Winter Quarterly Newsletter
 

Contents:

Winter 2016

snow, porch, shadows  

DIRECTOR'S COLUMN

photo of Mark Schoenbaum
Mark Schoenbaum

Looking back and ahead

Happy New Year, and welcome to this first Quarterly of 2016! 2015 gave us a lot to reflect on, with both wins and losses.

OJ Doyle died last summer, a major loss for both the EMS and broader health care communities. Starting out as a medic, OJ became an enthusiastic and effective advocate for EMS, especially rural EMS, at the Capitol and across the state. He was inimitable at telling the story of how EMS works, the challenges it faces and why it’s important.

Former state representative Roger Cooper of Bird Island was among those attending OJ’s funeral. Cooper, who left the legislature in 1996 after ten years, was rural Minnesota’s legislative champion during the health reform wave of the early 1990s, and he’s still very energetic. In addition to saying goodbye to OJ, this sad occasion was an opportunity to remember and be grateful for the past champions of Minnesota's health care safety net, both rural and urban, upon whose accomplishments we build.

The 2015 legislative session brought some significant wins for the health care safety net, and it was a major year for health workforce analysis investments. Here’s a partial recap, focusing just on those provisions directly involving the Office of Rural Health and Primary Care:

  1. Health Professional Loan Forgiveness program expanded; new professions added
  2. Federally Qualified Health Centers grants increased
  3. Primary care residency expansion grant program created
  4. International Medical Graduates Assistance program created
  5. Medical Education and Research Costs (MERC) appropriation increased
  6. Home and Community-Based Services/long term care scholarship program established

As we head into 2016, staff here is busy implementing all these new and expanded initiatives. We are already seeing some early signs of progress, with the first loan forgiveness awards made to mental health professionals, dental therapists and public health nurses, and strong interest in all of the new programs. Of special note, the University of Minnesota has created the first dedicated medical residency position for an immigrant or refugee physician through Minnesota’s new, first-in-the-nation state program to put more of these uniquely capable physicians to work. Programs such as these simultaneously respond to Minnesota’s workforce and health disparities challenges.

The Rural Health Advisory Committee is also diving into its latest issue priorities, working on a new model for rural dentistry, insurance coverage in rural Minnesota and mental health access. As always, we’re only able to make progress because of the partners who advise us and collaborate to make sure everyone in Minnesota has access to the care they need.

We wish you health and happiness this year. Please stay in touch, share your news, and we'll keep moving together.

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


LUCAS™ 2 deployment already saving lives

The Minnesota LUCAS 2 Outcome Report for Year One of the Minnesota Department of Health’s LUCAS™ 2 Grant has been published by the University of North Dakota’s (UND) LUCAS Grant Evaluation Team. Results indicate that use of the LUCAS™ 2 automated cardiopulmonary resuscitation (CPR) device in Minnesota has already made a positive difference in sudden cardiac arrest (SCA) care among rural patients. Last year, 106 LUCAS™ 2 Chest Compression System devices were delivered to all eligible rural licensed ambulance services and hospital emergency departments in the Northwest, Northeast and West Central Emergency Medical Services (EMS) regions in the state. In less than half a year of deployment across the northern and western portions of Minnesota, the LUCAS™ 2 device was used 83 times. Of that, nine patients were saved and discharged from the hospital. This 11 percent survival rate is remarkable given the sparse population of the area and long transport times. These early numbers are encouraging. Cardiac care providers across the state are eager to follow this trend as more devices are distributed in the coming two years and provider comfort level increases with each use.

Benefits of the LUCAS™ 2

It is crucial to provide a person with SCA immediate care. According to the CDC, approximately 300,000 out-of-hospital cardiac arrests occur each year in the United States and, out of those, only eight percent survive. During SCA, the heart malfunctions and suddenly stops beating resulting in no blood flow to the brain and other vital organs. Cardiopulmonary resuscitation (CPR) and often defibrillation are necessary to get the heart back to a normal rhythm but it must be done quickly. Chances of surviving an out-or-hospital SCA decreases five to ten percent every minute without CPR. The faster care is received, the better chance a patient has for recovery.

