative but to rein in the growth of health spending.
Will we develop the political will to tackle this enormous problem? Conventional wisdom says no. But conventional wisdom is based on extrapolation.
Wayne Myers, a pediatrician, founded the University of Kentucky Center for Rural Health and served as its director. He also served as director of the Office of Rural Health Policy in the Department of Health and Human Services' Health Resources and Services Administration. He is a past president of the National Rural Health Association.
Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Assistance Center.
Dr. Myers welcomes your feedback. Comments and questions can be sent to him at myers@raconline.org.
Forrest Calico, M.D., MPH, is one of the nation's leading authorities on rural health care quality. He has contributed to reports on health care quality including the 2005 Institute of Medicine report, Quality Through Collaboration: The Future of Rural Health and the 2003 National Advisory Committee on Rural Health and Human Services annual report, Health Care Quality: The Rural Context. Dr. Calico has also made numerous presentations across the country about health care performance improvement, rural health care quality issues and network development. He was honored as a "Rural Hero" during the National Rural Assembly's annual meeting in June and was given the President's Award by the National Rural Health Association's (NRHA) annual meeting in May.
Calico started his career as a flight surgeon in the Air Force and continued to work as an Air Force physician for ten years. He then worked on the medical staff and as a faculty member at St. Elizabeth Medical Center in Lexington, Kentucky. He later worked as vice president and then president for Appalachian Regional Healthcare in Lexington before coming to Washington, D.C. as a health systems advisor for the Office of Rural Health Policy. After retiring from that position in 2004, Calico returned to his 460-acre farm in Stanford, Ky., where he keeps a garden and a neighbor pastures cattle and raises corn and hay. In early 2005, he helped launch the NRHA Quality Initiative as the NRHA Senior Advisor for Quality, a position he held until May of this year. In his spare time he restores two-cylinder John Deere tractors, and helps to fix up the farm. He and his wife, Patricia, who is a national leader in nursing education, have been married for 41 years. They have two children and four grandchildren.
Why is rural health care quality an important issue?
We can help rural people to enjoy better health and improve the rural economy by improving access to and quality of care. By our focus on collaboration and continuity in the community context, we can lead the nation to the next level in improving quality and health care for all Americans. Our "system" (not!) is a catastrophe and we have the opportunity to show how to fix it.
Was there any particular experience in your past that sparked your interest in health care quality?
There's a lot of experience over the years that pointed me in this direction. But the most recent and most profound influence was when my mother-in-law was declining and seeing the cascade of horrible health care she received in several settings in two different states. We had to hire someone to stay with her when we could not be with her in the hospital or rehab unit to assure that something bad didn't happen to her (she had a degree of Alzheimer's that prevented her from looking out for herself). The whole spectrum of care was abysmal. Another influence was hearing Don Berwick talk and reading his essay Escape Fire - he is brilliant and persuasive-no one articulates the need for quality like he does.
How did you draw upon your experiences as a physician, a medical director and a health systems advisor in your role as a Senior Advisor on Quality for NRHA?
I have played multiple roles over the years. I have seen first-hand how things do not work, from every perspective. I know how professional education, practice as a cottage industry, dysfunctional reimbursement, organizational culture, physician autonomy, competition and vested financial interests collude to produce high cost and poor quality and effectively prevent improvement. Perhaps we can, through demonstrations of how to do it right, eventually influence policy positively.
What did the position involve?
I did a lot of traveling, tried to communicate effectively and did a bit of writing. During my first year I traveled the nation telling everyone who would listen about Quality Through Collaboration. During the second year I traveled a lot to look at model programs in rural health, resulting in the publication last month of the short NRHA publication "What Makes Rural Health Care Work?"
What would you say are the major issues in rural health care quality right now?
Resources, technology, competition, the will to take risk by independent thinking and getting out of the box are examples. We also have a big vision problem, fighting for scraps rather than looking at opportunities and possibilities. Rather than asking "How can I increase my bottom line and keep this hospital going?", we need to be asking "What constellation of services does this community need, and how can I help that to happen?"
What is rural health care system building and what is your interest in it?
