Spring Quarterly Newsletter



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photo of Mark Schoenbaum
Mark Schoenbaum


It’s clear Minnesota faces a health workforce shortage due to an aging population, aging providers and newly covered patients seeking health services. Educational institutions and others are working hard to produce more health professionals, and these efforts are essential. But they may not be sufficient to meet projected shortages.

At the same time, work is underway to transform how care is delivered. Many health care providers and health systems are working to strengthen care coordination, build team care models such as health care homes, respond better to Minnesota’s increasingly diverse population, and limit the progression of chronic diseases.

A unique Minnesota response to these trends has been to support four emerging health professions - community health workers, community paramedics, dental therapists/advanced dental therapists and doulas - with Medicaid reimbursement and state licensure or formal recognition.

Minnesota is the only state to take this important step to meeting workforce needs and improving care. So how can these emerging professions contribute to the state’s goals?

Community Health Workers come from the communities they serve, building trust and vital relationships so they can link their communities and systems of care and reduce health disparities. They provide access to services, improve the quality and cultural competence of care, improve chronic disease management, and increase the health knowledge and self-sufficiency of underserved populations (Source: Minnesota Community Health Worker Alliance).

Community paramedics are experienced paramedics who complete additional education and practice under the supervision of an ambulance service’s medical director. They provide non-emergency health services in the field as directed by a patient care plan.

Dental therapists and advanced dental therapists practice as part of a dental team to provide educational, clinical and therapeutic services. They are sometimes referred to as “mid-level” providers because their scope of practice falls between that of a dentist and a dental hygienist or dental assistant. Dental therapists and advanced dental therapists in Minnesota must practice in settings serving primarily low-income, uninsured and underserved patients.

Doulas are trained and experienced professionals who provide continuous physical, emotional and informational support to mothers before, during and just after birth, or provide emotional and practical support during the postpartum period (Source: DONA International).

As policymakers see the connections between health reform goals and workforce issues, they’re starting to look to these emerging professions as part of the solution. Strategies to advance emerging professions, along with other workforce recommendations, were integrated in the 2012 Roadmap to a Healthier Minnesota of the Governor’s Health Care Reform Task Force. More recently, Minnesota’s State Innovation Model project, funded by a major federal grant, includes support for new provider types to transform care delivery.

Though numbers in each field are small, these workers can help stretch staff in clinics organized around the team concept. They focus on basic services and patient engagement, freeing traditional providers for more of the complex tasks they’re trained to do. By improving access and spending time outside the facility with patients and families, these disciplines can help prevent chronic conditions from worsening and avoid more expensive care and hospital admissions.

Some key prerequisites led to the success of these workforce developments over the last 10 years. In each case there was:

  1. Acceptance by related professions.

  2. A defined scope of practice or role, legislative authorization and development of a regulatory framework.

  3. Advocates pursuing advancement of the profession.

  4. A body of knowledge, a curriculum and education programs.

  5. Prospective candidates interested in entering each field.

  6. Reimbursement for services provided.

  7. Help for prospective employers: implementation guides, templates, best practices for hiring and integration, and start-up funds.

  8. Complementary trends such as practice redesign and health care homes, and new priorities on improving access and reducing emergency department use.

  9. Acceptance by patients and families.

It will take time for these new occupations to have impacts statewide on health care delivery, but they're already showing promising signs. North Memorial's community paramedic program recently celebrated its first anniversary. In just one year, North has fully implemented a new primary care model that uses ambulance practitioners and is fully integrated within its health system. Earlier this year, MDH published the first report on the early impacts of dental therapists, who began to practice in Minnesota in 2011. Although the dental therapist workforce is in its infancy, this preliminary study found promising signs that dental therapists are improving access, especially for low-income Minnesotans, and providing quality care.

As knowledge and experience expands, we can expect ongoing evolution of roles and new occupations no one has imagined in coming years. Let’s keep our expectations high that Minnesota will continue to address health workforce issues through these kinds of innovation.

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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In health care’s transition to electronic patient records, emergency medical services (EMS) haven’t received much attention. Partly that’s because they operate at the intersection of three related but often separate realms - health care, public safety and public health - and partly because they haven’t always been eligible for the funding and incentives that have helped fuel the shift for other providers.

So unless you’ve been treated in an ambulance recently or work in that world, you might not know that EMS providers, like hospitals and clinics - and nursing homes and pharmacies and therapists and labs - have also been moving from paper to digital charts. ORHPC talked with two rural Minnesota EMS services to see how it’s gone.

