Contents:

• Director's Corner
• Profile
• Community Focus
• Program Focus
• Special Feature

quarterly
newsletter:
Fall 2008

Email Mary Ann Radigan at maryann.radigan@state.mn.us or call (651) 201-3855 with comments.

We invite you to forward this newsletter to your colleagues.

ŠExplore Minnesota Tourism Photo of Tamarac Lake in the Chippewa National Forest 

Director's Corner

Mark Schoenbaum, Director of the Office of Rural Health and Primary Care

Slices of the Pie

I recently read a good book that’s stuck with me, “Blink” by Malcolm Gladwell. Gladwell, a magazine writer and also author of “The Tipping Point,” uses a series of engaging and memorable stories that illustrate the power—and the pitfalls—of reaching conclusions based on the information we receive in the first two seconds we’re exposed to a new situation.

His examples cover quite a range. He tells of experts immediately spotting art fraud and of a researcher who achieves great accuracy predicting the longevity of marriages based on a brief couples assessment. He recounts another researcher able to predict the likelihood surgeons would be sued for malpractice by noting only whether their tone of voice could be characterized as “dominant” or “concerned.” The most compelling to me was the story of a fire captain who entered a burning house to find a routine kitchen fire. Something told him to get his crew out immediately, and moments later the floor where they’d been standing collapsed—the real fire danger had been in the basement rather than in the kitchen where flames were visible. 

This way of processing information is known as “thin slicing”—drawing conclusions and acting on them with just small slices of information. It’s a way of finding patterns in seemingly unrelated data. It acknowledges we can seldom wait for 100 percent complete information or we may never act. Gladwell says our brains are optimized for efficiency, not 100 percent accuracy. This type of decision-making often comes into play in the emergency room, and in a 2006 editorial in Annals of Emergency Medicine, Patrick Croskerry, M.D., Ph.D., discusses this phenomenon and ways to work around its dangers. Dr. Croskerry calls for matching decision-making approaches to the intricacy of each situation and recommends more reflection time when the situation is complex.

“Blink” was fresh in my mind as I read the articles in this issue of the Quarterly. If we consider the articles “slices” of data that represent different roles in the health care safety net, what can they tell us? This issue includes two articles on individuals and two on organizations. Keith Peterson is a physician just beginning a loan forgiveness program commitment to practice in Ely, truly at the end of the road in northern Minnesota.  Deb Carpenter is profiled as a member of the Rural Health Advisory Committee, and she shares her insights on the most important policy issues for the rural health agenda. Children's Hospitals and Clinics report their approach to sharing the specialized nursing expertise of an urban medical center with colleagues across the region, and North Point Health & Wellness Center documents 40 years of service and innovation in inner-city Minneapolis.

So what can I conclude by thinking just about these four examples? My main conclusion is that there are roles to play and vital contributions to be made by both individuals and organizations, whether they are practicing medicine, contributing as citizens to state policy discussions, sharing their institutional expertise with colleagues across long distances, or focusing resources, creativity and dedication on their own neighborhood. I also conclude that the challenges of the safety net are longstanding, but that both persistence and new dedication are being applied to make improvements. And that key issues include workforce, quality improvement, collaboration and integration of health care and related services, and that these issues are affected by demographic and economic factors.

So using my own version of “thin-slice” thinking, which tends to be my default style anyway, I’ve concluded that the articles in this issue together give us a good window into the strengths and challenges facing Minnesota’s health care safety net. I hope you enjoy them. Let me know what you think.

Mark Schoenbaum can be reached at mark.schoenbaum@state.mn.us or (651) 201-3859.

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Minnesota Rural Health Advisory Committee Member Profile

Deb Carpenter

Minnesota Rural Health Advisory Committee Member Profile: ORHPC talks with Deb Carpenter

Please explain your professional work to us . . .

I am executive director of Northern Connections, a nonprofit organization in Perham, Minnesota, which provides supportive services to families with low wages in 12 counties in west central Minnesota. Northern Connections works on job retention, re-employment, career advancement and asset accumulation with families that have recently left the Minnesota Family Investment Program (MFIP) or the Diversionary Work Program (DWP). We connect them to resources that can help them meet the challenges of living paycheck to paycheck. We provide our services by telephone. This alleviates the need for transportation and child care, which are both huge barriers in rural Minnesota.

