Summer Quarterly Newsletter



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photo of Mark Schoenbaum
Mark Schoenbaum


Critical Access Hospitals (CAHs) have received an unusual amount of attention - not all positive - in the past year. Most significantly, on August 15 the Inspector General of the U.S. Department of Health and Human Services released recommendations for modifying the program that, if they were to become law, could terminate the CAH designation for 62 of Minnesota’s 79 CAHs. The Inspector General concludes there are too many CAHs too close together. In particular, the report takes aim at states’ designations of certain hospitals as “necessary providers,” which allowed them to be eligible to become CAHs under criteria other than a fixed distance standard. This opinion is only the latest in a series of unfavorable reports on CAHs. Congress’ Medicare Payment Advisory Commission also criticized Medicare's spending on CAHs, and the last two budgets the President delivered to Congress proposed both reimbursement cuts and new location restrictions that would have reduced the number of CAHs.

What’s going on here? The National Rural Health Association titled its response to the new report “They just don’t get it,” and there’s a lot of truth in that judgment. Some researchers and policymakers view CAHs as no different than tertiary inpatient centers, except for size.

In reality, Critical Access Hospitals are most often the center of the local health system, providing much more primary care, emergency care and community services than high acuity inpatient care. The smaller the rural community, the harder it is for these community institutions to cover their fixed costs through traditional reimbursement, and that’s why Congress created the CAH program in 1997. It reimburses these small rural hospitals for the costs of their services and provides a floor of financial stability so they can continue to meet their communities’ needs. Congress also recognized that states are in the best position to understand their rural health landscape and determine where services are needed; Minnesota passed bipartisan legislation establishing a state definition of necessary provider in 1998.

The Inspector General writes that Critical Access Hospital payments should be revised to both preserve access and promote efficiency. Minnesota’s CAHs are already balancing these goals as they respond to health reform expectations for improving quality, coordination and cost control. After 15 years, the CAH law may need some updating to encourage the kind of transformation already underway in rural Minnesota, but many communities and patients could lose essential services if the recommendations in this report were to become law. Policymakers - and researchers - need your perspective on how to constructively improve health and health care in rural Minnesota. It’s time for all of us to get involved!

Mark Schoenbaum is director of the Office of Rural Health and Primary Care and can be reached at or 651-201-3859.

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by Deb Jacobi, RDH, MA

One of the greatest health access challenges in Minnesota - and across the nation - is the need for more pediatric oral health services, particularly for low-income children. Thanks to the leadership of the Minnesota Head Start Association and its dedicated dental partners, our state has a promising approach available to tackle this distressingly persistent problem. It’s called “community collaborative practice,” and there is now an opportunity to expand it to reach more children in need.

Struggle to meet federal requirements

The community collaborative practice model emerged from difficulties Head Start providers in Minnesota faced in meeting federal Head Start requirements. Head Start Performance Standards require programs to:

  • ensure that all enrolled children have a current dental exam,

  • educate parents about the importance of good oral hygiene,

  • assist parents in securing needed follow up and treatment, and

  • promote good oral hygiene through classroom activities.

Minnesota programs struggled to comply with the federal requirements. In 2001, the number of Minnesota Head Start children receiving dental exams dropped to 79 percent, well below the national average of 89 percent. That same year, nearly a quarter of the state’s Head Start grantees reported that only 50-60 percent of enrolled children had completed a dental exam as mandated under the Head Start Performance Standards. The state’s access challenge had worsened to the point that it threatened to put Minnesota grantees out of compliance with Head Start - and therefore at risk of losing funding.

Facing this longtime challenge head on, in 2002 the Minnesota Head Start Association (MHSA) convened dental stakeholders from around the state for an Oral Health Forum. The goal: to heighten awareness of the problems facing Minnesota’s youngest and most vulnerable population and to create a statewide agenda to improve access. The MHSA adopted an action plan and a “Vision for Oral Health” that recognized oral health as a vital component of good health and imagined innovative partnerships to implement strategies to increase access to oral health services.

