THE LONG VIEW
At the end of each month young Lewis Thomas watched his mother head into the yard in search of a four-leaf clover. Worried about paying the bills and making ends meet, she would return with her good luck charm and declare, "The Lord will provide." The year was 1918, and Thomas' father was a physician. Doctors' incomes then were both modest and unreliable, as was their success treating patients.
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.
VISION: TO BE THE PRE-EMINENT HEALTH CARE MODELBy Tom Resnick, Southside Community Health Services Development Director
Southside Community Health Services, Inc. is a nonprofit organization and a Federally Qualified Health Center (FQHC). Southside has two medical clinics in Minneapolis, one medical clinic in Stillwater and one dental clinic in Minneapolis. Southside has had an “Essential Community Provider” designation from the state of Minnesota since 1997.
Community comes together
In 1971, three Volunteer in Service to America (VISTA) workers recognized that residents of South Minneapolis had few resources for health care. They relied on the emergency room at Abbott-Northwestern Hospital or waited until they were quite ill to seek care. The VISTA workers set about organizing community support for a volunteer clinic that would provide basic services.
Local businesses, Southside Ministries and Abbott-Northwestern Hospital supported the clinic, with the hospital also providing x-ray, lab work, pharmacy services, supplies and backup services. Southside Medical Clinic was incorporated as a nonprofit corporation. The governing body of the clinic was structured to ensure community control and 11 residents of south Minneapolis made up the first board. The original Articles of Incorporation stated that at least 51 percent of the governing board should be community residents or users of the clinic to maintain the community input to the clinic, and this continues today.
Facilities grow with community need
In 1979, the first full-time physician was hired, which facilitated expanded clinic hours and in-patient care at Abbott-Northwestern.
Also in 1979, with the hiring of a part-time dentist and hygienist, dental operations could be offered. Dental services were expanded in 1993 to begin the Southside Dental Outreach Program with mobile facilities serving elderly and handicapped patients at nearby nursing homes. In 2004, the dental clinic began serving as a clinical training site for dental assistant and dental hygienist students from Herzing College.
Abbott-Northwestern funded a family practice nurse practitioner position in 1980, and in October of that year, a health educator was hired to develop the educational and counseling goals of the original clinic visionaries. As patient visits continued to increase, a sliding patient fee schedule was factored into the budget more significantly.
Mental health services are provided on a contractual basis through the Community University Health Care Center, La Familia Guidance Center and African-American Family Services.
SCHS is staffed with 65 full-time equivalent employees. Over half are minorities and bilingual or multilingual. All of the clinics are staffed with patient advocates who do social service referrals and help patients apply for Medicare, Medicaid, MinnesotaCare and other publicly subsidized health plans. All clinics offer an adjusted rate sliding fee scale for patients who are uninsured and do not qualify for federal or state assistance. Only 10.5 percent of SCHS’ patients have private insurance. In 2009, 68 percent of our patients were at or below 200 percent of the Federal Poverty Level.
Last year our clinics served mostly low income and underserved women, children and families. These 12,783 patients generated 34,739 clinic visits, including vision care. The rate of uninsured seen at SCHS grew to 38.2 percent in 2008 and to 46.2 percent in 2009 primarily caused by the economic recession and unemployment with its attendant loss of health insurance coverage. This caused a shortfall in operating revenues, necessitating some layoffs in non-patient care areas. To the extent possible, patients were placed on a sliding fee based schedule ranging from 0-100 percent of service charges. Publicly subsidized insurance such as MinnesotaCare, Medicaid, State Children’s Health Insurance Program and General Assistance Medical Care (GAMC) covered 41.6 percent of patients.
Our Clinics Today
Southside Medical Clinic (4730 Chicago Avenue South, Minneapolis) provides comprehensive primary care to a largely African-American and African immigrant patient base.
In 1994, we opened Green Central Medical Clinic (324 East 35th Street, Minneapolis) with the assistance of the community and Abbott Northwestern Hospital. It is located in a public elementary school and after years of waiting for expansion, Green Central doubled its space in 2008, when another program moved out. The majority of the staff is fluent in Spanish, addressing a strong need for bilingual health care. Green Central is seen throughout the Hispanic community as a source of medical and social assistance.