And your life away from work?

My husband and I live on a lake in the Erhard area. In the summertime, we enjoy boating in our pontoon and canoe and also bicycling and meeting up with a local bicycle club for summer evening rides. During the winter, we enjoy cross country skiing and snowshoeing. I also do some volunteering. I previously served on the Habitat for Humanity board. This fall I will be a mentor for the Kinship Program. I also have a 10-year-old grandson who spent three weeks with us this summer. We enjoyed our time with him as much as he enjoyed being “up north” and in and on the lake!

What do you think are the most important issues facing rural health?

There are a few areas that are challenging for rural health. As a consumer member on the Rural Health Advisory Committee I see availability and geography as primary challenges. It wasn’t until I moved to rural Minnesota and faced a serious health issue that I fully appreciated the issue of access. My care required me to travel 2 ½ hours each day to receive radiation therapy for six weeks during the winter months. Once the roundtrip was 5 hours. Traveling to treatment each day, while trying to work, was draining and I am younger and healthier than most of the individuals I saw there each day, many of them traveling even farther.

There is also an issue of access for specific types of care, such as dental care. Many of the families we meet through Northern Connections have Medicaid but service is still not available because most dentists in the region do not accept Medicaid. Apple Tree Dental’s mobile unit visits many communities once or twice a year but the appointments fill up quickly and it offers care only to children.

The other challenge is affordability. Many of our customers do not have health care coverage since many of the employers in this area cannot afford to offer it. Rural Minnesota is comprised of many smaller organizations and businesses. With health care increases of 22-23 percent each year it is difficult to provide health care to employees.

Age is the other issue. Rural Minnesota is aging faster than urban areas, posing real challenges in terms of workforce, transportation and the range of services required to meet these needs.

What do you think would make the most difference for rural health?

We need a plan to address the difficult issue of workforce. Many professions require increasingly costly training leaving students with heavy loans to repay. Loan repayment programs that encourage rural practice may be beneficial if they provided a large enough incentive to defray a sizable portion of the student loan.

More collaboration would be helpful. Rather than competing, regional providers could leverage resources to provide access to much needed services.

The Rural Health Advisory Committee advises the Commissioner of the Minnesota Department of Health and other state agencies on rural issues; provides a systematic and cohesive approach toward rural health issues; and encourages cooperation among rural communities and providers. Meeting information is online or contact Tamie Rogers at tamie.rogers@state.mn.us or (651) 201-3856.

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Community Focus

Nursing Outreach: building partnerships to enhance care

by Mary Pat McGinnes, Children’s Hospitals and Clinics of Minnesota

Whether they need assistance caring for a patient in crisis, are unsure about preparing a newly diagnosed asthma patient for discharge, or want to improve their ability to provide culturally sensitive care, nurses at Children’s Hospitals and Clinics of Minnesota have a range of nursing experts at their fingertips. They are further supported by a multidisciplinary team who provide critical insights and interventions—respiratory therapists, child life specialists and more. But those pediatric resources are not so readily available for nurses in smaller communities or at hospitals with few pediatric specialty services.

To provide children with comprehensive care over a continuum of health and illness, we depend on nursing colleagues throughout the community and region. As a specialty pediatric hospital, Children’s feels an obligation to share its nursing expertise. While Children’s has had a medical outreach program for some time, nursing outreach is relatively new. Phil Kibort, M.D., M.B.A., chief medical officer, says that several years ago, he and others at Children’s began to realize that “we were missing an important nursing component in our outreach efforts. Not only were we hearing from nurses themselves, but there were also physicians who were requesting support for nurses in their local hospitals.”

In addition, when Ginger Malone, M.S.N., R.N., became chief nursing officer, “she really recognized the role that nurses could play in outreach. She saw that it could help improve care in the region as well as allow Children’s nurses to share their knowledge,” says Kibort.

