Introduction

Given the projected increase in the rural elderly population, the need for transitional housing for seniors is on the rise. Assisted living facilities (ALFs) fill the gap between at-home living and nursing home care by allowing residents to live independently with some assistance, at a much lower average cost than nursing home facilities.

In its Summer 2008 issue, the Rural Monitor examined New Models of Senior Housing, with a strong focus on facilities, like nursing homes, that offer skilled care. Assisted living facilities were mentioned in one article as a housing model, but were not discussed at length. In this issue, the Rural Monitor widens its examination of senior options with a more in-depth look at ALFs, including two rural ALF programs in Illinois and Washington state. While nearly a quarter of assisted living residents are non-elderly, the focus in these stories is on ALFs for seniors.

Assisted Living Facilities

Assisted Living Facilities Offer Home Away From Home

by Candi Helseth

When Clara Lamb, 88, and Edna Skaar, 90, of Stevenson, Wash., realized they could no longer remain in their own homes, they wanted to stay in the community where they had lived for more than eight decades. Fortunately, they had a viable option. Both women are now residents at Rock Cove, an assisted living facility (ALF) that opened 11 years ago in Stevenson.

“I’m really happy here,” said Lamb, who cared for her sister in their home until her sister died. “I got so lonely alone. Now I can be busy all the time when I want to be and I have lots of friends here.”

Almost one million Americans reside in approximately 38,000 assisted living facilities, according to the National Center for Facility Profile. While every state has ALFs, availability is more limited in rural areas.

“Assisted living facilities vary widely from state to state because they are governed and regulated under state laws,” said Lisa Gelhaus, director of public affairs at the National Center for Assisted Living (NCAL). “Definitions vary among states concerning what assisted living is and the services that can be provided. What is uniform is that residents in assisted living play an active part in making decisions about their care. Assisted living settings encourage family and community involvement.”

ALFs can range from small settings such as five or fewer residents receiving limited services in a provider’s personal home to large, ornate retirement communities whose services include high-end options such as valet services, private therapy and coordinated group travel to other states.

Generally, ALFs offer private living space accompanied by a range of services, such as meals, activities, housekeeping, personal care, medication management, and 24-hour supervision and staffing. Residents live independently, choosing daily activities and the amount of assistance they receive.

Like Lamb and Skaar, three-fourths of all ALF residents are female and most residents are elderly. Most residents need assistance with approximately two daily living activities; for instance, 64 percent need help with bathing and 39 percent with dressing, according to NCAL.

ALFs offer wide variety of services

Almost all ALFs include meals among standard services. At Rock Cove, residents are served three balanced meals a day and can supplement meals using the kitchenettes in their apartments. Skaar says she likes having someone else do the cooking and dish washing. Lamb enjoys the social aspects of having meals with other residents.

Rock Cove strives to keep residents engaged physically and emotionally, Rock Cove Director Robin Aman said. Daily exercise classes, Tai Chi, line dancing and chair yoga improve strength, balance and mobility. Facials and footbaths are not only enjoyable, but also help ensure healthy skin. Musical entertainment, games, planned events and community activities encourage social interactions. Residents also engage in intergenerational contact through activities such as tutoring in local classrooms, hosting Easter egg hunts for preschool children and offering the facility as a meeting place for Girl Scout troops.

Residents are free to come and go as they wish. Lamb attends Rock Cove’s morning exercise class but also enjoys going for long walks and visiting friends in the community. Skaar participates in several planned activities and on Sundays she goes to the church she has always attended. She still gets together with church friends to quilt every week, too.

“I think one of the biggest benefits of assisted living is that we assist most of our residents with their medications,” Aman said. “It really helps them live healthier because they’re taking their meds correctly and at the right times. Our staff is very aware of our residents’ needs and when they notice any change in their condition, we contact their doctor. And we have a part-time nurse on call 24 hours a day.”

Since residents are receiving care and services related to their physical health and specific medical needs, Gelhaus said, they are more likely to delay entry into a nursing home. Assisted living does not replace nursing home care where residents have medical issues that require skilled nursing care. Nor do all ALFs provide medication management or medical-related services.

In fact, it is very difficult to specifically define ALFs. States may license the concept under the term "assisted living" or at least 15 other terms that essentially also fall under assisted living definitions. Some states have specific care conditions that must be administered to qualify as an ALF and some have care conditions that are not allowed under the ALF definition. Some states allow for unlimited personal services and help with activities of daily living, and even allow limited nursing care or special waivers for more continuous nursing care. Other states are more restrictive.

Overcoming barriers in rural areas

Rock Cove is professionally managed by Concepts in Community Living, Inc. (CCL), which has helped develop or manage ALFs across 30 states. CCL, which began operations in 1989, has particularly focused on developments in smaller communities. While land is less expensive in rural areas, there are significant barriers for rural developments, CCL CEO Mauro Hernandez said.

“Poverty rates are often higher and people can’t afford to pay so that makes it difficult to sustain rural facilities,” Hernandez noted. “We’ve experienced a shortage of nurses in some areas. In Hines, Oregon, it once took us eight months to hire a local nurse while we rotated in nurses from our other facilities to fill that void. If states want ALFs to serve their rural people, they’re going to have to adopt policies that make ALFs more attractive for developers and more accessible to lower income residents.”

