The National Advisory Committee on Rural Health and Human Services is examining the medical home concept in a chapter of its 2009 report. Its Medical Homes subcommittee held site visits at medical homes in the United States last year, in preparation for the report. The report will be available on the Committee’s Publications page this spring.
Additional Resources on Medical Homes from the Rural Assistance Center
The Medical Homes Information Guide offers tools and web sites devoted to creating and sustaining medical homes; relevant organizations, contacts and funding; and recent news items related to medical homes.
If you know of an additional resource for the Medical Homes Information Guide that is not currently listed there, please use the Suggest a Resource link.
Lakewood Health System in Staples, Minn., initiated a medical home program in 2008.
When her doctor suggested she be admitted to the medical home program at Lakewood Health System in Staples, Minn., Joan Morphew thought, “I don’t need that kind of care.” Morphew assumed a medical home would be like home care and hospice, services provided in their home when her late husband was ill.
Instead, the medical home embraces a team concept where a primary care provider works with other health professionals to ensure that patients receive coordinated, accessible, comprehensive care on an ongoing basis.
Now that Morphew is in Lakewood’s medical home, she understands the concept and appreciates the coordinated care it provides. Morphew is among approximately 500 patients, most with chronic or multiple illnesses, who have been admitted to the program since it opened in 2008. The rural regional center altogether serves about 30,000 people in a 40-mile radius.
Community Care of North Carolina (CCNC), which began coordinating care for Medicaid patients in 1991, adopted the enhanced patient centered medical home (PCMH) program in 1998. Today CCNC covers all 100 counties in the state with 14 networks and 891,000 patients.
“We began with the idea that we needed to provide patients access to a primary care provider, but as we went on, we realized that wasn’t enough,” said Denise Levis, director of quality improvement. “We also needed to support and work with these primary care providers to develop more patient centered care that really included medical home concepts like evidence-based practices and quality improvement measures. Ultimately, our goal is to improve quality of care while containing costs. The medical home has helped us achieve that.”
The numbers and types of health care providers involved in medical home networks vary, but a primary care provider and a primary point of contact—often referred to as a coordinator or case manager—are essential to the concept.
Dr. John Halfen, medical director of Lakewood Health Systems in Staples, Minn., says that the medical home concept allows doctors to view the patient's entire health care situation.
“Every patient has a specific physician, and the care coordinator is familiar with each of the patient’s diagnoses and has direct access to their physician,” said Lakewood Medical Director Dr. John Halfen, who has been a rural family medicine physician for 30 years. “We schedule physicians for longer visits with medical home patients because their problems are more complicated. What we’ve really tried to emphasize with each physician is that the medical home is a different commitment to the patient. Physicians still look at the problem a patient presents when he comes into the office, but they also view the patient’s entire health care situation. What can they do to keep this patient healthy long-term?”
“Patients can call the care coordinator any time they need help or have a question,” Halfen added. “Patients also have email connections directly to their provider. And our physicians keep time blocks open that the care coordinator can schedule if that patient needs to see the provider now.”
Morphew, 69, has chronic hypertension and elevated cholesterol levels. She takes six different prescription medications. “Sometimes I just have a question and I can call the coordinator and get an answer faster because she’s right there,” Morphew said. “It’s easier to get appointments set up when I need them, too.”
CCNC’s case managers identify patients with high-risk conditions or needs, assist providers in disease management education and follow-up, help patients coordinate care and access services, and collect data relative to the patient.
“Case managers are part of the network team and provide support from one delivery system to another,” Levis said. “If the patient is hospitalized somewhere else, the case manager makes sure the patient gets what he needs when he gets back to his home community, things like getting medications filled and setting up follow-up visits with the primary care doctor again. Physicians really like having a case manager embedded in the physical space of that practice. In the more rural areas, we might have five or six clinics with one case manager for several medical homes.”
Having care networks and case managers in the local communities also improves patient involvement, Levis said. “We’re dealing with more than just physical issues. Most of our patients are low-income and many of these counties are very rural. So we do a lot of things to help them get the care they need.”
CCNC and Lakewood invest considerable time encouraging patients to take charge of their own health. Individualized instruction, newsletters, educational sessions and support groups are among their outreach methods. Electronic medical health record systems help staff coordinate care and track patients’ progress.
“Without electronic records, we wouldn’t have a medical home,” Dr. Halfen said. “We’ve incorporated standards for nursing home care, preventative care, quality improvement and other standards into the weekly electronic searches our care coordinator does.”
While it might appear that medical homes are too labor intensive for already pressed rural providers, Dr. Halfen said staffing pressures are reduced because patients are more proactive and get help before problems become as acute.
CCNC has documented significant improvements in cost, utilization and quality measures, Levis said. A 2006 external accounting audit showed that North Carolina’s Medicaid program saved $124 million from what it would have otherwise spent. North Carolina physicians also have a higher participation in Medicaid, Levis said, because the state compensates them more, whereas physicians in many states refuse to see Medicaid patients because reimbursements are so low. CCNC leaders also regularly meet with physician organizations, legislators and other health care leaders to explain and validate the program’s value. “You have to do your homework,” Levis asserted.