In 2005, Children’s developed the role of nursing outreach and created two new positions. Lynn Eidahl, R.N., M.A., is outreach nurse liaison and focuses on pediatric nursing outreach; Jill Bauer, B.S.N., R.N., is neonatal outreach nurse liaison.

Although Eidahl and Bauer coordinate much of the work, nursing outreach wouldn’t exist without the participation of many. “We depend on nurses throughout Children’s who share their expertise and collaborate with us to support nursing outreach efforts,” says Eidahl.

Building relationships

Eidahl and Bauer say that a successful nursing outreach program hinges on building relationships. They make regular visits to hospitals in Children’s referral region to learn first hand about their needs and to share information about Children’s nursing resources.

“I really enjoy meeting with the nurses from different hospitals,” says Eidahl. “Sharing our expertise is very satisfying and I am always impressed by the experiences these nurses describe—an emergency department nurse in a small hospital may go from caring for a sick newborn to an adult trauma patient in the same shift.”

Speakers Bureau

The backbone of nursing outreach is the Speakers Bureau, which sends caregivers from Children’s to hospitals throughout the region. Currently, 128 nurses are registered in the nursing outreach database as presenters. Last year 45 nurse-based Speakers Bureau events reached more than 1,000 nurses. One of the most popular topics is S.T.A.B.L.E. (sugar, temperature, airway, blood pressure, lab work and emotional support), a nationally recognized eight-hour program that helps nurses care for a premature or sick newborn during the post-resuscitation/pre-transport stabilization period. “At some of the smaller hospitals, nurses may not see a critically ill infant more than once every six months. This program helps them know exactly what to do until the transport team arrives so that when the team does arrive, they can just scoop up the infant and go,” says Bauer.

In addition to the Speakers Bureau, Children’s reaches out to nurses through conferences, nurse shadowing, rural nurse manager meetings, and streaming education.

Collaborative projects extend Children’s reach

Nurse experts throughout Children’s Hospitals and Clinics of Minnesota collaborate with many organizations to create innovative outreach programs for pediatric health care providers, such as:

Emergency care simulation. Karen Mathias, M.S.N., R.N., AP.R.N., B.C., director of simulation, oversees the Kohl’s Mobile Simulation Center—a specially designed motor coach staffed with experts in emergency simulations. It is the first pediatric program of its kind in the nation. Inside the center, participants work together on a simulated pediatric or neonatal emergency. The “patient” is a computerized mannequin that mimics symptoms of distress and responses to treatment. “In community hospitals, emergencies with children are less common and are especially stressful,” says Mathias. “Simulation training is a risk-free way for clinicians to understand each other’s roles, improve clinical skills, and learn to communicate in crisis situations.” A generous donation from Kohl’s Department Stores provided the initial funding for the project.

Palliative care. Jody Chrastek, M.S., R.N., C.H.P.N., pain and palliative care program coordinator, provides training, continuing education, resources, consultation and technical assistance to health care providers who are interested in developing more opportunities for pediatric palliative care in their communities. Children’s Institute for Pain and Palliative Care has received grants from the federal government, the Robert Wood Johnson Foundation, and the Bremer Foundation to support outreach activities. “There has been more interest in this area since the Institute of Medicine released a report in 2002 showing that pediatric palliative care lagged far behind adult palliative care,” says Chrastek. To meet the growing need, she and other colleagues have developed a variety of programs including inviting health care providers to attend workshops at Children’s, hosting regional workshops and following up with phone consultation and email. The pain and palliative care program also provides care for inpatients, outpatients, and home care patients.

“Inreach” is important, too

Gathering feedback from referral hospitals about their interactions with Children’s is another important part of outreach. “Part of doing outreach is actually doing ‘inreach’—using what we learn externally to change processes internally,” says Angela Stoltz, medical outreach program supervisor.

For example, neonatal transports are routinely reviewed. “This is a great way to identify opportunities to strengthen the relationships we have with referral hospitals. Children’s transport teams are at the front lines because they have direct contact with nursing colleagues in referral hospitals,” says Bauer.

While some might question whether sharing Children’s nursing resources so freely might hurt Children’s in the competitive health care marketplace, chief nursing officer Malone says that is not the case. “Outreach offers a way to learn from one another. Moreover, there is a strong commitment throughout the organization that nursing outreach is at the core of Children’s mission to provide next generation care.”