Making the jump

Glacial Ridge EMS and Essentia Health Emergency Medical Services in Sandstone (formerly known as Pine Medical Ambulance Service) are both rural EMS services closely affiliated with hospitals, and both turned to ORHPC’s Rural Hospital Flexibility grant program for support to implement electronic patient care record (e-PCR) systems. Glacial Ridge Health System and Glacial Ridge EMS worked together to make the transition in 2010 and Sandstone switched in 2012.

The EMS services cited multiple reasons for the switch. They were looking to save time, improve the quality of their services, and increase billing efficiencies. Electronic recordkeeping is also becoming the industry norm, as it is in other areas of health care: According to the Emergency Medical Services Regulatory Board (EMSRB), roughly 55 percent of the state’s ambulance services are now collecting patient information electronically. The EMSRB itself requires EMS providers to provide data through a web portal for every request for ambulance services. For ambulance services without an electronic recordkeeping system, this can mean time-consuming manual entry of information from handwritten ambulance run sheets.

For such a major conversion, implementing the new systems went fairly smoothly in both cases - after some initial grumbling. “It’s like anything that involves change: ‘Why do we need something new?’ ‘What’s wrong with how it is now?’” said Greg Meyers, ambulance director at Glacial Ridge. “But now we couldn’t go back to the old way.” Essentia-Sandstone’s IT manager, Mary Beth Kester, agrees. Recently the ambulance service had a problem with one of its laptops and the backup wasn’t available. The crew had to go back to documenting on paper. “Let me tell you, I had EMS folks telling me they needed it back NOW,” recounts Kester. “‘We can’t do it this way anymore - don’t make me do that!’” But at the time the electronic systems were introduced, the opposite was true.

The biggest implementation task was training, and managing the resulting lag times as staff learned. According to Joe Newton, ambulance director at Essentia-Sandstone, initially the time to document went slightly longer than the paper-based average of 30 minutes. Partly that was because crews were learning not only how to operate the new software and equipment, but also a different sequence of documentation. After originally planning to set up the system based on how the paper run sheets were structured, they took the opportunity of implementation to analyze their workflow and decided to switch to a more logical sequence of entering the information. “We ended up kind of turning it upside down and redoing it, to something much more intuitive,” says Kester.

The result, after that initial lag period, is a much faster system. “Overall, it saves a ton of time,” says Joe Newton, ambulance director in Sandstone.

Reaping benefits

Several years into using the electronic systems, both Glacial Ridge and Essentia-Sandstone report a variety of benefits. Speed - especially critical in emergency services - is a major one, but so is accuracy. Not only does patient information get to emergency room providers more quickly - often before the patient arrives to the hospital, as the emergency staff are able to access it from the web-based system rather than waiting for the paper record to arrive with the ambulance - but it can be read more easily. “The ED absolutely loves it, because they can read the report,” says Newton. That wasn’t always the case with handwritten sheets.

The electronic system also standardizes where information can be found, another gift to hurried emergency department providers. “The caregiver consistently now knows what to expect on the call sheet, every time,” says Kester. “That’s huge. It makes an enormous difference for the staff waiting here in the ER, waiting for the truck to arrive, when they have all the information they need to get started. Two or five minutes in the exchange of a patient can make all the difference in their care. It also helps when an important decision has to be made about transferring someone - the difference in having the information accurately and that much faster."

Increased speed and accuracy have also been important for another crucial area for EMS: billing. Tracking down information missing from handwritten ambulance sheets often delays the billing process, which in turn can jeopardize or decrease reimbursements from insurance companies that require timely submission of claims. This is especially important for rural ambulance services, which face myriad financial challenges and are often small and volunteer-run. Both Sandstone and Glacial Ridge have seen significant improvements in billing time since the implementation of their electronic systems - in Glacial Ridge’s case, bill submission has sped up from an average of 14-21 days to only four.

Looking ahead

Both EMS services are eager to leverage their e-PCR systems still further. Essentia-Sandstone is exploring how best to expand wireless connectivity to their ambulances in the field, a capability increasingly possible thanks to recent improvements in broadband development in their service area. Currently, their EMS providers must be in range of the hospital’s wireless system before they can transmit the patient record to the web-based portal, but they hope to develop broader connectivity soon, along with ways to ensure the security of their patient electronic data transmissions outside the hospital’s immediate network.

Developing such in-the-field connectivity will not only speed up transmission of data to the hospital, but will also allow data from certain key pieces of equipment - such as cardiac monitors, which take vitals and monitor EKGs - to be imported directly into the e-PCR and to the hospital. Glacial Ridge’s system has that capability now, and their ambulance director sees the impact about to “grow two-fold” with a new STEMI (ST Elevated Myocardial Infarction) system. “I’ll put a 12-lead on a patient in the ambulance having chest pain, get that electrical picture, and if we notice a STEMI on the print out, that will automatically be fed to the ER and the doc will be able to pull up that exact information that I’m seeing on the monitor,” says Meyers. “That means the ER can get things started ahead of time with the STEMI protocol in preparation of arrival of EMS.”

