WORKING ON THE CURVE
Our environment in the Office of Rural Health and Primary Care is always changing, and I know the same is true for you. As new issues and trends appear, it’s hard to keep up with what’s coming at us, let alone find time to step back, catch our breath, sort out how to respond to the next new thing, and figure out how to finish what’s already keeping us busy.
The same concept can apply to social issues and trends, and we’ve used it for a shared, quick scan of trends and developments in our field. Think about what’s started its way up the curve recently in health care: a recession and government budget problems, the federal stimulus bill, electronic health records, Minnesota health reform, federal health reform and more. I find this kind of exercise can help me plan my work. It can also help our organization plan its work, by laying out what new issues we need to make room for, what issues are at or near their peak and require major efforts, and what’s receding in importance. The hard part for me is to stop doing something, but at least with a current trend analysis in hand, I can’t pretend everything is the same as it’s been. In the past we’ve done this exercise for both our internal and external environments; currently each of our work units is plotting trends on the curve, and we plan to overlay them for a broader view.
This issue of the Quarterly features innovators who have shown agility at understanding and responding to change. The Community Paramedic team saw that the connection in rural communities between low volume ambulance service challenges, primary care shortages and community health needs presented an opportunity to develop a new health care approach with potential to improve all of those concerns. Building on international models, a Community Paramedic curriculum has been introduced and graduated its first class. This effort appears to have passed the “testing” phase of the life cycle curve, and its momentum is building. It will be interesting to watch its next steps.
Children’s Dental Services has been tuned into changing community needs since 1919! In the article by Eilidh Reyelts and Sarah Wovcha, you’ll read how they’ve grown to serve more and more kids as the population has become more diverse, dental challenges have appeared across the state, and technology has enabled their satellite clinics to deliver wider services. CDS has also become an important training site, meeting their own staffing needs and contributing to broader workforce goals. They’re clearly good at both understanding trends and responding to them.
In this issue we also profile Rural Health Advisory Committee member Tom Crowley, CEO of Saint Elizabeth’s in Wabasha. Just as Children’s Dental has succeeded in pursuing its mission over the long term, Tom has been true to his personal principles and Saint Elizabeth’s founding mission during his 38 years in Wabasha. You will read that Tom and Saint Elizabeth's have responded to the costly chronic disease trends that diminish the community's health with a cutting edge effort that is producing documented health improvement in Wabasha.
These innovators inspire me with their dedication and their ability to understand and respond effectively to change. They are truly examples of what it means to be “ahead of the curve.” I hope you agree; as always let us know what you think.
Mark Schoenbaum is director of the Office of Rural Health and Primary Care and can be reached at firstname.lastname@example.org or (651) 201-3859.
Rolling out the Community Paramedic Pilot Program in Minnesota
by Don Sheldrew, Hennepin Technical College adjunct faculty member and Minnesota Department of Health’s Office of Emergency Preparedness At-Risk Population planner
When people in rural areas dial 9-1-1 for Emergency Medical Services, they reach personnel who know how to help and who know their communities. These Emergency Medical Services providers have the potential to do even more for rural residents—who often live far from basic health services—as community paramedics.
The Community Paramedic Program concept
The idea behind the Community Paramedic Program is to bring more health care services to people in rural and remote areas by adding to the skills of emergency medical services (EMS) professionals. When not responding to emergencies, community paramedics can help people manage chronic diseases such as diabetes, high blood pressure, cholesterol, and prevent disease and illness through immunizations and screenings. They can provide information and counseling about ways to care for themselves and their families.
Community paramedics can be the eyes, ears and voices of residents—looking out for problems and finding solutions. With their help, residents can have a consistent, convenient source of care from experts, who not only know what they are doing but who care because they live in the community too.
The roles of EMS workers expand to provide health services where access to physicians, clinics and/or hospitals is difficult or may not exist. While it is an expanded role, it is not an expanded scope: Personnel still function under medical direction and therefore are not independent practitioners.
Several areas in Alaska, Australia and Nova Scotia have developed similar programs by modifying and expanding local EMS roles. The Community Paramedic Program combines the best practices from these programs into a standardized curriculum. The curriculum can be used as the basis for implementing this type of service not only within the United States, but also internationally.
The curriculum was based on Community Healthcare Worker training and tailored to fit the skills of paramedics. The training is consistent internationally yet can be modified for each community, state and nation through a standardized multi-module delivery model.