“Children’s is a leader in both neonatal and pediatric care, and as a leader it only makes sense that we would want to promote the best nursing care for all babies and children,” says Eidahl. By working with other hospitals Children’s strengthens nursing practice by continually evaluating processes and procedures.

More information is online. Go to the “Nursing at Children’s” page and scroll to the Nursing Resources links, or contact Jill at jill.bauer@childrensmn.org or Lynn Eidahl at lynn.eidahl@childrensmn.org or (612) 813-6904.

Program Focus

Loan Forgiveness: Helping a Student, Helping a Community

by Amy Vallery, Minnesota Loan Forgiveness Program administrator

“Loan forgiveness” has a great ring to it—especially if you have student loans. As the Minnesota Loan Forgiveness Program administrator, I know the challenges students face. I hear from medical school graduates with over $140,000 in student loans and dental students who expect to have nearly $200,000 in loans. Health professional students are eager to serve the community and explore practice locations, yet they are anxious about their educational debt load. The Minnesota Loan Forgiveness Program can help to address these issues.

The purpose of the Minnesota Loan Forgiveness Programs is to recruit and retain health care professionals to needed areas. Health professionals who agree to practice in areas of need receive funds for educational loan repayment in exchange for their service. Many factors influence health professionals’ decision about practice site and location—cost of living, employment for their spouse, raising children, recreational interests, their own background, as well as the opportunity to try the community on for size and see if it is a good fit. It is only when all these pieces come together that participants and the community they are serving benefit.

Loan forgiveness is one approach to increasing the supply of primary care physicians and midlevel providers practicing in rural Minnesota, nurses working in nursing homes, dentists serving public program patients, and faculty teaching in nursing or allied health. The Office of Rural Health and Primary Care offered awards to 40 new health professionals entering practice this year.

Keith Peterson is one of five newly graduating physicians selected for participation in the Rural Physician Loan Forgiveness Program this year. Keith began his practice in Ely, Minnesota this August. He spent much of his third year of medical school in Ely through the Rural Physician Associate Program. In a recent letter, Keith wrote, “Being in Ely for an extended time period gave me a sense of what it is like to practice medicine in a small town. I love the strong relationships many of the physicians have with their patients and I enjoy the challenge of a varied practice. Ely is a wonderful place with a strong sense of community. My wife and I are excited to become a part of the community and are very grateful to have been selected to be a part of the Rural Physician Loan Forgiveness Program. The program will greatly help us pay down our educational debt. Thank you to everyone who works to make the program possible.”

The Loan Forgiveness Program is accepting applications thru December 1, 2008, for selection into the program next year. Participants must agree to practice for a minimum of three years and use the state funds to repay their educational loans. Qualifying applicants include primary care residents, pharmacy students, midlevel practitioner students, nursing students, dental students or individuals studying to become nurse or allied health care faculty.

Primary care physicians, pharmacists and midlevel practitioners must agree to practice in rural Minnesota, defined as areas outside the seven-county Twin Cities metro area, with the exception of the cities of Duluth, Mankato, Moorhead, Rochester and St. Cloud. Nursing students must commit to practice in nursing homes or intermediate care facilities for the mentally retarded. Dentists must agree to serve enrollees in state public programs or patients receiving sliding fee discounts. Faculty must teach in a postsecondary allied health care or nursing program.

Minnesota Loan Forgiveness Program guidelines and applications are online or contact Amy Vallery at amy.vallery@state.mn.us or (651) 201-3870.

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Special feature

NorthPoint Health & Wellness Center

NorthPoint: Celebrating 40 Years in the Community

This year marks the 40th anniversary of NorthPoint Health & Wellness Center as a multiservice community health center in North Minneapolis.

Making History on the Northside

In 1965, Minneapolis documented poverty and need in the inner city, which was particularly acute in North Minneapolis. To address these needs, Minneapolis began a city-wide community action program called Decision ’67, coinciding with the Neighborhood Services Program (NSP) begun through President Lyndon Johnson’s War on Poverty. Under NSP, five federal agencies collaborated to establish 13 multipurpose service agencies, called Pilot City projects, in poor neighborhoods across the country—including Minneapolis.

