Rural Hospices Use Team Approach to End-of Life Care
by Candi Helseth
Ella Pruett, a patient at Madrone Hospice Center, visits with Suzanne Ducharme, director of patient services, and Ducharme's granddaughter. (Ms. Pruett has died since this photograph was taken).
It’s a fact of life that everyone dies. When people know that they are going to die, most (90 percent of Americans, according to a Gallup Poll), would prefer to die in their homes. The hospice movement has helped make that possible for thousands of terminally ill patients since 1974.
Hospice care embraces a team approach, relying on physicians, nurses, other medical professionals and community volunteers to provide care primarily in patients’ homes when those patients are in the final stages of a terminal illness.
There are more than 4,500 hospice programs nationwide, with 39 percent defining themselves as rural and 40 percent defining themselves as both rural and urban.
Medicare provider numbers indicate that hospices began serving rural areas in the 1980s. However, according to Judi Lund Person, the National Hospice and Palliative Care Organization (NHPCO) vice president of regulatory and state leadership, “Geographic barriers like mountains, rivers and weather may define ‘rural’ even more than distance or population density. Many urban programs also serve rural people so it’s difficult to break down the number of rural people nationwide that have access to hospice services.”
Program Models Vary for Rural Areas
Madrone Hospice is an example of a successful rural hospice program. For 23 years, Madrone has served an area covering 6,000 square miles of Siskiyou County in northern California.
“Madrone Hospice is very rural,” said Audrey Flower, executive director. “We travel a wide geographic distance, all of it on mountain roads going 50 to 75 miles in all directions. Since 1995 (when they began tracking patients), we’ve served 1,600 patients.”
Hosparus (The Community Hospices of Louisville (KY), Southern Indiana and Central Kentucky) is an example of a hospice that serves both rural and urban patients. Of the more than 4,000 patients it serves each year, 83 percent live in urban areas and 17 percent in rural areas. Professional caregivers often drive 46 to 60 minutes to make home calls in the 23-county service area.
Hosparus’s southern Indiana program began services in 1978, just four years after the country’s first hospice program opened in New Haven, Conn. Hosparus is a nonprofit organization created when three separate programs in central Kentucky and southern Indiana merged into one entity.
“We weren’t the first, but Hosparus was early in the hospice movement,” said Senior Communications Manager Stephanie Smith. “We had some concerned citizens who knew of the hospice movement in England. A nurse and Catholic sister in Louisville had been to England and spent time with founders in the hospice movement. They brought that knowledge back and taught other nurses how to minister this care.”
Hosparus continued adding rural communities throughout the 1990s. “Rural people want to remain in their homes, and they are more comfortable when they’re surrounded by family and friends,” Smith said. “They want to stay close to their loved ones and they want to be in familiar surroundings.”
Before he died, Joyce Barnett was caring for her husband, Walter, at their home in Columbia, Ky. But Walter’s pain kept him bedridden, he’d become severely depressed and the couple was falling behind on their bills. When Walter was referred to Hosparus, pain management assistance allowed him to get out of bed and resume some activity. Because Walter’s disability claim had been denied, their electricity was about to be cut off and they were afraid they were going to lose their home. A Hosparus social worker helped the couple get extensions on utility payments, and qualify for Social Security payments and Medicaid insurance coverage.
Madrone Hospice is a freestanding, independent organization that became Medicare-accredited in 1995. Hosparus is also Medicare-certified.
While the hospice concept supports keeping patients at home surrounded by support from families and communities, there are times when some terminal patients can no longer remain at home. Madrone Hospice built a hospice house in 1999 to provide an alternative homelike environment with six guest rooms and 24-hour nursing care. Family members can participate in patient care, spend the night or even move in for periods of time. Hosparus meets these patients’ needs through arrangements with long-term care facilities and hospital inpatient units.
Collaboration with other providers is a key to rural programs’ success, Lund Person said, noting that most rural hospice programs are affiliated with larger organizations such as hospitals, home health agencies and county health departments.
Hospice Supports the Whole Family
The Madrone Hospice Center
Hospice care not only includes physical support, but also emotional and spiritual support for family members or primary caregivers as well as the patient, Flower said.
“The night before we lost my husband, my stepdaughter and I panicked,” said Cynthia Garland, who was introduced to hospice care when her husband, who had been diagnosed with cancer, was referred to Madrone Hospice. “We didn’t know what to do. We called hospice and the nurse drove 25 miles at midnight just to check on my husband and reassure us. Where else do you find medical professionals you can call on 24 hours a day?”
Some studies have indicated that hospice may increase the length of an individual’s life, but the hospice philosophy is intended neither to prolong life nor hasten death, Smith said. The team-oriented approach focuses on quality of life to include pain management, physical care, comfort and counseling. The patient and family determine the extent of services they prefer.
“I didn’t realize how professional and qualified these people are, and I was so thankful they came into our home to help us,” Garland said. “I’m a pretty private person, but I never felt like it was an intrusion, just support and gentle care.
