Charlie Sutterfield, a Perham resident, has thrived in the nursing home's small-group setting.
On his 65th wedding anniversary, Charlie Sutterfield purchased a gift and ordered flowers for his wife, Velma, at the gift shop. Later, a guitarist serenaded the Sutterfields while they enjoyed a romantic dinner for two.
The Sutterfields’ anniversary celebration took place under the roof of Perham Memorial Hospital and Home's skilled care facility where Charlie, 90, has been a resident for the last year. Staff helped Charlie shop in the Town Center connected to the nursing home and arranged the couple’s private celebration. The staff musical therapist serenaded the Sutterfields.
Welcome to the new generation of nursing homes. Traditional views of nursing home care are being challenged by new models that espouse intimate, home-like environments rather than institutional settings, quality of life choices for residents rather than regimented schedules, and staffing that focuses on relationship building rather than care taking. That’s not to say residents’ medical needs are ignored. Nursing and clinical care are woven into an environment that empowers residents and improves their overall health, according to proponents.
The Perham Memorial Hospital and Home in Perham, Minn., aims to make its skilled care facility feel like home.
The 96-bed nursing home in Perham, Minn., a town of about 2,700, originally opened in 1902. Following an extensive physical and philosophical renovation, a new nursing home emerged in 2006 as part of a larger medical complex meeting community needs.
Perham’s former institutional setting—long hallways interspersed with residents’ rooms and a centralized nursing station—has been replaced by six small group living settings. Charlie lives with 15 other residents in one of these households. (Velma, 91, continues to live in the hospital’s adjacent Briarwood Apartments.) Each household has its own living and dining room, kitchen, private bedroom, and a porch or deck. All six households look out on a beautifully landscaped courtyard. Residents and staff interact much like a family, eating meals and participating in activities together. Staff members are assigned to a household and encouraged to spend time developing personal relationships with residents.
“I truly believe my father would never have survived in the traditional nursing home,” said Bev Heschke, Charlie’s daughter. “But he has really thrived in this setting. It’s home.”
At Chase Memorial, a nursing home in rural upstate New York, CEO Roger J. Halbert has seen a lot of changes in his 37 years there. The Eden Alternative, a model that developed at Chase and has been duplicated in several states, was initially viewed as almost radical in the early 1990s when Chase leadership introduced it. They addressed what they termed the three demons of nursing home care—loneliness, helplessness and boredom—by incorporating pets, plants and children into the daily environment.
Now, Chase is raising funds to implement the Green House model, which also stresses physical facilities designed as separate homes and family-like atmospheres that encourage staff and resident interactions, such as preparing and eating dinner together. Dr. William Thomas, a former Chase medical director, has spearheaded the Eden Alternative and Green House models in several states.
Care improves with quality of life focus
Quality of care isn’t compromised by the trends to focus on quality of life, Halbert and Perham CEO Chuck Hofius stressed. Quality of life stresses actions that help residents make daily life choices and gain independence. For instance, Perham residents choose when to rise and when to eat rather than following dictated schedules.
“Before we made these changes, we did a trial run of 16 residents,” Hofius said. “Six residents had to be totally fed by staff. After only two weeks, only one resident was still unable to feed himself. When we rolled it house-wide, we saw the same kind of results. When residents wake up naturally and can take their time eating, they became much more self-sufficient.”
The Eden Alternative took root when Chase leadership observed the positive impact of children interacting with residents. Even residents with advanced dementia responded warmly when children who were enrolled in Chase’s day care program visited the nursing home, Halbert said.
In 1992, Chase added birds, cats and dogs and plant life inside and outside the nursing home. They also expanded the interaction between the residents and the daycare children. In addition to the little things—like the heartwarming smiles on residents’ faces when they touched a baby or planted a flower—Chase recorded a reduction in overall use of residents’ prescribed medications, including use of psychotropic drugs. Staff retention rates also improved.
Likewise, Perham’s quality indicators have revealed reductions in falls, in psychotic medications, in the incidence of depression and in the amount of medications that residents take.
“Every single quality care indicator has improved,” Hofius said.
That’s even more important, considering the fact that nursing home residents are getting sicker and older. The average age when a person moves into a nursing home is 79, and today’s residents need more assistance with daily tasks such as dressing and bathing, according to the last National Center for Health Statistics’ National Nursing Home Survey.
Culture change isn’t easy
Nursing homes throughout the nation are being transformed with philosophies centered on delivery of resident-directed care and staff empowerment, said Anna Rahman, a master social worker at Scripps Gerontology Center and author of The Nursing Home Culture Change Movement. According to Rahman, the trend began in the 1980s with a simple goal: getting residents out of restraints. The Nursing Home Reform Act of 1989 supported change but it still primarily centered on quality of care issues.
Resident directed care and caregiver empowerment were buzzwords related to nursing home change in the 1990s, Rahman said. In 2005, deinstitutionalization and culture change gained support from the Centers for Medicare and Medicaid Services, which implemented its own initiatives to support change.
“This culture change movement is complex,” Rahman said. “Culture change takes a lot of different forms and definitions. From my perspective, more extensive research needs to be the next evolution. It’s not possible for all nursing homes, particularly in more isolated areas, to come up with a lot of capital for major changes.”
Transforming physical space requires major investments because traditional, institutional models don’t lend themselves to small group settings. Chase needs $17 million to demolish a portion of its facility and construct eight Green Houses to accommodate 80 residents. Perham’s renovation cost $14 million. Both facilities conducted community-wide fund raising events and applied for local, state and federal grants to minimize long-term debt.