Oregon and Washington have a long history of encouraging providers to serve lower income people through legislation impacting Medicaid reimbursement policies, Hernandez said. They also have provided below-market interest loans to support rural development. Hernandez added that there have been some recent setbacks due to state budgetary problems.

Rock Cove is the only assisted living facility in Washington’s Skamania County. Almost all of Rock Cove’s residents have lived in that area most of their lives or have family members living nearby. If these residents can no longer have their needs met by ALF services, the next step is a nursing home. And there is no nursing home in Skamania County.

“It’s hard for them to be further away and harder for family members to visit them,” Aman said. “This is their home.”

Assisted living fills a gap that allows America’s growing senior population to maintain independence by relying on assistance, which, in turn, helps them maintain their independence even longer. It’s no wonder that the popularity of ALFs continues to grow.

Assisted Living Facilities

Partnerships in Illinois Bring Assisted Living to Low-Income Rural Residents

by Candi Helseth

With only 550 residents—and a good number of them senior citizens with limited incomes—Ullin, Ill., was an ideal location for an assisted living facility. The 40-unit Cache Valley Assisted Living Apartments, which opened there in 1997, was the first assisted living facility (ALF) established under an innovative program developed to provide affordable housing and services for elderly, rural, low-income populations in southern Illinois. The facility also created new jobs and is the town’s second largest employer.

River to River Residential Corporation, which partnered with the Illinois Department on Aging, built Cache Valley as a pilot project and has since built ALFs in Murphysboro and Herrin. River to River’s unique model for affordable assisted living in rural areas earned it the Governor’s Home Town Award and the Best of Home Award by the Assisted Living Federation of America.

“Our research indicated that seniors want to stay in the communities where they live, worked, raised their children and retired,” River to River Executive Director Sherry R. Hamlin said. “We knew they would thrive better if they could remain where they have family and friends. Our goal is to link health, social, and personal care with housing, and avoid nursing home placements or at least delay those placements.”

River to River focused its efforts on southern Illinois where, Hamlin said, assisted living facilities were almost non-existent and the population is largely low-income. Residents in its ALFs live in private, secure apartments. An on-site case manager assesses residents’ needs for services, which include housekeeping, laundry, transportation, meals, entertainment and personal care. A beauty shop, store and private family entertaining room are among additional amenities.

“I think one thing that really stands out with our model is that seniors don’t have to apply for Medicaid or bankrupt themselves to live in our buildings,” Hamlin said. “We finance units with low-income tax credits so we can offer lower rent than what you find in most assisted living facilities.”

Residents’ fees are based on a sliding scale. Payments come from a mix of private pay, Medicaid, and a Medicaid waiver program developed by the Illinois Department on Aging’s Community Care Program (CCP). Hamlin said Medicaid requires seniors to spend their assets down to $2,000 before receiving assistance, but River to River allows seniors to retain assets up to $17,500.

“Residents pay rent and remain independent—even financially,” Hamlin said. “That is really important to them. And they can age in place. As they need more assistance, their assistance will be increased.”

River to River’s fees range from $380 per month to $1,587, in comparison to average assisted living rates in rural Illinois, which exceed $2,400 a month, Hamlin said. Because of the use of low-income housing tax credits, 69 percent of River to River’s residents must be classified as low-income. Because ALFs for residents with higher incomes were unavailable in their area, Hamlin said, their Big Muddy Assisted Living facility in Murphysboro has both low-income and market rate apartments.

Commercial developers weren’t interested in building smaller facilities in rural areas so River to River turned to a variety of partners to accomplish its plan. Ullin was selected for the pilot project because its city leaders aggressively sought the project.

“Community support and involvement is essential on the local level for this model to succeed,” Hamlin explained. “We need assistance from their taxing bodies.”

CCP approved funding for the project, titled Comprehensive Care in Residential Settings. Grant monies from the Robert Wood Johnson Foundation’s Coming Home project, an initiative to help rural communities meet long-term care needs, funded pre-development costs. The Illinois Housing Development Authority financed construction using home funds, trust funds, low-income tax credits, tax-exempt bonds and conventional loans. The Illinois State Legislature also bought into the plan, approving legislation in 2004 to preserve and encourage future development of similar facilities.

Hamlin said the program has been an extraordinary success and River to River is currently exploring expansion into five more southern Illinois towns.

Assisted Living Facilities

States Making Significant Changes in Assisted Living Regulations

As assisted living continues to evolve, many states are examining how they can better support, regulate and fund assisted living facilities. Since 2007, about two-thirds of the states made some type of changes in assisted living legislation and more than 10 states are working on significant legislative changes in 2009, according to Lisa Gelhaus, director of public affairs at the National Center for Assisted Living (NCAL).

States’ actions cover a wide range. Last year, Maryland made sweeping changes in regulations. Tennessee extended regulations that allow facilities to care for residents with greater health care needs. Several states made changes related to emergency/disaster preparedness, fire safety, staff training, medication management, disclosure and background checks.

NCAL’s report, Assisted Living State Regulatory Review 2009, published in March, offers a state-by-state summary of assisted living regulations covering 21 categories. The report also provides contact information, including web site addresses, for state agencies that oversee assisted living activities.

Assisted Living Facilities

Cost of Assisted Living Prohibitive for Some Seniors

by Candi Helseth

Most researchers agree that assisted living is a less expensive alternative than nursing home care. But for many senior citizens, the cost can still be prohibitive.

