Contents:

WINTER 2012

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DIRECTOR'S COLUMN

photo of Mark Schoenbaum
Mark Schoenbaum

IT WAS 20 YEARS AGO

In 1992, the Minnesota Legislature considered major health reform legislation that would create the MinnesotaCare coverage program when passed. Among the concerns voiced during that session were doubts there would be an adequate health care workforce and misgivings that a wave of anticipated consolidations would harm rural communities’ access to care. Worried the law would end the ability of rural health leaders to have a say in these major changes, rural legislators insisted that to earn their support, the law must be responsive to rural needs and characteristics.

On a parallel track, both state and federal leaders were recognizing that state leadership was needed to improve primary care services for underserved urban communities.

The intersection of these trends created the Office of Rural Health and Primary Care in 1992. Its mission: to promote access to quality healthcare for rural and underserved urban Minnesotans.

At the time, a wave of hospital closures threatened access in large parts of the state. Pioneering country docs were nearing the end of their careers, with replacements uncertain. The rural ambulance system relied mainly on volunteers. Statewide, the uninsured and low-income workers relied on a limited health care safety net.

Since 1992, the Office has worked to be the voice of Minnesota’s health care safety net in state government. It has been fortunate to be able to direct grants and other financial resources to support the safety net workforce, rural hospitals and safety net clinics. It’s been able to enlist great technical experts to help improve clinic finances and build a state trauma system. The Office has also become recognized for its ongoing analysis of Minnesota's health care workforce.

Guided by the Rural Health Advisory Committee, along with the State Trauma Advisory Council and the Rural Flex Program Committee, the office has contributed to a variety of health policy and reform discussions. It published a report that paved the way for establishing Critical Access Hospitals in Minnesota, and put issues like the aging population, mental health needs, and more on policymakers’ radar.

The Office has helped stabilize essential facilities, maintain access and contribute to an ever- growing focus on quality. New Federally Qualified Health Centers (FQHCs) have formed to serve unmet primary care needs, largely in the Twin Cities but also in Mankato. Dental safety net providers have established several beachheads throughout the state, though unmet dental needs still swamp those clinics.

Through forums like the annual rural health conference, there’s a stronger sense of community and connectedness among safety net leaders than 20 years ago. Many policymakers have a growing understanding that smaller rural facilities and urban FQHCs are often the first to innovate, despite daunting challenges.

Today’s environment has a lot in common with 1992’s, doesn’t it? Health reform is again front and center, and the role of Minnesota's health care safety net -- both rural and urban -- will change.

The safety net faces new questions and challenges: Is Minnesota ready for the newly covered population that will seek care at community health centers? Will rural clinics, hospitals and nursing homes play a role in new models like Accountable Care Organizations? How will communities respond to rapid growth in an already older and increasingly diverse population? Will local leaders set the direction for health improvement, or will decisions be made in regional headquarters? And who will staff those rural ambulances as the supply of traditional volunteers dries up?

This year marks the twentieth anniversary of the Office of Rural Health and Primary Care, and in many ways it’s also the anniversary of a statewide partnership dedicated to improving the health of Minnesotans regardless of their address or their income. There’s been great progress since 1992, and the only certainty is there will be great challenge ahead. Thanks as always for your commitment to those served by Minnesota’s health care safety net. Here’s to many more years of collaboration!

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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PARTNER FOCUS


MINNESOTA'S FIRST SENIOR-FOCUSED COMMUNITY HEALTH CENTER

Tucked away in a corner of north Minneapolis is a kind of oasis for seniors. Surrounded by landscaped green space, the new Heritage Park Senior Campus offers assisted living, memory care and an elegant community center that brings together a range of elder-tailored health and wellness services, including a “boutique” YMCA open only to those 55 years and older, an indoor walking path and one of the state’s few therapy pools.

This summer, a Community Health Center (CHC) joined the mix, with the new Heritage Seniors Clinic. Operated by Neighborhood HealthSource, the clinic is unique among Minnesota CHCs in its focus on eldercare. CHCs, also known as Federally Qualified Health Centers (FQHCs), generally tend to serve much younger populations -- only 7 percent of the patients served by such clinics statewide are over the age of 65, though rural FQHCs tend to see far more. In northeastern Minnesota, for example, seniors represent nearly a quarter of the patients seen by Scenic Rivers Health Services. But no other CHC in the state has a seniors-only clinic.

