Contents:

• Profile
• Partner Focus
• Community Focus
• Director's Column

quarterly
newsletter:
Winter 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.

Photo courtesy of ©Explore Minnesota Tourism  

RHAC MEMBER PROFILE

John Baerg

Baerg Family Farm

RHPC talks with Rural Health Advisory Committee member John Baerg

Please explain your professional work to us . . .

I have been a Watonwan County commissioner since 1996 and was re-elected this fall for another four-year term. Watonwan County is in south central Minnesota, St. James being the county seat. As one of five county commissioners, I administer roads, ditches, ordinances, libraries, programs in the county and county jail, Emergency Management, along with Health and Human Services for county residents with low incomes, and the list goes on and on. This is supposed to be a part-time position but it is not uncommon to attend 15 meetings a month plus responding to our constituents. The varied responsibilities at times seem overwhelming; however, we have good staff helping us. My special interests are Health and Human Services, Emergency Management, and Drug Court.

I am secretary/treasurer of the Association of Minnesota Counties. I am also the Association’s Health and Human Service Policy chairman, which places me in lobbying positions for health and human service issues at the Capitol. My interest in health care encouraged me to serve on the St. James Hospital Board, and an advisory board to a long term care facility advisory board, the Minnesota EMS Regulatory Board and to be an EMT in St. James Ambulance Service. I was pleased to receive an Outstanding Dedication to Local Public Health Award from the commissioner of the Minnesota Department of Health. I especially like working in public health because prevention of illness is a goal of mine.

And your life away from work?

My life’s work has been farming. I am now retired; however, my wife Marjorie and I still live on the farm and lease the cropland to a neighbor. When we were actively farming, she and I worked as a team. That is still true—I keep my hand in farming with a large garden and Marjorie cans and freezes the results. When Marjorie has had enough produce we give it to family, friends, and whoever will take it!

Marjorie and I have four children and five grandsons, who like to come to the farm and explore interesting things and have a bonfire and a wiener roast.

Along with others, I helped develop a rural water system to serve farms in an eight-county area. This system now provides 2,000 rural farm locations and eight small communities with pure drinking water. I also was an officer with Minnesota Rural Water Association and then a member of National Rural Water Association—a very interesting learning experience.

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

Looking around and listening to my friends and neighbors most people seem to be satisfied with their health care. Sometimes people wish for better access to special health professionals. At times a diagnosis is difficult to reach. Health specialists are always a long distance away and the wait for an appointment is too long. Treatment and guidance specialists are needed for the growing alcohol and other drug addiction problems. The dedication of our health care professionals in rural areas is very good; however, they may be overworked. When I look at the reduction of some illnesses from years ago I see how public health has been a positive factor in making for a healthier community—and, of course, it needs public financial support to continue.

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

Bringing more health specialties to the rural areas would make the most difference. The time and money to drive to a specialist are great. Often an appointment is a four- to six-week wait. It is not good to suffer in pain, or worse yet, have a condition worsen while waiting to see the correct provider. The loan forgiveness program needs to be expanded or made more attractive to encourage health care providers to come to rural or underserved areas. This is especially true for the mental health specialties. Training and incentives for EMTs and First Responders need to be improved so that when a person enters the Trauma System they are transported quickly with proper care.

Rural Minnesota is a good place to live. We have a good safe environment and great outdoor activities. By working together we can keep that going.

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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PARTNER FOCUS

Sally Buck

Kami Norland

Creating a Culture of Wellness in Rural Communities

by Sally Buck, associate director, and Kami Norland, community specialist, Rural Health Resource Center-Duluth, Minnesota

During 2008, the Rural Health Resource Center developed a multistate initiative to improve the health of individual communities and their economies through a pilot called the Culture of Wellness. The Northwest Area Foundation funded this initiative to help rural communities in its eight-state region design and implement broad based strategies to optimize the health of their diverse populations, and reduce poverty. Moose Lake and Madelia, Minnesota, and four locations in Idaho and Montana were selected for participation in the pilot. Selection was based on previous community organizing success, health leadership, the presence of a Critical Access Hospital, a population under 5,000, and the level of community poverty.

Health is a Community Asset

America is facing a health care crisis. Our waistlines and chronic disease rates have exponentially increased over the last 25 years adversely affecting our health, our communities and our economy. Traditional thinking on health focuses on illness rather than wellness, pills rather than healthy eating and exercise, downstream treatment rather than upstream prevention and is primarily driven by reimbursement and money. These factors led to the current health trends of a rise in obesity, diabetes and heart disease. Eighty percent of all chronic disease is caused by three preventable behaviors: poor nutrition (overeating, yet being undernourished), physical inactivity and smoking. These factors combined with poverty, skyrocketing health insurance costs, and inaccessibility to health care, puts an economic strain on families and their communities.