“We’re in a rural, economically deprived area,” Halbert said. “We’ve raised $1.2 million since last summer and that’s a hefty amount for a community this small. We’re hoping to keep our long-term debt at no more than $8 million.”
State laws can be a barrier. When Chase first decided to add pets to its facility, state health department regulations limited pets. Converting to a Green House model was also delayed by health department regulations.
Resident-directed care means staff must learn to work differently. “Everybody here is a universal worker,” Hofius explained. “Initially, our employees struggled. The same person who makes breakfast will clean the room and help with activities. Nurses spend about 80 percent of their time using nursing skills but they are also expected to help with household tasks. This allows staff to get to know residents really well. But it is also a major adjustment for staff.”
Results are worth the investment
Both Halbert and Hofius say the successes outweigh the struggles.
“Can we say what’s happened here is all about birds singing and residents and staff being less stressed?” Halbert speculated. “There are probably multiple reasons why you have good changes, but there’s no doubt these have been good changes and they’ve certainly contributed to improved outcomes.”
Chase’s future physical expansion will further benefit residents, he added. Green House surveys report higher satisfaction levels, less physical decline and less depression. More than 40 Green House models operate in 10 states.
“The best reward comes from our residents,” Hofius said. “We have people who have been temporarily placed in the nursing home and when they’re ready to go home, they don’t want to go. Our residents like living here. And that was our goal.”
Continuum of Care Aims to Provide "Under One Roof" Services
by Candi Helseth
At Chase Memorial nursing home, Nicole Meyers (left), visits resident Lucy Colon in the facility's garden. The garden has raised beds so that residents can access them more easily.
A physical and philosophical transformation focused on providing a continuum of care for the elderly has redefined nursing homes and other types of senior housing across the country. Many of these facilities aim to provide under-one-roof services for residents.
At Perham Memorial Hospital and Home, in Perham, Minn., the original skilled nursing facility has been redesigned as six separate households, each accommodating 16 residents. Its new Town Center offers amenities such as a café, hair salon, bank and theatre. The $14 million expansion opened in 2006, and is part of the all-under-one roof medical complex that also includes a 25-bed acute care hospital, medical clinic and laboratory, and independent senior living facility. Plans call for renovation of the hospital to begin next year.
Two of its residents, Charlie and Velma Sutterfield live a life of comfortable familiarity with everything they need under one roof. The Sutterfields can shop for groceries, get haircuts, eat at the café, see their doctor, and go to church or a movie. Last year Charlie’s dementia progressed so much he could no longer live safely with Velma and had to move out of the apartment they shared together in the medical complex’s Briarwood Apartments. Though no longer sharing the same residence, they continue to live in the same complex, he in the nursing home and she in the apartments.
Next month, Hillsboro Medical Center in Hillsboro, a town of 1,500 in eastern North Dakota, will celebrate the grand opening of a $12.2 million expansion. Also all under one roof, the complex includes the addition of an assisted living facility to the existing clinic, 20-bed Critical Access Hospital and a 36-bed nursing home. That nursing home is also being converted to separate households.
Growing number of seniors spurs new care models
A growing senior market—along with reduced financial reimbursements for hospitals and nursing homes—has spurred the health care industry’s interest in developing continuum of care services, also referred to as non-acute care or alternate sites. Between 2007 and 2015, the number of Americans 85 and older is expected to increase by 40 percent. Health care providers are looking at ways to capture that market and diversify services to offset reimbursement losses. The continuum of care philosophy is intended to provide medical and social interventions that help seniors maintain independence and delay entry into nursing homes, the most costly form of long-term care.
Perham’s model has been a source of interest for many health care leaders. Hillsboro, about 115 miles from Perham, sent staff members to Perham to learn more about Perham’s revised approaches to patient and resident care. In fact, more than 300 health care leaders from throughout the nation have visited Perham’s facility in the last two years.
“Simply put, we’re trying to improve the quality of life for our seniors and help them make transitions more easily,” Perham CEO Chuck Hofius said. “We’ve created home-like environments for seniors to live in and we encourage staff to spend work time developing relationships with residents. The same therapies follow patients through transitions of patient care. Patients and residents are likely to see the same caregivers in their home, at the hospital and in the nursing home.”
At Hillsboro, Angela Kritzberger can’t wait for her grandma to move in to the new nursing home. “I’m excited and so is she,” Kritzberger, the Foundation CEO, said. “This is more than a building project, it’s a move to a whole new care philosophy throughout our entire facility. In the past, we had the typical institutional model for our nursing home. Now, both assisted living and the nursing home will be resident-directed models of care.”
This new model of housing will be of particular interest to rural areas, which generally have high populations of elderly people. The rural elderly are older, rate their health as worse, tend to have more physical limitations, are more likely to be poor and have higher use of nursing home care, according to Catherine Hawes, a researcher with Southwest Rural Health Research Center at Texas A & M Health Science Center. In addition, the percentage of rural elderly is increasing, according to an Economic Research Service report on Rural Population and Migration, which predicts that the number of rural elderly aging-in-place will triple in the next decade, while more elderly will retire to rural areas and more young people will move out.
Continuum of care eases transitions
At Briarwood Apartments, where Velma Sutterfield lives, residents get one meal daily and assistance with housekeeping. Activities such as bingo and game nights encourage social interaction. At Hillsboro, Kelleher Manor is a privately owned 14-apartment senior facility that also offers some meals and planned activities. Facilities like these are often the first step in the continuum, offering independent seniors living options with limited assistance.
Perham’s continuum of care also includes a home health agency that serves 160 clients and St. James Manor, another senior apartment building that isn’t physically connected but is on the same campus.