The LUCAS™ 2's ability to administer automated and consistent chest compressions for patients in a variety of settings and for long periods of time makes it an important tool especially in rural areas where there are few responders, access to health care can be miles away and/or acute services may not available. The UND outcomes report cites one paramedic who said, “Historically it has been very difficult for us to achieve effective CPR during transport or when moving a patient; LUCAS allows us to do both.”

In order to avoid neurological damage, a steady supply of oxygen to the heart and brain is needed quickly. To create the necessary circulation, effective and uninterrupted chest compressions need to be performed which is difficult and tiring for any one person to do. In some situations, it is impossible to do manually. One emergency medical technician (EMT) told the UND evaluation staff, "I am often exhausted from doing compressions by the time we meet up with the ALS intercept, but this time [using the LUCAS device] I was still fresh and able to help the medic treat the patient." In addition, the quality of chest compressions varies depending on who provides CPR and it can deteriorate quickly even after only a couple of minutes, no matter how skilled the provider is. The LUCAS compressions can provide a higher blood flow to the brain and to the heart than a person providing manual compressions can.

In addition, while the LUCAS™ 2 device is performing CPR, EMS staff are free to perform other necessary tasks and can secure themselves in the ambulance during transport.

Distribution coordinators and schedule for Minnesota’s seven rural EMS areas

2015—Year One—Completed

2016—Year Two

2017—Year Three

April: Northwest EMS Region,
Tom Vanderwal, Program Director

South Central EMS Region,Mark Griffith, Executive Director

Central EMS Region, Marion Larson, Regional Coordinator

May: Northeast EMS Region,
Patrick Lee, former Executive Director

Southwest EMS Region, Ann Jenson, Executive Director

Southeast EMS Region, Don Hauge, Executive Director

September: West Central EMS Region, Mark McCabe, Executive Director

 

 

Regions with the fewest providers and furthest travel time to receive care were selected to receive devices first, followed by regions with greater provider density and shorter point of care distances.

While the LUCAS™ 2 is used widely within the Twin Cities metro area, many ambulances and hospitals in Greater Minnesota still lack access to the device. Acquiring the latest technology can be a challenge for rural providers with smaller budgets and these LUCAS™ 2 devices will give rural hospitals and EMS services one more tool within their cardiac care protocols to improve SCA outcomes.

Going forward

For the next two years, the Office of Rural Health and Primary Care will continue to purchase LUCAS™ 2 devices, distribute them to the remaining EMS regions and coordinate training on their use.

Jodi Millner, ORHPC LUCAS Grant Coordinator, will continue to work with the UND’s LUCAS Grant Evaluation Team on creating videos highlighting providers' success stories. She is also collaborating with the Minnesota Resuscitation Consortium on providing LUCAS™ 2 recipients a Quality of Care Review report for every cardiac arrest incident in which they have participated. The resulting data will serve as a basis for developing quality care improvement initiatives throughout the state.

The Leona M. and Harry B. Helmsley Charitable Trust LUCAS Grant helps move all Minnesotans one step closer to the department’s goal of providing equitable access to care no matter where a person lives. As the Commissioner of Health Dr. Ed Ehlinger has stated, "This is part of our effort to ensure quality health care for all Minnesotans."

For more information on Minnesota's LUCAS Grant, please contact Jodi Millner, LUCAS Grant Coordinator, at 651-201-3856.

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COMMUNITY FOCUS

2015 Minnesota Telemedicine law increases eligible sites and providers for same as in-person reimbursement of services

By Maureen Ideker MBA, BSN, Director of Telehealth at Essentia Health, Duluth, MN

Effective January 1, 2016, Minnesota Medicaid expanded its eligibility for reimbursement to include additional Minnesota licensed healthcare providers, such as: rehabilitation therapists (PT, OT and Speech/Audiology); dentists; diabetic educators; pharmacists; and several others based on the 2015 Minnesota Telemedicine law. Effective January 1, 2017, Minnesota commercial insurance plans will also add more licensed healthcare providers based on the new law. The narrative in this article is based on the actual Minnesota Telemedicine Act, discussions with Minnesota Health Care Programs (MHCP or Minnesota Medicaid), the Minnesota Hospital Association and Great Plains Telehealth Resource and Assistance Center (gpTRAC.) The new law is referenced at the end of this article.