Clara Lamb and Edna Skaar are financially capable of paying their way at the 30-unit Rock Cove complex in Stevenson, Wash. Rock Cove Assisted Living offers residents a choice between studio or one-bedroom apartments, and three levels of care. Depending on their living arrangement and the level of care required, residents pay anywhere from $2,710 to $3,890 per month.

Assisted living costs vary widely from state to state and even within states because ALF providers set their own rates for housing and services. Some have an all-inclusive monthly fee while others have tiered plans or charge residents a flat fee with additional fees based on the number of services they choose. An average monthly fee appears to be about $3,022 per month or $36,264 per year, said Lisa Gelhaus, director of public affairs at the National Center for Assisted Living (NCAL). In comparison, according to the 2008 MetLife Mature Market survey, nursing homes average at least $70,000 annually, depending on the level of care and the privacy of the room.

“The size of the units, the extent of services and in some places, specialized services such as Alzheimer’s or dementia care, can all impact costs,” Gelhaus said. “Location is another factor. Generally, the more inexpensive areas are those that are less urban and have less population. The most expensive markets are right outside of New York City. Some of the lower priced markets are in states such as Arkansas, Missouri, Oklahoma, and North and South Dakota.”

Rock Cove residents cover their expenses using money from savings and retirement accounts, investment plans and other private means, said Director Robin Aman. The state of Washington provides assistance for seniors who qualify financially and are deemed to need assistance in at least three different areas of their health.

“If they don’t have the means or they live here and are running out of money, we refer them to a state caseworker who can help them,” Aman said.

Some states provide subsidies for senior assisted living and many long-term care insurance policies include some type of coverage for assisted living. Medicare does not cover day-to-day assisted living costs, but there are Medicare benefits that may pay for certain services provided at the ALF in the same way that Medicare would pay for those services if the individual resided in his or her own home, according to the National Senior Citizens Law Center.

The Center also reports that Medicaid covers nursing home costs in every state for people who meet financial eligibility requirements. And, more than half of all nursing home residents are covered by Medicaid, according to a policy document from the Center on Budget and Policy Priorities.

Recognizing that ALFs are a less expensive alternative to nursing homes, about two-thirds of the states have implemented some type of legislation that allows Medicaid waivers for assisted living support, Gelhaus said. Again, the specifics vary; states have several options for using Medicaid to fund services in residential care settings.

“Obviously, not all people in rural communities have lower incomes, but rural areas do have higher rates of poverty,” said Mauro Hernandez, CEO at Concepts in Community Living, which manages Rock Cove and has been involved in ALF development in more than 30 states. “Anything smaller than a 50-unit ALF has become harder to do affordably. It’s even more difficult if you’re limited to private pay and units can’t serve lower income residents. This makes adequate Medicaid rates essential for assisted living in rural markets.”

The Apocalypse Avoided - But an Uncertain Road Ahead

If you look around, there are many signs that the proverbial “light at the end of the tunnel” might actually be daylight—not an oncoming train. We are losing jobs at a decelerating rate. Equity values have risen by over one-third since the bottom was hit in early March. Housing prices inched up by 0.5 percent between April and May, marking the first increase in about three years. Finally, the Index of Leading Economic Indicators (LEI) has risen some 13.8 percent over the past three months.

Such a jump in the LEI has reliably signaled an end to every recession since 1960. Even Larry Summers, economic advisor to President Obama and former Harvard President, noted that in April he finally stopped waking up at 4:00 a.m. each morning to check on the Asian markets. Until then, the threat of a global credit squeeze and a worldwide economic meltdown worried the best and brightest. But even if we see visible signs of recovery this fall, as anticipated, the current economic decline will be the steepest in the past half century and the longest since the Great Depression.

The big unknown is what kind of recovery might we expect? After the last recession, earlier this decade, job growth was sluggish and fueled largely by a speculative housing market that was destined to be short-lived. Many fear that future job growth will be slow, if not glacial. The July Bureau of Labor Statistics data show that we have lost 6.5 million jobs since the onset of the recession and have fewer jobs now than nine years ago. Consumer confidence, after jumping some 30 points between February and May of this year has slid once again over the past two months. Additional countercyclical spending attached to the stimulus bill passed this winter will start to flow in earnest over the coming months. Unlike past stimulus efforts, this spending will hit the streets when needed, not after the crisis has past. Still, it may not be enough to jumpstart the economy and there is little political stomach for more pump priming.

Federal stimulus spending, moreover, comes at a time when state and local revenue flows are collapsing. State and local spending on social welfare declined by 3.1 percent between 2005 and 2006, the first decline in real terms since 1983. While cash assistance to low-income families has been falling since the mid-1990s, non-cash social service spending declined after reaching a peak, or inflection point, in 2002. Even state and local spending on medical services began to fall after 2005.

If anything, the capacity of state and local jurisdictions to meet increased human needs that are likely to persist for years appears questionable at best. Based on Census Bureau data, analysts from the Rockefeller Institute for Government estimate that state first-quarter tax collections (January through March) dropped by 11.7 percent, the sharpest decline in the 46 years that such data are available. Preliminary data for April and May suggest a worsening revenue situation. The California spectacle may capture the headlines, but virtually all states are struggling to meet human needs.