A new workforce and collaboration model emerges

Cognizant of these dental access issues, the Minnesota Department of Human Services (DHS) Dental Access Advisory Committee was simultaneously examining workforce solutions, which led to the 2001 legislative authorization of collaborative practice. This workforce initiative provided the basis for a 2006 partnership between the MHSA, the Minnesota Dental and Dental Hygienists’ Associations, committed dental providers such as Apple Tree Dental and Children’s Dental Services, and DHS to adopt the community collaborative practice model as a solution for Head Start.

In community collaborative practice, a Head Start program joins forces with its local dental resources to provide oral health education and prevention onsite at a Head Start Center. The key is a “collaborative agreement” between a dentist and a dental hygienist that allows the hygienist to provide an assessment, triage and referral for all the children at the Head Start center. This “limited authorization” is spelled out in an agreement that delineates the locations and types of services to be provided, and is registered with the Minnesota Board of Dentistry.

The approach has effectively expanded access - as well as our understanding of oral health needs - in multiple ways. Early and appropriate contact with the oral health care system is accomplished by providing as many children as possible with education and prevention to prevent tooth decay. In addition, collaborative practice dental hygienists identify and prioritize those children needing restorative treatment. Head Start staff and the dental partners then work together to address barriers to care and provide care coordination.

The model also helps collect important surveillance data. As part of their onsite services, the collaborative practice hygienists complete a standardized in-mouth assessment for each child. The assessment not only helps guide follow-up action - through a simple rating of urgency for future care - it includes an age-specific indicator of oral health and measures of the incidence and prevalence of tooth decay. These four measures are elements of the Association of State and Territorial Dental Directors’ Basic Screening Survey and are used for the National Oral Health Surveillance System. The data collected by collaborative practice hygienists may also contribute to the Minnesota Oral Health Surveillance System (MNOHSS) and understanding of the burden of dental disease in the state.

Road blocks followed by renewed opportunity

After receiving approval from the Minnesota Department of Human Services (DHS) and the Office of Head Start in 2006, the collaborative practice model was in place for approximately three years. Early evaluations were positive and the majority of Minnesota’s Head Start grantees were using the model.

A successful example was Child Care Resource and Referral, a Head Start grantee in Rochester. Implementing collaborative practice at that site improved access dramatically: from less than 30 percent of children receiving oral health exams in 2003 to over 90 percent in 2008. It also increased the number of children receiving additional dental treatment: by 2008, 97 percent of children at the site who needed treatment received it. Using the approach helped the site come into compliance with federal dental performance standards, prompting their director to state that community collaborative practice is the “biggest change for families to access services that I’ve seen in Head Start - ever.”

Despite that promising start, however, concerns about whether the innovative approach was in compliance with state and federal regulations led to its de-authorization until 2012, when the Centers for Medicare and Medicaid Services (CMS) clarified that the practice is authorized under existing guidance. DHS then re-authorized the approach as well.

CMS also recognized that the approach can overcome the myriad barriers to oral health and dental care faced by Head Start families. In fact, the CMS has recently encouraged states to enact similar expansions to help more children with dental disease to connect needed treatment.

This fall, local Head Start programs across the state will be able to form new community collaborative practice partnerships to help meet the oral health needs of their enrollees. MHSA is spearheading efforts to establish a single data collection system to track follow-up care. It will also provide the ability to share population-level data with the State of Minnesota. This proactive, community-based approach is in line with the CMS Oral Health Initiative, the broader goals of health reform, and the mission of the Office of Rural Health and Primary Care to promote access to quality health care for all Minnesotans. Most importantly, it is a critical step towards oral health for Head Start children and families.

Deb Jacobi is the former Director of Policy and Advocacy for Apple Tree Dental, and is currently Associate Director of Helping Services for Northeast Iowa. She also serves as the interim president of the Minnesota Oral Health Coalition.