Overlooking a courtyard and gardens, the Town Center serves as a source of lifestyle necessities as well as a place where residents can socialize and entertain visitors. Hofius said the number of family members visiting residents has increased substantially since the Town Center opened.
“This has been a wonderful solution for my parents,” said Bev Heschke, the Sutterfields’ daughter. “They have everything they need right there. And even with dad in the nursing home now, my parents can be together whenever they want. If it’s good weather, Mother can walk outside to the home. If it’s not so perfect, she can stay indoors and still walk over to see Dad. She doesn’t drive and we’re 16 miles out in the country so we can’t just run pick her up.”
Continuum of care philosophies and models for new development guide health care facilities’ decisions as they make cultural changes. Perham and Hillsboro have contracted with Action Pact, one of several models being marketed to providers. These models primarily center on restructuring physical settings and redefining the delivery of care.
Assisted living fills gap
Hillsboro’s community surveys revealed a gap between independent living options and nursing home care. New construction in their complex includes an assisted living complex, Comstock Corner, with 16 one-bedroom apartments. Hofius said an assisted living facility, similar in design to their nursing home, is being considered at Perham.
Assisted living is one of the most rapidly growing senior options, according to Lisa Gelhaus, National Center for Assisted Living director of public affairs. Almost one million Americans reside in approximately 38,000 assisted living facilities in all 50 states.
Assisted living facilities (ALF) are home-like households for seniors who need daily assistance but don’t have medical issues that require the skilled nursing care found in a nursing home. Typically, ALF services include 24-hour supervision, planned meals and snacks, personal care services, medication management, social and religious services, exercise and educational activities, housekeeping, laundry and linen service, and transportation to area facilities.
Diversification strengthens continuum
“Having assisted living and the nursing home physically connected to our clinic, lab and hospital makes it much easier for residents to get care quickly and to feel more comfortable in environments where they already have familiarity,” Kritzberger said.
The number of swing beds in Hillsboro Hospital has been expanded to accommodate patients that need skilled care on a short-term basis, but do not need long-term nursing home care. As a Critical Access Hospital, Hillsboro can “swing” beds to use them either for inpatient acute care or for patients who may need care they can’t get at home such as rehabilitation after surgeries, Kritzberger said.
“With the clinic and pharmacy right there under the same roof, my parents have had everything they need medically,” Heschke commented. “We really appreciated that when Dad’s health began deteriorating.”
Both Perham and Hillsboro contract with a larger system, Merit Care Health in Fargo, N.D., for management services.
“Merit Care provides assistance in administration, services like lab and physical therapy, group purchasing and other benefits for us, but our local board maintains complete control,” Hofius said. “It’s a huge savings for us.”
Maintaining the continuum also benefits facilities financially, he added. As an example, he pointed to the 1980s when Perham’s hospital faced financial difficulties. At that time, the nursing home offset those losses. Currently, the nursing home’s financial constraints are being offset by the hospital’s improved income.
“When one part of that continuum has a hard year, we still do well as a facility because the other parts of the continuum can hold that up,” Hofius concluded. “While continuum of care is first and foremost about patient and resident centered care, diversification and partnerships really assure the survival of small town services and contribute to their success in providing that continuum of care.”
By 2026, the population of Americans ages 65 and older will double to 71.5 million.
Among people turning 65 today, 69 percent will need some form of long-term care, whether in the community or in a residential care facility.
There are more than 1.4 million nursing home residents in the United States.
An individual's average age when he or she moves into a nursing home is 79.
Women are almost three times more likely to live in nursing homes than men.
There are 16,100 certified nursing homes in the United States.
The average daily cost for a private room in a nursing home is $213, or $77,745 annually.
The average daily cost for a semi-private room in a nursing home is $189, or $68,985 annually.
Medicaid payments cover the care of more than half of all nursing home residents.
Overall, nearly 96,000 full-time equivalent nurses and other health care professionals are now needed to fill vacant positions in America's nursing homes.
By 2010, the number of vacant positions in nursing homes is expected to reach 810,000.
Emerging Research Suggests Safety Net May Fail Growing Numbers of Non-Working Poor
Our economy is laboring through a trying period. Equity markets are flirting in bear territory, with major averages recently falling by 20 percent since last fall. Banks and other financial institutions are stressed. Housing prices are falling. The numbers of unemployed and under employed are growing. On August 1, the Bureau of Labor Statistics reported that another 51,000 jobs were lost in July for a total of 463,000 this year. Underemployment, people working fewer hours than they would like, rose to 10.3 percent, the highest level since 2003.
What does all this negative news mean for those least able to withstand an economic decline? To answer that question, we need to take a fresh look at the economically disadvantaged among us, as well as our nation’s social safety net.
To do this, I draw upon a number of papers in progress that are being developed for the next edition of a series of books on poverty that began with a volume titled Fighting Poverty some two decades ago. The chapter authors of the forthcoming edited volume gathered at the Institute for Research on Poverty (IRP) located at the University of Wisconsin-Madison in late May to share their work and receive feedback from their colleagues.
In the middle of this decade, before the economic turndown, 12.6 percent of all Americans were poor according to the official measure of poverty. As previously discussed, the official measure omits important forms of government help. When Food Stamps and the Earned Income Tax Credit (EITC) benefits are included, the poverty rate falls to 11.4 percent. In short, well over 30 million Americans are poor even in times of robust economic growth.
Why don’t they just get a job? Work helps but work alone won’t eliminate the problem. About 12 percent of the adult poor are elderly and essentially out of the workforce. Another one-third of all the poor (35 percent) are children. Of the adult, non-elderly population (those expected to work) more than half worked during the prior 12 months, with over one-third of those essentially working full-time/full year.