In addition to physicians and nurses, health professionals such as social workers, chaplains and therapists are generally members of the hospice team. Many hospices also offer alternative approaches to control symptoms and improve well-being. Music therapy, pet therapy, massage therapy, aromatherapy and Native American ceremonies are among options at Madrone Hospice. Hosparus has volunteer certified massage therapists who provide massage therapy upon request. “We support patients’ use of any complementary therapies that can bring them comfort at the end of life,” Smith said.
Medicare-certified hospices are required to offer grief and bereavement counseling for family members, generally up to one year afterwards. Both Smith and Flower said their bereavement programs exceed minimum standards.
“I went through months of just sitting,” Garland said. “They kept in close contact with me, regularly stopping by, always leaving the door open to counseling, but they never forced it.”
Palliative Care is Extension of Hospice
As hospice usage has increased, providers have recognized the need for medical care for chronically ill people who are not diagnosed with a terminal illness. Many hospice programs also provide palliative care services.
“One of hospice’s primary benefits is helping patients stay as pain-free as possible but there are many chronically ill people who can benefit from palliative care even though they are not terminally ill,” Flower said. “Madrone has a palliative care program for patients that don’t meet hospice criteria.”
“Palliative care is broader, and may segue into hospice care as the illness progresses,” Lund Person explained. “These patients may bridge from home health or chronic disease treatment into hospice. Licensed physicians and advanced practice nurses can bill Medicare and other payers for their professional services.”
Hospice Movement Growing
In 1982, Medicare certification for hospice was approved. Other third-party payers followed suit. With reimbursement systems strengthening hospices’ financial bases, programs have continued to open throughout the United States.
“Hospice care is available in every state now,” Lund Person said. “It may not be available in every county of every state but there are many, many states with 100 percent coverage.”
“Once a hospice family, always a hospice family,” Flower said. “Rural hospice programs are best sustained by those individuals who have received our support. They become lifelong supporters. They are our voices in the community.”
Garland confirmed Flower’s theory. “They do so much for you that it makes you want to help them.”
Lower patient volumes, along with higher costs of care in rural areas, make it more difficult for rural hospice programs to achieve economies of scale.
As one of its fundraising efforts, sponsors who give $5,000 to Madrone Hospice are noted with an engraved tile on its Memorial & Recognition Wall.
Other issues compound those challenges. Medicare and other third-party payers reimburse rural programs at a lesser rate. Medical professionals who can staff hospices are in short supply in rural areas, and even volunteers can be difficult to find in small towns where populations have declined and most residents are elderly.
“Rural hospice programs are vulnerable,” said Michelle Casey, Senior Research Fellow and Deputy Director with the University of Minnesota Rural Health Research Center at Minneapolis. “The Medicare reimbursement is based on the hospice wage index, similar to the hospital wage index, and that tends to be lower in rural areas. So their per unit cost for providing care is higher. Medicare pays on a per diem basis. The theory is that you average out costs over the number of patients. But in rural areas, patient volumes can be very low. When you have a small number of patients, per patient costs are high. And hospices can’t refuse to continue caring for a patient when the per diem isn’t covering the cost. Even if you have a patient with extraordinarily high cost needs, you must continue to care for that patient until death.”
Per diem payments don’t take peripheral costs into account either, such as the rising price of gas and the fact that rural programs cover much greater distances in their service areas.
Yet, many hospices are successfully providing services by blending resources, sharing costs, and drawing on community support, Casey said. Sharing staff is a common practice to increase productivity and decrease cost. For instance, hospice staff may work in both urban and rural settings. Or rural settings may share staff in departments, such as hospice and home health. Fundraising efforts, as well as community and philanthropic support, are also essential to successful operations.
Rural Providers Build Relationships to Stay Viable
“If you look at the success of our program, it’s all about broad-based relationships with community, churches, senior providers, nonprofits and strong, supportive medical professionals,” Madrone Hospice Executive Director Audrey Flower said. “We provide hospice services to over 50 percent of all deaths in our county; that’s almost double the national average. We can do that because of our community support.”
Two thrift shops and a boutique, all operated by volunteers, enhance Madrone Hospice’s revenues. Flower said diversification into programs such as an adult day care center and palliative care program have also increased financial stability as well as their community connections.
Sharing staff and melding urban and rural areas works well for Hosparus - The Community Hospices of Louisville (KY), Southern Indiana and Central Kentucky. Originally, three separate programs that began operations in the late 1970s and early 1980s in Kentucky and Indiana, they continued to expand service areas throughout the 1990s, eventually covering a 23-county urban and rural area. They shared resources as the Alliance of Community Hospices & Palliative Care Services, changing the name this year to Hosparus Inc.
“We formed the alliance so the rural areas would have access to additional resources without necessarily having to absorb all the costs,” said Stephanie Smith, Hosparus senior communications manager.
