Spring 2009 Quarterly Newsletter





photo of Margaret Kalina

Margaret Kalina

ORHPC talks with Rural Health Advisory Committee member MARGARET KALINA

Please explain your professional work to us . . .

I am the director of Patient Services and chief nursing officer at Douglas County Hospital, a 127-bed, acute care hospital in Alexandria. I am also a member of the Minnesota Hospital Association Policy and Advocacy Committee and Patient Safety Committee. As director of Patient Services, I am responsible for the Department of Nursing, Infection Control, Quality, Education and the Mental Health Out-Patient Unit. We have 610 employees and approximately 300 are in the Department of Nursing. We are in the middle of a $28 million building project scheduled to be completed in June of 2010, which includes an 80,000 square foot expansion. Plans feature a three-story addition on the southeast side of the hospital. The ground floor will be the new home of Alexandria Orthopedic Associates, P.A., while the second and third floors will consist of surgical inpatient rooms and a new maternity unit.

And your life away from work?

My husband Darrel and I are both originally from Alexandria. Darrel works at Runestone Electric Cooperative and we live south of Alex on his childhood farm. We both love gardening, the lakes, and summers in Minnesota. We have three grown children. Patrick, his wife Haley and their son Sam live in Alex. Pat works as the marketing coordinator for Alexandria Area Economic Development Commission. Frank also resides in Alex, and operates Midwest Pressure Washer. Rachel is a freshman, pre-nursing major at North Dakota State University. On weekends I am an organist at an area church. Occasionally, I teach a leadership class to nursing students pursuing their four-year nursing degree.

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

Recruiting and retaining physicians and other health care providers is very difficult in rural Minnesota. In general, the salaries are lower than metro areas so we are competing for providers.

In today’s economic climate, it is vital that health care institutions provide quality services in the most efficient manner. The net operating margin must be sufficient for reinvestment in the institution to provide quality state-of-the-art health care.

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

A high percentage of hospital patients in the rural setting are covered by government programs, Medicare and Medicaid. But the reimbursement level for Medicare and Medicaid patients is generally lower in the rural area than in the metro. If the reimbursement was increased for these patients, more competitive salaries could be offered to physicians and other health care providers to recruit and retain them.

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.



photo of albert lea

Walkability study in Albert Lea

Albert Lea on the move into the Blue Zone

It was the middle of January. It was 34 degrees below zero. Albert Lea was in the middle of a walkability study—an audit to determine how the city could become more bikeable, walkable and livable. It was an invigorating start to Albert Lea’s participation in the AARP/Blue Zones Vitality Project.

The AARP/Blue Zones Vitality Project is a 10-month project designed to improve health and projected life expectancy. It encourages the development of social networks; provides healthier restaurant menu options; and makes it easier to get around on foot or by bicycle to create the kind of community where healthy habits are natural. The project, funded by United Health Foundation, sets an ambitious goal of adding at least 10,000 years of projected life expectancy to the people of Albert Lea (two years of projected life expectancy per participant) through environmental and individual changes.

What are Blue Zones?

In the 1990s, native Minnesotan Dan Buettner was transmitting videos and stories into classrooms from his cycling expeditions around the world. During these trips he became interested in demographics and longevity and began his research into “Blue Zones,” his term for regions with the longest disability-free life expectancy or concentration of persons over 100.

Over six years, Buettner and his team of physicians and demographers studied four “Blue Zones,” specific regions whose populations are reaching age 100 at an extraordinarily high rate: Loma Linda, California; the Nicoya Peninsula in Costa Rica; Okinawa, Japan and Sardinia, Italy. These Blue Zones have a sense of community—an element of happiness and vitality that goes beyond a diet and exercise program. The team identified and studied common threads in lifestyle, behavior, diet, outlook and stress-coping mechanisms.

The AARP/Blue Zones Vitality Project is designed to replicate elements of these common practices in other communities around the country. AARP’s highest priorities are health and economic security for all generations. The joint project is combining AARP’s healthy behaviors expertise and Blue Zones’ longevity expertise to help Americans live longer, healthier lives.