Through a standardized curriculum, accredited colleges and universities train first responders to serve communities more broadly in:
The Community Paramedic Program introduces higher levels of paramedic and other health career options for future and current EMS professionals. Given the structure of the training, students can enter the program at different points, including:
The curriculum features these phases:
Phase 1—Foundational Skills (Approx. 100 hours, based on prior experience) Comprehensive didactic instruction in advocacy, outreach and public health, performing community assessments and developing strategies for care and prevention
Phase 2—Clinical Skills (Range of 15 to146 hours, based on prior experience) Supervised training by medical director, nurse practitioner, physician assistant and/or public health provider.
Minnesota pilots Community Paramedic Program
Minnesota’s pilot of the Community Paramedics Program is being taught through Hennepin Technical College and based at the Medewakanton Sioux Fire Department in Shakopee. The 10 students in the training include three from Medewakanton Fire and the balance from other urban and more rural EMS services in Minnesota. Currently, the Sioux are able to travel to other tribes in Minnesota and do screenings and provide care to tribe members. The medical director is actively working to involve the other students in using their skills within communities they serve. The students in this first class have a minimum of 15 years EMS experience and their education ranges to the PhD level.
The foundational training helps these EMS professionals understand how some basic roles in emergency response may change when working as a community partner. Part of being a community paramedic is understanding the needs of the community, identifying gaps, and looking at trends in the community. Aside from serving individuals and families, this also means serving as community advocates, liaisons and facilitators for community health.
A focus of this initial training is what may feel different when not working in a strictly emergency setting. Many of the discussions focus on issues more related to social work. Issues of ethics and boundaries may shift somewhat when a life threat is not imminent. The instruction takes a bio-psycho-social approach to understanding the overall health of people and communities. One of the very interesting parts of the class is the level of detail the EMS professionals delve into when discussing material. The group essentially takes a topic and runs with it and then incorporates the concepts into their current work setting.
As part of the course, each student works with a community to map its resources, both governmental and non-governmental. They also interview residents at community events using a basic survey tool and later look at themes that appear and start to understand how these can indicate certain features or even a certain demographic within the community. In addition, the students work with community groups, faith-based organizations, public health, medical systems and others to identify a possible service gap or need. Then they work with these groups to fill that need. These projects have ranged from looking at a community’s pandemic planning, to forming a support group around Alzheimer’s for a local nursing home and family members, to developing further education on how the local EMS systems can interface better with group homes. The goal is to have the students gain experience in planning using multiple systems and developing relationships. They are developing skills to assist them in looking at both micro and macro levels. But several of the projects have real potential to impact systems on a broader scale.
The last piece of training focuses on enhanced medical assessment in several settings including Emergency Departments, pediatric and family medicine arenas, with the program’s medical director and other physicians. We expect this first group of students to complete their training next month.
Worldwide effort to improve rural health
The program is a collaborative effort among multiple entities including, in Minnesota: Healthcare Education-Industry Partnership, Hennepin Technical College, Mayo Clinic Medical Transport, the Minnesota Office of Rural Health and Primary Care and North Central EMS Institute. The partnership extends to Nebraska: Creighton University EMS Education, University of Nebraska Medical Center, and the Nebraska Department of Health and Human Services-Office of Rural Health; and to Nova Scotia: Dalhousie University and the Rural Centre and to Queensland: the Australian Centre for Prehospital Research.
The Community Paramedic Program adapts to the specific needs and resources of each community and exists solely to serve the needs of a particular community. Success relies heavily on collaboration among stakeholders such as the people who live or travel in medically underserved rural and remote areas; elected officials responsible for maintaining the physical and fiscal health of a community; health officials and clinic and hospital administrators who assess needs and manage resources to provide services; and educational institutions that train first responders.
It will succeed through the combined efforts of those who have a stake in maintaining the health and well-being of its residents.
Dr. Do with Aarcelia Sanchez
Outreach worker and dental assistant Zahara Shaie with Abolulghattar Jacobowski
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 Children's Dental Services.
Focus on Oral Health: Children’s Dental Servicesby Eilidh Reyelts, assistant manager of Children’s Dental Services and Sarah Wovcha, executive director of Children’s Dental Services
Established in 1919, Children’s Dental Services (CDS) is a nonprofit public health dental clinic serving pregnant women and children from families with low incomes. CDS accepts public and private dental insurance and has a sliding fee scale for families with low incomes who are not eligible for dental insurance. CDS sees children with painful emergency dental problems without waiting to determine if they are financially eligible.
Staff across the state
CDS operates out of more than 100 clinical locations in the Twin Cities metropolitan area and provides comprehensive preventive services in the Duluth and St. Cloud School Districts. In the fall of 2009, CDS will extend services to the Iron Range and International Falls. CDS was the first organization in the nation to provide on-site dental care within Head Start centers and continues to serve children at Head Start by using collaborative practice hygienists to provide care.
