Spring Quarterly Newsletter


Spring 2015



photo of Mark Schoenbaum
Mark Schoenbaum


In some ways, we know a lot about what should be done to address health workforce shortages. The facts and figures have been available, a range of strategies has been identified, and there has been some level of public and private investment.

But problems of supply and geographic distribution remain, with most predicting worsening shortages. And the work of government, higher education and healthcare employers doesn´t seem very well coordinated, even though there are some longstanding forums for sharing information.

Over the last year there´s been an unprecedented confluence of health workforce policy and planning activity underway at the state level in Minnesota. At least six formal workgroups, taskforces or commissions met in 2014 on health workforce issues. Some of these efforts focused on a specific component of health workforce education and development; some were chartered to address state level coordination, data analysis and planning. Five groups issued reports to the 2015 Minnesota legislature, and the sixth will report to the governor in fall 2015. Here´s the list:

1. Governor´s Blue Ribbon Commission on the University of Minnesota Medical School – Charged to recommend future strategies, investments, and actions to strengthen the position of the University´s Medical School.

2. Task Force on Foreign–trained Physicians – Charged to develop strategies to integrate immigrant and refugee physicians into the Minnesota health care delivery system.

3. Legislative Health Care Workforce Commission – Chartered to study and make recommendations to the legislature on how to achieve the goal of strengthening the workforce in health care.

4. Mental Health Workforce Summit – Charged to develop a comprehensive plan to increase the number of qualified people working at all levels of the mental health system.

5. National Governors´ Association Healthcare Workforce Policy Academy – Chartered to establish an infrastructure and strategies for coordinated health workforce data, planning, and development.

6. Minnesota PIPELINE Project – Charged to develop competency standards and apprenticeships for occupations in high–demand industries, including health care.

Trends that may help explain this unprecedented attention to health workforce issues include ongoing transformation of the health care system, moves toward more team-based approaches and value–based payment models, and the imperative to integrate mental health services and medical care to better meet the needs of patients and families. Also at play is a growing understanding of the mismatch between Minnesota´s increasingly diverse population and the make–up of the health workforce that serves it, and continued interest in the role of Minnesota´s higher education systems in health professions education.

These and other drivers created a unique opportunity for progress on health workforce issues, and many proposals from these planning projects became law in the 2015 session. Here´s a preliminary report:

• Loan Forgiveness – Mental health professionals, public health nurses, dental therapists/advanced dental therapists were added to the state´s health professional loan forgiveness program, and its $740,000 budget was increased by $2.6 million each year.

• Primary Care Residency Expansion – A $1.5 million per year grant program to fund new residency positions in family medicine, general internal medicine, general pediatrics, psychiatry, geriatrics, and general surgery was established. A Veterinarian Loan Forgiveness program was also funded.

• Home and Community Based Services (HCBS) Scholarships – A $1 million per year program was created so employers can help HCBS staff advance their education and careers. The nursing home scholarships program was also revised, and loan repayment for recent nursing graduates was added as an eligible expense.

• Foreign Medical Graduates – $1 million/year was appropriated to provide career guidance and license test preparation, clinical preparation experiences, assessment of immigrant physicians´ qualifications to enter residency, and a revolving fund for dedicated residency positions. The program will also address remaining barriers to securing residency and explore pathways to non–physician careers.

• University of Minnesota Medical School – $15 million/year was dedicated for the recommendations of the Blue Ribbon Committee, a portion of which will be invested in physician training programs in rural and underserved communities.

• Dual–Education Apprenticeship Programs – $3.4 million will be available in 2016—17 for “earn while you learn” training in high growth sectors like health care, including developing the medical scribe, health information technician, health support specialist and psychiatric/mental health technician occupations.

• Community Emergency Medical Technician (CEMT) – A new certification, similar to community paramedic, was established, and details for possible Medicaid reimbursement for CEMT services will be developed.

• Medical Education and Research Costs (MERC) Program – $1 million/year was added to this program´s $57 million budget.