Buettner explains, “The goal is to add two years of good life—to live long and live well. We know that additional years of life and better health can be achieved through some relatively simple changes. We are putting this to a test by selecting Albert Lea to take the Vitality Project challenge with the intent that if one city can do it, more can and will follow along. We are looking for a scalable public health initiative that can be replicated by other American communities and individuals.”

Enhancing health and longevity

The average life expectancy in America is about 78. The capacity is 90. The AARP/Blue Zones Vitality Project is looking for the other 12 years by focusing on four areas considered to be crucial to health and longevity: Community Environment, Social Networks, Habitat, and Individual Sense of Purpose. 

Improving Community Environment means making the healthy and active option the easy option. Are sidewalks and bike trails available, smooth, safe and well connected to the places people need and want to go? Can employers, community centers, faith communities, public sports facilities and schools that serve food make more nutritious options available? A community-wide audit will assess improvements that can be made.

Emphasizing Social Networks focuses on helping participants identify and spend time with friends and family who have a positive impact on their health. In addition, it aims to encourage participants to expand their social circles to include more positive influences. Research shows that our social circle has a powerful impact on our long-term health behaviors.

Improving Habitat means making subtle changes to home and work environment to increase calories burned and reduce the calories eaten. Experts will help residents improve their personal environments and eat healthier without thinking about it.

People who have an Individual Sense of Purpose in life live approximately seven years longer than those who tend to drift through their day. The Vitality Project will feature seminars to help residents identify their values, passions and talents, as well as find outlets to put these qualities to good use.

Measuring progress

The success of the project will be measured by asking participants to calculate their life expectancy with a longevity calculator called the Vitality Compass™. This will happen twice—once at the beginning and again at the end of the project. The Vitality Compass estimates life span based on current lifestyle and habits. It also estimates how many of those years will be healthy years.

Blue Zones collaborated with the University of Minnesota-School of Public Health to create the Vitality Compass. It is based on a scientific algorithm created by using more than 350 recognized studies that measure the impact of certain behaviors on health. When it is taken more than once, the Vitality Compass measures the impact of changes in behavior and adjusts its projection. The compass is a series of 35 questions, which takes about four minutes to complete. While the Vitality Compass is an accurate predictor of how behaviors affect longevity, it is not a health-risk assessment tool. Rather the Vitality Compass helps individuals understand and improve their positive healthy behaviors.

Why Albert Lea?

The University of Minnesota helped design the right community size to select for the pilot project. After reviewing the demographic and health statistics of several small cities in Wisconsin and Minnesota, targeted cities were asked to apply and they competed to be the subject of the Vitality Project. Community leaders sent in comprehensive proposals explaining how they would help this project succeed. Albert Lea was selected as the pilot because:

  • Public health experts recommended piloting the project in a town of 10-20,000 people. Albert Lea has approximately 18,000 residents.

  • Elected officials, school administrators, the health care providers and employers in Albert Lea made a commitment to support community changes and to help individual residents make personal changes.

  • Albert Lea has statistically average health conditions for the United States so any other average city in America will be able to replicate this project.

  • Albert Lea is close to the headquarters of Blue Zones and the University of Minnesota. Dan Buettner is leading the effort. Faculty from the University of Minnesota are acting as academic advisors, providing research insights and helping to measure the success of the project.

The walkability audit validated many things that Albert Lea’s leaders already knew. The town has a historic form that makes the community a good place to live and invest. The presence of a well located, quality downtown, with good streets, roads, a waterfront, trails and neighborhoods made for an excellent start for the future. The walkability study also determined that bicycle parking in the downtown lends little support to bicyclists. Seniors have too few places to sit. Principal roadways lack bike lanes or other friendly features. Sidewalks are needed to support children walking to school, in and around all senior centers, and as approaches to all retail centers. Crosswalks need to be repainted to increase their visibility.

Albert Lea is finding opportunities to listen to the citizens and to involve them in volunteering and decisions regarding community improvements and opportunities. These efforts will engage residents to make personal changes that require little or no ongoing effort but will improve their health and increase their longevity. 

For more information, to participate in the AARP/Blue Zones Vitality Project or to take the Vitality Compass, go to www.bluezones.com. To learn more about Buettner’s experiences and insights leading up to the project, read his book, The Blue Zone: Lessons for Living Longer From the People Who’ve Lived the Longest.