Because hospice is primarily a 24-hour, home-based care service, staff must sometimes work irregular hours and be willing to travel long distances—often on poorly maintained and sometimes dangerous rural roads. Sharing staff between urban and rural areas helps spread out the load so staff members are less burdened.
Hosparus also relies on fundraising activities to strengthen its budget. For instance, the Southern Indiana program held its 8th annual Bar-B-Q Bash and 5th annual Charity Poker Run last month. Madrone encourages philanthropy through recognition programs. Donors giving anywhere from $200 to $1,000 are recognized with a tin, copper or gold leaf on Madrone’s Tree Sculpture. Gifts of $5,000 entitle donors to an engraved granite tile on the Memorial & Recognition Wall.
Volunteers are critical in keeping costs down and maintaining services, Flower said. Before Congress approved the Medicare Hospice Benefit in 1982, volunteer-based hospice programs relied primarily on community donations for funding.
“We could not meet our mission without volunteers,” Smith said. “We have 455 employees and 600 volunteers. In the rural areas, volunteers live in those areas and cover those rural counties.”
Volunteers have become even more important as the extended family structure has weakened in rural areas. Declining populations and younger people moving away for jobs in the cities is changing the fabric of rural America, said Dennis Dudley, an Aging Services Program Specialist in the San Francisco Office of the U.S. Department of Health and Human Services' Administration on Aging.
Medicare Reimbursement Still a Big Issue
Madrone Hospice also raises funds through its tree sculpture, where donors' names are inscribed on tin, copper or gold leaves.
Medicare certification requires that all patients and families requesting services receive coverage if they meet the criteria, regardless of whether or not they are covered by Medicare or other insurers. While that’s good news for patients and families, it can further burden rural providers’ already stretched budgets.
Today, 92 percent of hospices are Medicare-certified and Medicare reimbursements account for 83 percent of their income, according to Jon Radulovic, vice president of communications with the National Hospice and Palliative Care Organization (NHPCO). In addition, because the Medicare benefits system serves as a condition of payment eligibility for Medicaid and many third party insurers, adjustments in Medicare’s system could result in reimbursement changes from other payers too. Last month the Centers for Medicare & Medicaid Services (CMS) announced it is planning to make changes in the Medicare hospice wage index. (For up-to-date information on these changes, see the CMS Hospice Center web site).
“Rural hospice leaders seem to be in agreement that a look at the payment structure for the Medicare Hospice Benefit could be warranted,” Radulovic said.
Since its inception in Europe during the Middle Ages, when members of religious orders took in dying people and cared for them, the hospice concept has always focused on pain management and palliative care as a primary emphasis. Though the service is still fairly new to the United States, having been offered only since 1974, it has grown significantly.
To be accepted into hospice, patients must no longer be seeking curative treatment and a physician must determine that they are likely to be in the last six months of their lives. Medicare, Medicaid and most third party insurers cover hospice care. (For more on costs/coverage, see previous article, Rural Hospices Face Financial Challenges).
Most hospice care is provided in the patient’s home. A family member or close friend assumes responsibility as the primary caregiver and hospice staff provides expertise in comfort care. This can include arranging medications and therapies to relieve pain and symptoms, providing medical equipment such as hospital beds and oxygen, or simply “being there” for the family in the form of 24-hour support from the hospice team.
If a patient can no longer be kept comfortable at home or family members can no longer serve as primary caregivers, hospice programs generally have hospice homes or arrangements with hospitals or long-term care facilities to continue providing hospice support for the patient within the framework of that facility. Some hospice programs also provide 24-hour skilled nursing care; that service is neither required nor covered by Medicare reimbursement.
From 1996 to 2006, hospice usage increased 162 percent, serving 1.3 million patients in the United States. Four out of five patients are 65 or older and one-third are 85 or older.
In the 1980s cancer accounted for 90 percent of hospice patients; today, 44 percent of hospice patients have cancer diagnoses. The other top five terminal conditions served by hospice programs in 2006 were heart disease (12.2 percent of admissions), unspecified debility (11.8 percent), dementia (10 percent), and lung disease (7.7 percent).
Eighty percent of hospice care is provided in the patient's home, family member's home and in nursing homes.
Nearly 20 percent of hospices also operate a dedicated inpatient unit or facility. Most of these facilities (87 percent) are either freestanding or located within a hospital.
Three out of every four hospice patients (74 percent) in 2006 died in a private residence, nursing home, or other residential facility versus acute care hospital settings.
These days it is hard to ignore the 800-pound gorilla in our economy—the prospect of a national or even global recession. If the worst occurs, both rural and urban areas will be swept up in the economic carnage.