• Emeritus License for Social Workers – This provision provides a reduced fee so senior social workers can contribute supervision or pro bono work.

• FastTRAC – This program was continued at $1.5 million/year, pending final enactment in a special session. It helps educationally under–prepared adults succeed in well–paying careers, including health care, by integrating basic skills education and career–specific training.

• Telehealth – Legislation was enacted requiring coverage of telehealth services by health plans and mandating that telehealth and in-person services be reimbursed the same.

• Interstate Physician Licensure Compact – Minnesota became the seventh state to allow expedited licensing of physicians in other Compact states.

These investments will make significant contributions to meeting Minnesota´s health workforce needs; and, of course, much remains to be done. Both the Legislative Health Care Workforce Commission and the National Governor´s Association Minnesota Policy Academy will continue their work in 2015 and 2016. The seeds sown by 2014´s workforce planning have borne substantial first fruit, and the ground is prepared for continued progress.

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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By Kristen Tharaldson, MPH

Minnesota has taken major steps in increasing access to doulas, a service known to improve birth outcomes. A new law means more low–income women will be able to afford to have a doula’s assistance. The challenge now is ensuring that all communities—particularly rural areas—have an adequate doula workforce.

The doula role

Childbirth is the number one reason for hospitalization in the United States. Medicaid programs finance 48 percent of all births at a cost of approximately $13 billion per year. Medicaid programs aim to provide high-quality maternity care for approximately 2 million low–income mothers and infants each year. However, racial and geographic disparities in birth outcomes persist, and costs associated with obstetric services continue to rise.

Doulas are non-medical professionals who provide guidance, information, and one–on–one physical and emotional support before, during and after childbirth. They play key roles in childbirth education and breastfeeding support. Research has shown doula care to be effective in lowering cesarean section rates, decreasing the need for other interventions in the hospital setting, and improving breastfeeding initiation and duration. Research has also demonstrated the potential for reductions in medical costs due to less costly interventions and better health outcomes for mothers and babies.

Minnesota's pioneering doula policy

In the 2013-2014 legislative session, Minnesota became the second state (following Oregon) to authorize Medicaid to pay for services from a certified doula. Doulas added to the state doula registry who meet specific certification requirements will be eligible to receive Medicaid payment of $411 for a bundle of care. This package includes six visits (prenatal and postpartum) as well as support during labor and delivery. Additional visits would be paid upon recommendation of a physician according to “medical need.”

Previous legislation added doula care to Minnesota’s Patient Bill of Rights. This allows women to have a doula on their obstetric care team and permits doulas to work in hospitals and birth centers. The doulas must be certified and follow a scope of practice that clarifies their role as a non-medical support person.

Passage and implementation of the Minnesota Doula Bill means many low-income women will now have access to doula care. This is significant because Minnesota has some of the nation’s worst gaps in perinatal health outcomes. A national survey of doulas from 2003 found the majority of doula services were provided for white, well-educated married women with children who could afford to pay privately. This is because most doula care is an out-of-pocket expense, and many insurance providers do not cover the cost. Anecdotal evidence from the Minnesota Better Birth Coalition suggests that most privately paid doulas in Minnesota are paid between $700 and $1,200 per birth.

Tackling the challenge of access in rural Minnesota

A challenge presented by this new legislation is the lack of certified doulas in communities that could benefit the most from their care. Most doula trainings are offered in metro areas, so rural communities may not have adequate access to certified doulas. In 2013, the Rural Health Advisory Committee wrote the Obstetric Services in Rural Minnesota report and recommended an increase in access to doula care in rural areas. Native American and African–American communities have the highest rates of infant mortality and poor birth outcomes in Minnesota. Training doulas from these communities holds promise for better birth outcomes and more women feeling empowered by a better birth experience.