The Culture of Wellness helps communities identify their most important health needs and develop community goals and strategies to address their concerns. It builds on local perspectives, strengths and expertise so each community is working to address its own health needs.

The individual health of citizens is often an overlooked community asset. Improved health is linked to increased employability and reduction in poverty. When people are well, they are able to gain and maintain employment, which circulates revenue. School and work absenteeism rates are less for healthy individuals, which translates into greater production and economic security.

It is also optimal to keep health care dollars within the local community. While the vast majority of health care can be provided locally, rural citizens often drive to large medical centers, making health care and non-health care purchases. It is estimated that within a typical rural community, millions of dollars of revenue are lost in this way. This revenue could be retained by enhancing local access to health information and services thereby improving community health and economic growth. Embracing a Culture of Wellness will improve the overall function of the health care system and reduce health care costs and improve the economic viability of rural communities.

Developing a Culture of Wellness

The Rural Health Resource Center begins the Culture of Wellness initiative by identifying community liaisons at Critical Access Hospitals (CAH). These leaders are drawn from a variety of positions within the CAH, including administrators, marketing directors, quality directors, and at one hospital the physical therapist. Next, a Community Council is recruited from city leaders, chamber of commerce members, school superintendents, principals, hospital and clinic board members, senior advocates, the media, local health care providers, public health, youth, representatives from the economic sector and business owners. Together, the Community Council, the hospital liaison, and staff from the Rural Health Resource Center identify assets and needs in the health care system using a community health survey, secondary data analysis, focus groups and an economic impact assessment conducted by the Office of Rural Health and Primary Care.

The group creates community health goals using a systems approach to increase success and sustainability. This enables communities to address health goals from multiple perspectives: community assets, services, partnerships and the economy. The Culture of Wellness health initiative is unique because it frames health goals using a strategy map to unite the community’s vision and provide direction in goal development. Each community can customize the Culture of Wellness strategy map template, which offers a holistic view for addressing health goals.

A Community Health Scorecard is then created to articulate the community’s health goals and action steps, which measures and monitors success, identifies gaps in performance, and facilitates communication and partnerships. The Community Health Scorecard is a framework for aligning people, processes and resources to improve individual, community and economic health. This alignment comes through understanding the community health vision and identifying each citizen’s role in the health goals.

Community Health Goals

Creative thinking through the Culture of Wellness can generate opportunities for rural residents to access resources beyond the traditional health care delivery systems of medical clinics, dental clinics and hospitals. Prevention and wellness resources, without traditional funding rules and constraints, could be placed in non-medical and clinical settings, such as “health resource workers” in libraries and community centers, community health workers rotating at daycare centers, or oral hygiene products and services in schools and senior centers. These alternative methods create local job opportunities that don’t require extensive years of training, but enhance access and delivery of health care to more diverse populations.

The Rural Health Resource Center has also been assisting Culture of Wellness communities develop directories to promote education and awareness of local health services. The next step for the Rural Health Resource Center is to develop a leadership curriculum geared toward rural hospital administrators, boards, physicians and community members for a combined effort in building a Culture of Wellness in rural areas throughout the nation.

For more information on the Culture of Wellness health initiative, contact Kami Norland at the Rural Health Resource Center, in Duluth, Minnesota, at 1 (800) 997-6685 extension 223 or by email at knorland@ruralcenter.org.

Community focus

Community Dental Clinic in Maplewood

Community Dental Clinic in St. Paul

FOCUS ON ORAL HEALTH: COMMUNITY DENTAL CARE CLINICS

At the same time that evidence suggests a relationship between periodontal health and overall general health, many people lack access to dental care. Over the next few issues the Quarterly will explore how innovative dentists are addressing need in their communities. This issue looks at the successful work of Vacharee Peterson, D.D.S. and chief executive officer of the Community Dental Care Clinics in the Payne-Phalen area of East St Paul and in Maplewood.

Community Dental Care is a nonprofit organization and community dental clinic. For over 20 years it was the private practice of Peterson & Peterson Dental Clinic and one of the first private clinics in the metro area focusing on ethnic minority patients with low incomes. To ensure continued access to high quality dental care for the 90 percent of their patients enrolled in public programs, the clinic was incorporated into a nonprofit in August 2004. Of the clinic’s 20,000 plus active patients served within the last three years, 80 percent are members of an ethnic minority, and 50 percent are children under age 18. Dr. Peterson explains, “By offering dental care and preventive programs in a culturally and linguistically sensitive manner, we improve patients’ overall health and quality of life.”