Poverty is an urban, minority issue, isn’t it? It is true that about half of the poor at any one time are from a minority group and that the proportion of the poor coming from non-white populations has increased between 1968 and 2005. But the other half is not. Moreover, rural poverty has remained stubbornly high. The rural poverty rate in the mid-2000s was 14.5 percent, higher than the national average but lower than the central city poverty rate of 17 percent. And rural poverty is as high now as it was three decades ago.
Still, the U.S. does a good job on poverty, doesn’t it? The international figures are not encouraging. Tim Smeeding, the incoming Director of IRP, has done the international estimates using a metric that estimates the proportion of individuals falling below 50 percent of the national medium income figure. Using this approach, all the European countries he looked at, plus Canada, had lower poverty rates than the U.S. This remains true even though low-income parents in the U.S. work more hours per year, on average, than peers in, for example, Germany, Canada, Belgium and the Netherlands.
But don’t we spend enough on social assistance to help the poor weather the economic turmoil confronting us? By many measures we do spend a lot of money on the social safety net. Since 1990, spending on the EITC, now the major cash transfer system for low-income families, grew from a little over 10 billion dollars to about 46 billion (in constant 2007 dollars). Spending on Medicaid has more than doubled while spending on Food Stamps, Head Start, Housing and a host of other programs has also grown.
Not all parts of the safety net shared in this growth. We do know that the one program evidencing a decline (in real dollars) in support is the Temporary Assistance to Needy Families (TANF) program, the cash welfare program for poor families with children. In real terms, federal spending for TANF fell by almost half in the decade after 1996.
What does this mean? Basically, we have restructured our social safety net to reward working low-income families at the expense of those outside the labor market. The EITC goes to participants in the low-income labor market while TANF is oriented to those seeking work.
Some recent research suggests that average monthly benefits for a poor single parent with no earned income fell by about a third between 1993 and 2004. That same parent in 2004, on average, would get significantly more in government help if they had earnings equivalent to half the poverty threshold than they would have gotten in 1993.
In effect, the welfare reforms of the 1990s are working as intended. The nation’s cash transfer system has been tilted to reward work as opposed to non work. This approach accords with a national consensus that self reliance is a prized public virtue. And all observers agree that the fraction of low-income single mothers in the labor force grew dramatically during the economic boom years of the late 1990s.
But those halcyon days are nearly past. Layoffs, plant closings and business failures are today’s headlines. In addition, our annualized national budget shortfall is in sight of a half trillion dollars, limiting any government flexibility. We have never done a great job in tackling the scourge on poverty in the U.S. Now that a recession seems unavoidable, a safety net premised on work may put our national safety net to its severest test yet. The annual federal poverty data due out at the end of summer might give us an early warning of emerging problems.
Note: The data used in this article is drawn from two unpublished sources:
Poverty Levels and Trends in the U.S. and the U.S. in Comparative Perspective by Daniel Meyer and Geoffrey Wallace (conference draft paper prepared April 2008 for IRP conference May 29-30).
Trends in Income Support by John Karl Scholz, Robert Moffitt, and Benjamin Cowan (conference draft paper prepared May 2008 for IRP conference May 29-30).
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.
In June, Paul Moore, H.D. Cannington and I were invited to Baghdad as advisors to the Iraqi Ministry of Health. Paul is a pharmacist, pharmacy policy expert and the President of the National Rural Health Association (NRHA). H.D. is a hospital CEO, the Chairman of the NRHA’s Rural Hospital Constituency Group and past member of the National Advisory Committee on Rural Health and Human Services. The occasion was a national conference on health care restoration and reform convened by the Ministry of Health. I’d like to tell you some of what we saw and heard.
First, Baghdad is a big city with about seven million people. By way of comparison, Chicago has nearly three million people within its city limits, but over nine million within the three-state metropolitan area. Baghdad has no mass transit system, so traffic is dense. Cars are old and breakdowns frequent. The city is battered but millions of people are getting on with their daily lives. Rental property is in increasing demand, as Baghdad becomes a reasonable place to live and do business. Sidewalks are piled high with crates of new merchandise for sale, especially generators. Outside the International (“Green”) Zone, all the police and military personnel I saw were Iraqi.
The current phase of health care reform is titled, “Primary Care Reform First” (PCRF). The Minister of Health and his colleagues propose to first overhaul the national primary care system before dealing with hospitals and other elements. The five-day series of PCRF meetings included three days of small group sessions reviewing specific proposals. Meetings held on the last two days reviewed overall strategic proposals—these were large, formal sessions of several hundred people including members of the Iraqi Parliament, leaders of most of Iraq’s national health-related organizations, the Ministry of Health, the U.S. military and State Department, the World Health Organization and several non-governmental organizations. In all the meetings the focus was national policy. None considered rural problems separately.
Before the Coalition invasion of 2003, Iraq had 2,000 public clinics providing some care for an average of 14,000 patients each. Most closed during and after the invasion but practically all are now operating. Iraqi doctors have traditionally been required to work in the morning in these public free clinics for a few dollars per month. Doctors earn their livings in private practice clinics in the afternoon. This divided system is generally acknowledged to work poorly with patients being rushed through the public clinics, and occasionally seen in groups, by doctors hurrying to get to their private fee-for-service practices. One of the priority reforms for the Ministry of Health is to separate public and private practice, paying reasonably for doctors making careers in public care. Salaries for public clinic work are expected to increase from three dollars per month for work in the morning clinics to 3,000 dollars per month for full-time doctors in the public clinics.