Rural Health Advisory Committee (RHAC) member Millicent Simenson is taking the lead in promoting doula care and training for Native American women in northern Minnesota. Dr. Katy Kozhimannil from the University of Minnesota received a grant to train 15 urban doulas from racially diverse communities. She will measure how implementation of the doula bill improves doula access and women’s experiences with doula support. And Everyday Miracles recently expanded doula services to include Duluth. While new Medicaid payment mechanisms are being tested, a new cadre of doulas is being trained to address cultural and geographic access to doula care in our state.

The following websites provide additional information about doula care and Minnesota’s doula bill:

Kristen Tharaldson was formerly a planner with the Office of Rural Health and Primary Care, and is now a Healthy Start Coordinator/Public Health Specialist with the City of Minneapolis. Contact Kristen at kristen.tharaldson@minneapolismn.gov

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By Darlene Mechtenberg, RN

Reaching all the residents of a rural county can be a big challenge. However, a “Big Blue Bus” is helping the Murray County Medical Center (MCMC) overcome that hurdle and improve the health of those across the county.

The idea of a traveling bus started after a 2010 wellness study conducted by the county revealed that many seniors were concerned about accessibility to health care. Members of the community and the staff of Murray County Medical Center debated the best way to address that concern. The group came up with the idea of a medical bus, and thanks to a grant, a 1996 Blue Bird bus was purchased and stocked with the necessary supplies and equipment.

Planners then decided to go another step. Betsy Plotz, Mobile Education Manager, spoke with other managers to develop a bus plan. “It was a collaborative effort.” Plotz said, “Our maintenance department even customized chairs for us.” Kim Olafson, a registered nurse, identified the need to provide toenail trimmings for seniors. Murray County Medical Center sent four nurses to become certified in this service.

One of those nurses was Darlene Mechtenberg. She said offering toenail trimmings is important because many seniors have physical limitations that prevent them from performing their own trimmings.

“It is a joy for me to help them,” said Mechtenberg. “It is rewarding to hear them say afterwards that their feet don’t hurt and they can walk much better.”

Nurses like Mechtenberg have now helped more than 130 residents of Murray County with toenail trimmings with more than 380 visits to the bus for the service.

In addition to toenail trimmings, visitors of the bus were recipients of blood pressure readings, blood glucose monitoring and diabetic foot assessments. Each month different health spotlights were offered such as diabetic education, heart healthy snacks, pulmonary assessments, reviewing of medications by a pharmacist and seasonal flu vaccinations.

Through these regular visits with patients, it was clear that the bus made a difference in Murray County. Richard Illg is a Murray County resident who wished to share his experience:

I saw the “Big Blue Bus” pull into Currie, Minnesota. I heard about the bus, but I really didn’t know what services were provided. It had to have something to do with medical because I saw the whole “wrap” around the bus said Murray County Medical Center. I walked past the bus three times before I was asked by one of the staff if she could help me. I asked the nurse if she could look at my feet. When she sat me down and pulled off my socks and I saw the expression on her face I knew I was in trouble. She asked me how long my feet had been cold and bluish in color. I told her “for a while.” She also took my blood pressure, which was abnormally high as well. She told me that I needed to be seen immediately by my medical provider. She contacted Murray County Clinic Slayton, and I was able to be seen by a provider that afternoon. My provider immediately made plans for me to go to Sioux Falls to be seen by a vascular surgeon. He arranged for me to have surgery ASAP. My surgery consisted of placing a stent into one of my two femoral arteries that supply blood flow to my legs. When this was done the circulation to both my legs was restored. The surgeon said that if I would have waited any longer, I might have had to have my toes removed.

I can’t say thanks enough to Murray County Medical Center and the staff that provide services on the bus for their quick assessment and getting me to the right medical providers at the right time. I don’t want to think where my life would be right now if it wasn’t for the nurses on the “Big Blue Bus”. I can still work every day. I am not disabled. I can get around without a cane, walker or the use of a wheelchair and my medical expenses were at a minimum compared to what they would have been if I would have had to have my toes removed. My “whole quality of life” would have changed. Thanks again to the staff on the “Big Blue Bus.”