Dr. Halfen and Levis believe medical home programs will continue to grow as existing programs demonstrate how patient care improves when facilities implement the Joint Principles of the Patient-Centered Medical Home, which were developed cooperatively by four national physicians’ organizations.
“Chronic patients are seen as the patients that most benefit being in the medical home but in reality, all patients benefit from this type of care,” Halfen said.
Information Technology Plays Key Role in Medical Homes
by Candi Helseth
Rural providers must embrace information technology to successfully implement a medical home program. Yet, only 10 percent of American primary care providers currently use electronic medical records, according to Dr. Ted Epperly, president of the American Academy of Family Physicians.
“One of the most unfair ironies of a health care system that now spends $2.3 trillion per year—over $7,000 per citizen on health care—is the burden it places on patients to transfer their medical information among their health care providers,” Epperly asserted. “Electronic medical records provide the ability to coordinate and track a person’s health over time. This is essential to patient-centered medical homes (PCMH) where the focus is no longer on treating an acute condition, but rather keeping patients well and healthy.”
Research has demonstrated that patients are not trained in medical language and it is difficult for them to remember all their symptoms, history and medications. This is particularly true for patients with multiple or chronic illnesses, which constitute the majority of PCMH patients. Paper records may be inadequate or unavailable when patients travel outside their immediate care network, and patients living in rural areas are more likely to travel to tertiary centers for specialty care. When those patients return home for follow-up care, paper data is less likely to be transferred to the primary care provider. With electronic records, patient health information from multiple, diverse sources is pulled together into a single electronic system that is easily accessible for all patient providers, Epperly noted.
Research data indicates that 40 percent of primary care visits do not require a physical visit to a physician’s office, according to Paul H. Keckley, executive director of Deloitte Center for Health Solutions in Washington, D.C. “Patients welcome more technology,” he added. “Our data shows that non-urban patient populations with chronic conditions want more use of technology in coordinating their care.”
In addition to electronic medical records, information technology may include physician-patient interaction such as email visits and prescription emails to better coordinate and integrate a patient’s care, Epperly said, noting, “Family medicine physicians are ahead of the curve here. Forty-seven percent of family medicine physicians incorporate electronic technology into patient care. Family medicine strongly emphasizes overall care coordination rather than focusing on acute care only.”
Deloitte Center’s research also indicates that rural primary care providers without electronic medical record systems cite cost as the primary barrier to PCMH implementation. Keckley said the federal government’s stimulus package allocates significant funding for physician practices, community health centers and critical access hospitals in rural areas to purchase electronic medical record systems.
“The money is there now so there is no excuse for rural-based physicians and providers not to be moving toward electronic medical records,” he asserted. “Access to primary health services can be delivered in a variety of ways and information technology can greatly augment conventional care in rural areas where there are already provider shortages.”
In rural Minnesota where Lakewood Health System at Staples implemented its medical home program in 2008, the new electronic medical system is critical in managing patient care, said Medical Director Dr. John Halfen. “With electronic records, we access patient information that would be virtually impossible if we were still using a paper system,” Halfen said. “Communication between all providers and having all the information in electronic medical records is absolutely necessary to make the medical home program work.”
Medical Homes Provide Coordinated Care for Chronic Conditions
by Candi Helseth
Sarah Jones* repeatedly brought her baby to a local emergency room because it suffered from chronic asthma. Jones assured the physician that she was keeping her home clean to minimize the baby’s asthma attacks. In fact, a local case manager with one of the networks in Community Care of North Carolina (CCNC) visited the home and found it spotless. But, as she visited with Jones, she learned that the mother was proudly cleaning her home with bleach—so much bleach that it was triggering the baby’s asthma attacks. Since that home visit, Jones’ emergency room visits have stopped.
Lauren Smith*, a patient with diabetes, heart disease, hypertension and high cholesterol, takes several prescription medications and is also an alcoholic. A CCNC case manager began working with Smith to help her use her medications properly. As the case manager gained Smith’s trust, she also got Smith to promise to eat whenever she drinks because eating helps stabilize her blood sugars. As a result, Smith’s frequent visits to the emergency room for diabetic shock have greatly decreased.
Patients with chronic conditions are better managed in medical homes because of the long-term coordinated approach, said Denise Levis, CCNC director of quality improvement. This is especially important in the United States because 45 percent of Americans have a chronic medical condition, according to a report on the medical home model from the Deloitte Center for Health Solutions in Washington, D.C.
“A lot of our Medicaid patients were using ER for their primary care,” Levis said. “People with chronic conditions are really the ones that benefit the most being in the patient centered medical home (PCMH) because their care was very fragmented before.”
Patients with multiple chronic illnesses account for as much as 75 percent of total health care spending. Within Medicaid, 5 percent of beneficiaries—80 percent of them having three or more chronic conditions—account for up to 50 percent of total Medicaid spending. Chronically ill patients are also often on multiple medications, and improper usage or over-medication can exacerbate chronic conditions. Pharmacists are integral members of CCNC’s networks, monitoring and evaluating patients’ medications. Levis said CCNC local network staff members also work directly with patients, teaching them how to properly take meds and better manage their disease.