I'm talking about systems at two levels. First, all the components of health care services and the continuum of care in a given rural service area must learn to work together with the goal of improving health of the community and of providing safe, timely, effective, efficient, patient-centered and equitable care. Competition is dysfunctional; communication around shared goals is essential. Second, each community-based system described above must develop working relationships with other community systems and referral centers, to complete the continuum of care, provide optimal care and increase efficiency and effectiveness.
What do you see as the major workforce issues for rural health care right now?
There are two things that are a top priority for me. We need to totally renovate health professions education so we can do effective interdisciplinary care and change state-level scope of practice legislation to enable us to have more flexibility. The best example of this is dental hygienists-allowing them to work independently so they can actually go out and improve oral health through cleaning and education for a population that dentists aren't serving right now. That's a really big deal. The other issue for me is for rural communities to work to interest their children in health care careers, starting in high school, and even in kindergarten, so they will be more likely to come back and work there. They also need to build local systems of care that provides challenge and growth, so that working in a practice there will be viewed as an opportunity and not seen as a big burden.
Now that you are no longer a Senior Adviser, will you continue some kind of role in promoting health care quality?
I'm just an old retired guy now. I'm available and interested but I'm not looking for work. I got tired of the airlines. I feel that developing "What Makes Rural Health Care Work" was the "mountain-top" of my work with the Quality Initiative and represented a perfect time to get back on the farm full time and enjoy the grandchildren.
Do you think there will be any big changes in rural health care quality over the next five to ten years and are you optimistic about its future?
That's a tough question. So much depends on what happens at the national level with the current, renewed discussion on health care reform. We have to have investment because rural health care has been systematically under-resourced for decades. If there is a national commitment to genuinely improve health care (rather than pretending as we are prone to do) and invest appropriately, such as getting technology in rural communities, then I'm optimistic. But if we maintain the "budget neutral" fantasy and there's no investment, no money to get health care professionals trained and tech savvy, I'm not as optimistic. I think rural communities can make change if they have the necessary resources, so I am very optimistic about our ability to build effective rural systems of care given appropriate resources.
Navigating the varied definitions of rurality can be quite overwhelming. RAC has teamed up with the Rural Policy Research Institute's (RUPRI's) Community Information Resource Center (CIRC) to simplify the process. With the new Am I Rural? tool, users can enter an address or ZIP code and determine if their location can be characterized as "rural" using many common administrative definitions. The tool is built on top of robust geographic information system (GIS) technology, yet is as simple to use as pushing a button. Behind the scenes, the tool drills down through many geographic layers to determine the rurality of the location entered and generate a custom report for the location. In order to help determine eligibility for rural programs, the resulting report lists not only common rural definitions but also whether the location would qualify as "rural" under the programmatic definitions determined by Office of Rural Health Policy (ORHP) and Centers for Medicare & Medicaid Services (CMS).
Using the tool is very simple. From the RAC's Am I Rural? page (http://www.raconline.org/amirural/), click on the link for "Create a custom report for your location: Am I Rural?" The screen that appears (Step 1) contains textboxes where a user can input a street address, city, state and/or zip code. The only requirements are that a city and state are included or a zip code. Once the necessary information is entered, the user clicks on the "Next" button, which moves to the next screen (Step 2).
The second step is to select which rural programs to include on the report by checking the appropriate box. The user can also elect to display common rural definitions for the location. For convenience, there is a "Check All" button available to quickly check all options for display on the final report. Once the selections are made, the user clicks on the "AM I RURAL" button at the bottom of the page to create the report.
The "Am I Rural" report uses the address supplied from Step 1 to query a geographic database of rural definitions. The top of the report shows the location for the report including zip code and county. The first section of the report, the "Program Report," illustrates whether or not the user's location is defined as rural in addition to the criteria each program uses to define rural. These criteria are made up of various administrative geographies such as zip codes, census tracts or county boundaries.
The second section of the report shows the common rural definitions for the location. Using the various geographies mentioned above, the report dynamically generates results for each rural definition based on location. For example, one popular rural definition is the Rural Urban Commuting Code (RUCA). RUCAs are defined using both census tracts and zip codes. This report will automatically query an extensive database to determine the RUCA code for a particular zip code or tract and display it on the report. One can also acquire further information for each type of rural definition by clicking on the "more info" link.
Finally, a location summary appears at the bottom of the report, which provides the latitude, longitude, county and county map of the user's location.
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