Last fall, former U.S. Treasury Secretary Lawrence Summers warned that the “odds now favor a U.S. recession that slows growth significantly on a global basis.” (U.S. must do more to avert a recession, Financial Times, Nov 25, 2007). The consensus of 54 economists as reported in a January 2008 Wall Street Journal survey put the odds of a recession in 2008 at 42 percent and estimated overall growth for 2008 to be in the anemic 2 percent range. More recently Federal Reserve Chair Ben Bernanke has mentioned the dreaded "R" word.
According to conventional wisdom, we are in a recession when the economy experiences negative growth over two consecutive quarters. However defined, there is no escaping the hurt being experienced in the economy these days.
The official unemployment rate recently crept above the 5 percent mark. Employers cut jobs in each month in 2008, with the number of unemployed persons losing permanent jobs reaching nearly 2.3 million by March of 2008—a level about 595,000 higher than a year ago. In addition, the number of involuntary part-time workers began to jump in late 2007 and is now 600,000 greater than it was in early 2007. Why is all this happening?
Let’s start with a few problems in the Financials, Insurance and Real Estate sector of the U.S. economy. This FIRE sector now accounts for 21 percent of the economy, a share that is now much larger than manufacturing at 12 percent.
First, the housing bubble of the last few years has burst with median prices expected to decline by 20-25 percent by the time this sector returns to traditional pricing norms. Second, sub-prime loans and other exotic credit devices lured too many households into financially risky arrangements that were unsustainable in the long run. Now, credit markets are seizing up and the federal government is rushing in to add liquidity to a system that was verging on collapse.
In the past, U.S. consumer demand drove economic growth here and abroad. It is now unclear whether this can continue. Almost all real income growth has been at the top of the income distribution. Between 2000 and 2006, the top tenth of 1 percent saw their typical incomes jump by 22.2 percent but the vast majority of Americans (the bottom 90 percent) saw a decline of 4 percent on average.
About 52 percent of all U.S. workers are hourly employees and their prospects are declining. The proportion of these workers earning $20 per hour, the widely accepted threshold to the middle class, has declined from 23 percent in 1979 to 16 percent in 2000.
The collapse of the manufacturing sector is not surprising given the reality of the global economy. We have out-sourcing, off-shoring, two-tier wage schemes, temp workers replacing real employees and contractual givebacks in exchange for job security. And still, it is hard to compete with countries with drastically lower wage scales or even our peer countries that do not face huge health burdens as part of the cost of doing business.
Not surprisingly, we are also becoming an asset poor country. Nearly half of all lower income families are considered "asset poor." They do not have sufficient economic reserves to last three months at poverty-threshold expenditure levels if their income were interrupted. The saving rate of all Americans has systematically declined from around 8.5 percent in the mid-1980s to negative rates in some recent years.
Add to this the growing specter of hyperinflation. Crude oil prices now approach $120 per barrel while other commodity prices are also skyrocketing as global demand rapidly outstrips our ability to produce what is needed. Truth is we may never see cheap oil again, such as the $10 per barrel oil of the 1980s. As with all commodities, emerging markets in Asia and elsewhere will result in demand pressures for a long time.
A final ingredient to our perfect storm is a collapsing dollar. This helps export U.S.-produced goods but exacerbates inflationary pressures since imports cost more. Higher food prices (abetted by bio-fuels investments) help our farmers but are not an unambiguous good. Some 100 million persons globally will be pushed into extreme poverty as basic food stuffs become unaffordable. And besides, looming inflationary pressures limit what the Federal Reserve can do to stimulate the economy without further weakening the dollar and fanning additional price increases.
Since World War II we have experienced 11 recessions. Compared to the past, most of these have been relatively mild and reasonably short in duration—the longest lasting 16 months. Perhaps our current troubles will prove no different. On the other hand…
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.
Americans have great faith in their ability to choose the best doctors, and great mistrust of anyone else, particularly anyone connected with government, choosing for them. When I was in small town military and then private practice I was puzzled, bemused, by that phenomenon. My Fairbanks incarnation began nearly 40 years ago. Most of my physician colleagues of that era are now dead and/or gone, and therefore beyond if not above reproach, so don’t bother trying to figure out who I’m talking about.
As a physician, I regarded the quality of care being provided by the Alaska Area Native Health Service, a part of the Indian Health Service (IHS), as the best in the state. The military seemed to me to be the second in quality and private practice care highly variable and overall third. The military and the IHS had few incentives for bad practice, and systems to detect and correct problems. In private practice the opposite situation prevailed. “The more you see, the more you bill.”
The public perception seemed to rank these three systems of care in exactly the opposite order: private care best, military second and IHS third. IHS beneficiaries with job-related private insurance were likely to use private care. Military personnel stayed with military care, except an irate spouse would occasionally head for town and the private system.
During my private practice days the same phenomenon seemed to prevail at the level of the individual doc. The private physician community included some superb docs, and some really bad ones. There was little correlation between the popularity of a physician and the quality of care he or she provided. In the invasive and surgical specialties the more skillful and “evidence-oriented” doctors may have been busier, perhaps because many of their patients were referred by other docs. In primary care, though, the busier docs seemed to those who practiced poor medicine: penicillin shots for upper respiratory infections and most everything else; no inquiries about smoking, drinking, family abuse; lots of imaging studies. They were practicing poor medicine but giving their patients what they wanted.