Telemedicine is the delivery of health care services or consultations while the patient is at an “originating site” and the licensed health care provider is at a “distant site”. Services must be interactive audio and video telecommunications allowing for real-time communication between the originating site and the licensed provider at the distant site.

The Minnesota Telemedicine Act requires parity (equality) of coverage and payments of services whether provided in-person or by telemedicine. The eligible licensed health care providers are specifically listed in the Minnesota statutes list: Highlights of the law include:

  • No in-person initial visit requirement prior to using a telemedicine visit.
  • Rural restrictions have been removed; both urban and rural areas are eligible, even federally designated Metropolitan Statistical Areas (MSA).
  • Site of service restrictions have been removed. Home, hospital, clinic, nursing homes, assisted livings, group homes and schools are all eligible sites for Telehealth services to originate from. A patient can access services at any location.
  • Eligible uses include assessment, diagnosis, consultation, treatment, education and care management.
  • Telephone, email, fax are not included in the law's definition or coverage.
  • Medicaid limits services to up to three visits per week.

The interpretive guidelines from the Minnesota Department of Human Services are expected to be issued soon for use in 2016. A self-attestation form will be required to attest to Minnesota Health Care Programs (MHCP) that the health care services provider meets all conditions of the MHCP telemedicine policy. Documentation requirements will be detailed in the guidelines with five specific items for inclusion related to the telehealth visit.

Covered telehealth services use the same Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes used for in-person, same site services. Examples will be provided in the MHCP guidelines. A “GT modifier” (via interactive audio and video telecommunications system) is used for billing purposes for professional fees to signify the service was delivered via telehealth. Commercial insurers in Minnesota will have interpretive guidelines due for January 2017, and allowable coverage will be based on policy contract language.

Keep in mind that the Medicare guidelines for provider and site eligibility are different than the new Minnesota law and have not changed. In the past, commercial insurer eligibility looked much like the Medicare rules. There are efforts underway at the federal level to update the Centers for Medicare & Medicaid Services (CMS) rules, and Minnesota’s Senators Al Franken and Amy Klobuchar are actively working with this. However, changes are not imminent.

The Minnesota Telemedicine Parity Law-2015 can be read in its entirety (Article 9 Sec. 1-3 and 13.)

Stretching the reach of limited Minnesota healthcare professionals

What the Minnesota Telemedicine Act—2015 means for Minnesota licensed healthcare providers?

  • Improved access for patients to specialty medical and healthcare services
  • Less travel for patients and providers
  • New options for providing services
  • Need to develop/adapt techniques for services using telecommunication technology strengths and weaknesses.

Maureen Ideker RN, BSN, MBA, System Director of Telehealth, Essentia Health, Holy Trinity Hospital, 115 West Second Street, Graceville, MN 56240; P: 320-748-8239/ C: 218-371-0596; maureen.ideker@essentiahealth.org

 

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SPECIAL FEATURE

Engaging the rural health workforce of tomorrow

Minnesota’s population is aging, new immigrant and minority populations are growing, and many areas are facing shortages in the health care workforce. These challenges are particularly difficult for rural Minnesota. An estimated 23 percent of the state’s total population – 1.2 million of 5.4 million Minnesotans—live in rural areas. And more than half of Minnesota’s population lives outside of the seven-county metropolitan area (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott and Washington counties). Ensuring a robust rural health care workforce in the future involves thoughtful planning and sustained collaboration of many local, regional and statewide partners.

Rural organizations and communities across the nation are working to recruit and retain an adequate workforce. This challenge is a priority for the Minnesota Rural Health Association. Steve Gottwalt, MRHA’s Executive Director, believes that “perhaps no other factor will more clearly define the future of health and health care for rural Minnesotans.”