Southside Dental Clinic and Administration (4243 Fourth Avenue South, Minneapolis) houses dental operations including preventive, restorative, rehabilitative and emergency care. In 2009, we began expanding and renovating the dental clinic and administrative offices thanks to capital grants from the Bureau of Primary Health Care-American Recovery and Reinvestment Act and the Patterson Foundation.
Dental care is a growing need in the community Southside serves. During Children’s Dental Health Month, one fourth of the local students admitted they had never seen a dentist. A sampling of most of the student population found that 27 percent were in the categories of “high-risk—visible caries” or “high-risk—urgent care needed.” More than two students a week are sent home with dental pain/problems. When looking at students in kindergarten to third grade alone, 31 percent were found to be at high risk. An average of four decayed teeth was shown in a retrospective chart review at Southside Dental Clinic. Only 25 percent of patients had no decay. SCHS also found a prevalence of baby bottle mouth among first time presenting Hispanic children.
Southside’s mobile dental van stands as a positive story for the nursing home facilities we serve. Several of the dentists, dental assistants and dental hygienists take turns rotating through the mobile program. The mobile dental van driver serves as the schedule coordinator, so it becomes an efficient use of labor.
We have found, not surprisingly, that a critical factor is the mobile unit’s state of repair. The older the mobile unit becomes, the more it is in the repair shop, causing the missing of appointments and the need for re-scheduling. We embarked on a capital campaign to replace our Dental Outreach Mobile Van and received grants from the Minnesota Department of Health-Office of Rural Health and Primary Care and the Healthier Minnesota Community Clinic Fund. The new van will have two operatories instead of one in the current van so the dentist and the dental hygienist can work side by side instead of alternating visits. With a more reliable vehicle and two operatories, we will increase the number of days of service, numbers of nursing homes visited, and the number of patients seen.
In 2004, SCHS took over CommonHealth Clinic. The clinic, now known as St. Croix Family Medical Clinic (5840 Memorial Ave. N., Suite B, Stillwater), provides comprehensive medical services to residents of Stillwater/Washington County and portions of Ramsey County and western Wisconsin.
Southside Community Outreach, now known as Q Health Connections (4243 Fourth Avenue South, Minneapolis and Lutheran Social Services-Center for Changing Lives 2414 Park Avenue, Minneapolis), provides health education to minority populations suffering dramatic health outcome disparities.
Q Health participates in local health fairs and community events, reaching over 10,000 residents, provides connections to a wide variety of community social and health related initiatives and operates:
• The Father’s Program for 17- to-37-year-old men who are actively involved in their children’s lives. After the fathers attend sessions with a health educator and “graduate” from the program they qualify for a free medical physical and dental exam. The men are also encouraged to meet with Southside staff to apply for medical assistance or prescription assistance programs. Class sizes range from one to eight participants and cover a range of health, child care, nutrition and relationship issues.
• The Step To It Southside and Step To It Challenge programs persuade and motivate people of all ages to get started on a physical activity.
• The Plain Talk/Hablando Claro strategy is simple: If you increase adult/teen communication about sex, and increase sexually active teens’ access to contraceptives, the number of unwanted pregnancies, STDs and HIV/AIDS will decrease. After five successful years of operation, the program was discontinued due to a lack of funding.
Through all of these services, the vision that drove three VISTA workers in 1971 is alive in south Minneapolis today. We are still proudly serving people of all ages, income levels and occupations, in a neighborhood setting that fosters learning and respect. We accomplish this through collaboration and communication, which patients accept as an opportunity to improve their health.
HEROIN: NORTHFIELD'S RAPID RESPONSEBy Ellen Tichich, clinical nurse educator, Northfield Hospital
When news of a significant pocket of heroin abuse in northern Rice County made the headlines in the summer of 2007, Northfield residents and community leaders responded with a mixture of shock, anger and denial. The numbers were disturbing. According to local law enforcement and treatment providers, an estimated 150-250 young people were abusing heroin or other opiates such as OxyContin. Many of them started using/abusing prescription pain medication and turned to heroin because it was easier to obtain and less costly.