In March 2015, MCMC identified the need to expand their two-day-a-month toenail clinic that was previously provided on the “Big Blue Bus” to their Outreach Department at MCMC in order to accommodate and serve all the citizens of Murray County. Presently, MCMC is pursuing other areas of medical interest as identified in their Business Plan and will be bringing the “Big Blue Bus” back out to local businesses and communities to meet those needs.

For more information, visit Murray County Medical Center´s website to read about the Murray County Medical Center (MCMC) Mobile Education and Health Screening Service..

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By Anne Schloegel

Health information exchange (HIE) efforts have expanded greatly in Minnesota over the past five years, including within community collaboratives and public health agencies. With federal funding under the State Health Information Exchange (HIE) Cooperative Agreement Program, from 2011-2014 the Minnesota e–Health Connectivity Grant Program for HIE supported these efforts, providing over $2.8 million to individual providers, hospitals, pharmacies and community collaboratives. In total, the 51 grants included over 200 community partners, whose projects experienced a range of successes and challenges in undertaking these innovative exchanges.

Taking HIE to new levels

Grantees in the Minnesota HIE grant program worked toward the following goals:

1. Expanding e–prescribing capabilities

In 2011, an estimated 45 independent retail and hospital pharmacies in Minnesota could not accept electronic prescriptions. With the help of grant funds, 13 additional pharmacies (eight retail and five hospital) are now e–prescribing. Most of these pharmacies report that between 60 and 90 percent of local prescribers (e.g., clinics, hospitals and dental offices) are now sending prescriptions electronically. They also note that electronic prescribing has improved both productivity and safety, and many wish they could have implemented it sooner.

2. Connecting to State–Certified HIE Service Providers

Grants awarded in late 2011 connected individual providers and hospitals to a State–Certified HIE Service Provider but frequently found their preferred exchange partners limited within their communities. Both partners must be connected to a State–Certified HIE Service Provider, and grantees frequently discovered that the providers they wished to exchange with were not yet connected.

3. Expanding exchange within Community Collaboratives

To address the need for exchange partners, the 2012 grant program was restructured to promote broad-based exchange within a community or region. Community Collaboratives (two or more organizations or exchange partners) received grants to implement clinical data exchange.

These efforts helped health organizations meet requirements for federal incentives for meaningful use of an EHR, and also helped more broadly to expand community-level capabilities to conduct health information exchange for medical care and public health.

Local public health leading the way to community–based HIE

Several projects took on the challenge of exchange within a community collaborative. The “Minnesota HIE Partner Project”, encompassed four regional projects led by county and multi-county local public health departments in northwest, southwest, east central and west central Minnesota connected through a shared public health EHR vendor. Their story provides a model for community-based exchange and underscores both the power and the complexity of such initiatives.

The Minnesota HIE Partner Project built capacity for local data exchange using resources from several regions to promote efficiency and consistency across the state. Initially, 56 grant partners from public health, long–term care, hospitals and clinics were identified and awarded funds. Their goal was to increase the technical capability of grant partner organizations so they could securely exchange protected health information with other health care providers, specifically focused on sending and receiving specific segments of the Continuity of Care Document (CCD).

2011-2012 MN e-Health Connectivity Grant Program for Health Information Exchange: Cities with Partner Organization Sites

Each grant partner was evaluated to determine the best HIE solution(s) for their organization (see definitions in text box). Each partner received funds to implement as many solutions as needed to achieve the grant’s goals.

Health Information Exchange Transactions

A one–directional “push” or send of information between two known entities with established business relationship (e.g., from specialist to primary care).

A bi–directional “pull” of the information that involves: 1) a query for information about a patient, and 2) a response with information on the location and/or the content of a patient’s records. 

Direct Secure Messaging
Health and health care providers exchange health information using push transactions with direct addresses to move information among providers using common Internet standards for Direct secure e–mail communication.