You’ve seen the survey results to the effect that people think that health care in general is faulty, but their own doctor is excellent. I think this reflects people choosing docs with practice styles that suit their own preferences. Some people want lots of information, some none. (“Don’t tell me about it. Just fix it.”) Most seem to want more imaging studies and prescriptions than are justified. Information is no substitute for a prescription.
Market theory says that purchasers make choices in line with their own best interests when they have accurate information about the quality of the products and services they are buying. Medicare, several state governments and a few payers are trying to give patients more information on the quality of care being given by different providers, though these programs usually look at hospitals rather than individual practitioners. I suspect that these programs are more useful to primary care docs deciding where to refer patients, and to practitioners working to improve care in their own hospitals, than they are to patients trying to make informed decisions.
Our dysfunctional approach to buying health care in this country has great potential for wrecking our economy. Freedom of the patient to choose his/her doctor (shorthand for diagnostician and therapeutic caregiver) is a major factor in national health policy. It was a factor in the decline of the managed care movement. Some may remember the “Harry and Louise” televisions ads skewering the idea of a national health plan with the line, “Choices we don’t like are no choices at all.” There was no mention of choices leading to harm instead of healing.
Perhaps after 20 years of experience with restrictive private managed care plans, patient choice of physician has lost some of its sanctity. Perhaps continued efforts to give the public more information on the quality of care from various providers will lead to better choices. It appears to me that as more docs are in structured systems, exuberantly bad practice is disappearing. Perhaps the public will notice that in our largest federal health program, Medicare, patients choose their doctors, whereas most private plans restrict physician panels. Perhaps. But I am willing to bet that as we start into another round of debate about federal health policy we’ll hear lots of rhetoric about government bureaucrats and patients’ right to choose their doctors.
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.
Frontier Extended Stay Clinics Provide Acute Care in Remote Areas
by Candi Helseth
Cindy Gamble, former administrator at Alicia Roberts Medical Center in Klawock, AK., was instrumental in development of the clinic.
In some of the United States’ most remote areas, weather and distance can keep severely ill or injured patients from reaching a hospital. Clinic providers step in to stabilize and observe patients until the patient can be transferred. However, because clinics are not licensed for acute care, they do not receive reimbursement from Medicare or other payers for these services.
The Health Resources and Services Administration (HRSA) federal Office of Rural Health Policy (ORHP) is in its fourth year of operating the Frontier Extended Stay Clinics (FESC) Cooperative Agreement Program, a demonstration project to explore the unique circumstances in these situations. Project coordinators are examining the effectiveness and appropriateness of a new type of provider, the FESC.
Frontier Extended Stay Clinics care for seriously or critically ill patients until they can be transferred to a hospital; they may also provide monitoring and observation services for limited periods of time. Under the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA), FESCs are defined as clinics located in communities at least 75 miles from the closest hospital or inaccessible by public road.
“Providers in these frontier areas are often the only health care source in their community,” said Caroline Cochran, ORHP policy coordinator. “Patients come to them in emergency situations or with extreme conditions that require advanced levels of care and an extended stay until they can transfer patients. But with the current reimbursement system, the provider is only reimbursed for a standard clinic visit. It puts a severe strain on clinics’ operations.”
The ORHP demonstration project has been working with model FESC clinics in the Alaska FESC Consortium to explore and evaluate the operational viability and financial sustainability of a FESC. The Alaska FESC Consortium, which began in 2004 and is slated to continue through 2011, is a consortium of five independent clinics in Alaska and Washington.
“Frontier clinics may be hundreds of miles from the nearest hospital, and poor weather conditions can make travel difficult or impossible,” said Patricia Atkinson, FESC program manager for the SouthEast Alaska Regional Health Consortium, the lead agency for the Alaska FESC Consortium. “This project is really about improving the financial sustainability and demonstrating the high quality of care available in these clinics. Additional income to these clinics’ extended stay services allows us to hire more staff to meet the community’s need for round-the-clock access to health care services. There are many communities that could benefit from this model, especially in frontier areas of Alaska and the lower 48 states.”
According to Atkinson, these clinics have recorded numerous instances where they stabilized patients who normally would have been treated in a hospital emergency room or immediately transported to a hospital if conditions had permitted it. For instance, a non-English speaking man with diabetes arrived after hours at Iliuliuk Family and Health Services in Unalaska, located on a remote island 800 air miles from the closest referral hospitals in Anchorage. The patient was having a heart attack and his blood sugar levels were out of control. Additionally, staff suspected a possible cervical spine fracture from an accidental fall nine days earlier. Due to bad weather, Medevac teams were unable to reach the clinic for 23 hours.