For more information about working with Head Start in your community, contact Gayle Kelly at the Minnesota Head Start Association.

Another excellent resource is the Minnesota Oral Health Plan, produced by the Minnesota Oral Health Program in collaboration with an array of stakeholders. The Plan recommends expanded collaborative models like Head Start’s to advance three of the four priority areas identified for Minnesota:

  • Prevention and Education.

  • Health Care Integration and Access to Oral Health Care.

  • Surveillance.

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by Kristen Tharaldson, Rural Health Planner

Dementia has been called “The Game Changer” and “The Disease of the Baby-Boomer Generation.” Statistics highlight its growing impact in our state. Over 100,000 Minnesotans live with Alzheimer’s disease and nearly 250,000 Minnesotans care for a family member with Alzheimer’s. The exponential growth of the elderly population over the next 40 years will cause a substantial increase in the number of people with Alzheimer’s disease and other dementias. Early detection is possible, but it is expensive and there is currently no cure for Alzheimer’s disease.

Rural living has been associated with an increased risk of Alzheimer’s disease, and studies suggest that rural living in early life further increases this risk. There is an urgent need to better prepare community members and health care systems for dementia, particularly in rural communities. A “dementia-capable” community is informed, safe and respectful of individuals with dementia and provides supportive options that foster quality of life.

How can rural communities become dementia capable and ready to support families and caregivers affected by this disease?

ACT on Alzheimer’s, a Minnesota initiative, has developed a toolkit to help communities address this challenge. Implementation of the toolkit brings people together to identify approaches to support residents living with dementia, as well as their families, caregivers and medical providers. ACT on Alzheimer’s is a volunteer-driven, statewide collaboration preparing Minnesota for the personal, social and budgetary impacts of Alzheimer’s disease and related dementias. Over 50 organizations and nearly 200 individuals are already working with ACT on Alzheimer’s in Minnesota. And that is just the beginning.

Walker develops a community action plan for dementia

Walker, Minnesota is a bustling community located on the south shore of Leech Lake in Cass County. While driving into this town in the summer, you may notice signs of an active tourist town - a farmer’s market, kayaks and fishing gear for sale, and families enjoying a mid-afternoon ice cream break. In the near future, you may also see signs in the windows of downtown businesses indicating that Walker is a dementia-friendly community.

In 2010, long-term care and aging services providers in Walker began conversations about their community’s needs related to dementia. They wanted to identify education and dementia resources for caregivers and families. To develop a community action plan, they interviewed 70 people to assess their local assets and needs. Volunteers worked in pairs to interview employers, social services and other sectors impacted by dementia. The interview process took about four months to complete. It helped identify local gaps in dementia resources and planning.

As part of the community assessment process, Debbie Richman from the Alzheimer’s Association Minnesota-North Dakota chapter offered a presentation to retailers and other businesses in Walker. She asked about Walker’s plans for a dementia-capable community and hopes for area residents living with dementia. She mentioned a new toolkit to address community readiness and connected the group with Olivia Mastry, executive lead of ACT on Alzheimer’s. Soon after this introduction, Walker community members agreed to be the first rural community in Minnesota to pilot the ACT on Alzheimer’s dementia-capable communities toolkit.

The pilot project challenge of “being a guinea pig”

Use of the ACT on Alzheimer’s toolkit ushered in the second phase of preparedness for dementia in Walker. Additional community volunteers were engaged to share their experiences and move the pilot project forward. Because the toolkit had not been community-tested, there were some challenges to its use. First, a survey used to collect information from community members needed to be tweaked to gather more useful information. Second, a synthesizing tool was adjusted to streamline data from different versions of the survey. Community volunteers shared these and other challenges with ACT on Alzheimer’s staff, who then adapted the toolkit.

Despite these early challenges, it was clear that people were engaged in meaningful discussions about Alzheimer’s and other dementias. Community members’ awareness was growing and new relationships were created. As more people engaged in these discussions, the questions were “What happens now?” and “What will Walker do about it?”