Heroin quickly became “Northfield’s number one public health problem,” and a tragic one at that. In an 18-month period, five young adults in northern Rice County died from heroin/OxyContin overdoses. The rate of overdose in 2007 in Rice County alone was approximately twice that of Hennepin and Ramsey counties. An alarming 6.1 percent of Rice County residents seeking treatment for addiction reported heroin as their drug of choice, nearly twice the state average.
Heroin’s devastating impact cannot be overestimated. After cocaine, heroin is the leading cause of overdose death in the United States. Not surprising, considering the potency and addictive nature of the drug, both of which are often unknown or underestimated by users. Without accurate and aggressive community-wide education, the resurgence of heroin and the illegal use of other opiates, such as OxyContin, pose a significant public health threat for communities everywhere.
Northfield Hospital, working closely with local and county agencies, began addressing the problem of heroin and opiate abuse in northern Rice County with the opening of its Opiate Agonist Therapy (OAT) clinic in August 2008. Charles Reznikoff, M.D., the clinic’s director and an expert in addiction medicine, is one of two physicians on staff trained to administer Buprenorphine, a medication vital for those seeking sobriety.
While the opening of the OAT clinic offered local access to medical care for individuals struggling with opiate addiction, there was still much work to be done. In 2009, the hospital received a Minnesota Rural Hospital Flexibility Grant from the Minnesota Department of Health - Office of Rural Health and Primary Care and formed a coalition that included ARTech Charter School, Northfield Healthy Community Initiative, Northfield Mayor’s Task Force on Youth Alcohol & Drug Use, Northfield Police Department, Northfield Public Schools, Rice County Chemical Health Coalition, Rice County Drug Task Force and the Rice County Sheriff’s Office. The coalition began implementing a comprehensive education/awareness project to:
• Provide education to health care professionals regarding best-practice care for patients abusing opiates and using heroin, as well as recovering addicts receiving treatment with Buprenorphine
• Increase awareness and understanding among educators, service providers, parents and youth about the impact of opiate addiction, research-based response methods, available local resources and
• Raise awareness and reduce the amount of prescription drug abuse in the community.
Members of the project workgroup were Kathleen Meier, division administrator for Ancillary Services at Northfield Hospital and project leader; Zach Pruitt, Northfield Healthy Community Initiative; Dr. Charles Reznikoff, addiction specialist and lead physician for education and policy initiatives of the project; Kathy Sandberg, Rice County Chemical Health Coalition; and Andrew Yurek, Northfield Hospital’s Safety/EMS Director. They met monthly to discuss and set timetables for proposed action items, evaluate the effectiveness of project initiatives and provide follow-up as needed.
One of the group’s initial goals was to develop and implement policies on state-of-the-art care management for patients receiving Buprenorphine treatment who present to the hospital. Buprenorphine acts as an opioid agonist when administered in low doses, enabling opioid-dependent individuals to discontinue opioids without experiencing withdrawal. At moderate doses the agonist properties reach a plateau, and at higher doses the opioid antagonist properties dominate and can actually precipitate withdrawal symptoms in acutely opioid-intoxicated individuals.
Health care providers who are unfamiliar with the effects of Buprenorphine, or who work without specific guidelines for treating individuals using Buprenorphine, may inadvertently provide medical care that is inadequate, inappropriate, and in some cases, detrimental. For doctors, nurses, EMS technicians and paramedics to deliver best care to these patients, policy development and comprehensive training/education regarding Buprenorphine therapy is essential.
Working with Dr. Reznikoff, Northfield Hospital developed two protocols: “Acute Pain Control for Patients in Buprenorphine Treatment” and “Maintenance Pain Control for Patients in Buprenorphine Treatment.” These protocols, accompanied by in-depth staff education, ensure personnel in the emergency department, operating room, same day surgery, and medical surgical units are properly prepared to care for patients undergoing Buprenorphine therapy for opiate addiction.
In collaboration with Rice County Chemical Health Coalition Provider’s Team, Dr. Reznikoff conducted education sessions for medical personnel throughout the region on identifying drug-seeking patients, the use of Buprenorphine as treatment for heroin and opiate addiction, and the role of providers in reducing prescription drug abuse.