CCNC networks remind patients when they need appointments and encourage them to come prepared. Patients are asked to write down their questions prior to the appointment, bring all their medications and keep personal records. If they have needs outside the medical realm, such as lack of transportation to an appointment, CCNC network case managers make appropriate referrals or arrangements.
CCNC has developed quality improvement initiatives for management of chronic patients with asthma, diabetes and heart problems that are available online at the CCNC web page, under the Quality Improvement/Program Wide Initiatives tabs.
* Names have been changed to protect patient privacy.
Reimbursement and Workforce Issues Hamper Medical Home Implementation
by Candi Helseth
In addition to the absence of electronic medical record systems (see Information Technology Plays Key Role in Medical Homes), declining numbers of primary care providers and skewed reimbursement systems appear to be the greatest barriers for rural providers interested in implementing medical home programs.
The number of primary care providers across the country is waning and shortages are more acute in rural areas. In the patient centered medical home (PCMH), a primary care provider coordinates the patient’s care within the PCMH network.
“Primary care is broken in our health care system,” said Dr. Ted Epperly, president of the American Academy of Family Physicians. “The United States has about 70 percent specialists and 30 percent generalists. Other healthy countries have about a 50-50 mix. It’s only going to get worse. In the last 10 years, our medical schools have graduated 90 percent specialty and 10 percent primary care physicians.”
The reimbursement system contributes to that maldistribution of providers by reimbursing specialists for high cost procedures and reimbursing primary care providers only for office visits. Medicare and managed care reimbursement systems cause physicians to treat sicknesses rather than focusing on keeping patients healthy, Epperly said, noting that primary care physicians receive no reimbursements for “non-sick” care such as patient education, overall medical management, outside office visits, and telephone and email consultations with specialists who may be involved in that patient’s care. Additionally, specialists earn much higher salaries, so that medical students—whose average educational debt is in the $150,000 range—pursue careers in the better paying specialties.
Medicare and most major payers do not yet have reimbursement systems covering PCMHs, but there is hope on the horizon. Medicare and several major payers have implemented PCMH pilot programs to determine care and cost benefits. One of these, the TransforMED National Demonstration Project, has been examining 36 patient-centered family medicine practices from all across the United States and has begun to issue reports on the project.
The analysis of medical homes and the sophistication being applied to looking at various models has dramatically increased in the last year, said Paul H. Keckley, executive director of Deloitte Center for Health Solutions in Washington, D.C. “I’d speculate that in three to five years we’ll see a dramatic increase in medical homes, but we just don’t know enough right now to know how best to do it, how to make adjustments for differences—for instance, rural and urban areas. In rural areas, you have to factor in more variables such as transportation needs.”
The reimbursement pattern itself has begun to shift slightly as major insurers, such as AETNA and CIGNA, have begun test programs that include better reimbursement for PCMH practices, Keckley said.
“The medical home plays a key role in the necessity to change the way services are delivered and the way the payment mechanisms reward performance,” Keckley commented. “We’re already seeing employees who have made changes in their benefit structures. We can expect to see Medicare and Medicaid making changes as well, and others following suit.”
The current recession is now in its eighteenth month, making it the longest economic downturn in the postwar period. Moreover, real gross domestic product (GDP) fell by 6.1 percent on an annualized basis in the first quarter of 2009, following up on a 6.3 percent decline in the last quarter of 2008. The cumulative drop in GDP since mid-2007 has been more severe than any other post-World War II period except for a very sharp, and blessedly brief, decline in 1957.
Until recently, rural America had not felt the full fury of the recession because high agricultural commodity prices were muting expected effects. But the prices farmers get for their products have fallen. For example, milk prices in Wisconsin (the dairy state) have declined from $18 to $22 per hundredweight (100 pounds) in 2008 to between $12-13 in the spring of 2009. This is below the breakeven point of $14 to $16. On a larger scale, world trade numbers are expected to decline this year for the first time in a quarter century. This is critical to rural America since one-fifth of all U.S. farm production is exported.
Rural economic problems are not all found on the farm, however. In fact, farming-dependent rural counties did fairly well on the job front through most of 2008 when urban centers experienced a sharp economic decline. In recent months, however, rural jobs have been disappearing at an alarming rate. A recent Rural Economic Update issued by the Rural Policy Research Institute reveals that, according to seasonally adjusted employment data from the Bureau of Labor Statistics, nonmetropolitan counties have now lost 3.4 percent of their jobs as of January 2009 compared with a 2.8 percent drop in metro counties.
As the report summarizes, “Rural factories have been especially hard hit. Rural areas dependent on manufacturing have now lost nearly 5 percent of their jobs since the recession began, as compared with around 2 percent in other parts of rural America.”
So, where is the light? To start with, some 1,000 lawyers per month have lost their jobs since the beginning of the year. Surely, fewer lawyers must be good news. (In the interest of full disclosure my wife is a lawyer and she also thinks my wit somewhat lacking.) More seriously, there are a few signs that we are reaching a bottom. After hitting a bottom in March, equity markets have rallied in recent weeks. Even more surprising, consumer spending jumped by 2.2 percent in the last quarter according to recent numbers. Moreover, April’s overall job loss number, while still high, was below expectations and the lowest in six months.