As Alexander Hamilton penned in a 1787 Federalist Paper arguing for a new American constitution (which was quoted in a recent issue of the journal, Publius), “Tax laws have in vain been multiplied; new methods to enforce the collection have in vain been tried; the public expectation has been uniformly disappointed, and the treasuries of the states have remained empty.” Our first Treasury Secretary might well be describing our contemporary situation.

In short, we face a slow recovery with exhausted treasuries and growing human needs. I cannot find many reputable observers who believe that we will simply grow our way back to prosperity as has occurred in previous downturns. This will be a long-haul recovery demanding creativity and imagination.

In such challenging times, many rural communities remain particularly vulnerable. The Carsey Institute just published a report, Place Matters, which surveys some 8,000 randomly selected respondents from several rural communities. The study taps surveyed residents living in four distinct communities: amenity-rich areas, declining resource-dependent areas, chronically poor areas and areas in transition. The authors assumed that rural communities are not homogeneous, nor are one-size-fits-all policies likely to work.

Study data were collected in the fall of 2007, just before we slid into the current recession. Even then, rural folks were worried about jobs. Only 40 percent of respondents worked full time, well below the national average. But averages always obscure deeper patterns. Let us focus on two of the community types—the declining resource-dependent areas and the chronically poor areas.

The first type depended on agriculture, timber, mining and related manufacturing to sustain a middle class and provide opportunity. Now, the study concludes that resources are depleted and globalization is bringing harsh new realities into the picture. The survey results suggest that populations are declining and aging, hope is evaporating and infrastructure quality is threatened. The sense of a permanent downward spiral is present.

In the second type (chronically poor rural America), according to the report, “…both residents and the land have experienced decades of resource depletion and underinvestment, leaving behind broken communities with dysfunctional services, inadequate infrastructure, and ineffective or corrupt leadership. Generations of families have been held back by inadequate education and weak civic institutions. As the population suffers, so does the environment, and the downward spiral continues.”

These kinds of communities might well have been ignored in the best of times. Though we probably have dodged a catastrophic depression, we may not experience good times again for many years. Will vulnerable rural communities be part of America’s recovery agenda? How should we rethink human services in an era of diminished resources? Stay tuned…

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.

Will Anyone Ring the Bull?

As some country people know, to “ring the bull” is an important process. Once it’s done you can control the bull, but it’s scary if you wait too long and the bull gets too big, as we have in this case. The ring is jointed with two pointed ends. You have to push the two pointed ends through the septum of the bull’s nose and clip them together. It hurts the bull. Such an act seems beyond the courage of the folks we have in Washington right now, perhaps because the bull is already too big.

Thirty-five years ago, when I was a young doc, Congress suddenly decided to rein in health spending. Until then the national plan had called for more care: more money in the form of Medicare and Medicaid; more medical schools and students through enormous start-up grants and per-student payments to school; regional continuing education programs; and, satellite-mediated consultation. Suddenly the growth promotion programs stopped. Health care costs were at 7.4 percent of the economy. Detroit was spending more on health care than steel. The sudden pronouncement in 1974: growth in health spending simply had to slow down.

Growth slowed for three or four years and then made up for the pause. There was a similar effort in the 1980s. That cycle had, I believe, one very unfortunate unanticipated consequence: the conversion of most U.S. health insurance companies from not-for-profit to for-profit. It went like this.

Health insurance companies were born during the 1930s and 1940s. The national models were Blue Cross and Blue Shield, regional not-for-profit companies managed by volunteer boards of businessmen and businesswomen. There were a few for-profit companies but I believe their roles were minor. In 1984 Congress decided to pay hospitals to care for Medicare patients what Congress and its advisors thought it should cost, instead of what the hospital had actually spent. A few hospitals went broke. Most hospitals shifted the difference in their expenses (the term “cost shift” should sound familiar!) to the private payers through large and sudden cost increases. The not-for-profit “Blues” couldn’t or wouldn’t raise rates to their premium payers fast enough, and saw their reserves plummet.

At the same time, the country was entranced with the idea of “health maintenance organizations.” Health insurance companies were to become beneficent overseers of their subscribers’ health care needs. But the computers then were new, huge, crude and very expensive. It was going to take lots of money to buy the enormous computers required to keep track of the health needs of all those beneficiaries. The not-for-profit companies could barely raise the money to function as insurance companies through the abrupt shift in congressional Medicare policy, let alone turn themselves into computerized modernized HMOs. They sold themselves to the for-profit firms. Those firms had access to plenty of capital and no scruples about raising rates. They did no health maintenance, eased themselves toward the exit of the risky individual market and became fiscal intermediaries to self-insured employers while charging very large commissions.

The net effect was to put our health cash flow into commercial hands at very high overhead rates and very little corporate risk. The practical point for today is that commercial health insurance is not the traditional American model. Our for-profit pattern of health insurance is the result of well intended but poorly timed congressional action. It is only about 20 years old—a very young but powerful bull. Any mention of curbing its growth seems politically unspeakable.

So here we are, 35 years into our nation’s stuttering efforts to control health care costs. Said costs are now up around 17 percent of the economy. That means that the people controlling all that money have enormous resources at their disposal to control the political process. It now seems fairly likely to me that our health care cost increases will not be controlled.

Recently President Obama predicted that the United States and China would shape the 21st century. I am doubtful that the U.S. will be at that table. I’m afraid, in a couple more decades, our health spending will have wrecked our economy and the U.S. will have joined the list of countries that once were great. But do not confront the bull.