The professionalization of public clinics may be particularly helpful in rural areas. Rural and other hard-to-staff clinics are now heavily dependent on young doctors in mandatory national service between internship and specialty residency. During a two-week trip to Northern, Kurdish Iraq in 2004, I encountered only one fully trained career rural physician. All the others were short-term assignees straight out of internship. Rural hospitals were battered and poorly supplied but clean, with staff proud of their work. My impression was that physician coverage was the weakest element in the rural system of care. Rural Iraqis face hazards ranging from land mines to cholera with care by partially trained personnel. U.S. rural health care has its problems but they are of a different order than those in Iraq.
Iraq has no health insurance. Serious illness often means family bankruptcy. The Ministry of Health is determined to develop a system of health insurance in the course of primary care reform. I could not determine whether a decision or consensus has been reached regarding the nature of the national insurance system: public or private, for-profit or not-for-profit. The insurance program is seen as an important contribution the government can make to stabilize private fee-for-service care.
Nursing is a new profession in Iraq. In the past nurses got their training in vocational high schools. Quite recently the nursing high schools have been closed. Several universities have established nursing programs using faculty trained in other countries. The professionalization of nursing in Iraq is an enormous task and complex challenge.
Some basic management systems are lacking or not well understood. Stories of corruption in the UN Oil for Food program, in contractors under the Coalition Provisional Authority and in the Iraqi Government have been widely reported. At the moment, though, fear of corruption is also a serious problem. Last year the Ministry of Health reportedly spent less than 70 percent of its budget. Officials were often unwilling to release funds that might be diverted. Establishment of basic management systems is an urgent need.
Other major challenges include the establishment of pharmaceutical and medical supplies manufacturing across Iraq, the modernization of clinical data systems and carving out a reasonable share of the national budget for health.
Will the Iraqis succeed in reforming their national approach to health? I think there is a good chance that they will accomplish several of their goals. In the final plenary meetings there seemed to be general consensus on many points. Iraq is writing on a blank slate. They have some oil income to work with. The clinic system is getting back on its feet as physicians return to the country and security improves. There is a sense of urgency.
There is a lot to be done. A half-dozen Americans are being recruited to help the Iraqis draft policies, procedures and standing orders to implement all these changes. If you are willing and able to do high-level national policy work in Baghdad, drop me an email for more information.
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.
Sarah Akers (left) enjoys a group activity at the PACE center near her home, in Big Stone Gap, Va.
Following the deaths of her husband two years ago and her mother in January, Sarah Akers added acute depression to a lengthy list of health problems. Akers couldn't live alone without assistance and she didn't want to enter a nursing home. Akers, 64, found her answer in PACE (Program of All-Inclusive Care for the Elderly). PACE is a national program that allows frail adults 55 and older who need nursing home care to stay in their own homes with assistance from PACE services.
Mountain Empire Older Citizens (MEOC), whose headquarters are in Big Stone Gap, Virginia, five miles from Akers' home, is among the first five rural grantees to begin PACE programming following Congress's approval in 2006 of the Rural PACE Provider Grant Program. Congress awarded $500,000 each to 15 grantees in 13 states. "PACE does everything they can to help me stay out of a nursing home," said Akers, who was one of the first enrollees. "It has helped me tremendously. My income is very small and I couldn't have continued living alone without help."
Established in 1974 as an Area Agency on Aging, MEOC serves a 1,500 square mile service area of 91,000 people living in three counties in Virginia's mountainous southwestern tip. MEOC's service area has a poverty rate of about 25 percent.
Under PACE, MEOC contracts with Medicare and Medicaid to provide a broad range of health and social services, said Mountain Empire PACE Director Tony Lawson. MEOC receives a set amount of payment for each PACE enrollee with the Medicare capitation rate adjusted according to each enrollee's frailty. Lawson said MEOC expects to enroll about 50 PACE patients this year, eventually reaching a level of 180 to 200 participants.
Aides visit Akers at home five days a week to assist her with bathing, dressing and light housekeeping. PACE provides light breakfast items that Akers eats at home and the PACE bus transports Akers to the PACE center for meals three days a week.
"I can't drive and I need help doing practically everything," Akers said. PACE services, depending upon need levels and the provider's service availabilities, may include nursing, physical, occupational and recreational therapies, meals, nutritional counseling, social work expertise and assistance with personal care. Home health care, respite care for caregivers, prescription drug coverage, vision and dental, and hospital and nursing home care are also covered under PACE.
An interdisciplinary team develops an individualized plan of care for each patient in Mountain Empire PACE. Lawson said the team includes a wide range of professionals who assess the individual's ability to live at home and provide that person with necessary tools and assistance. PACE staff also make appointments, arrange transportation and coordinate care with specialists.
"PACE helped me come out of my shell," Akers said. "We exercise at the center and they make it a game. You don't even realize it's exercise. The therapy groups have helped me with my depression too."
Donna Mahon, activities director for the Mountain Empire PACE program, leads a group exercise.
A full-time PACE physician sees participants and admits and follows them if they need hospital or nursing home care. "Participants can see the doctor whenever they want," Lawson said. "They really thrive in this patient-centered environment and with the individual attention they receive."
PACE capitation funding meets needs not traditionally covered under Medicare or Medicaid. For instance, MEOC has provided at-home preventative solutions such as grab bars in bathrooms and automatic door closers for patients in wheelchairs.
"We're taking steps to reduce the danger of patients falling at home because falls are a major problem for the older population," Lawson said. "We also have a goal to reduce over-medication. One woman we admitted was taking 36 different medications."