The CDS clinical headquarters in Minneapolis is equipped with 10 dental operatories and nitrous oxide analgesia for fearful or uncooperative children. The 100 satellite clinics have one or two operatories each in schools, Head Start centers and community centers. All sites have intraoral x-ray machines and can produce digital x-rays. Routine restorative and preventative care can be done at all sites. Additionally CDS provides hospital-based care, including intravenous sedation and endodontia.
Satellite clinics are staffed with a dentist or dental hygienist and one or two dental assistants. Children with parental consent receive dental treatment during school hours. If parents or guardians wish to be present for their children’s dental care, appointments are scheduled in the location most convenient for the family.
The organization’s multilingual and multicultural staff collectively speak 15 different languages and hail from 18 different countries. The cultural similarities that CDS staff share with the communities they serve build trust and a sense of understanding between patients and providers. Ultimately culturally targeted care leads to a greater likelihood of treatment compliance and returning for follow-up care.
To reduce transportation barriers CDS operates a network of portable care across Minnesota. Equipment that can be collapsed into suitcases and transported is used in almost any setting. This includes a self-contained water system that is sanitary and can be used without complicated connections. Through the use of portable equipment and teledentistry, CDS has increased the number of patients served in the metropolitan area by 50 percent over the past five years and has increased out-state care by 90 percent. In 2006, CDS received the Minnesota Council of Nonprofit’s Mission Innovation Award for more than 40 years of portable care.
To further reduce access barriers, oral health midlevel providers provide preventive care to children in Head Start. CDS also uses registered dental hygienists who are trained and certified to practice restorative expanded functions.
Intern and Screening Program
CDS hosts volunteer interns including high school students, college and community college students, post-secondary students (including law, dental and graduate students), and dental professionals. CDS partners with Century College and the University of Minnesota dental hygiene programs to serve as a host training site for dental hygiene interns. Other partnerships include registered dental assistant programs at Century College, Herzing College, Hennepin Technical College, Normandale, Lake Superior College and others. Volunteers support clinical treatment, records retention, outreach, research, and administrative tasks. CDS works with dental training programs to fulfill scholastic requirements.
CDS also partners with Delta Dental to provide dental screenings to public school students and Head Start students regardless of insurance status. This screening program is instrumental in expanding CDS services to thousands of children in Minnesota who would otherwise be without dental care and enables children with urgent and immediate dental needs to be readily identified. Based on the results of the dental screening, follow-up contact is made with the family and they are provided a referral for care. CDS screening directly benefits children’s academic performance, by attending to any discomfort that may distract them from learning. The enhanced education and outreach provided as a result of this program leads to prevention of oral disease. Access to care for these children is also improved, as they are now linked to a dental home. Oral health behaviors and healthy habits improve as a result of the education, outreach and other prevention components of this program.
CDS is funded by both private and public entities, as well as through many different philanthropic organizations. As reported in the CDS 2007 Annual Report, 60 percent of CDS funding came from program fees, 21 percent from grants, 18 percent from government support and 1 percent came from other revenue. In its 90 years of service CDS has remained financially secure and has never had layoffs.
For more information contact Sarah Wovcha, executive director of Children’s Dental Services at ( 612) 636-1577 or email@example.com.
Marilyn and Tom Crowley
ORHPC talks with Rural Health Advisory Committee member Tom Crowley
Please explain your professional work to us . . .
I have the privilege of carrying out the mission of the Sisters of the Sorrowful Mother, the founders of Saint Elizabeth’s Medical Center in Wabasha. They established the hospital with few resources but abundant passion. I consider this calling a vocation, and every day I feel blessed to work alongside a committed and dedicated team of employees, providers, sisters and volunteers. As president, I try to set a directional path that inspires our staff to provide exceptional care and services to the people in our service area. Saint Elizabeth’s has grown and diversified its services over the years to include a broad scope of inpatient, outpatient, long term care and outreach programs. One of my roles is to engage local, area and state providers; organizations and businesses; legislators and government; donors and foundations; and other key stakeholders in meaningful partnerships that ensure the long-term viability of Saint Elizabeth’s. The support of these partners has strengthened our capacity to develop new programs, advance technologies, and renovate facilities. In recent years, we have raised over $6 million in financial support. This is a true testimony of our communities’ loyalty to our organization.