Response to the project’s second objective of increasing awareness and understanding among educators, service providers, parents and youth regarding opiate addiction, response methods and available resources has been very encouraging. More than 230 educators and 1,000 students have attended information sessions to date, over three times the original project expectations. In addition, over 550 community members have attended public presentations. These numbers attest to the level of professional and public interest in the problem of heroin and opiate abuse as well as the community’s intention of actively working together to find realistic and attainable solutions.
Another key objective for this project focused on decreasing prescription drug abuse, a known precursor to heroin and opiate abuse. In 2009, project partners, along with local stakeholders launched “Take It To The Box.” This program focuses on the safe use, storage and disposal of prescription and over-the-counter medications as well as extensive community education about the dangers of prescription medications. Secure drug disposal boxes—in the Northfield and Faribault police department lobbies—are available 24 hours a day, seven days a week. In the first few months of operation over 700 pounds of medication was collected, significantly reducing the amount of medication available for potential abuse. Rice County’s drug disposal program is the second of its kind implemented in Minnesota.
Impact of collaboration
Through the planning, development and implementation of an aggressive and comprehensive community-wide education/awareness program, protocols guiding the treatment of patients receiving Buprenorphine for opiate addiction, and working to reduce prescription drug abuse, the Northfield/Rice County coalition’s response—in collaboration with local community leadership and overwhelming community support—serves as a model for rural communities facing the issue of heroin and opiate abuse.
Relationships with partnering organizations and agencies in Northfield and greater Rice County have been significantly strengthened. Awareness and attention to a significant community health problem has increased. Patients battling opiate addiction have continued access and support through the Opiate Agonist Therapy Clinic.
These efforts are making Northfield and northern Rice County safer, stronger and healthier.
PINE TECHNICAL COLLEGE WILL TRAIN ALMOST 1,200 IN HEALTH CAREBy Stefanie Schroeder, director, Pine Technical College Strategic Initiatives
Before debating costs, benefits and delivery of health care was in vogue, east central Minnesota and western Wisconsin were delivering highly trained health care workers. Yet the situation remained grim:
Our health care community “is on a demographically-induced collision course defined by an increase in retirees and fewer workers coupled with a growing demand for healthcare services,” reads Healthcare Labor Shortages: Get the Facts. Workers will not meet the demand in the near future, and funds have not been available to address that shortfall. The report goes on to quantify the coming crisis: Minnesota will likely experience vacancies in registered nursing—the largest employment group in health care—of over 4,400 by 2010 and 9,200 by 2015. Alarmingly similar forecasts are anticipated in almost all health care programs including laboratory, radiology, pharmacy, home health aide, respiratory therapy and nursing assistants.
In 2007, Pine Technical College (PTC) gathered partners from area school districts, higher education, health care providers and the workforce development center system to address the pending worker shortage. Initially the group—dubbed the Healthcare Alliance—included 12 partners. Nearly three years later and more than two dozen partners strong, the assembly has “built a vision for a strong, qualified workforce with opportunities for professional growth,” says PTC President Robert Musgrove.
HOPE is on the way!
PTC is setting into motion a $4.2 million grant project (U.S. Department of Labor American Recovery & Reinvestment Act funding). Over three years, the project, called Health Occupations Providing Economic Stimulus (HOPES), will touch almost 10,000 people in our region through outreach. HOPES will recruit, train and employ almost 1,200 registered nurses, licensed practical nurses, certified nursing assistants, home health aides and medical laboratory technologists in east central Minnesota and western Wisconsin.
HOPES will provide:
• $270,000 in scholarships over three years
These components come together to create a flexible career pathway that interests our youth and supports unemployed, dislocated and incumbent workers. This pathway also translates into solid job opportunities and limits the predicted health care worker shortage.
Spreading the word
This region is about to hear a lot more about HOPES. From traditional flyers at partner sites to postings on partner Web sites, e-newsletters, e-mail and social networking sites, and informational presentations and forums. HOPES aims to reach potential, future health care workers of all ages and backgrounds to ensure the right people achieve the right training to fill critical needs in their communities.