MEOC established a PACE Center in its headquarters in April and is building a new center adjacent to headquarters. PACE is one of numerous programs under MEOC's umbrella.
Congress authorized permanent provider status for PACE programs in 1997. Those programs have served predominantly urban settings. Yet one-fifth of the nation's elderly live in rural areas, according to Peter Fitzgerald, PACE vice president of strategic initiatives. The rural elderly report worse health status, are generally older, have more functional limitations, are more likely to live alone at age 75 and older, are more likely to be poor or near poor, and are at greater risk of being placed in a nursing home.
"The need in our area is tremendous and the funding isn't there," Lawson said. "PACE, with its own funding source, helps us increase accessibility to long-term care services for the patients we serve. The way it's set up also lets us be more creative in meeting needs. PACE helps us help the elderly remain in their homes and communities where they want to be."
The National PACE Association (NPA) and the National Rural Health Association were awarded the contract to implement the Rural PACE Technical Assistance Program (RP-TAP) from the Department of Health and Human Services' Health Resources and Services Administration. RP-TAP has produced resources for and provided technical assistance to organizations interested in developing a PACE program to serve rural areas.
More information about PACE is available at the NPA web site and at NPA's web site on Rural PACE Resources. Providers interested in RP-TAP can contact Peter Fitzgerald at 703-535-1521.
SID, the robot, helps patients and hospital staff access an off-site intensivist.
Staff in the Intensive Care Unit at Healdsburg District Hospital like working with SID, the friendly robot that rolls up to patients’ bedsides for an examination by the ICU physician or intensivist. SID’s addition has allowed Healdsburg, a small Critical Access Hospital (CAH) in northern California, to reopen its ICU by using off-site physician expertise combined with on-site staff assistance.
A live image of the patient’s physician appears on the monitor that tops SID’s five-foot frame. The physician can view and treat the patient; in turn, patients, families and hospital staff can confer directly with the physician. The robotic telemedicine includes a camera for the physician to visually inspect the patient, a stethoscope, and ultrasound equipment to examine the heart, lungs, abdomen and vessels. Working through SID, the physician can also view and transmit medical records, X-Rays, CT and MRI scans. Staff members in the ICU position equipment and the robot to assist the physician in his examination.
Dr. Jim Gude, who developed a robot used for ICU consultations in Healdsburg, Calif., can look in on patients from his laptop.
Healdsburg is the first CAH and the smallest hospital among several northern California hospitals that have begun using robots in their intensive care units and emergency departments. Robotic telepresence results in more rapid assessment of unstable patients, according to Dr. Jim Gude, Healdsburg’s primary intensivist and a developer of the robotic technology. Gude heads OffSite Care, Inc., a company that has led the installation of digital monitoring robots in small California hospitals.
Eight years ago the Healdsburg board of directors closed the hospital’s ICU due to low patient volumes and high costs, said board member Kurt Hahn. But the closure had a negative impact the board didn’t foresee at the time. Physicians were reluctant to admit patients to a hospital with no ICU, further compromising Healdsburg’s viability.
“Using the robot in conjunction with an off-site intensivist provided the support we required to reopen our five-bed ICU,” Hahn said. “Working with other hospitals, we are also spreading out costs, which makes it more economically viable to have an ICU in a small hospital like ours. With the technology, we have access to specialists that we didn’t have before. And the robot is very patient-friendly. Our patients like it. It’s like having a doctor right in the room.”
Gude named the PR7 Robot SID for Thomas Sydenham, a 17th century British physician recognized for his non-traditional, innovative approaches to medicine. A California corporation, InTouch in Santa Barbara, makes and services the robots.
“Dr. Gary LeKander is the intensivist ICU director for Healdsburg ICU, and SID enables him to do the work of three (three intensivists or critical care physicians), covering 24-hour shifts alternating with me,” Gude said. “Using robotic telemedicine, Dr. LeKander and I can cover four ICUs at the same time.” During their shifts with SID, Gude and LeKander can work from a central office, from other hospitals, even from home.
According to Gude, robotic telemedicine studies of 2,000 patients indicated ICU patients had shorter lengths of stay. Hospitals experienced improved efficiencies and decreased costs. Healdsburg leases the robot for $4,500 a month, which Hahn said is less cost prohibitive than hiring additional physicians.
“And that’s assuming that we can find physicians to hire,” Hahn added. “It’s become exceedingly difficult to attract physicians to rural areas. Most of the family practice doctors that retired in the last 10 to 15 years in our area haven’t been replaced. Over the next five to seven years as half or more of our county’s family practice doctors retire, access will become even more limited.”
Healdsburg’s board plans to increase its physician access through OffSite Care’s remote network, which includes primary care physicians and various specialists working with 10 small northern California hospitals. Healdsburg has been selected as one of two hubs.
“This is good for us because it will connect us to a network of hospitals and clinics sharing specialists who are in California’s teaching hospitals,” Hahn said. “That will dramatically increase our access to specialists, which means improved care for our patients.”
Healdsburg recently completed a $4 million emergency department expansion. “The robot is unbelievably mobile, and we’ve been able to use it in ICU and ER,” Hahn said. “We’re considering purchasing a second robot for permanent use in ER. We’ve had very good success with this model. I think the robots could be an answer for many rural hospitals and clinics.”
Alison Hughes has worked in the rural health field for over two decades. She currently serves as the Director of the Arizona Rural Hospital Flexibility program in the Arizona Rural Health Office and is a Director Emeritus of the Arizona Rural Health Office. For a decade Hughes has also been the Associate Director of Outreach at the Arizona Telemedicine Program, a position she currently retains. In addition, she is a faculty member in the Mel and Enid Zuckerman College of Public Health, and was the Faculty Chair of the Policy and Management Section from January 2007 to June 2008.