In another case, a hallucinating patient with erratic and “at times explosive” behavior required constant staff supervision for more than six hours before an airplane arrived to transfer the patient to a psychiatric hospital. Many Alaskan clinics transport patients by air or boat because Alaska has hospitals in only 19 communities.
Clinic staff in Alaska FESC clinics may monitor and observe patients who do not meet the criteria for inpatient hospital admission for up to 48 hours before discharging them to go home. Frontier area residents may not have running water or electricity in their homes, may live alone or there may be other circumstances that make it safer for the patients to remain in the clinic for an extended period, Atkinson said.
The Alaska AHEC at the University of Alaska is also evaluating the project. Each of the FESC clinics reports extended stays and transfers and these encounters are entered into an online database.
“We’ve learned some very important things from our data,” Atkinson said. “On average, each of these clinics has about 100 extended encounters (four or more hours) per year. These clinics provide all the emergency care in the region and serious and life-threatening injuries are all too common. We believe that documenting the work we are doing will help policymakers understand our need for adequate recognition and reimbursement.”
Moose gather before the Cross Road Medical Clinic in Glennallen, Alaska, one of the clinics in the Alaska FESC Consortium.
The MMA authorized the Centers for Medicare and Medicaid Services (CMS) to conduct a separate demonstration program in which FESCs would be treated as Medicare providers. Recently, CMS announced that it has selected six clinics in Alaska, Montana and Washington and will begin the demonstration this year.
For many clinics Medicare might constitute only a small portion of FESC visits. However, Medicare reimbursement is often the first step in recognition of a reimbursement category for Medicaid and other private payers. The CMS demonstration will explore what actual payments may be and how feasible the provider type is.
QuadCo: Offering Prescription Assistance in Rural Arkansas
by Candi Helseth
Jennifer Campbell, a Patient Assistance Manager for the QuadCo Prescription Assistance Program, shows Bettye Thurmon how to use a glucometer (purchased with QuadCo funds).
Dana Cottrell was just managing to make ends meet as a waitress in her hometown of El Dorado, Ark., until her health took a downturn two years ago. Her blood pressure skyrocketed out of control and then she suffered a debilitating stroke.
Cottrell, a 40-year-old single parent with three children, says she can’t afford health insurance on her salary and her employer doesn’t provide coverage. She couldn’t afford the prescription medications her physician prescribed either.
“It was $1,500 a month!” she exclaimed. “There’s no way I could pay that.”
Cottrell’s physician at Interfaith Clinic, a faith-based organization providing free care for low-income people, referred her to the QuadCo Prescription Assistance Program. Now in its fourth year of providing prescription drug assistance for uninsured and underinsured populations, QuadCo is a rural health network serving Calhoun, Dallas, Ouachita and Union counties in Arkansas. All four counties, when compared to state averages, have higher numbers of uninsured residents below the poverty level and large elderly populations.
From June 1, 2006, to Jan 15, 2008, QuadCo met prescription needs for 9,098 clients in these counties. All the patients had medical conditions requiring more than one prescribed medication and were in income levels 200 percent below the federal poverty guidelines.
Unexpected benefits of the prescription assistance program have been its return on benefits, according to Joni McGaha, a rural health specialist with the Arkansas Department of Health.
“We put together a Return on Investment Plan in 2006 and found that when the cost savings in prescription meds provided to clients is added to the dollars saved through reduced emergency room visits and hospital stays, along with the benefits of improved prevention education and chronic disease management, the total estimated impact is $31,344,388,” McGaha said. “Comparing this impact to the total expenditures of $1,061,000 yields a return on investment conservatively estimated to be $29.54 for every dollar spent operating our program!”
QuadCo leaders selected prescription assistance as a primary focus after conducting a survey that revealed more than 70 percent of area participants were not taking medications prescribed for chronic conditions. Of those surveyed, 96 percent said they couldn’t afford the medications.
QuadCo’s prescription assistance program brings together a variety of professional providers, including pharmaceutical companies that provide medications at reduced prices, local health care providers that ensure proper procedures are followed and clinics where patients can pick up their prescriptions.
Unused prescription medications, which previously were being thrown away by nursing homes when patients died, are also being redistributed. House Bill 1031, initiated by a QuadCo board member and passed by the Arkansas Legislature in February 2005, allows nursing homes to donate these meds to approved clinics. In 2007 alone, Interfaith Clinic, which is one of the approved clinics, distributed medications valued at $49,000.
QuadCo’s research also revealed that many patients using multiple medications were not taking them properly or consistently. Collaborating with home health agencies, QuadCo staff distributed more than 3,000 pillboxes to elderly and homebound residents. Home health nurses oversee patients’ usage. McGaha said QuadCo has implemented additional programs to improve patient care too.