I don’t know how long it may take for that decline to come about. The health care bite of the economy will increase by about one half a percent per year in the coming decade. Where is the tipping point? I obviously don’t know. At some point before my grandkids graduate from college, health-spending growth will consume more growth than the rest of the economy can provide and our overall standard of living will decline.

When I was young I was confident that when things got really serious our leaders would do the right thing. But now I’m older.

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.

The Health Wagon Serves Up Care to Virginia's Rural Uninsured

by Candi Helseth

Trundling along treacherous mountain roads, The Health Wagon visits geographically isolated areas in southwest Virginia’s Appalachian Mountains. Before the mobile clinic on wheels has even ground to a full stop, a line of people waits at the door. Last year, clinic staff and professional volunteers provided treatment for 2,647 of Virginia’s poorest residents. For free.

“I just thank God for The Health Wagon,” says Celia Rice. “I’d been to the welfare office and the health department looking for help. But I couldn’t get help. When I finally saw the doctor after The Health Wagon got me help, he told me I would have had a heart attack and died.”

Rice, a lifelong Buchanan County resident, is among more than one million Virginians without health insurance. Buchanan, Dickenson and Russell counties, which are served by The Health Wagon, have high poverty rates.

“These are real people facing some unusual circumstances and diseases, and they need help but they can’t get it because they can’t afford it,” said Teresa Gardner, executive director of The Health Wagon.

Gardner is a family nurse practitioner and this year’s recipient of the American Academy of Nurse Practitioners State Award for Excellence. A 17-year veteran of The Health Wagon, Gardner says she and her staff—three nurses and two office workers—view their jobs as their mission. Gardner, who is completing a doctorate in nursing, provides comprehensive primary care for all the patients, diagnosing problems and prescribing medication as needed. The nurses follow up with health and lifestyle education.

“It’s hard work but we’re saving lives, changing lives, making a difference every day,” Gardner said.

Physicians and other professional staff who volunteer their time help fill the gaps in care. Dr. Tim McBride donates time to supervision, consultation, chart reviews and backup. Physician specialists provide services in acute needs areas, often giving more than professional expertise.

Take Dr. Joe Smiddy, a pulmonologist who practices in Kingsport, Tenn. Smiddy gets no pay but serves as The Health Wagon’s medical director, as well serving as a board member for the last seven years and as a physician seeing Health Wagon patients for the last nine years. He has participated in medical missions in Third World countries and says the patients he sees at The Health Wagon are just as needy.

The Appalachians have a multitude of health-related lung problems. Known as a coal mine belt, southwest Virginia has a high incidence of mine workers with lung disease. In addition, several area industries work with asbestos and histoplasmosis, a fungus in the soil, also causes lung disease, Smiddy said. Smoking and obesity rates are high.

“When we broke the numbers of smokers down by zip codes, we saw that the average age for starting to smoke was 12 in these areas,” Smiddy said. “By the time they’re in their early 30s, they already have 20 years accumulated in their lungs.”

Smiddy decided better X-ray technology was necessary to diagnose lung disease. So he purchased a high quality X-ray machine, tackled the legalities and insurance complexities involved with providing mobile X-rays, and then spent 180 hours in class and behind the wheel being trained to drive the truck that pulls the trailer carrying the X-ray equipment. Once they arrive, staff screen and X-ray patients and Smiddy sees every patient personally.

“We’ve done 2,200 free X-rays and we’ve found a lot of disease that wouldn’t have been diagnosed,” he said. “That’s about a $1,200 value if they had to go see a doctor for the same thing. And we carry donated medications if they need drugs.”

When fixing a patient’s problem is beyond their resources and their partnership relations, Health Wagon staff does whatever they can to get help for the patient. By the time Celia Rice found The Health Wagon, she said, “I’d been bleeding for two or three years and felt sick all the time.” Rice needed a hysterectomy. Health Wagon staff spent hours on the phone pleading Rice’s case until they found a surgeon who agreed to do the surgery.

“These are good, praying people who really care about the people they see,” Rice said. “I’m here today because of The Health Wagon people.”

Gardner says her staff has become “very resourceful” when patients have to be referred for ongoing care. “We have partnerships with several areas that help us plug those patients into another point of care, but it is very time consuming and difficult. And there are a large number of patients that need more help than we are equipped to give. It breaks my heart when we have to turn a patient away or we can’t get them the help they need.”

Geographic isolation and cost barriers contribute to the likelihood that these patients are less likely to get the medical assistance they need, Smiddy said. “Even the ones that have insurance often can’t afford the co-pay or the medications that are prescribed. A lot of them don’t even know where they should go if they need help.”

Financial stressors plague the service. Fundraising is constant, Gardner said. Funding for the $440,000-a-year budget comes from private foundations and donations. Patients are not asked to pay for anything, although donations are welcomed.

Founded in 1980 by Sister Bernie Kenny, The Health Wagon received support from St. Mary’s Hospital until 2006 when a for-profit entity bought the hospital and dropped the clinic. Now The Health Wagon operates independently, but Gardner said various churches and faith-based organizations have been good to continue supporting it. Gardner and her team will continue to focus their efforts on the people that need them in southwest Virginia.