Some of the more intriguing signals are found in a recent uptick in confidence expressed by U.S. citizens. In a recent Washington Post-ABC News poll taken between April 21-24, half of all respondents felt that the country was going in the right direction. While not an overwhelming endorsement of future prospects, the results are a dramatic improvement over sentiments displayed last October when some 90 percent of respondents felt we were going in the wrong direction. When asked specifically about the state of the economy over the next 12 months, some 55 percent were optimistic, a jump of 7 percentage points in just two months. Most respondents now feel that this downturn is a normal economic downturn than something more dangerous and intractable.
Among so-called experts, there is a collective sigh of relief that we may have avoided the big one, that this will be a recession and not a depression. Much pain remains and much can still go wrong. Jobs are still disappearing. Companies, such as carmaker icon Chrysler, are still going into bankruptcy court. State taxes declined by some 5.6 percent in the last quarter of 2008 and will not recover for some time. Ballooning federal deficits also will present challenges for years to come. And sudden, unknowns like a Swine Flu pandemic (the H1N1 virus) may yet halt the flow of people and commerce on a worldwide scale. But, for the moment, the sense of panic is abated.
If that really is light we see at the end of the tunnel, perhaps the crisis itself was overblown. I think not. Consider the following. The historical average price-earnings ratio for equities is calculated to be a little over 16 (where the price of a stock is 16 times earnings). At the onset of the Great Depression in 1929, it was roughly twice that level, standing at 32.6. In 1999, that same index stood at about 44, clearly suggesting an unsupportable speculative bubble in the equities markets and possibly another economic crash of historic proportions.
If such a bubble existed a decade ago, why didn’t the economy collapse then? Essentially, we buried our head in the sand and delayed the inevitable, but in a very dangerous way. We rode a housing bubble through 2006 when the median price of a house hit 200 percent of the historical, inflation-adjusted standard. By way of comparison, that metric was only about 10 percent above the historical standard as recently as the mid-1990s. We also delayed the inevitable through easy credit and excessive spending. Household debt jumped by almost one-third over the past decade (much higher than the increase in government debt) while the savings rate collapsed to zero. We were spending everything we had and could borrow.
That was not sustainable. If the reckoning does turn out not to be as bad as it might, it still remains a wakeup call. As the saying goes, every crisis is also an opportunity. Perhaps we can use this crisis to get our fiscal house in order. If we don’t we may not be as lucky the next time.
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.
We farm in Waldoboro, Maine. It’s a generally congenial place with a mix of working local people and mostly retired newcomers. Though I’ve been doing health-related stuff for almost 50 years, now I’m learning health policy from our neighbors.
One senior neighbor, I’ll call him Samuel, turned 80 this spring. It kind of hurts to watch him walk. Each leg takes a circuitous route to the ground. He logs in the winter, digs clams in the summer (dreadful, cold, barehanded stoop labor on a schedule driven by the tide) digs and sells gravel from his pit on request, and hauls rich retirees’ trash on weekends. He certainly knows all about doctors and hospitals, having lost his wife to diabetes some years ago. He has never, as man or boy, seen a physician as a patient. He considers getting one or two knee replacements but hears that sometimes they work, sometimes they don’t.
A second neighbor, John, age 50 or so, is a self-taught local historian who can start with a standing ash tree and some weeks later present a very respectable basket. A building tradesman, I believe he does not borrow. He works and saves and buys what he needs if he cannot make it himself. He and his wife have adopted a youngster, the child of a family member with problems. He asked me recently, “What do you think of “socialized medicine?”
I answered, “I’m never sure just what that means…Usually it just means the speaker doesn’t like whatever is being proposed. Why do you ask?”
“There is just not any way that a working man can take care of his family when it comes to medical insurance. I work hard and my wife works hard but there is just not any way we can do it. But if I say much, somebody says I’m talking about ‘socialized medicine’!”
A third neighbor, Martin, is an insulin-dependent diabetic. He has been on insulin now for 51 years. He works hard at his farming. He believes that the unremitting demands of 60 cows keep him moving and working: “I farm to stay alive.” He is missing a few toes and has been blind a time or two. He is probably entitled to disability twice over, but if he quits milking, he feels he won’t last long. His wife has a pretty good job with health insurance, though taking care of Martin could be considered another. Her job brings him health insurance. Ten more years and he’ll be eligible for Medicare.
Finally, you’ve probably seen another, well-known former neighbor. Her name was Christina Olson. She was the subject of Andrew Wyeth’s famous painting, “Christina’s World.” The painting depicts her in a hayfield below the house where she lived with her brother in Cushing, the town next to ours. She was crawling back up from visiting her folks’ graves. Though she could walk a bit as a child she progressively lost that ability. She entered the medical care system just once, letting herself be hospitalized in Boston at age 25. She found it such a demeaning experience that she was never seen by a physician again. A well-intended benefactor once gave her a wheelchair. Having devised her own approaches to activities of daily living, she had her brother take the chair out into the bay below the house and heave it overboard. Practically paraplegic, she lived until age 74 in 1967. She stayed in her own home on her own terms without medical care until the last two months of her life.