A collaboration that began with a housing agency

The idea came from an unlikely source: the Minneapolis Public Housing Authority (MPHA). In planning the nation’s first public housing facility with assisted living and memory care, the MPHA envisioned a senior services center that could support the full well-being -- physical, emotional and social -- of its residents. It saw a medical clinic as essential and invited Neighborhood HealthSource to provide primary care services there.

Formerly known as Fremont Community Clinics, Neighborhood HealthSource has served north and northeast Minneapolis for over 40 years, so it was familiar with the neighborhood and had a track record of providing affordable, accessible health care. It also had experience co-locating clinics with other agencies and programs. Its Sheridan Clinic is located in the Northeast Neighborhood Early Learning Center, which houses a number of agencies focused on supporting families with young children.

The MPHA and its four partners -- Neighborhood HealthSource, the YMCA, Courage Center and Augustana Senior Services -- met for over a year to plan the multi-faceted center. It’s been a challenging but exciting venture, according to Neighborhood HealthSource Executive Director Steve Knutson. “One of the great lessons learned has been the power of collaboration -- the power of getting like-minded community service providers together and the possibilities that can come from that,” he said. “Hopefully places like this can be a test tube for learning what can be developed for our seniors.”

Tailoring CHC services to seniors

So far, the Heritage Seniors Clinic operates like many other community health center sites: it provides a full spectrum of primary care along with supportive services such as transportation and interpretation, and does so equally for both insured and uninsured patients, turning no one away for lack of ability to pay. Over time, however, it intends to adapt and expand its services to meet the unique needs of its 55+ patients. It is currently expanding its diabetes program, for example, and will be launching a nutrition program tailored to seniors. Thanks to being co-located with partner organizations, providers can ensure that patients follow up on exercise or therapy referrals, which are scheduled directly on site. Clinic leadership also hopes to add podiatry services -- a “huge need,” according to Mr. Knutson -- and to augment its mental health program, which currently stretches one provider across three sites. The new site is physically equipped to add dental services as well, but there are no immediate plans to build out that portion of the clinic.

In its six months of operation, the clinic has seen a steady increase in the number of patients. Initially, most patients came from the adjacent assisted-living campus, but more seniors from the surrounding community are hearing about the clinic and finding it a welcome option. Part of the draw seems to be its main provider, a board-certified family medicine physician with a public health degree, Dr. Frances Truitt, whom Mr. Knutson calls “perfect” for this new site. But he also credits the senior center itself and the environment it has created for connection and health. “North Minneapolis has a vibrant, engaged senior population,” Knutson said. “This center gives a place for those seniors to flourish and to connect with each other.”

For more information about the Heritage Seniors Clinic, contact Neighborhood HealthSource at 612-588-9411 or visit their website.

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PROGRAM FOCUS


BRINGING PEDIATRIC EMERGENCY TRAINING TO RURAL MINNESOTA

Trauma cases involving children are infrequent -- in 2009, they accounted for less than 6 percent of all ambulance runs statewide, according to Minnesota State Ambulance Reporting (MNSTAR) data. Yet when they do occur, the results are often tragic. Trauma is the leading cause of death among pediatric patients in the state.

Children’s cases are often stressful and challenging for emergency medical services (EMS) personnel. Not only is it difficult to see a child suffer, but such cases call for unique skills and techniques specific to children -- knowledge that can be difficult to retain when it is put to use so infrequently. In rural areas, where low-population density often means low-volume EMS calls, providers can go for months or even years without seeing pediatric trauma incidents. Yet when those traumas do occur, the children are at increased risk of disability and death compared to their urban counterparts, largely because of longer transport times.

Last year, the Emergency Medical Services for Children Resource Center (EMSRC) stepped up to address this challenge in rural Minnesota. After surveying EMS providers across the state and finding that just over half cited a “lack of confidence in treating pediatric patients” as their biggest concern when responding to pediatric calls, and 75 percent indicated difficulty accessing pediatric education, EMSRC applied for a grant from the Office of Rural Health and Primary Care’s Flex program. The project’s goal: to use simulation training as a way of equipping rural providers with the skills and confidence needed to respond to pediatric trauma effectively.

Creating a new kind of pediatric emergency training

The EMSRC -- a collaboration of the Emergency Medical Services Regulatory Board (EMSRB), Children’s Hospitals and Clinics of Minnesota and the University of Minnesota -- has worked for over 15 years to improve the quality of emergency care for children in Minnesota. It is part of the federal Emergency Medical Services for Children Program, which works to ensure that all children and adolescents, no matter where they live, attend school or travel, receive appropriate care in a health emergency.