“Pine Technical College is no stranger to leading this type of collaborative effort,” explains Musgrove. “Just one year ago, the U.S. Department of Labor awarded Pine Technical College $1.9 million to provide advanced manufacturing training to our students, industry partners and high school students across the region. It has already made an impact invigorating the manufacturing industry with a workforce of well trained individuals. This HOPES grant will do the same for health care.”
Our partners came together with a tremendous amount of enthusiasm and commitment for growing our region’s health care workforce. We’re proud to lead this partnership in bringing valuable resources to our community.
Dr. Jeffrey Hardwig
ORHPC talks with Rural Health Advisory Committee (RHAC) member JEFFREY HARDWIG
Please explain your professional work to us . . .
I work as a general psychiatrist in International Falls, a town of 6,000 on the Canadian border. The practice is entirely outpatient and divided between the clinic side of Rainy Lake Medical Center—my employer and a primary care clinic—and Northland Counseling Center—a community mental health center. My colleague, Kathi Henrickson, a certified nurse practitioner, and I see patients of all ages, from children to residents of two nursing homes.
A shortage of new patient openings is causing a bottle neck in psychiatric care. It is no longer feasible to assume care of all referred patients because established patients require ongoing follow-up. My work is evolving from referred patients becoming part of my ongoing patient load to a consultation-based practice. In the consultative model, psychiatry provides support to primary care, where responsibility for ongoing management remains for all but the most complicated situations. For someone who derives professional satisfaction from treating patients within a therapeutic alliance, the consultative model is not something I want to practice 100 percent of the time; however, it may be a necessity if we are to achieve access to care for rural Minnesota.
For the past seven years, I have been involved in the Minnesota Psychiatric Society and other public service activates such as the Rural Health Advisory Committee. Active involvement enriches my professional life through contact with idealistic, hardworking, unselfish people. I feel a sense of connection, hope and movement toward solutions to our health care problems.
And your life away from work?
We aren’t living here for the shopping. My bond to this place is rooted in the natural setting, the boreal forest and my early experiences on the lake. While living away from Minnesota, I vacationed here. And during those summers, I never dreamed of vacationing anywhere else. This is where I wanted to be—and still do.
My desk job makes me acutely aware of an inner drive for movement. This is soothed by a daily three-mile walk with my wife and insistent black Lab. In the winter, we cross country ski and snowshoe. In the winter we also travel to Arizona—not for the weather—but to visit our new granddaughter, Leighton.
In the summer we spend time at our cabin in Canada where we fish, swim, read and just hang out. Summers also include canoe trips to nearby Quetico Provincial Park and farther north to Woodland Caribou Provincial Park.
What do you think are the most important issues facing rural health?
As always, the main issue is access. Family doctors have it rough. As a psychiatrist who works in a primary care setting, I worry for my colleagues when demands threaten to overwhelm supportive resources.
One challenge is that 85 percent of patients with psychiatric illness are seen in the primary care setting with little access to psychiatric care. There is also a glaring lack of resources for those with chemical dependency problems. And children’s mental health services are lacking.
The segregated and fragmented condition of our non-system of care leads to poorer psychiatric outcomes and increased medical costs. Conversely, there is a need for medical services within the behavioral health sector: Seriously ill psychiatric patients die 15-25 years younger than the general population.
What do you think would make the most difference for rural health?
Psychiatry can help and we want to help primary care meet the needs of our shared patients. In my own practice in a primary care clinic, my colleagues have been welcoming and supportive of integrated care and want more psychiatric support, as well as child services, chronic pain and chemical dependency expertise. Telehealth must be more fully developed to fill the breach in these services for primary care.
Segregated care is a failed system economically, conceptually and morally. It has not been equal or equally reimbursed. Why do we not have integrated care after a decade of seeking it? Barriers exist in the form of carved out behavioral managed care. These separate management systems must end and behavioral health and chemical dependency services must be made subspecialties within the field of medicine, which would be paid for out of the same budget and use shared medical records to facilitate safe and effective care.
In such an integrated system, teams of providers (psychologists, social workers, psychiatric nurses, psychiatrists, physician assistants, etc.) will produce better results for patients and healthier working conditions for providers. Such a supportive system will attract and retain providers proud to be a part of a real system of care.
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 email@example.com or (651) 201-3856.
View online all previous issues of the Office of Rural Health and Primary Care publications.
|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|