The Health Wagon has received the Virginia Governor's Volunteerism and Community Service Award for Outstanding Nonprofit Group, the Virginia Rural Health Association's Best Practice Award, and the Award for Outstanding Devotion to the Community by the American Breast Cancer Foundation.

But the best reward, Gardner said, is their patients. Many, when asked who their doctor is, respond simply, “The Health Wagon.”

AROUND THE COUNTRY

Delivering Doctors

by Wendy Opsahl

The Apgar score for newborn babies is a rather novel concept if you think about it. This fast, simple physical assessment immediately following childbirth and repeated at five and ten minutes thereafter determines if babies are ready to meet the world without additional medical assistance.

What if there was a similar test for hospitals to assess readiness for recruiting physicians? That is precisely what Dave Schmitz, M.D., a family physician from Boise, Idaho, wondered, when he took a new job as associate director of rural family medicine at the Family Medicine Residency of Idaho. After years of observing Idaho communities struggle with recruiting health providers, Schmitz envisioned something new. Something based on quantifiable data. Something that incorporated the whole community. Something that shows people on graphs and charts where they are and how to achieve their goals.

Enter Ed Baker, PhD, director of the Center for Health Policy at Boise State University. Schmitz brings experience from the trenches, Baker brings the research know-how, and together they’ve developed the Community Apgar Questionnaire (CAQ), an innovative, evidence-based way for health care facilities to see how they stack up in the eyes of the health care providers they are recruiting.

The Community Apgar Questionnaire got its start in 2007, when Baker and Schmitz received funding from the Idaho Office of Rural Health and Primary Care to develop a tool that identifies and weighs factors important to communities in recruiting and retaining rural family physicians. The 50-factor CAQ contains questions about geography, economics, scope of practice, medical support, and hospital and community support. It is typically administered at a hospital, where Schmitz acts as a physician interviewing for a job. He meets with administrators, physicians and staff, and also gets to know the community in the way that a visiting physician would typically do—perhaps meeting principals, real estate agents and pastors, among others. The responses are recorded, the results are analyzed, and a return visit is made to present scores to hospital leadership, board members and key community decision makers. This program is funded by the Idaho Office of Rural Health and Primary Care for use in each critical access hospital in Idaho over the next four years, but is also ready for use beyond state lines.

“The evidence is a way for communities to see themselves the way a physician might, and it opens productive discussions,” said Schmitz. “Hospitals are learning, for example, that sometimes offering a favorable on-call schedule is more important than a large salary.”

But the CAQ doesn’t end there. Baker and Schmitz also identify areas for improvement and help to address gaps and priorities. So, if a community has a fantastic school system and is home to parks and recreational activities, those are highlights to feature for physicians with young children. But if the physician would be on-call every evening and weekend (an unattractive option), Baker and Schmitz help communities explore solutions such as on-call sharing.

“Hospitals learn what their selling points are,” said Baker. “But this tool also gives hospitals directions to apply their limited resources strategically to make improvements. If they have only $5 to spend on recruitment efforts, we can show them where to spend that $5 most effectively.”

Baker and Schmitz return 12 months after the first assessment and complete another CAQ, followed by another return visit and presentation. This time, they also measure how well the community achieved its goals.

“As a physician who’s practiced in rural Idaho, I had an inkling of what might be important,” said Schmitz, “but as researchers, we wanted to be able to develop these parameters that are evidence-based, that are reliable, so that if you make decisions to improve the recruitability of your community, then you can be confident that this instrument shows you how you look relative to your peers, and where you can have the biggest bang for the buck.”

While Baker and Schmitz have only done their assessments in rural facilities, they are confident the process can transfer to urban environments as well. They also have begun the development of CAQ tools for Community Health Centers and the nursing workforce.

To learn more, contact Dave Schmitz, M.D., FAAFP, by phone: (208) 367-6468 or by email: dave.schmitz@fmridaho.org; or visit the Idaho Rural Outreach web site.

Adapted from an article that originally appeared in the June 2009 issue of Health Workforce News, published by the Health Workforce Information Center.

An Interview with Theresa Cullen, M.D.

Theresa Cullen, M.D., is the Chief Information Officer (CIO) and Director of the Office of Information Technology for the Indian Health Service (IHS). As CIO, Cullen oversees a diverse range of agency functions in information systems planning, development and management. Cullen is a commissioned officer in the U.S. Public Health Service and holds the rank of Rear Admiral. Cullen began her IHS career in 1984 as a General Medical Officer at the IHS Hospital in San Carlos, Arizona. She later served as the Tucson Program Area Maternal Child Health Coordinator and Area HIV Coordinator at the Sells IHS Hospital in Sells, Arizona, before becoming its Clinical Director. From 1999 to July 2006, when she became CIO, Cullen was an OIT Senior Medical Informatics Consultant for IHS in Tucson.

Cullen graduated from Johnston College at the University of Redlands in Redlands, Calif. with a dual undergraduate degree in biology and philosophy. She earned a medical degree from the University of Arizona and a M.S. in administrative medicine and population health from the University of Wisconsin in Madison. Cullen is Board Certified in Family Practice and has a certification in Addiction Medicine from the American Society of Addiction Medicine. Cullen’s honors include HHS Secretary’s Award, a Federal 100 IT Award and the IHS Director’s Award.