EMSRC used part of their Flex grant to design a training curriculum that would be especially valuable in rural settings. Past EMSRC trainings had focused solely on “pre-hospital” providers such as EMS personnel and paramedics. Here they tried a new approach: training both pre-hospital and Emergency Department providers together, in part to strengthen communication and relationships across the two settings.

Making the training hands-on was also key. EMSRC contracted with Hennepin Technical College (HTC) to bring its 45-foot mobile simulation trailer to rural training locations throughout the state. Participants used mannequins and actual equipment to treat four “on-the-job” trauma scenarios. Some of the equipment was specialized and provided by EMSRC, but the educators also showed how to adapt local equipment for use with children. Having these multiple, hands-on opportunities to practice what was being taught was crucial to building confidence among participants, according to Kjelsey Kluge of EMSRC. “We wanted everybody to be able to say, ‘I did that.’”

A group effort and success in the field

Overall, 240 pre-hospital and hospital-based providers attended the free simulation trainings in rural locations including Eveleth, Owatonna, Marshall, Bemidji, Thief River Falls and Two Harbors. EMSRC worked with each of the state’s five Regional Trauma Advisory Committees (RTACs) and the seven regional EMS programs in greater Minnesota to organize the 11 sessions. In addition to its trailer, Hennepin Technical College also provided the lead educator, and many local educators donated their time as well.

EMSRC hopes to build on the project’s success by making the curriculum available for groups to use on their own and, if resources allow, to organize more in-person sessions with the mobile simulation trailer. The need for such training continues.

“No matter how many years an EMT has worked, they always tell me their hearts race when they see a child,” says Kluge. She knew their trainings had succeeded when one participant later thanked her and mentioned a child she had treated a week after the training. “She said she had been able to apply the information and felt she had done the right things,” she said. “That’s so key for people working in EMS.”

For more information about Emergency Medical Services for Children, call 800-660-7022 or visit their website.

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SPECIAL FEATURE


TAKING A STEP TOWARD BETTER HEALTH

by Amber Dallman and Chera L. Sevcik

A hot, 95-degree day did not stop 25 citizens and community leaders from attending a walkability and bikeability workshop in St. James on Tuesday, September 11. The workshop, facilitated by the Minnesota Department of Health, provided communities in Watonwan County with information on how street and community design is essential to increasing physical activity levels and improving the health of their community.

Participants spent an hour learning how to increase safety and support people who want to walk and bike more through the “5 E” approach. The "5 Es" include: evaluation, engineering, education, enforcement and encouragement. The group then put on their walking shoes and went for a mile walk around St. James to practice completing a "walkability audit." Upon returning, participants broke into smaller groups based on the communities they were from. The groups brainstormed ideas and strategies they could apply back home.

Next, Active Living Coalitions in St. James, Madelia and Butterfield will begin the work of mapping out specific areas in their communities to complete a walkability assessment. Upon completion, groups will work with Region 9 Development Commission to develop an action plan as well as multimodal transportation plans. Groups will also look at upcoming street, highway and land use renovation projects to ensure plans contain facilities for walking and biking.

The local Statewide Health Improvement Program (SHIP) grantee, Cottonwood-Jackson-Faribault-Martin-Watonwan (CJ-FMW), hosted the September workshop. The group is no stranger to discussing how to increase walking and biking in rural Minnesota communities. Back in 2010, similar workshops were held in Faribault and Martin Counties. The City of Wells took the information about increasing walking and biking and ran with it, working with Region 9 to develop an action plan for walking and biking. They also increased the shoulder width and placed rumble stripes on a highway project connecting their community to Winnebago.

Engaging Active Living Coalitions in road projects is just one way to support more walking and biking. These groups are also addressing systems and policies that make it easier for people to choose the healthy choice. Through the work of SHIP, communities throughout the state are realizing the opportunities to increase Active Transportation beyond urban centers. The Rails-to-Trails Conservancy recent report, Active Transportation Beyond Urban Centers: Walking and Bicycling in Small Towns and Rural America, notes that “many rural small towns are choosing to invest more in promoting active transportation, and making it safe and convenient, because of economic, health and demographic benefits these modes return.”