Query–Based Exchange
Health and health care providers exchange health information using pull transactions where many data sources can be searched and accessed information may be used for care coordination, population health and data analytics.

State–Certified HIE Service Providers in Minnesota may offer one or both types of exchange transactions.

Today, connections for two types of health information exchange (Direct Secure Messaging and Query Based Exchange) are in place along with a legal framework for the remaining 40 participating grant partners. Each partner has moved their organization forward in securing the creation, storage, receipt, transmission and maintenance of electronic protected health information. The foundation has been established not only to exchange the current CCD, but also more patient data as it becomes available in a standardized format.

Lessons learned

The project documented valuable lessons that suggest that the following are critical for project success:

Complete HIE assessments for each collaborative partner
Take the time to assess where each partner is in terms of understanding data exchange. Make sure to engage partners at their level of HIE understanding and offer education on terms, concepts and technical solutions.

Establish project priorities and time commitment required
Partners must be willing to make the project a priority. Understanding the expectations, goals and level of commitment in the beginning is critical to decision-making, and teamwork is critical to success.

Build and strengthen organizational relationships
Projects like these can strengthen already existing partner relationships while building new ones. Use the shared vision to enhance and/or improve current and prospective relationships. “One of the greatest gains (although not technical in nature) was the development of the relationships between local public health and community partners that share in the need to exchange client health data,” said Greta Siegel, project lead from the Douglas County Public Health Department. “We knew which organizations we needed to exchange data with, but we didn’t know how to identify the correct individual at those organizations to make it happen. With this project we were able to identify those key individuals and we continue to foster and grow that working relationship.”

Develop policies and procedures
Ensure that any template documents must safeguard privacy and security. Organizational policies need to be in place as well, and some organizations need more help than others.

Create regional leadership overall and communications
According to project participants, a regional leadership structure was invaluable as a resource and critical as a structural component. Having a “Super Committee” composed of a broad spectrum of expertise was also a tremendous asset, including communication through the life of the project.

Develop overall program management and communications strategies
A project of this size and complexity needed centralized project management, as many were not experienced in the work. The program management team brought partners along and educated them as they went. And, as might be expected, the teams struggled with finding the right balance between “too many emails and meeting notices” or too few to keep people informed without face–to–face interactions.

An unintended but important additional outcome of the Minnesota HIE Partner Project was the connections forged beyond communities and counties to share tips and tools to avoid common challenges. “With four regions involved in this project, we were able to reach across county lines and form connections with others dealing with the same HIE issues,” said Siegel. “The network has proved valuable in many other areas of our work as well, and will help to grow the ’network’ of providers that exchange client data in a standard format.”

Laying the groundwork for more advanced HIE

The community collaborative groundwork created with these HIE connectivity grants was very instructive and laid the foundation for other programs, including the Minnesota Accountable Health Model e-health grant program that is part of the Minnesota State Innovation Model (SIM) project. This project is part of a $45 million State Innovation Model (SIM) cooperative agreement, awarded to the Minnesota Departments of Health and Human Services in 2013 by The Center for Medicare and Medicaid Innovation (CMMI) to help implement the Minnesota Accountable Health Model.

This new e–health grant program, modeled on the HIE Connectivity Grant Program, is intended to support the secure exchange of medical or health-related information. Applicants are required to be part of a community collaborative participating in or planning to participate in an accountable care organization (ACO) or similar health care delivery model and must include at least one of the priority settings of long-term/post-acute care, behavioral health, local public health and social services.

In July 2014, 12 collaboratives were awarded over $3.8 million for Development and Implementation e-health grants to support the use of HIE to identify health improvement and coordination opportunities and readiness for accountable health. A second round of projects will begin this summer with an additional $2 million available for more implementation grants.

map of Development and Implementation e-health grants

Anne Schloegel is the Minnesota e-Health Project Lead in the MDH Office of Health Information Technology. Contact Anne at anne.schloegel@state.mn.us or 651-201-4846.


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

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June 29-30 in Duluth, MN



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.