Cullen works at the IHS office in Rockville, Md., during the week and sees her family, who are back in Tucson, most weekends. She and her husband, John Sartin, an artist, have three children and one grandchild.

Note: References to American Indian/Alaska Native have been abbreviated as AI/AN.

What sparked your interest in Native American health?
I worked as a Red Cross volunteer at the Phoenix Indian Medical Center when I was 16. It was like being a Candy Striper, with the little uniform, pushing the water and the cookies except it was an IHS facility and it was all Indians. I worked on the pediatric ward, and I met lots of tribal members and traditional healers. I was enraptured with the culture and the caring. It was my first experience with Native American culture.

After I graduated from college, I wasn’t sure if I wanted to go to medical school, because I loved philosophy. I planned to get a PhD in philosophy but that was the year that the American Philosophical Association sent out a letter that said, “We welcome your applications, but there are no jobs.” At the same time, I was working at the College of Ganado in Ganado, on the Navajo reservation, teaching science. I loved it there. We lived in trailers and the woman next door to me was a physician at Sage Memorial Hospital. We became good friends and she let me tag around with her. She asked a mom who was in labor if I could watch her baby being born and I just fell in love with it—I loved that you could deliver health care in a rural setting as a primary care physician. So then I applied to medical school and got accepted in 1979.

What were some of your challenges in becoming a doctor?
The summer before I started medical school, I called the admissions officer at the University of Arizona and told them I just couldn’t come. I was poor and my family was poor at that time. I had been making $6000 a year at the College of Ganado. And they told me that was no reason not to come to medical school.

I qualified for a needs-based National Health Service Corp (NHSC) scholarship where they gave you your tuition and a monthly stipend and you did not incur an obligation. And then I became a NHSC scholar my third and fourth year, which I think is one of the best things, and I’m glad it’s been refunded again. That’s how I became a physician. The NHSC wasn’t just about financial support. You felt like you were part of a group of people committed to doing a practice for a poor and vulnerable population. My payoff to NHSC was to go to San Carlos, on the Apache reservation, and I loved the work.

What are some of the challenges of providing health care on a reservation?
Rural health care is really taxing and trying and incredibly rewarding, but the one thing that happens is that you have to tolerate a fairly high level of ambiguity in medical decision-making because you may not have access to a CT scanner, or an ultrasound or an MRI, and you probably have only basic lab evaluations. So you learn how to practice medicine without using technology—I use my ears and my voice and my hands to figure out what’s wrong with somebody. It’s the old way of practicing medicine. And still today. I still practice medicine at Sells, at the Tohono O'odham reservation, where I’ve worked since 1986, after transferring from San Carlos.

What does the CIO at IHS do?
I am responsible for all of our information technology—the usual stuff like desktops, and the laptops, and the Internet—but because we’re a health delivery system, our primary emphasis is on developing and supporting health IT (information technology) that can positively impact health care outcomes. So the major thing we do is electronic health records (EHRs), which we’ve done for 25 years. We’re far ahead of most other organizations that way. And, our drivers for our HIT system were the improvement of care, as opposed to increasing collections.

For instance, we couldn’t afford to do chart reviews for quality. We’ve done clinical quality reporting since 2001. We don’t do hand chart reviews because we can’t afford it. The industry says a hand chart review costs $75, but if you do it electronically, you pay for the programming and then you just push a button and everyone gets a report, including the patient. And we’ve had patient registries since the mid-90s. Because we’re a public health agency, our emphasis isn’t just on the patient, but the population. I don’t think everyone knows this. We don’t have the time to market what we do, and we don’t have a research branch. But West Virginia health system uses our EMR and Hawaii is adopting it.

Our major emphasis right now is ensuring quality in a fiscally constrained environment—and to make sure the $85 million we got from ARRA (American Recovery and Reinvestment Act) are put to good use.

How are you able to serve as the IHS CIO and still practice medicine?
Because I make it a priority. I make sure I have time in my schedule to do it. I am really, at heart, a physician—I love being a doctor. I only am the CIO because I believe that what we do impacts patients’ lives in a positive manner. I struggle—I think many people who are clinical in health IT struggle. But I think what we do improves the lives of all patients. I also see patients to be reminded of why I am here.

I go out to Sells every couple of weeks and do a 12- to 20-hour shift. I delivered a baby eight weeks ago. Tucson is 70 miles away, so we only do emergency deliveries, so this woman came in almost complete and with no prenatal care. It could have been a real nightmare and not everyone would have been comfortable, but I’ve done a ton of deliveries so I’ve seen almost everything already.

How did you get from working as a doctor on an Indian reservation to an IHS office in Rockville, Maryland?
We always used health IT at Sells since I was there. Later, I changed positions and did health informatics in Tucson. I applied for the position believing that our work in HIT was cutting edge and enabled us to increase our efficiency and improve our ability to deliver quality care. My family and I thought for a long time about the impact of this job prior to my applying for the position because my husband is a single dad while I am gone and that is stressful.

Are there any similar health issues on Indian reservations and in rural areas or are they different?
The same problems facing AI/ANs are the same problems confronting rural America, except the percentage of the population affected on reservations is greater because poverty is greater and there are fewer resources available. For instance, the diabetic epidemic obviously hit AI/AN before anybody else, but now it’s all over, the obesity epidemic got AI/AN first, and now it’s all over. It’s not that the problems are different, it’s just that they may be magnified. I also think it’s because we have a health technology system that allows us to track the data and looks at the outcomes that enables us to do the reporting.