A community meeting to share results of the assessment was a critical catalyst to move ahead. A clear finding was the need for a “one-stop shop” for dementia resources specific to Walker. The sheriff wanted to know where to call when someone presents with dementia. Long-distance caregivers with family members in assisted living or memory care centers wanted to know their options for purchasing support services in Walker. Education and training were also needed. Community members wanted to know more about dementia. Retailers and other businesses wanted training on the early warning signs of dementia and how to effectively communicate with people with dementia and their caregivers.

Walker’s ACT on Alzheimer’s initiative is now working to address these and other local needs through use of the toolkit and continued engagement of community members.

Toolkit implementation and next steps

Communities implementing the toolkit and becoming dementia capable work to advance these ACT on Alzheimer's goals:

  • Prepare and equip communities to support residents who are touched by dementia.

  • Raise awareness and reduce stigma by engaging community members.

  • Identify and invest in promising approaches that reduce costs and improve care.

  • Increase detection of Alzheimer's and improve ongoing care and support.

  • Sustain caregivers by offering information, resources and in-person support.

Resources associated with the ACT on Alzheimer’s toolkit include: a list of available dementia trainings for direct care staff; clinical provider tools for identifying and managing cognitive impairment; and community-based service provider tools to improve screening and care coordination. ACT on Alzheimer’s also engages health care systems and care providers in preparing for Alzheimer’s. Essentia Health System, for example, is beginning to use a “SmartSet” in their electronic health record system to allow for standardized dementia screening. Health care homes, established through state health reform efforts in 2008, are developing an Alzheimer’s curriculum for their statewide learning initiative.

ACT on Alzheimer’s has an ongoing effort to recruit and engage additional rural communities. In addition to the comprehensive toolkit, they can offer resources, technical assistance and other support for community planning and assessments. For more information about becoming a dementia-capable community, visit or email

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Please explain your professional work to us . . .

I am a Family Physician and have worked in Albany, Minnesota for close to 19 years. I work in a clinic, help cover the emergency room, care for people in the Albany Area Hospital, and do nursing home rounds. After 18+ years and close to 500 babies, I stopped doing deliveries January of this year. I have taught several residents, medical students, physician assistant (PA) students, and nurse practitioner (NP) students in my clinic for periods of one week to nine months. I have served nine years on our hospital Board, and have been the Chief of the Medical Staff of the hospital in various years.

And your life away from work?

I have been married to Patti for 22 wonderful years. We have 3 children: Nick, Molly and Anthony. I enjoy reading, running and astronomy. I am the Mayor of Albany. This year I was also elected the President of the Minnesota Academy of Family Physicians. I am an adult leader for the Boy Scouts and serve as their treasurer. I belong to the Knights of Columbus and the American Legion. In our "free time," my wife and I like to travel.

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

Access. This comes in many forms: access to subspecialist doctors, primary care providers, mental health, ambulance, and nursing home/home care, just to name a few. The main reasons for the access problem are workforce shortage and payment. How do we get the people to come to the rural areas and how do we try and keep payments high enough so they stay and don't leave to the urban areas where payment is better?

Health Care Reform. We need to make sure that the reform is doable for rural areas as well as urban areas. If not, we are in danger of making the separation between the two worse and could make the access issue worse, not better.

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

It is all about workforce. From high school on, we need to find people from rural areas who will go back to rural areas and then train them for the jobs needed. The University of Minnesota Duluth Medical School has been able to use this model very successfully over the years. It is time we ask the other institutions of learning - from certified nursing assistants (CNAs) to physicians (MDs) - to do the same. Not much else will matter if we don't have the people to carry out the work.

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

  MISSION: To promote access to quality health care for all Minnesotans. We work as partners with policymakers, providers, and rural and underserved urban communities to ensure a continuum of core health services throughout the state.