Staff

Almost 80 percent of the 71 full-time and 25 part-time employees are ethnic minorities and three-quarters are bilingual in English and Hmong. Other spoken languages include Chinese, Farsi, French, Hindi, Laotian, Oromo, Spanish, Tagalog, Thai and Vietnamese. Staff are also experienced in delivering treatment through the communication services of interpreters. “Our dentists and staff are multilingual and multicultural and they pride themselves on being gentle, kind and compassionate,” explains Dr. Peterson.

In addition to full-time employees the clinic also operates with the help of dental hygienists and dental assistants from Century and Herzing Colleges, along with interns and externs from dental schools. The clinics provide on-site clinical training and the students see cultural competence in action and learn community dental practices.

How it works

Community Dental Care Clinics treat patients of all ages, races, ethnic backgrounds and economic circumstances. The decision was made not to restrict the number of public program patients in spite of low reimbursement rates, difficult procedures for filing claims, and a high rate of no-shows. Instead husband and wife team Drs. Andrew and Vacharee Peterson adapted or created operational and administrative systems to improve clinic cost-effectiveness and productivity.

Dr. Andrew Peterson designed a software system for filing claims electronically directly connected to public program systems. This accommodates electronic billing for Medical Assistance, bypassing clearinghouse fees, saving staff time and increasing collection rates. Dr. Vacharee Peterson developed a uniform record-keeping system for simple, accurate and organized communication among clinic personnel about patient treatments, which follows the Minnesota Board of Dentistry rules and regulations.

The clinic adapted a system of double-booking appointments to increase productivity by making up for 30 to 50 percent of no shows. Volume dentistry offsets the low compensation of public program reimbursements. They hire dentists with an interest in developing special skills such as oral surgery, pediatric or endodontic dentistry so the clinic can refer among its own providers.

The clinics offer staff a complete benefits package including insurance, in-office dental care for family, vacations and education reimbursement. Competitive wages and benefits ensuring quality employees became possible with nonprofit status. As a nonprofit the clinics receive additional reimbursements for services from the Minnesota Department of Human Services Critical Access designation and as a community clinic.

The original clinic has expanded seven times. What began as a one-dentist office occupying 600 square feet grew into 24 operatories between two clinics with 21 dentists and 75 auxiliary staff.

In 2007, 94 percent of Community Dental Care’s patients were on public programs; 6 percent were patients with commercial insurance; and 4 percent were self-pay patients. Every self-pay patient receives a 10-40 percent discount based on a sliding scale. In addition to the sliding scale, Community Dental Care maintains a patient emergency fund of between $10,000-$30,000 per year funded by private donors, foundations and the clinic. This fund is used to offset patient fees for truly indigent patients; priority is given to emergency patients in pain, homeless and minor patients, and patients on General Assistance who must copay for all non-preventive services.

With new legislation shifting toward utilization of expanded-function dental assistants and hygienists, the clinics intend to make every room into a multi-function operatory equipped for both operative and hygiene treatments. This will improve the ergonomic delivery of dentistry, increase efficiency, decrease clinic costs and save patients from waiting for available space or equipment or returning later for another appointment.

Focus on Children

Research shows that tooth decay is the most common chronic childhood disease, affecting 50 percent of U.S. first graders. Despite the reduction in cases of caries in recent years, more than half of all children have caries by the second grade, and, by the time students finish high school that rises to around 80 percent. Low income is a known risk factor for several oral diseases, including dental caries. To increase the number of children who could be treated, and provide an alternative for parents who didn’t want or couldn’t afford in-hospital treatment and anesthesia, Dr. Vacharee Peterson invented the PedoBurrio. Patented in 1995, it remains the only parent and child-friendly restraining device approved by the FDA.

Throughout childhood and adolescence, there are many opportunities for the primary prevention of dental decay. The earliest opportunity occurs during prenatal counseling about diet, oral hygiene practices, appropriate uses of fluorides, and the transmission of bacteria from parents to children. The clinics reach out to pregnant women by explaining that the 20 primary teeth that will erupt in the first two and one-half years are already present in the baby’s jawbone. The clinics suggest children begin coming into the dental clinic at 6 months and guides parents how to care for their children’s teeth and gums. The clinic staff shows parents and children how to brush and floss, and what foods to eat to prevent tooth decay. And Dr. Peterson adds, “Just in case a smile and a healthy mouth isn’t enough, each time they visit the dentist, they get a special gift!”

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DIRECTOR'S COLUMN

Mark Schoenbaum

What would it look like?