Essentia-Sandstone is also looking forward to expanded possibilities with health information exchange, beginning with continuity of care documents that could be shared across the many different types of EHRs and providers involved in patient care. The Sandstone hospital is currently working on such a document with their long-term care facility, and is hopeful this and other tools now in development might soon lead to fuller sharing and integration capabilities with the ambulance service and other providers.

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By Rebecca L. Ratcliff, MD

Fairview Northland Medical Center, situated in Princeton, Minnesota, is a typical rural hospital providing comprehensive obstetrical care to a significant area north of the Twin Cities. However, what makes Northland hospital unique is the stability and size of the obstetrical team. Tasked with handling both normal and operative/high risk deliveries, this team is made up of both OB/GYN physicians and Family Medicine physicians with advanced training in obstetrics.

In light of the recent alarming report by the Rural Health Advisory Committee (RHAC) on obstetrical services (OB) in Minnesota, which documents both a shortage of OB providers in the rural area and its consequences in terms of maternal and infant mortality and morbidity rates, this team model of obstetrical rural care has much to offer. By recruiting Family Medicine physicians to join the obstetrical team, Fairview Northland is able to provide the community, which includes Sherburne, Mille Lacs and Isanti counties, with a sufficient number of obstetrical providers.

“We have had strategic discussions about moving to an OB/GYN exclusive model,” said Dr. Greg Schoen, a practicing family physician and Vice President of Medical Affairs for Northland. “However, having OB/GYNs and Family Medicine physicians doing obstetrics is critical to our success. We would not be able to sustain our obstetrics practice without them. If we hired all OB/GYNs to cover the obstetric services, they would not have enough gynecology cases to sustain them."

The members of the obstetrical Cesarean section team include 1 OB/GYN, 1 double- boarded FP/OB/GYN and 2 Family Medicine physicians with advanced training in obstetrics. In addition, there are 5 Family Medicine physicians who manage their own obstetrical patients with C-section back up from this team.

“It’s worked out really well,” said Dr. Kristen Williams, an OB/GYN graduate from the University of Minnesota OB/GYN residency. “This model gives you more people who can cover or help if there is a complicated C -section case. And it allows our rural families to have continuity of care with their own doctors as opposed to locums people coming up for C -section coverage."

Dr. Americo Fraboni is an example of a provider who is committed to this community. A Family Medicine physician, Dr. Fraboni started his relationship with Northland as a medical student in the Rural Physician Associate Program (RPAP). (This is statewide program through the University of Minnesota that places medical students in rural hospitals throughout the state.) After completing his Family Medicine residency at St. Joseph’s Hospital in St. Paul, Dr. Fraboni went to Brown University for a two-year fellowship in operative/high-risk obstetrics combined with a Master’s in Public Health. “I did a lot of obstetrics in residency and I first assisted on C -sections, but I felt that this was not adequate training. I did a fellowship because I wanted to be competent surgically.”

Dr. Fraboni represents a growing number of Family Medicine physicians who graduate with advanced training in obstetrics, either because they have done an obstetrical fellowship or because they receive advanced obstetrical training in residency. The American Board of Physician Specialties has recently instituted a Board Certification in Family Medicine Obstetrics (BCFMO) in order to formalize this higher level of obstetrical training in Family Medicine.

In response to detractors who say family medicine physicians cannot provide obstetrical care, Dr. Greg Schoen notes that Northland meets national benchmarks for standards of quality of care in obstetrics.

“With the appropriate training, a Family Medicine doctor or General Surgeon can learn how to do C-sections,” said Dr. Williams who started 6 years ago at Northland. “Family Medicine physicians doing C-sections is just normal to me.”

Rebecca L. Ratcliff, MD, is a faculty member of the Family Medicine Residency Program at Hennepin County Medical Center.

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By Will Wilson (Office of Rural Health & Primary Care) and Sarah Bohnet (Minnesota Hospital Association)

Recruiting health care practitioners is difficult, and retaining them can be even harder. But there are some strategies that employers active in their communities are using to build loyalty and reach potential employees early in their careers - in fact, very early. Even in high school.

That’s why the Office of Rural Health and Primary Care (ORHPC) is happy to announce the re-launch of the Summer Health Care Internship Program. State funding for this program was cut for two years, but with funding now restored, ORHPC has again selected the Minnesota Hospital Association (MHA) to administer this popular program. The Summer Health Care Internship Program aligns well with other workforce development initiatives in both ORHPC and MHA, including efforts targeting the skills gap, effective career pathway systems, and workforce shortages in such key areas as primary care and mental health.