Community focus

Photo in Rice Regional Dental Clinic

photo in Rice Regional Dental Clinic

photo of dental student and patient

Dental student Matthew Sievers with his patient D.J. and young D.J.'s mother

In the Winter 2008 Quarterly, ORHPC began a series on oral health, exploring how innovative dentists are addressing need in their communities. This issue looks at the successful work of Rice Regional Dental Clinic at Rice Memorial Hospital in Willmar.

by Karen Carlson, clinic administrator

Access to oral health care is a challenge, especially in rural areas, and Minnesota is no exception. After more than two years of planning and raising $2.6 million in public and private support, including $500,000 from the Office of Rural Health and Primary Care Clinical Dental Education Grant Program, Rice Regional Dental Clinic in Willmar started taking patients in December 2007. The primary focus of the clinic is to serve uninsured or underinsured patients in a 17-county area of central and southwestern Minnesota who are unable to access or afford dental care.

Located in and owned by Rice Memorial Hospital, the clinic gives the University of Minnesota’s dental and hygiene students a chance to enhance their clinical skills by treating patients with diverse oral health needs. Although oral health is not traditionally thought of as a hospital-based service, more and more rural hospitals are becoming involved as the shortage of dentists worsens.

Getting Started

In 2005, as chief executive officer of Rice Memorial Hospital, Lorry Massa approached the University of Minnesota School of Dentistry to help find a way to meet the area’s burgeoning dental needs. Massa asked the School of Dentistry to work with the hospital on behalf of the thousands of underserved patients in central and southwestern Minnesota, many using public assistance programs, who have a difficult time accessing dental care.

Rice’s mission of restoring and promoting health and well-being was a good fit with the School of Dentistry’s commitment to outreach, which has long included a learning tour of duty away from campus. Through this community-based clinic, Dean Patrick Lloyd, D.D.S., recognized the opportunity to meet the needs of central and southwestern Minnesota residents and contribute to the University’s educational efforts.

Overwhelming Response

On its first day of operation, patients filled the 10 chairs of the Rice Regional Dental Clinic. The response was immediate and overwhelming. Even though publicity was minimal—patients mainly heard about the facility through local social service agencies—the clinic staff fielded 92 phone calls in the first half day it was open. In the first 12 days of operation it hosted 171 patient visits. After 15 months of operations, interest remains strong. Hundreds of calls continue to come in on new patient call-in days.

The state of the art 6,100 square foot clinic is equipped with digital radiography and integrated practice software with electronic patient records. One room is equipped with a ceiling mounted lift, for transferring patients who use wheelchairs into the dental chair, for optimum oral health care.

Students who elect to participate in the clinical rotation in Willmar work under the direction of adjunct faculty member Robert Erickson, D.D.S. Dr. Erickson is a University of Minnesota School of Dentistry alumnus who relocated from Wisconsin to lead the program. In 2008, the students performed over 13,000 procedures during 6,200 patient visits. Many patients have not had a dental exam in five or 10 years or even longer and need multiple appointments to complete their treatment plan.

On average, a dental student performs 10 procedures per day at Rice Regional Dental Clinic. Because of the high one-to-four faculty-to-student ratio, students see more patients each day than then they would in the University’s on-campus dental clinics. The setting helps students hone skills they will need in practice while exposing them to every kind of dental condition.  

The dental clinic utilizes many different funding sources. The clinic was awarded a three-year, $375,000 federal Health Resources and Services Administration grant to assist with operating expenses and to enable the clinic to offer a sliding fee for uninsured patients. About 80 percent of the patients have Minnesota Care or Medical Assistance insurance, which covers approximately 60 percent of the clinic’s operating expenses. Private foundations, including Delta Dental, UCare and the Bremer Foundation, awarded three-year grants that will cover the other 40 percent and will carry the clinic through the first three to five years of operations. Going forward, it appears fairly certain that insurance reimbursement alone will not cover the clinic’s day-to-day operating costs so grant writing and fund raising will be ongoing and sustainability will be a challenge. 