What is the point of these stories? Samuel with his 80-year-old arthritic knees and lifetime without health care reminds me that most of us are well most of the time. We see doctors more than we should. Reform needs to go beyond finance. Also note that Samuel substitutes hard work and eating well for medical care.
John, the building tradesman, was really worried. A conscientious person, he simply could not make responsible health provisions for his family. Reform should help. When he tried to discuss it he got back only a pejorative label, “socialized medicine.” In our policy discussions we need to focus on content and beware of dismissive generalizations.
Christina lived reasonably long and reasonably well in spite of being dealt a bad deck of cards. Medical care was of no help to her. Had she been more receptive to care, it's my guess she'd have gotten a bladder catheter and died of infection a few decades sooner. Medicare got rolling about a year before she died. Access to care wasn’t an issue for her. We all hope that care today is more safe, effective and patient-centered than it was during her lifetime. We know more now than then. I’m not sure we’re kinder.
Finally, Martin is the long-term, hardworking diabetic. He puts the policy issues in perspective. For him, staying alive is a 24-hour-a-day, physically demanding job. “Well, I got through the night without insulin shock. Can I get my boots on…? Can I see well enough to get around the barn?” Issues like paying for insulin and foot surgery and eye surgery are distractions from the realities. Reform should help him. I’ve resisted asking him, a rockbound conservative, how he feels about it.
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.
Dr. Mary Wakefield, Health Resources and Services Administration Administrator, says that Recovery Act funds can be used for capital improvements and adding staff at rural clinics.
Goshen Medical Center in Faison, N.C., normally functions in relative obscurity, meeting the needs of a largely poor, rural population. But this spring, the clinic was thrust into the public eye when Vice President Joe Biden visited the clinic with U.S. Health Resources and Services Administration (HRSA) Administrator Dr. Mary Wakefield.
There, Biden announced that Goshen Medical Center would receive $635,876 from the American Recovery and Reinvestment Act (ARRA). About $2 billion of the $787 billion federal stimulus package is being allocated nationwide to community health centers like Goshen.
“In the entire country, there are 7,000 clinics like Faison’s, and they serve 17 million people a year,” Wakefield said. “Most of these patients live in poverty. Another 40 percent have no health insurance. A million are homeless. Another million are farm workers. One-third are children.”
Sixty-seven percent of Goshen’s patients, which are from Duplin County and adjoining eastern Sampson and southern Wayne counties, are uninsured or covered by Medicare or Medicaid. Federally Qualified Health Centers (FQHCs) like Goshen operate with the assistance of federal funds awarded by HRSA. One of every 19 people in the United States seeks primary care from an HRSA-funded clinic, making these health centers the largest primary care network in the United States. By law, HRSA health centers must serve everyone and provide equal quality of care regardless of ability to pay, Wakefield said.
To date, $500 million of Recovery Act funds have been distributed to support 126 new health center sites and help increase services at existing sites to support spikes in demand from uninsured populations. Funds are expected to stimulate the creation of additional jobs and add to the number of clinicians and other staff working at health centers. According to Wakefield, the remaining $1.5 billion of the Recovery Act funding dedicated to health centers will go to “pressing capital improvement needs, such as construction, repair, renovation and equipment purchases, including the acquisition of health information technology.”
HRSA also received $500 million under ARRA for health care professions programs—approximately $300 million of which will go the National Health Service Corps (NHSC) to increase the primary care workforce in rural and underserved areas. Finding qualified personnel in these areas is an ongoing challenge, Wakefield said, adding, “20 mostly rural states report workforce shortages.” With its funding, Goshen Medical Center plans to add two more physicians, two more nurses and three administrative staff members.
The remaining $200 million of ARRA funds will be directed toward support training in health care professions programs. Wakefield said NHSC and health professionals programs are in place to help increase the number of primary care clinicians. The President’s budget for fiscal year 2010 also proposes funding for additional health care professions programs to increase both the number of students in professional programs and the number of providers practicing in rural areas.
"Recovery Act funds may be used to hire local help, and we certainly encourage folks from rural areas who want to train in the health professions to get the education they need to provide primary care,” Wakefield said. “It is much more likely that practitioners will stay to work in rural areas if they enjoy the setting and are familiar with the lifestyle.”
HRSA will monitor and assess the success of ARRA-funded projects as well as providing technical assistance to assure that health centers are in compliance with program rules and achieving expected outcomes. Recovery Act Community Health Centers program funding is limited to FQHCs, so other non-federally supported health centers are not eligible for this particular funding, Wakefield noted.
Indiana Collaborative Addresses Health Care Worker Shortages
by Candi Helseth
James R. Buechler, M.D., Director Emeritus for the Lugar Center for Rural Health, speaks at a RHIC gathering that includes local government and college officials.
The new Rural Health Innovation Collaborative (RHIC) in Terre Haute, Ind., is bringing together community partners to address health care worker shortages, a growing issue that impacts access to health care as well as the strength of local economies.