In some ways, what we have that rural communities don’t have is an integrated health system—50 percent of it is run by tribes–but there is an integrated presence that lets people learn from each other, and share successes and new models of delivery that are effective. And it lets us track a population with multiple morbidities. The health IT system is the enabler because it lets people do an intervention, lets them track it, look at the outcomes right away—today as well as tomorrow—and then decide whether it’s effective.

What can rural and AI/AN health learn from each other?
Cross-cultural issues are really important. And there are additional opportunities that could be developed to facilitate best of practice sharing. Sometimes there’s a sense that IHS is an isolated health care system. But we provide comprehensive care on a capitated basis that is equal to 40 percent of what the rest of the U.S. spends. Some of that is because our physicians are employed versus independent practitioners, and they’re working in an integrated health system that can leverage the benefits being integrated. We support the community-oriented primary care model, which is a wonderful model. We are a medical home—we’ve been a medical home longer than that term was in use. Our definition of a medical home is broader, though, than the term is usually used—our medical home includes the community and the family as well as the patient.

We have a ton of primary care docs. There is this concept, “Working to the maximum of your license.” That’s what our providers do. We provide what in an urban setting might be specialty care—we provide it through our family medicine and our internists and our pediatricians. I think this is true for a lot of rural providers. You learn how to provide care that is geographically isolated with up-to-the-moment care delivery because you use consultants remotely, through telephone consultation and telemedicine, as well as online resources. I used to take care of HIV patients and I’d call a HRSA hotline all the time. Managing patients remotely is a skill you aren’t taught in medical school, but you have to develop it to excel in remote practice.

And that ambiguity. You have to realize that there are days you’re not going to know what’s wrong with patients. I think that’s an OK model. You can’t make health care risk-free. The issue is how to mitigate the risk. In a rural area, it’s a different discussion.

What do you think is the biggest challenge facing your agency right now?
Funding.

What are some of the other challenges?
We have high turnover. We have difficulty recruiting, we have difficulty retaining. It’s a population with the highest morbidity of any population group in America, and the lowest life expectancy, but it’s all colored by a culture that is alive and supporting. The nice thing about IHS is that we really believe in tribal self-determination. The federal government can run the facility or a tribe can run it—it’s really an amazing non-paternalistic model.

Are there particular challenges in providing health IT?
Broadband access is such a huge issue. Urban America doesn’t understand that when your Internet flickers 100 times a day, you really have problems. Our health IT system is predominantly a client-server application, which means that because of the issues with broadband, the data set is maintained at the local facility, they don’t access the Internet. But the problem with all that is not sharing information outside of that one health care facility. Access to medical Web-based resources in a timely manner, transmission of images to appropriate people to read them, whether they be eye exams or radiological exams, all require adequate Internet bandwidth. We do use satellite sometimes, but the weather can interfere with it.

We track our patients’ Internet accessibility by surveying them when they come in and have found that only 22 percent of them report having Internet access, whether at home or in a library. That’s far lower than any reported statistic on that. We’re hoping Recovery Act dollars will make a huge difference in terms of our band access into the health care facilities.

What keeps you going? What are the rewards for your work?
Our patients are wonderful. They’re unassuming, they understand the difficulties that confront them on a daily basis, they live lives that are full of pathos and beauty. And we work in teams as a collaboration—it’s why people work in Indian country, and why they stay there. The rewards are so much greater than what you give. My patients beguile me with stories and sometimes the beauty, the intimacy that is shared with you, as a physician in an AI/AN community, can be overwhelming. It’s tragedies too, of course. It’s a sense of a life that I haven’t lived. My patients have created visions for me that I would never have been privy to if I hadn’t been working on a reservation.

I feel so blessed here 25 years later. I still think it’s a gift.

— Interviewed by Beth Blevins

Rural Clinic Director Nominated for Surgeon General Post

Dr. Regina Benjamin, who was highlighted in an Around the Country feature in the Spring 2007 issue of the Rural Monitor, has been named by President Barack Obama to be the next Surgeon General of the United States.

Benjamin started the Bayou La Batre Rural Health Clinic in the small shrimping village of Bayou La Batre, Ala., in 1990, after serving as a National Health Services Corps doctor in rural Alabama for three years.

“My passion is the uninsured and underinsured,” Benjamin said in the Monitor article, adding, “The biggest health care issue for me is getting health care coverage for all. About one-half of my patients are uninsured. Most work. They make too much money to qualify for Medicaid, but they can’t afford to buy insurance.”

In nominating Benjamin for the post, Obama said, “Of all (her) achievements and experience, none has been more pertinent to today's challenges or closer to Regina’s heart than the rural health clinic that she has built and rebuilt in Bayou La Batre.”

Obama noted the tremendous obstacles that Benjamin has overcome, including the floods and fire that have destroyed her clinic, which she has worked to rebuild after each disaster, saying that Benjamin “represents what's best about health care in America — doctors and nurses who give and care and sacrifice for the sake of their patients; those Americans who would do anything to heal a fellow citizen.”

At the Rose Garden ceremony marking the nomination, Benjamin said that public health issues are personal to her because she has lost most of her immediate family to preventable diseases, and that she wants to “be a voice in the movement to improve our nation's health care and our nation's health for the future.”