She holds a master’s degree in public administration from Harvard University’s Kennedy School of Government where she focused on leadership development and public policy interests.
Hughes was born in Glasgow, Scotland and moved to the United States when she was 19. She has lived in Tucson since 1970.
Hughes says she “is interested in absolutely everything and gets involved in absolutely too much.” In addition to her other advocacy work, she is currently serving on the board of the Borderlands Theater in Tucson and has served on the board of her local neighborhood association for 20 years. She has been involved in local and state politics and has held a number of Arizona gubernatorial appointments, including currently serving as a Commissioner on the Arizona Arts Commission.
Photography is one of her major hobbies. Some of her pictures of Arizona scenery have appeared on the rural health office’s web site and one of her cacti photographs was published in the University of Arizona Alumni magazine.
Why did you emigrate from Scotland?
I moved to the states because my mother was here. She was born in Alabama of Scottish immigrant parents who eventually returned to Scotland. My grandfather was a union organizer and worked in the Alabama coal mines. Eugene Debs, an American union leader, introduced him to politics. When he returned to Scotland he was a member of the Fife Town Council, and later he ran for Parliament and lost. My mother found her way back to the states after WWII.
How did you get to Tucson?
The man I was married to at the time was accepted to the University of Arizona and we came to Tucson together. Tucson was “love at first sight” for me. I thought it was breathtakingly beautiful and didn’t want to leave. That appreciation still stands.
Before I got my graduate degree, I worked as a Congressional Aide for then-Congressman James McNulty of Arizona’s Fifth District. Previous to that, I served as Executive Director of the Tucson Women’s Commission. We held hearings that dealt with discrimination against disabled women and elderly women. Before that, I worked as the grant writer at Pima Community College. Prior to coming to Tucson I worked for the U.S. Commission on Civil Rights in Washington. That experience raised my consciousness immensely about the injustices that needed to be righted.
What prompted you to get a graduate degree in public administration?
The degree was a natural extension of what I had been doing professionally. The training simply gave me a better academic perspective on decision-making principles.
Despite your other political and work involvements, you’ve been active in art organizations. Is art important to you?
I come from a family of artistic folks with solid working class roots. My father and mother both painted; my sister is a potter. They all had other jobs to earn survival money. I am the family workaholic who pours her lifeblood into making a difference in the rural health arena.
What first sparked your interest in rural health? Did an interest in health policy gradually become focused on rural or were you always interested in rural health?
None of the above.
When I completed graduate school and returned to Tucson in 1985 I was offered two different positions at the University of Arizona. The one I knew the least about was at the Rural Health Office. One of my former professors, Dr. Richard Neustadt, used to say, “Play to your weakness.” I remembered that advice when I was struggling with which position to accept. I chose rural health, and have never regretted that decision. I have not stopped learning in over two decades.
It is wonderful to get up in the morning and look forward to going to work. A lot of working people don’t have that luxury.
What do you think are some of the biggest challenges facing your office?
In Arizona big city legislators dominate the legislature. Legislators who represent rural residents often can’t get the votes to pass legislation that is responsive to constituent needs. I love it when rural legislators call on our office for assistance.
Have the issues changed much in the last 20 years?
Some challenges have not changed much. Recruitment and retention of the rural health care workforce is just as challenging today as it was in 1986. Rural residents still can’t get adequate dental or eye care. Access to orthopedic devices is another challenge for them.
There have been positive changes though. We see more efforts nowadays to build a healthier America through nutrition education and exercise promotion. In Indian country, I see lots of walking clubs sprouting up. The inscription on my favorite coffee mug is "Hopi Wellness 100 Mile Club." If people get healthier they won’t need to depend as much on a broken health system. Insurance companies don’t reward prevention activities by covering exercise club memberships. If they did they would save a lot of hospital costs.
One of our critical access hospitals was financially forced to close its long-term care wing as the reimbursement was much less than what it cost to provide the service. The hospital CEO got community funding support to turn that hospital wing into a community exercise program. They did some remodeling and bought work-out equipment. I visited the hospital recently and that exercise room was packed!
What would you like to see happen with health care—particularly rural health care in the West—in the next five to 10 years?
I would like to see individuals taking control of their own electronic patient records that they can use regardless of what system of care they are using. A nutritionist friend of mine was once a missionary in Africa. Many of the people were nomadic and if they showed up at a clinic there was no record of patient histories. My friend created a little book for each patient. It was a personal health record. They were asked to carry the record with them at all times. These books became very precious to the villagers. They treated them like identification cards and took them everywhere. Eventually the concept spread and everyone started to create the books for villagers in other areas. Today we can do this electronically. When people take control of their own electronic health record, it will be like a super high-end version of the Hopi 100 Mile Club!
Technology is not the solution, but it can be used to lift us to the next level of health care. We must remember, however, that lots of rural residents don’t have computers in their homes, or access to high speed Internet services. There is a lot yet to be done.
What are the some of the other potential problems with expanding the use of technology in rural areas?
Telemedicine is supposed to give rural residents better access to specialty care and in many cases succeeds. Telepsychiatry works well, for example, and is a reimbursable telemedicine specialty.