In recent columns I've written about health reform developments underway in Minnesota and their possible impacts on the health care safety net. With such major change in the air, it can be hard to see what the safety net health care system will look like as these changes unfold, and how we can get from here to there. This past fall, three work groups prepared responses and recommendations to make sure these changes work for safety net systems while achieving policymakers' goals for better quality, efficiency, transparency and access. As these work groups explored how health reform could work for both rural and inner city areas, they examined some trendsetting efforts that offer a preview of the future.

The Rural Health Advisory Committee's project to develop a new rural health care delivery model finished its work in October, and its report will be available soon. Last year the advisory committee reviewed trends affecting the future of rural health in Minnesota. After noting growing workforce shortages, rapidly evolving technology, changing demographics, financial pressures, and the heightened expectations of citizens and health care payers, the committee concluded that a whole new model of rural health care is needed.

The work group they established looked at these trends and at Minnesota's health reform legislation. They pictured a model that acknowledges and builds on the connections between our everyday lifestyles and our health, the primary care that takes place during clinic visits, and the broad continuum of services needed to recover from illness and manage chronic conditions.

The work group noted that rural health systems have the agility to try new concepts that build on existing services for their patients. For example, they heard that Lakewood Health System in Staples has already developed a working health care home model. This rural health system is applying the principles of the health care home to their chronically ill patient population, including provider-supervised patient care, individual care plans with follow-up, electronic health records, medication management, and care coordination with home care, pharmacy and physical therapy.

They also learned of a great example of the connection of acute and post-acute care from the Sanford-Canby Health System, where telehome monitoring is provided for local patients in need of chronic care management. The collaboration involves home care nurses and pharmacists monitoring patients and intervening before crises occur. Simple equipment in frail seniors' homes keeps the patients connected to their health care providers and allows them to continue to live independently and avoid additional hospitalizations.

The group also heard from St. Elizabeth’s Hospital in Wabasha, where the connection between acute care and clinic services has filled a gap in the community’s need for mental health services. St. Elizabeth’s is one of the few small, rural hospitals with a full-time psychiatrist. Mental health services are coordinated with the hospital’s medical services, resulting in better management of a patient’s physical and mental health needs. As a Critical Access Hospital, St. Elizabeth’s is actively involved in assessing, prioritizing and marshalling the necessary resources to address community health needs.

The work group didn't get all the way to its ambitious goal of designing a whole new system, but it did make the vision more tangible, and it offered recommendations that will be important to achieving health reform’s potential statewide. Among its recommendations:

• Encourage and support efforts by higher education to offer training in team-based, inter-professional care. Broaden providers’ understanding of health care homes through education and leadership development.
• Pursue rural primary care workforce development strategies simultaneously with health care homes development.
• Provide health care home startup funding for small and rural providers and ensure equitable participation from small, rural and independent health care providers. Establish multiple options for health care home certification. Provide for community self-assessments for health care home readiness.
• Encourage communication improvements across a variety of sectors and encourage financial collaborations for meeting technology needs.
• Make payment reform a priority to reward provider collaboration.

This fall, two work groups created by the state legislature explored workforce changes to accompany an evolving health care system. A Health Workforce Shortage Study Group examined licensing and regulatory changes to ensure staffing for Minnesota's new health care homes initiative and the primary care system as a whole. In addition to recommending changes to better allow advanced practice nurses and physician assistants to practice “at the top of their license,” the work group also examined how pharmacists could be more fully integrated into the primary care team, enabling each discipline to put its full knowledge and skills to use.

Current pharmacist integration projects are tangible illustrations of what a reformed system looks like. One of the group’s members practices as a pharmacist in rural Paynesville, with his office in the clinic alongside other members of the team. And at Twin Cities community clinics such as North Point, Cedar Riverside and West Side, pharmacists are providing clinical pharmacy services to improve patient safety and care.

Finally, an Oral Health Practitioner Work Group weighed in on details needed to implement the new midlevel dental provider created by the 2008 Legislature. This provider will be a new member of the dental team intended to improve access and patient care. The work group reviewed similar models in Alaska, Canada, New Zealand and Great Britain.

Health reform changes will start to become concrete over the next few years, though as baseball great Yogi Berra put it, "It's tough making predictions, especially about the future." Berra would be proud, though, of the insights and examples brought to us by this year’s Minnesota work groups. Yogi is also the philosopher who said “You can observe a lot by just watching.”

Mark Schoenbaum is director of the Office of Rural Health and Primary Care and can be reached at mark.schoenbaum.state.mn.us or (651) 201-3859.

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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