One strategy for fostering professionals who choose to work in rural healthcare is to support and mentor them while they are still in school. Last October, the MRHA announced the formation of a Student Chapter that will engage medical health students in shaping the future of rural health. Gottwalt believes it is important “that we tap their passion, energy, ideas and talents as we address rural health needs.” The MRHA Student Chapter started on the University of Minnesota Duluth campus, and Gottwalt expects the student chapter to spread to more college and universities in the next several months. “We’re seeing great interest from a number of other organizations involved in health care workforce issues, and we look forward to the collaboration,” he says.

Dr. Ray Christensen, Dean of the University of Minnesota Duluth Medical School, and long-time rural health advocate, is the chapter's faculty advisor. He says that, while the national associations and organizations representing health professionals acknowledge the unique and pressing challenges of providing rural healthcare, priorities often focus on the disciplines themselves and the issues of the larger membership. “Those of us who have invested our lives in rural healthcare are becoming more aware that our professional organizations need a larger unified voice for healthcare in rural America,” said Christensen. Providing health care in urban areas can be very different from providing health care in rural areas. Organizations such as the MRHA and The National Rural Health Association are specifically focused on rural issues. Christensen says, “We need to unify our voices to assure we have appropriate state and national recognition and a desirable career climate for students who are interested in providing rural care and living in rural America.” Emphasizing to students the opportunities and unique challenges of providing rural healthcare while they are still in school gives them time to assess their priorities and determine if a career in rural healthcare is a good fit.

We asked two local medical students what drew them to medicine and rural health in particular. Alena Tofte, a medical student at the University of Minnesota Duluth, has been appointed the first President of the MRHA Student Chapter. We asked her what drew her to medicine, and rural health in particular.

Alena Tofte, MPH:
Blink just once on the long and winding lake shore drive toward the Canadian border, and you might miss the town my family is from. It’s 250 people small, tucked in along the North Shore, with a few amenities but not much else. As commercial fishermen at the turn of the century, my great grandfather and his twin brother carved out an existence for themselves and their growing families on that rocky coastline of mighty Lake Superior. With hands hardened by days spent in every weather from blazing sun, to driving rain, my relatives relied on their tiny community to care for each other's basic needs, ensure the day-to-day workings of the town, and, most importantly, enjoy life when given the chance.

Comfort can come from knowing those surrounding you are invested in your well-being. After a few years spent in the often claustrophobic commotion of colliding sounds, smells, and sensations in Boston, I reflected on my upbringing in the dotted lakes and sprawling woods of Northern Minnesota. My formative years were shaped by close-knit, supportive social networks, drawn from a much smaller pool than from the population-rich suburbs covering the coastline of Massachusetts.

Although many cite social isolation in remote communities as a deterrent for physicians choosing to practice rurally, from my perspective, closeness to others is determined by much more than proximity to major population centers. My interest in pursuing a career in rural medicine comes from an ideological affinity for serving in the varied roles rural providers play in their respective communities. I also look forward to forming close, long-term relationships with the residents of a single community. In this light, rural medicine does not only involve caring for patients, but also requires supporting small town cohesiveness, promoting economic viability, and advancing public health for an entire community.

Likewise, from my rural clinical experiences, I’ve seen how valuing health locally can foster regional collaboration in the medical community. Despite the changing landscape of healthcare under the Affordable Care Act, rural medicine retains some vestiges of a former era, wherein individual physicians shouldered responsibility for any and every medical concern. Trends toward regional consolidative care models will undoubtedly continue to change rural practice. New care models such as accountable care organizations, value-based payment models, and shifting incentives which reward performance on population health metrics will help geographically dispersed rural communities advance medical care, drive technological development, and address workforce issues. Strong professional relationships can promote innovations to ensure the continual safety and quality of medical care in rural populations.