Saint Elizabeth’s has become a noted leader in providing an array of primary prevention and chronic disease management services. Programs are now in place that help patients prevent or manage heart disease, pulmonary disease, diabetes, obesity, stroke and metabolic syndrome. Through this medical model approach, we are intervening earlier, and consequently, we are reducing risk factors, improving health and preventing disease. Saint Elizabeth’s stellar group of clinicians work with our patients to help them make healthy lifestyles a lifelong habit. Through a unique blend of education, exercise and support patients learn how to live with these changes, but it’s the relationships with staff and fellow patients that keep them coming back. Our outcomes are showing that we are changing and saving lives! This focus also extends beyond our doors. We have created and supported many community-wide wellness initiatives, including walking and fitness programs, nutrition education, tobacco cessation, and others, that are inspiring children, families, and seniors to take control of their health and live well. We believe we have found a rural model that seems to be making a difference in a big way!
Another important responsibility we have is to make sure all people are served. Saint Elizabeth’s is a careful steward of our resources so we, in turn, can meet the needs of the most vulnerable. Medication assistance, community benefits and charity care programs are placing a heavy hit on our bottom line, but it’s the right thing to do—it is what we are called to do.
It is extremely rewarding to fulfill the mission and values of the sisters as we advocate for the poor and underserved; take risks and celebrate innovation; and work together to improve community health.
And your life away from work?
We are so proud of our family! My wife, Marilyn, and I have three grown children. Ryan is a marketing rep for a surgical parts company. Angie works for an insurance company, and Megan is a school teacher. Marilyn studied medicine but instead of pursuing her residency, she was a stay at home mom raising our children. She now spends time volunteering in many different capacities. Nine months ago we became grandparents for the first time. Our grandson, Vinnie, has added a new dimension to our family. Seeing life through his eyes is a real joy! We try to visit often and look forward to a future with more grandchildren!
Our family has always loved animals—especially horses. When our children were younger, they raised a foal to show every year. It’s become quite a family hobby! When I am not behind my desk, I am judging horses. I travel to shows around the country, judging paints and quarter horses. Judging offers a wonderful opportunity to mentor and teach horse enthusiasts. I also look for ways to give back. At a recent show, judges donated our fees to a scholarship program that benefits low-income students. Judging has taken me to many parts of the country and has placed me in the company of some amazing and interesting people representing various regions, cultures and nationalities.
What do you think are the most important issues facing rural health?
I grew up in western Minnesota. When I started working at Saint Elizabeth’s I promised to stay six months. That stint stretched to 38 years and counting! Over that time, I have seen tremendous breakthroughs in what we can do to help people live healthy lives.
Sixteen percent of our population is over 65. As these numbers increase, one of the most important issues facing rural health is how we meet the needs and expectations of this growing demographic. Understanding their preferences; empowering them to make decisions that affect them; and offering a continuum of care that respects their independence need to be our priorities. Our challenge—to ensure we have the human and financial capital to remain viable and strong in the months and years ahead.
Protecting rural health care requires our focused attention on recruiting and retaining qualified health care providers and physicians. There are shortages within the health care workforce—especially in rural areas. At Saint Elizabeth’s, we are one nurse away from a crisis, and it took us three years to recruit two family practice physicians. Many of these providers no longer wish to do obstetrics. In response to these challenges, we have created care teams and unique approaches to delivering care. Certified nurse-midwife services, Medication Therapy Management and geriatric nurse practitioners are collaborative team models that are working in our rural region to protect access to local health care services.
Rural areas also need access to mental health services. Despite the attempts at parity, mental illness is not given appropriate attention or reimbursement. Too many people are suffering from mental illness and do not have the coverage they need to seek the help they deserve. We are fortunate to employ a full-time psychiatrist; yet, it is not enough to meet all the needs of our service area. Saint Elizabeth’s subsidizes this program to a great degree.
What do you think would make the most difference for rural health?
We don’t underestimate, or take for granted, our team of dedicated employees! Over the years, they have built relationships with our communities; earned the trust of our patients and residents; and established credibility with everyone we serve. They also stay!
Our workforce is our greatest asset and resource. When we grow our own, we are building our future. Through mentor programs, career exploration, internships and job shadowing experiences, we are exposing young people to the challenges and rewards of rural health care. Saint Elizabeth’s has also gone to great measures to establish partnerships with area technical schools and colleges to offer education and distance learning opportunities that are moving staff up the career ladder. Employees who were students 15 years ago are the leaders in our clinical areas today. We are always gratified to hear from referring physicians and facilities that, “Saint Elizabeth’s has the best trained staff.” Our community and service area are cooperatively making this happen. Every rural hospital should make this a priority.
It does my heart good knowing that the work we are doing today will ensure that the legacy of the sisters will live on for centuries to come!
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 firstname.lastname@example.org or (651) 201-3856.
View online all previous issues of the Office of Rural Health and Primary Care publications.
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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.