Not all payers, however, reimburse the rural practitioner for providing care using telemedicine technology. The problem is most specialists are usually located in urban locations. The rural practitioner who takes time to be with her or his patient during the telemedicine consultation with a specialist is not reimbursed. Consequently they don’t want to take time away from seeing another patient for whom they can be reimbursed. Although there is no requirement for an eligible telehealth patient to be presented by a licensed physician or practitioner at the originating site unless it is medically necessary, all presenters must have received appropriate training to present the patient. If a presenter is different from the referring clinician, the designated presenter should be sufficiently familiar with the patient's medical condition and have appropriate clinical training to present the case accurately. This means they need training and that costs money.
A few years ago there was a noticeable decrease in telemedicine utilization numbers coming from one of our community health centers. When I visited with the CEO of that center to ask why, his response was honest and direct. “Our doctors are spending too much time in the telemedicine room. During that same time they could have seen three more patients, and we could have billed for that time.”
If you had to put your energy into only one effort, what would it be?
We need to change the country’s complicated, multiple-layered, many-payer health reimbursement system. When you think of it, there are many payer and provider systems: private insurance carriers, fiscal intermediaries for Medicare and Medicaid, the profit and non-profit hospitals, clinics, pharmacies, mental health institutions and mental health clinics, physician practice offices, the prison health system, the military system, the veterans’ system, the tribal systems and the Indian Health Care system. People can be in and out of more than one of these systems at a given time in their lives and there is no real continuity of care record exchanged among them. We have to find a way to make this less complicated. A few years ago one of the Arizona payers with a managed care contract pulled its services out of the rural areas of our state leaving everyone high and dry. That should not be allowed to happen.
Today’s progressive health care leaders have a similar mantra: “Operate health care like a business.” The approach makes sense but it can be detrimental to the patient’s need for more education during the consultation. Physicians should not have to hurry through a consultation with a patient so they can meet their billable quota.
People who live in rural areas should have a right to receive the best possible health care within the best possible system of care. They often have to travel long distances for health care, and when they seek care, they should get as long as they need with the practitioner. They produce most of our food. We can’t live without them.
RAC Funding Searches: Helping You Find Funding Sources
by Holly Gabriel, RAC Information Specialist
Are you looking to fund a new project? Do you need capital funding for hospital renovations? Are you looking for statistics to support your grant application?
The Rural Assistance Center can help you:
Find funding opportunities
Locate resources using RAC’s information guides, news and listserv
Determine if your location meets the rural eligibility requirement for certain funding programs
Find statistics, research and maps to support your grant applications
RAC can help you locate funding sources in rural topic areas including:
Hospital renovation and expansion—including new equipment
Program addressing childhood obesity
Literacy program for a non-for-profit agency
Loan repayment programs for heath professionals
Domestic violence prevention
Faith-based food bank
Infrastructure for a town—water tower, water wells, street repairs
Dental health services
Wellness center—building, equipment, and programming
Transportation programs
Find funding opportunities
You can view summaries of funding programs available to rural communities on the RAC web site in the following ways:
Browse by Topic the program addresses (Housing, Health Research, etc. )
Browse by Sponsor (Administration on Aging, Commonwealth Fund, etc.)
Browse by State for funding opportunities available to limited geographic areas
Locate resources using RAC’s information guides, RSS feeds and listserv
Information guides Funding is a guide with many resources including web sites, organizations, journals, and documents related to funding.
Capital Funding is defined as funding used to expand or renovate a building, purchase major equipment or construct a new facility. It is important that facilities consider and use a variety of potential funding sources, including public grants and loan programs, as well as private sources such as foundations and donations from local residents.
Grantwriting is the process of applying for funding in support of a project that provides a social good. Grants may be sought to begin a new activity, to support ongoing operations, to make capital improvements, to purchase needed equipment and supplies, and for other purposes that support a project.
Health Education Financial Aid can help you locate grants, loans, fellowships, scholarships and loan repayment programs available to health professionals who agree to practice in rural, underserved areas.
RSS Feeds
On the RAC web site, funding announcements are added daily Monday-Friday and you can use RSS feeds to receive them using a newsreader. To receive the feed for federal and foundation funding programs, add the following URL to your newsreader: http://www.raconline.org/rss/funding.xml.
Listserv
You also may want to sign up for the RAC listserv to receive twice-monthly e-mail notices about new funding opportunities. You can subscribe at: http://www.raconline.org/listserv/.
Determine if your location meets the rural eligibility requirement for certain funding programs
The Am I Rural? service can be used to help determine whether a specific location is considered rural based on various definitions of rural, including definitions that are used as eligibility criteria for certain federal programs. The grant programs currently covered by Am I Rural? include:
Office of Rural Health Policy Grant Programs
Centers for Medicare & Medicaid Services Rural Health Clinics status
Centers for Medicare & Medicaid Services Medicare Telemedicine Reimbursement
If you are interested in applying for one of these programs, you can check whether your location is eligible by entering the address in the Am I Rural? service. Most programs have additional requirements you will also need to meet to be eligible. Your "Am I Rural?" report is not a guarantee of your eligibility status. Please check with the program contacts directly to verify your eligibility for specific federal programs.
Find statistics, research and maps to support your grant applications
In addition to the information guides listed above, which address funding directly, the Rural Assistance Center has other information guides on a variety of topics that can be used to support grantwriting. In particular, the Statistics and Data information guide and the Maps information guide include many useful links.
Maps can be an effective way to illustrate the needs facing your community. The RAC Maps section provides national maps addressing a variety of health and human services topics. Maps can be customized to focus on a specific state or county and to show additional data, labels and boundaries. More mapping options are available through the Center for Applied Research and Environmental Systems.
If you have a funding need and you would like us to do a custom search, we would be happy to help. Please contact us at the Rural Assistance Center, toll free, (800) 270-1898, or email info@raconline.org
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.