Although the network didn’t adopt the name QuadCo until 2004, many of its members became involved in 2001 when they applied for a planning grant from the Arkansas Delta Rural Development Network (ADRDN). ADRDN receives funding from the Office of Rural Health Policy of the Health Resources and Services Administration. By early 2004, organizers had united the four counties under one umbrella, named the network QuadCo and selected prescription assistance as the first priority.
ADRDN continues to be the primary funding source, and McGaha said additional support comes from a variety of sources, including local foundations, private donations, community fundraisers and in-kind contributions.
Although she still battles ongoing health problems, Cottrell is grateful for Interfaith and QuadCo. “If I didn’t have this help, I couldn’t survive,” she said. “My blood pressure is still really high and taking these pills is the only way I am able to function. It’s a wonderful program.”
To learn more about QuadCo, contact Joni McGaha at 870-863-5101.
Dennis Mohatt is Vice President for Behavioral Health at the Western Interstate Commission for Higher Education (WICHE), which works to improve systems of care for people with mental illness and their families and to advance the preparation of a qualified mental health workforce in the West. In addition, Mohatt serves as Director and Principal Investigator for the WICHE Center for Rural Mental Health Research, one of eight Rural Health Research Centers funded by the federal Health Resources and Services Administration (HRSA) Office of Rural Health Policy (ORHP).
In his previous work, Mohatt was Deputy Director of the Nebraska Department of Health and Human Services and the state’s Medicaid Managed Care Director. Prior to that, he was the CEO of the Menominee County Community Mental Health Center in Menominee, Mich., from 1989 to 1995.
During 2002-2003, Mohatt served as a consultant to the Rural Issues Subcommittee of the President’s New Freedom Commission on Mental Health, and helped prepare its report to the President. He served on the National Advisory Committee on Rural Health from 1994 to 1998. He has been a member of the Board of Directors for the National Association for Rural Mental Health (NARMH) and served as the association’s President from 1992 to 1995. In 1996, he was awarded the NARMH’s Victor I. Howery Award for outstanding contributions to rural mental health.
Mohatt received an M.A. in rural community-clinical psychology from Mansfield University in Pennsylvania (a program that has since ceased). He is a native of the small farming community of Vail, Iowa and has lived in several areas of the United States, which has given him considerable exposure to cultural diversity, especially in working in partnership with Native American people. Mohatt is married to Dr. Karen Sharer-Mohatt, a psychologist. The couple and their teenage daughter live in Lincoln, Neb. In his spare time he volunteers as an Alpine Patroller in the National Ski Patrol, rides his Harley and enjoys listening to music—he has attended more than 100 Grateful Dead concerts and now subscribes to a weekly Grateful Dead podcast. His iPod also currently contains music by Bonnie Raitt, Amy Winehouse and Diana Krall.
A select list of his past and current research projects is available at the Rural Health Research Gateway page for Dennis Mohatt.
Dennis Mohatt on his Harley, which he rides more than 10,000 miles a year--including, sometimes, the 500 miles to work.
What sparked your interest in rural community-clinical psychology?
I think that the fact that my dad died in the line of duty as a volunteer fireman had a huge impact on my brothers and me. It drove us all to do public service work. Everyone talked about my dad in glowing terms, and it gave us a great sense of the value and worth of public service. So, that was a big part of the motivation.
The other part of it is that I was only 14 months old when he died. My mom suffered from some real serious mental illness in the aftermath of losing her husband and was eventually institutionalized. Although she died last year, she was institutionalized the rest of her life, so I was a virtual orphan after that—from ninth grade on, I was living with relatives or in boarding school or in foster care. I was assigned a caseworker since I was on public assistance. I remember as a young guy in college writing my caseworker in my home area of Iowa and asking if I could do a summer project to work with youth in foster care and others with problems, sort of a mentoring program I had been thinking of. They just blew me off, told me to go back and get my degree and start my own practice. That ticked me off and made me buckle down and work to help make things better in rural communities.
I have found only unmet need in rural mental health since then, and have continued to push for attention to the disparities rural people face in getting quality care. That’s not to say that non-rural people get the best care, by the way, the mental health system in the country is so broken it should just be thrown away and a new system created. There would be no loss.
What keeps you going now? What are the rewards?
One thing is that hard work does pay off. I believe now I’ve gone from being a rabble-rouser to being a mentor. I’m 54 and there are young professionals that seek me out and who want to work with me and are interested in rural things. That keeps me going. You go from being the young guy/listener to the talker. I love my job—I love working with WICHE.
What does WICHE do?
We help states improve services and higher education improve the quality of the workforce. They only have us there when they want us. There’s no one standing in your way. People don’t ask the WICHE mental health program for assistance unless they are willing to pay for it and they want it.
We’re very unique in doing both research and technical assistance. For example, our HRSA-funded rural health research center has focused a lot on collaborative care models in primary care for depression and other serious mental illness; we have provided training to primary care providers in multiple states to support the adoption of collaborative care models; and we have advised state policymakers on how to support that adoption in their Medicaid and other programs. At the current moment in time, we have 30+ projects going in 12 different states, supporting the improvement of mental health services and building a better mental health workforce. Nearly all are rural or frontier focused.