Research shows that if we grow our own health care professionals by educating and training them in Minnesota, they are more likely to stay. Creating this mindset begins early, by sparking students’ interests and giving them real-life experiences before they choose a career path.

The Summer Health Care Internship Program helps participating facilities reach out to future workers in their home communities, with a focus on diversity. The program gives balanced attention across rural and urban communities, and across education systems. Funds are limited, but the program can have a lasting impact on meeting the future demand.

Connecting with students interested in health care as early as possible can help ensure that Minnesota continues to be positioned as a leader in health care quality, access, education, practice and innovation. Providing high school and college students with a hands-on experience helps them gain the skills, understanding and confidence they need to commit to a rewarding career in a health care profession.

How it works

Hospitals, clinics, nursing facilities and home care providers apply to the program on behalf of qualified students in their community. Participating organizations employ students between Memorial Day and Labor Day for six to 12 weeks and pay them at least minimum wage. Up to half of the intern’s hourly wages are reimbursed through the program. In 2011 (the last year funds were available), the Summer Internship Program provided 237 students with 65,960 hours of intern experience in 83 hospitals, clinics and long-term care organizations.

Students apply directly to the facilities participating in the program. To be eligible, the students must have completed either their junior or senior year of high school and must intend to complete graduation requirements. Post-secondary students must be enrolled in a Minnesota educational institution or be a resident of Minnesota enrolled in an out-of-state program. Post-secondary students must be enrolled, or plan to be enrolled, in a two- or four-year health care degree program, with the intention of completing the program.

The Summer Health Care Internship Program is also a wonderful way to build collaboration across education, health care, long-term care, and home care partners to increase awareness and interest among students and educators regarding future health care careers they may not have considered. “As someone who didn’t think I would like to work in a nursing home, the experience definitely changed my mind,” said one former intern. “I now think I would work in a nursing home, if the opportunity ever came about."

For more information, visit MHA’s Summer Health Care Internship Program website or contact Sarah Bohnet, MHA’s SHCIP Coordinator, with any questions at 651-603-3494 or sbohnet@mnhospitals.org.

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Please explain your professional work to us . . .

I’ve been on the faculty of Minnesota State University in Mankato for 29 years. In that work, I do two things: I coordinate advising in the College of Social and Behavioral Sciences, which has about 2,200 undergraduate students, and I help prepare secondary social studies teachers.

These days, I’m also in the Minnesota Legislature. In addition to serving on RHAC, I sit on the Health and Human Services Policy Committee and other legislative committees. In that role, I try to ask questions about the pertinence of issues to rural Minnesota. For example, in a recent transportation finance meeting, we were looking at the dangers of oil freight and I asked about the implications for rural first responders.

And your life away from work?

I’m married to a school social worker and we live a quiet life, enjoying each other and friends. I also have a tree farm up north, which I inherited from my father and have managed for 10-15 years. It’s a labor of love - very isolated and beautiful. I enjoy managing the farm itself, but just love being there as well. I also bicycle and cross-country ski.

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

I’m very concerned about workforce. It’s a documented issue and as people are retiring, it will get worse. We need to keep our eyes on it, in part because the physician shortage will likely be even more acute in rural Minnesota. We need to figure out ways to attract people to do health care in rural Minnesota, which is closely related to having economically healthy communities. Such communities are more appealing and stronger all around.

Also important are long-term issues like healthy eating and exercise. At a recent Rural Health Community Forum, ORHPC presented data on our region that really struck me. I was looking for outliers, and an outlier for our part of the state was heart attacks. Preventing those through healthy eating and activity is very important, as is how we respond. That’s one of the reasons I’m glad to be part of a bill to improve STEMI (ST segment elevation myocardial infarction) care and establish a statewide registry. But equally if not more important are the underlying causes of these health conditions, and I think efforts like SHIP (State Health Improvement Program) play a big role there.

Another important issue is the fact that health care costs more in rural Minnesota, something we learned through MNsure. We need to keep focused on this - it’s not over with the Affordable Care Act. When the competition issue doesn’t exist in a community, are there alternative ways to handle costs? We can’t stop asking these health care cost questions. And amid all the talk about outcomes and costs, let’s not lose sight of the value of people being healthy. That’s a tremendously important thing, just for its own sake.

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

We need to develop incentives for health care professionals, especially primary care practitioners, to live and practice in rural Minnesota. It will probably require a menu of incentives, ranging from scholarships to building collaborative practices that involve social workers and other professionals in rural communities.

Having economically vibrant rural communities is important to that too. Minnesota has a long tradition of economically vibrant rural communities and we need to maintain that. Many things tie into having such a community, including good schools and addressing poverty. It’s hard to be healthy when you’re poor. An economically vibrant Minnesota will be a healthy Minnesota.

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.