The benefits of Bicycle and Walk Friendly Communities include:

  • Improving the health of people.

  • Reducing traffic demands.

  • Improving the quality of life.

  • Increasing economic development opportunities.

  • Increasing local tourism.

  • Providing transportation choice and equity for people.

What can you do to reap the benefits of more walking and bicycling opportunities in your rural community? Here are a few things to check out:

  • Find an existing active living coalition. The Statewide Health Improvement Program (SHIP) facilitates many throughout the state.

  • Check out what your Regional Planning Organization is doing -- regional planners are aware of upcoming projects and can advise local residents on how to support safe walking and biking facilities.

  • Ask if your community has a master plan to support walking and bicycling facilities.

  • Go for a walk and report back to your decision-makers about what you find. Use the Let’s Go For A Walk handout from MDH to help.

For more information about what MDH is doing to promote physical activity in communities throughout the state, contact Amber Dallman at amber.dallman@state.mn.us or 651-785-8463.

Amber Dallman is physical activity coordinator with the Minnesota Department of Health. Chera Sevcik is Statewide Health Improvement Program (SHIP) supervisor for Cottonwood, Jackson, Faribault, Martin and Watonwan Counties.

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RHAC MEMBER PROFILE



ORHPC TALKS WITH RURAL HEALTH ADVISORY COMMITTEE (RHAC) MEMBER NANCY STRATMAN

Please explain your professional work to us . . .

I’m a licensed nursing home administrator working as the CEO/Administrator at the senior campus of Cokato Charitable Trust in Cokato, which is about an hour west of the Twin Cities. The campus consists of a 56-bed skilled facility, 46 units of assisted living, a 10-bed dementia unit, a Medicare-certified Home Health agency, home-delivered meals, child day care and adult day care. We serve a total of about 225 people in the community and employ about 180 staff.

I am also a board member for Aging Services of MN and the Aging Services Group, a member of the state’s Diabetes Steering Committee and chair-elect of Care Ventures Cooperative. On RHAC, I am the Long-Term Care Representative.

And your life away from work?

Six years ago I was widowed and since then have had many life-changing events...I’ve remarried, changed jobs, moved. Both of my children have married and I have three grandchildren. So, now life finally seems to be settling into a “new normal.”

My husband and I have a cabin in the Aitkin area that is about 80 percent complete, so weekends are often spent there making dust in preparation for having it finished in time to enjoy before and during retirement, when we’ll move there.

Visiting the North Shore and enjoying the outdoors are renewal for me. When I find the time to read, I curl up with a book about self-improvement or management. I love visiting my children and grandchildren in San Diego and San Francisco. I was recently reminded of the blessings of rural life when my 18-month-old granddaughter visited “Grandma-in-the-Woods” and was so excited about all the “tars” in the night sky, saying “Woooooow!” You don’t get that kind of viewing in San Diego!

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

I grew up in a community of about 500 people in central North Dakota, where my parents still live. The county’s population is approximately 4,000. Their issues of accessing healthcare are a personal reminder of the challenges and concerns of elders in rural areas. My mother comments that in rural areas it takes a village to support elders, a reminder of the campaign, “It Takes a Village to Raise a Child,” spearheaded by former First Lady Hillary Clinton.

Our challenge is to create and to help facilitate the “village” of support, both formal and informal, for elders in rural areas through technology and education, building networks where neighbors check on neighbors, etc. to avert the episode that will be catastrophic both in terms of health and costs. There is strength and synergy that is unique to rural in bringing the community into health care.

Statisticians show that the number and needs of the elderly are on the rise, while the workforce is dwindling. This phenomenon will be a force to contend with for many years to come and has already had an impact in rural areas where the elderly dependent ratio is highest. Our challenge is to train and retain the talent of rural folks.

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

Engagement in healthy living! This is not true only in rural Minnesota, but also for all of Minnesota and the country in general. According to the CDC:

  • Chronic diseases, such as heart disease, stroke, cancer, diabetes and arthritis, are the most common and costly of all health problems, but they are also the most preventable.

  • Four modifiable health risk behaviors -- lack of physical activity, poor nutrition, tobacco use and excessive alcohol consumption -- are responsible for much of the illness, suffering and early death related to chronic diseases.

Reaching out and engaging people to take command of balanced living and general wellness would make a big difference. Our challenge is to prevent, delay, detect and control.

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.

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


 

 


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

  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.