By June 1967 planning for the Minneapolis Pilot City program was underway, and included representation from the Northside Federation, an umbrella group representing 78 Northside resident groups, agencies and institutions. Stella Whitney West, chief executive officer explains, “I believe that Pilot City—the last of the demonstration projects—is still thriving because a lot of time and effort was put in on planning and bringing in community members to develop a model that had sustainability. The key was that early-on involvement.”

Pilot City Health Center opened in January 1969 and by March had seen 1,200 patients. Dental and mental health services were soon added. In keeping with the original model to create access to health care, economic development, education and social justice, in 1974 a new human services buildings was completed, allowing Pilot City to expand and house programs such as Big Brother, Big Sisters; Putting It All Together (program to motivate unemployed single mothers), University of Minnesota Extension classes, Minnesota’s largest energy assistance program, Metropolitan Visiting Nurses Association, furniture pickup, and a tool lending program.

Part and heart of the community

During the 1970s, Pilot City Health Center was transitioned to Hennepin County while Pilot City Regional Center remained a separate entity. But in 2004, Pilot City Health Services was reunited with Pilot City Regional Center and renamed NorthPoint Health & Wellness Center. This merger was designed to improve patient care by integrating health and human services on the NorthPoint campus—providing a one-stop for clients’ social, physical and mental health needs. Currently, NorthPoint Health & Wellness Center (NorthPoint) is both a department of Hennepin County and a private nonprofit organization with a unique model of shared governance. 

NorthPoint Inc.’s clinics offer a comprehensive array of primary care services including family practice, obstetrics, internal medicine, pediatrics and specialty care. In addition, NorthPoint provides full service dentistry and behavioral health services. Teen services are provided at North High School and Plymouth Christian Youth Center. Ancillary services include optometry, nutrition services, laboratory, a full-service pharmacy and radiology. Because many North Minneapolis residents experience barriers to health care, NorthPoint facilitates services with transportation, culturally competent and multilingual staff, translation, assistance in applying for public programs, and a sliding fee scale.

“We do a lot of advocacy. By having a food shelf we encourage good nutrition. We have multiple outreach efforts such as WIC, HealthyStart for pregnant women, diabetes support groups, a smoking cessation program, Breathe Free North—a smoke free homes social marketing program, chemical dependency assessments, charter school screening and dental education programs,” explains Whitney West.

Plans are underway to construct new facilities that will house NorthPoint’s Behavioral Health Clinic and Human Services, the University of Minnesota’s Child & Family Center, a YMCA Health & Wellness Fitness Center, Hennepin County Human Services & Public Health, Hennepin County Juvenile Corrections and several community nonprofit and educational organizations. NorthPoint and its partners in this new facility will be operating within the context of a Family-Community Wellness Model to coordinate and integrate services to achieve improved health outcomes. The new building will be connected to the existing clinic building and to a new parking ramp.  

Avoiding the band-aid approach to solving problems and treating symptoms

Much of NorthPoint’s success is attributed to the long held partnerships with community organizations. Especially important is the merger of essential social services to help families achieve self-sufficiency and wellness. Outreach through the efforts of community health workers also connects residents in need of services to the NorthPoint campus. The Innovation Center is the home for developing, planning and testing ideas. Through this new unit, NorthPoint has a mechanism for working with the community and partners to learn about and develop the most effective ways to improve health and well-being in North Minneapolis.

Whitney West sums up 40 years in the neighborhood this way, “The staff are indeed health care heroes. They establish relationships with their patients and families—even generations. Many of our staff began coming here as children and have developed a career here to give back to the community.”

More information on the NorthPoint Health & Wellness Center is online.

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View online all previous issues of the Office of Rural Health and Primary Care publications.

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Minnesota Office of Rural Health and Primary Care
P. O. Box 64882
St. Paul, Minnesota 55164-0882
Phone (651) 201-3838
Toll free in Minnesota (800) 366-5424
Fax: (651) 201-3830
TDD: (651) 201-5797
www.health.state.mn.us/divs/orhpc