“Our challenge is to improve health care in areas that are rural, have acute health care professional shortages and are medically underserved,” said Lorrie Heber, system director at Union Hospital Health Group in Terre Haute.
One-half of Indiana's 92 counties are designated as whole or partial medically underserved areas, 17 are designated as health professional shortage areas and 11 are low-income counties. The RHIC will begin by targeting shortages in Vigo County, where Terre Haute is located, and in surrounding rural communities.
Although the effort is still in its infant stages, with formalized committees involved in information gathering and research, Heber said training programs focused on rural development are already in place.
“Through programs developed by the Richard Lugar Center, we’re training family medicine physicians and placing them in rural areas,” she said. “Rural physicians are often professionally isolated, so we help provide the technology and tools they need to succeed in rural areas. We’re still in the process of defining what our largest shortages are in the rural areas but primary care physicians are clearly one of them. We’ve also recognized that we’re going to have more success getting family medicine physicians who come from rural areas so we’re trying to recruit rural students. If you take urban-raised medical students and place them in rural areas, it’s very difficult for them to be successful and it’s difficult to keep them there.”
ISU is planning a new or renovated facility to expand programming offered by the College of Nursing, Health and Human Services. The IU School of Medicine has changed its structure so that medical students stay at Terre Haute for a full four-year, rural-focused curriculum rather than moving to a large medical hub for two years, as has been the custom for all medical students. The number of student openings will be doubled from 32 to 64. Ivy Tech will increase the number of certifications and associate degrees it offers in allied health fields.
“We’re early in the process yet and we’re still looking at ways to finance all of this and set up the legal structure,” Heber said. “Each of the institutions has its own funding sources and we’ll be looking at how to use those as well as other resources. We’ve already begun to see a greater level of partnership and cooperation among collaborative members. They’re thinking about how we can all work together to change the level of health care in our rural areas.”
Five working groups representing all partners have been formed to address finances, communications, education, economic development and facility development. A leadership committee represented by executives from the partners makes major decisions and the operations committee, with members representing each of the institutions, implements elements that the leadership committee approves.
Heber said the combined efforts will also spawn neighborhood revitalization and economic development in a 1.5 mile area between Union Hospital and Indiana State University. The stretch of land has several deteriorating buildings and the partners plan to develop multidisciplinary, rural-focused training and research sites anchored by the hospital campus to the north and the IU campus to the south. Heber said some medical software companies that heard about RHIC have already made inquiries.
“Right now, we’re really working on assessing where we have training deficits and barriers, what classes of workers we particularly need and what program development and kinds of facilities it will take to fill needs,” Heber said. “This is an evolutionary process. These partners have been here a long time and I think the collaborative will grow and change and shift as time goes on.”
Tim Size is the Executive Director of the Rural Wisconsin Health Cooperative, a position he has held since 1980. Previously, Size worked at the University of Wisconsin Hospital and Clinics in Madison in a variety of positions including Associate Superintendent and Director of Community Services. He also worked as Administrator at the Hospital Metodista in La Paz, Bolivia in the early 1970s.
Size graduated from Duke University with a B.S.E. in Biomedical Engineering and from the University of Chicago with an MBA in Health Administration. He has been a member of numerous professional associations and boards including the National Advisory Committee on Rural Health and Human Services and the Institute of Medicine’s Committee on the Future of Rural Health Care; he served as president of the National Rural Health Association (NRHA) from 1997-1998. His awards and honors include the NRHA President’s Award, NRHA’s Louis Gorin Award for Outstanding Achievement and a W.K. Kellogg Foundation National Fellowship. In 2008, he was voted one of the “100 Most Powerful People in Healthcare” by readers of Modern Healthcare.
Size lives in Madison with his wife, Pat, an Episcopal priest who is also a native of Philadelphia, whom he met in Bolivia. They have four children. In his spare time, Size enjoys reading books on his Kindle, live theatre, gardening, walking, traveling and spending a few days each month with his eight-year-old granddaughter.
Copies of Tim Size’s publications are available at the RWHC Publications page.
How would you briefly describe what RWHC does? We’re a hybrid organization with a twin mission, to facilitate shared services among rural hospitals and to advocate for rural health. Our professional services include workforce development, financial consulting and legal services. The RWHC Network negotiates contracts with insurance companies, managed care plans and employers on behalf of the member hospitals, resulting in more favorable rates and terms for the hospitals. RWHC Clinical Services provides staff for hospitals that don’t need full-time staff in areas like physical therapy and speech pathology. We also sponsor the RWHC Information Technology Network, a nonprofit platform for sharing medical records—we have four hospitals online now sharing records. Some of the other programs we provide include quality improvement measures for hospitals and credentialing for insurance companies.
One of the most popular things we do is host Professional Roundtables, which meet every few months at our Office and Training Center in Sauk City. The participants share information, bring in guest speakers, and directly address the isolation that can be a problem for professionals and managers working in rural hospitals. They meet in person, via phone or video conferencing.
There’s a list of all the professional services and quality programs we provide on our Products & Services web page.