The other thing about WICHE is that we are not university-centered—we can put our research findings to immediate use. The IOM report, Crossing the Quality Chasm, said that the time from scientific verification to adoption of practices is around 17 years, but we’re really able to get our research out there faster. That’s the exciting part of what we’re doing, having a direct impact on government and health organizations.
You live in Lincoln, Neb. but your WICHE office is in Boulder, Colo. How does that work? Do you telecommute? I travel all the time. We work with 15 western states, so if I’m doing my job I’m out doing things with our states. I flew over 130,000 miles last year, and took a few road trips in the car. And I do commute often from Lincoln to Boulder (501 miles one-way). But I’m usually home for a three-day weekend and I’m able to fix my schedule to be home when big things are happening with my daughter. And I telecommute from my house, as well.
The WICHE Mental Health Program lists three Ongoing Research projects for 2007-2008 (for which you're the principal investigator). Are there any surprising findings so far?
One of the interesting things we’ve found in depression work is that urban folks get this positive economic bump from depression treatment. Rural people are getting better but not getting as much gain as their urban counterparts. Those of us who have worked with recovery around mental health care know that to get gainful employment, seeing some kind of economic improvement in your work, helps with the recovery. That’s a pretty interesting area we want to look at more closely downstream. Is it that economic factors are more limited in rural areas so there’s not the capacity for them to gain from being that much healthier? Is there some relationship to them not getting as well as their urban peers? This was not even something we were looking at, but something we just happened to find in the data. If it turns out it’s stigma in rural areas, you can do things about attitude. But if, it turns out, it’s because it’s more of a flat economy in rural areas, there’s not much you can do about that from a public health approach.
What do you think are the major mental health issues for the rural United States right now?
Accessibility – The consumer’s mental health literacy, ability to physically get to care, and the ability to pay for the care. Disparities exist in all areas.
Availability – That a trained mental health professional will actually be in rural America to help. Over 60 percent of rural America has had mental health professional shortages for more than 45 years!
Acceptability – A mental health workforce that is actually trained to work in rural places, has access to the tools to provide quality care, and the care they offer is actually what the consumer seeks. All is missing today.
What do you think will happen or should happen with rural mental health in the next five years?
I do not think rural health can survive with the continued fractured model. About the only rural health worker we don’t have a shortage of is CEOs. Each organizational structure adds administrative cost, and the potential for a consumer to “fall through the cracks.” We actually discuss “navigating the health care system.” There is something really stupid about that, and it all goes back to a lack of effective planning and mutual investment in healthy communities. I believe we need to integrate systems, and create rural community health systems that include public health, hospitals, primary care, long-term care, behavioral health, etc. with unified governance, leadership, etc. Can we really go on paying for multiple sets of everything from workers to information systems? I don’t see this happening—we don’t do collaboration well in America (e.g., marriage), so the odds are not in favor of building partnerships in caring. But it is worth shooting for.
Customized Assistance: Information Tailored to Meet Your Needs
by Kathleen Spencer, MLS, MS, Information Specialist
Are you looking for grant opportunities to support projects in your community? Do you need an expert to guide you on federal rules and regulations? Maybe you are searching for statistics and data to support a grant proposal. Answering these types of inquiries is one of the ways our information specialists at the Rural Assistance Center can help you. RAC's free customized assistance is just that: assistance tailored to your specific information needs.
RAC Information Specialists, from left: Mary Reinertson-Sand, Holly Gabriel, Aubrey Madler, and Kathy Spencer.
RAC’s information specialists are professional librarians trained in American Library Association accredited graduate schools with a focus on information technology. These skilled Internet librarians have subject expertise on rural health and human services and actively seek information throughout the nation for our rural clients. Furthermore, these information specialists attend and participate in national conferences and professional training to keep abreast of new information and improved ways of finding that information.
RAC maintains an electronic clearinghouse of rural health and human service resources that allow our professional staff to quickly perform detailed searches. We utilize a variety of online sources to obtain timely information—literally at our fingertips—including a searchable database that indexes thousands of foundations and more than a million grants, and a comprehensive national directory that provides information regarding state and local service agencies. This knowledge base is further supported by the resources and staff of the RAC partner organizations, the University of North Dakota Center for Rural Health and the Rural Policy Research Institute, as well as a large network of experts on rural health and human services across the country.
At RAC we collect and find resources to support a variety of requests in these areas:
potential funding opportunities both public and private
appropriate federal or state agency contacts
professional documents, research reports, and fact sheets
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RAC is here to help your rural community access the full range of programs, funding and research that can provide quality health and human services for your residents. Why not try us for customized assistance tailored to your specific information needs? Please contact us at the Rural Assistance Center, toll free, (800) 270-1898, or email, info@raconline.org.
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