As first-year medical students at University of Minnesota Medical School - Duluth, we’ve learned about the challenges we’ll face as physicians. As a new generation of rural practitioners, we’re accepting responsibility for more than having the diagnostic and clinical skills to care for the health of our future patients. We’re expected to understand state- and national-level policy drivers, health care financing, local community characteristics, and individual socio-behavioral traits which influence health. Impressing upon medical students the expansive range of opportunities available as rural practitioners in these diverse arenas and demonstrating the benefits of practice in the unique, supportive social context of a rural community may help alleviate the shortage of rural medical providers in Minnesota.

Alena Tofte, MPH, The Dartmouth Institute for Health Policy and Clinical Practice, Class of 2015, University of Minnesota Medical School - Duluth Campus, Class of 2019

From the other end of the state, Tony Blankers, a medical student at the Mayo Medical School, responded to our question about what drew him to medicine and rural health.

Tony Blankers:
Becoming a doctor began, oddly enough, with a career day—attending an inspiring talk by a local Physician’s Assistant. Further bolstered by role models in my church and rural Iowa town, I began to see that doctors were not super humans, but genuine people, dedicated to serving their community. Moving to the big city for college at Bethel University, I dabbled in teaching, but after shadowing family physicians in my hometown and an underserved clinic in St. Paul, I decided that family medicine was the field for me.

Arriving at Mayo Medical School, I wondered if family medicine would be a viable option. The looming shadow of the world’s best sub-specialty experts was certainly intriguing, but I felt at home in small-town and student-run free clinics. A particular experience working with a rural physician in Black River Falls, Wisconsin, cemented my decision. His vitality for life, passion for the outdoors and participation in the community was inspiring. Simple things like bar-league sand volleyball, horseback riding and whitewater rafting captured my spirit and the spirit of rural medicine. Beyond this personal experience, my newly wedded wife is also from a small Minnesota town, the daughter of a career community dentist. Both she and I share the desire for the slower-paced, know-your neighbor lifestyle a rural community affords.

One appeal of family medicine is the ability to adapt to the community’s needs. As such, it is difficult to nail-down my particular area of interest. Lately, the idea of direct primary care is intriguing. Time will tell if this is a feasible and broadly applicable model, but the growing popularity and success stories show promise. Outside of that structure, wilderness medicine, public health and environmental medicine all appeal to me. The effects of context are important in all healthcare settings, but rural areas in particular rely on natural resources for both occupation and recreation. Addressing these problems will require collaboration and I envision leveraging local resources like schools, public health departments, and community groups.

In addition to local connections, rural health of the future will draw upon regional and national networking. Technological innovations like telehealth, improved and combined EMR’s and larger health networks will facilitate communication and access to resources. As for me, from the nose-bleeds of medical school, a career seems a distant goal. That doesn’t stop my wife and me from dreaming. We have our eyes on northern Minnesota, perhaps her grandparent’s old place, a homestead in Mora, Minnesota with a riverside view.

But I am just one person, rural medicine deserves the brightest and the best. Selling this idea to my peers from the east and west coast has proven a challenge, but one that can be overcome. Immersive, hands-on learning experiences with inspiring mentors can quickly change minds. A week in a rural community like Black River Falls, or longitudinal experiences like the Rural Physician Associate Program (RPAP) or Mayo’s version - CPAP) are prime examples of powerful programs. Whatever the draw, I believe firmly in the future of rural medicine and look forward to joining a thriving and dynamic field!

As in all fields, students are drawn to various careers because of personal preferences, beliefs, needs and abilities. Tofte and Blankers both grew up experiencing what rural communities have to offer. “Grow your own” programs introducing rural students to health careers seem to show promise. Blankers' experience of working with a rural physician early on helped cement his decision. Personal backgrounds and peer-to-peer sharing are powerful tools for building the rural healthcare workforce of tomorrow, and great reasons to build a State Rural Health Association Student Chapter.

__________________

Note: The MRHA plans to host a Student Chapter Dinner/Mixer the first evening of the 2016 Minnesota Rural Health Conference, June 20-21, and present the first annual MRHA Emerging Rural Health Leader Award to an outstanding rural health care student.

 

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Minnesota 2016 Rural Health Conference logo

June 20-21 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
www.health.state.mn.us/divs/orhpc

  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.