How is the cooperative an advocate? RWHC was incorporated to be a shared services network and subsequently “discovered” it had a role to play as an organized rural health advocate. This happened in the late 1970s, after I was hired but before my first day on the job. At that time a federally financed regional agency released a plan, developed below the radar and with little rural input, to close or consolidate almost all of the rural hospitals in southern Wisconsin. To say the least, the response was explosive. At the request of my new Board, I stood in front of an angry crowd of rural people from all over the region, and learned that an organized cooperative had a role to play as an advocate.
In a cooperative, each member of the board of directors is both a member of a governing board and a customer. At our monthly board meetings, we seek guidance from both perspectives and learn a lot from each other. We try to foster an environment in the meetings where people feel safe in bringing up new ideas. On a good day, they’re pretty rambunctious! This ongoing dialogue helps feed the policy development process.
Our advocacy priorities now reflect the diverse health issues faced by rural communities, including mitigating workforce shortages and maldistribution, promoting fair federal and state payments and policies, keeping local care local, and resisting inappropriate regulation of hospitals.
How have the cooperative, and your role at the cooperative, evolved over the years? RWHC was incorporated in June of 1979, and I had worked with the founders from my position at the University of Wisconsin for about a year before that. I then became the first RWHC employee on January 1st of 1980, so both RWHC and I will soon be celebrating 30th anniversaries. Although many things are still the same, the cooperative has continued to evolve. We’ve grown from a staff of one to 50, and from no shared services to dozens of them. We’re also externally networked with a large and diverse array of strategic partners. And we recently adopted a set of Core Values, which help
make explicit the values we have stood for and evolved over the last 30 years.
Given the increasing opportunities for advocacy as well as part of long-term succession planning, we have just hired a Director of Advocacy. When the time eventually comes for my “retirement,” a new Executive Director will have a team of senior leaders representing all key operational areas. (I’m 62 and hope to be here a good ten years, so no retirement parties just yet!). To be honest, I resisted this for a while, even though it was my own idea, but once we found the right person to fill the slot, I was wondering why I didn’t do it a lot earlier.
One thing that hasn’t changed is that I still can’t believe my good fortune in having a job that is also a vocation. My career goal starting out was to do something that I hoped would be meaningful and to avoid being bored, as I had been in so many summer jobs. I hope I have made a difference but I know that I have succeeded in not being bored. I love weekends and vacations but workdays are no less enjoyable and are probably often more interesting. And like most of us working in rural health, I enjoy the challenge of wearing multiple hats. In this job, I get to be an executive director, networker, advocate, grant writer, editor and cartoonist—what could be better!
You have published a newsletter since the mid-1990s. Has its audience changed? Originally there were about 20 subscribers, composed of just our board members; now it goes out on paper or electronically to about 2,000. It started, as so many good things at RWHC, at a board meeting with a member asking, after yet another long verbal report about the rural health environment, “Tim, why don’t you just write it down, we can read more quickly then even you can talk.” In April of 1994, the “executive director report” went external, starting with an item that still has resonance today: “Obey Asks HCFA About Wage Equity.” By the next year, it gravitated to our new and then very primitive web site as a newsletter, with the subtitle, “A monthly report of experiences and observations to colleagues.” A couple of years later it was renamed Eye On Health.
It has a very diverse audience, from rural health movers and shakers to friends and relatives who get one sent to them whether they ask or not. It is still written as a primary tool for me to share with my board what I believe is going on in rural health, just now it is shared more widely. While it is a platform for some editorializing, it is mostly a “readers digest” of the many interesting news and research reports that are relevant to a broader view of rural health that many people just don’t have the time to skim.
Many opportunities in life that are both fun and productive come by chance. The year when the newsletter went online was also the year I was bought a CD with 500 pen and ink cartoons with copyright permission to use and to change the text. That led to a pretty regular three cartoons a month in the newsletter to illustrate or expand on key articles. I think this makes it unique.
What prompted you to begin The Rural Health Advocate blog in April? A friend, John Eich, director of the Wisconsin Office of Rural Health is “very enthusiastic” about social networking tools like blogging. Basically he kept nagging this early Baby Boomer into a Gen X activity. He set up the site up for me and I posted a few editorials and the first response was from a good friend saying how much he disagreed with a point I was trying to make. But that is the point of blogs, to create a dialogue. Our newsletter doesn’t give the reader a chance for feedback. The blog will allow an interaction with the newsletter audience and others. It’s not the type of blog that will be updated every minute of the day. Instead, I will put my editorials in both the newsletter and the blog to allow reader comments and hopefully for readers to “talk” with each other.
In my editorials, while I believe strong advocacy is always data driven, I don’t have the professional responsibility to appear neutral like my friends in academe. In other settings, people have a tighter control over what folks can safely say; one of the perks of being an executive director is a fair amount of freedom. On most days, my board very much likes the fact that I can be a bit of a loose cannon. We don’t move forward without controversy. I want to create the opportunity for multiple voices to be heard. It’s fundamental to the field’s progress to have competing ideas. We need to keep talking with each other.