One of the program’s goals is to introduce students to community and professional life in underserved rural areas. Students whose educational experience includes clinical rotations in rural and underserved areas are more likely to choose to practice in these areas after their training is complete. While in Willmar, dental students reach out to students in area school districts through interdisciplinary community service activities, building on the efforts of the Southern Area Health Education Center (AHEC). AHEC is another University-community partnership, which encourages students to consider health careers in underserved areas. As a result of Rice Memorial Hospital’s commitment to training health professionals, it became the host site for the Southern Area Health Education Center office. The relationship between the hospital and the Southern AHEC office greatly contributed to bringing the dental clinic collaborative effort to fruition. While in the area schools, the dental students teach children about proper oral hygiene techniques and encourage them to consider careers in dentistry. 

Going Forward

The most recent addition to the clinic is a School of Dentistry Pediatric Resident Dentist Program two weeks a month to help alleviate waiting months for appointments. Pediatric visits at the clinic are limited to the 12 and under age group.

Because the clinic is hospital-based it opens the opportunity for future inter-professional experiences, such as an endodontic resident. Very few endodontic specialists in Minnesota accept public assistance program payments making this a much needed service for the 10,000 plus residents on public assistance in the clinic’s 17-county service area. 

For more information, contact Karen Carlson, clinic administrator, at (320) 214-2621 or email kcarl@rice.willmar.mn.us


photo of Mark Schoenbaum

Mark Schoenbaum

Survival Tools

"It was the best of times, it was the worst of times. . ." So Charles Dickens begins A Tale of Two Cities, his novel set before and during the French Revolution. I was reminded of this quote thinking about the tumultuous environment for Minnesota's health care safety net.

The recession has definitely hit the health care sector. With uninsurance rising and the insured acting cautiously, the volume of discretionary health care is down and uncompensated care is up, reducing revenues while increasing costs. The stability of reimbursement levels is uncertain. Some health care organizations have laid off staff; in other areas workforce shortages persist. These challenges are intensified for safety net providers in both Greater Minnesota and the Twin Cities.

Conversely, the federal stimulus package has already begun to infuse unprecedented support into Minnesota's health care safety net. Open Door Health Center in Mankato, which had been struggling to serve its region, not only received first time funding from the stimulus budget, it has already received a second federal grant. Minnesota's community health centers have received $4.8 million to date in new federal stimulus support for their care of the underserved. The stimulus package also includes cash incentives and affordable loans for use of electronic health records, additional funding for health professions education and insurance support for the newly unemployed.

State health reform is underway, and federal health reform may be on the horizon. To many those are positive developments; others are not so sure.

Our job at the Office of Rural Health and Primary Care is to be the most help we can in this environment. We try to be a voice for the safety net in health policy discussions, and we also feel fortunate we can offer direct assistance. A few examples:

  • Reimbursement and practice management assistance. Our staff consultant, Craig Baarson, is available at no charge to help your clinic or hospital examine reimbursement strategies and practice management issues that may feel more pressing than in the past.

  • Preparation for quality reporting under health reform. Rural and safety net providers face unique issues as they contemplate changes ahead in quality measurement and reporting expectations. The Office of Rural Health and Primary Care has just made a grant to Stratis Health, Minnesota's Quality Improvement Organization, to offer assistance to small and rural providers to prepare for participation in health reform initiatives on quality incentives, payment structures, and health care homes. Look for learning opportunities with Stratis in the coming months.

  • Electronic health records. The Office of Rural Health and Primary Care is involved in planning how state government will put federal stimulus funds to use in ways that can help small providers implement electronic health records, improve care and obtain federal incentive payments. 

  • Grants and loans. Minnesota is fortunate to have a variety of direct financial assistance programs focused on the health care safety net. Two actually have the term "planning and transition grant" in their title. Though created in earlier periods of change, they can clearly fill a need now. Our grant programs are all very competitive, a limitation we and you must live with, but consult each program's staff person for advice on preparing the strongest application. Most ORHPC grant programs will be open again for applications in the summer and fall.

Check out our Web site at http://www.health.state.mn.us/divs/orhpc for information about these and other services. Our mission is to help the safety net achieve its mission. Please let us know how we are doing and what more we can provide. 

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.

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

  Our mission
to promote access to quality health care for rural and underserved urban Minnesotans. From our unique position within state government, we work as partners with communities, providers, policymakers and other organizations. Together, we develop innovative approaches and tailor our tools and resources to the diverse populations we serve.