You started out with a degree from Duke in Biomedical Engineering. How did you get from that to an MBA in Health Administration, and then a specialty in rural health policy? I spent the summer of my senior year in a lab and realized I didn’t want to spend my life in a lab. It was during the Vietnam era, and I wanted to continue my education in a meaningful way. I didn’t want to be a scientist or an academic, I wanted to be more out in the world, so I went into hospital administration by default.
My first job after school was running a hospital in La Paz, Bolivia. It was a wonderful experience and gave me a much better appreciation of our own country. It also gave me a cross-cultural perspective on how context and place matters. This has very much been a useful frame throughout my career when trying to understand rural-urban differences within our own country.
When I returned, I applied for a job in Madison, where I was a university hospital administrator for five years. I gradually made the shift from internal administration to community relations in Madison and then outreach on behalf of the University to rural health providers. One thing led to another and I helped them start RWHC, with our original bylaws having been written for a dairy cooperative with “dairy” crossed out and “hospital” written in.
If you could make a wish list for changes in health policy in the next five years, what would be on it? Is there anything on that wish list that would be particular to Wisconsin, or your region? For me it’s not a wish list, but we absolutely have to make wellness a population health agenda. Health Care Reform will fail unless it is understood to be Health Reform with substantial emphasis on a wellness agenda and a population health perspective. We don’t want and we simply cannot afford the exploding trend in illness and injury; we must create financial models for wellness, and make health care primary care based. Community health and wellness must be a partnership between business, health care, hospitals and schools or we’re going to pay—we’re already paying—with an epidemic of obesity and diabetes.
Equally important is workforce. The preparation cycle for advanced degree health professionals is eight to 10 years. With so many baby boomers retiring, we’re not going to have those positions filled. When urban and suburban areas start having health professional shortages, it’s going to make it that much more difficult for rural areas to fill those positions. With or without universal coverage, it will be a severe crisis with major shortfalls and waiting lists. We should have spent years building up our capacity. Now we have to ramp up quickly. Rural areas will get a double whammy. They’re losing practitioners while getting a more rapid influx of patients, since rural tends to have a disproportionally older population. Wisconsin has 150 vacancies for primary physicians now. If it’s raining in Madison, it’s a tsunami in rural.
I also want to see us working toward collaboration. I’d like to see us tone down the hyper-partisanship and focus on quality and service. For that to happen, many more of us in what I hope could be the “Muscular Middle” need to both listen more and not be drowned out by the extremes.
by Kathleen Spencer, MS, MLS, RAC Information Specialist
Rural communities are challenged on many fronts during this economic downturn. Leadership development may be the key to helping these communities continue to provide quality health care, keep their schools open, support workforce development and improve economic opportunities. In rural America, where the population pool is small and the resources are slim, leadership is about engaging ordinary citizens to create a vision for the future and facilitating collaborations between local governments, community organizations and public agencies to make that vision a reality. Opportunities to lead exist at all levels of an organization, at work and in the community—not just at the top. Most importantly, leadership is not about exercising power as much as it is the empowerment of others, of encouraging and inspiring others to step up.
The Rural Assistance Center (RAC) offers rural community members an introduction to leadership with the Leadership Information Guide. This online resource is a special collection of information and resources to help you and your community members develop leadership potential.
Contact information is provided for expert assistance.
Current reports and articles from professional organizations focused on leadership are listed and accessible through the guide’s Documents and Journals links.
Daily updates of relevant news, events and funding opportunities are added to the page by RAC staff.
RSS feeds are available to help keep users abreast of newly added information.
The Leadership Information Guide also identifies several unique organizations that offer professional leadership training around the country, on-site or through webinars. In addition, leadership training curriculum is listed for local communities to establish their own training program. One valuable resource found on this guide is the Community Tool Box (CTB), a web site featuring information and curriculum on the essential skills for promoting community health and development from the University of Kansas. CTB offers more than 7,000 pages of practical guidance to make it easier for people to bring about change and improvement in their communities.
Expert leadership training can be found at the Heartland Center for Leadership Development, an independent, nonprofit organization that is listed in the guide’s Organizations section. The activities of the Heartland Center focus on leadership training, citizen participation, community planning, facilitation, evaluation and curriculum development. Their programs and publications stress the critical role played by local leadership as communities and organizations build capacity for sustainable development.
If you are in search of model programs designed to engage community residents, then you may want to browse the Documents section of the Leadership Information Guide. There you will find “Empowering Local Communities Through Leadership Development and Capacity Building,” published by the U.S. Department of Housing and Urban Development. This document features examples of successful initiatives that teach leadership skills to individual community residents, as well as examples of positive efforts to build the capacity of community-based organizations.
There is no better time for leadership than right now. In this period of limited resources and economic woes, rural communities cannot wait for help; they must forge a new road ahead. Citizens at every level in a rural community can step up to lead. Ensuring quality services, good schools, healthy economies and a strong workforce in our rural communities now and in the future takes quality leadership today.
Reprint Policy: Articles, photos, and charts appearing in the Rural Monitor may be reprinted with the permission of the Rural Assistance Center and proper citation. For permission, please contact ksande@raconline.org.
