September 2017



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Director's Column

Partner Focus

Program Focus

Workforce Topic

RHAC Profile

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Mark Schoenbaum

Director's Column

Community is the heart of the work

Community is the indispensable center of our goals at the Office of Rural Health and Primary Care. It’s also the soul of the stories in this month’s Quarterly.

One story records the successful effort of a family and a nonprofit organization to overcome a young man’s injuries and make sure he has a meaningful life. Another tells the latest chapter of a community institution that began 118 years ago when three nuns acted on their belief in the value of community collaboration. There’s also an interview with a Rural Health Advisory Committee member who tells us how she pursues her priorities for lifelong learning, community and equity. And there’s a new rural health workforce analysis from our Office that we hope will better equip community health leaders and policy makers to respond to rural primary care challenges.

I’ve had occasion recently to review some of our previous Quarterlies and reflect on the history of our work together. Community is embedded in so much of what makes the health care safety net flourish. We’ve reported in the recent past on the Prime West and Southern Prairie health plans, each formed by rural counties working together to serve their communities. The Quarterly has also introduced community paramedics, dental therapists, community health workers and other emerging professions to readers. These innovations grew from the ground up to meet community needs throughout Minnesota. Last month’s newsletter showcased Jode Freyholtz-London, this year’s Rural Health Hero, who’s worked with the mental health consumer community to bring peer mental health specialists to rural communities. And recently we’ve shared a new survey of rural ambulance agencies, which found that rural EMS remains staffed predominantly by community volunteers.

Community has also been a thread in my Director’s columns, and even though those columns are getting old, they  include examples that still seem to apply. I wrote about Michael Perry’s book Population 485, in which he describes his small town fire squad’s response as “my people acting on behalf of our people.”  And we’ve regularly reported on the work of the Rural Health Advisory Committee, whose members bring their community perspectives and priorities to setting a rural health policy agenda for state government. The throngs from all over Minnesota at a previous State Fair once reminded me that we share basic health care needs wherever we live and wherever we travel, whether in rural Minnesota or in the Twin Cities.

Looking at the health care safety net across the state, Paul Wellstone’s quote “We all do better when we all do better” comes to mind. Before going to the U.S. Senate, Paul taught in rural Minnesota, and he joined farmers fighting bankruptcy, workers fighting wage cuts in Austin and rural communities disrupted by power lines. His legacy includes schools and community centers bearing his name in the Twin Cities and across the country.

Paul understood the interconnections and interdependence between community life and public policy at the state and national levels.  As we approach the 15th anniversary in October of the 2002 Iron Range plane crash that took his life, it’s energizing to me to know that if Paul were a Quarterly reader, he'd be proud to see what we’re accomplishing together.

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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Partner Focus

St. Elizabeth's Medical Center

Making a difference in their community through collaboration


At this year’s Minnesota Rural Health Conference in Duluth, speakers provided insight and examples highlighting this year’s conference theme, “Shaping Sustainable Solutions.” There were opportunities to discover how various organizations are improving and integrating mental health access in rural communities; and how we can support the health of rural populations with best practices from around the state. St. Elizabeth’s Medical Center (SEMC) in Wabasha is one of those organizations that has worked hard to find sustainable solutions for the changing health needs of their communities.

SEMC is one of Minnesota’s 78 critical access hospitals (CAH) located in Wabasha, Wabasha County. Historically, CAHs have been a vital and essential component in the health of their rural communities. They understand that the business of keeping communities healthy is collaborative by nature. This has certainly been the case throughout SEMC’s history. The legacy of improving the health and well-being of the surrounding Mississippi Valley communities began over 118 years ago when three Sisters of the Sorrowful Mother arrived in Wabasha to establish a health care ministry. Those founding sisters understood the need for and value of community collaboration. They forged powerful partnerships, realizing that there were so much stronger together. This commitment to interdependency remains key to Saint Elizabeth’s wellness success to this day. “Our efforts to instill a culture of wellness in our community is a way for us to fulfill our mission and live our values,” said Tom Crowley, Saint Elizabeth’s Medical Center president.

Hospitals are a vital part of their communities and the services they provide extend well beyond the four walls of the hospital.
- American Hospital Association Community Connections

In 2016, SEMC was awarded the Carolyn Boone Lewis Living the Vision Award by the American Hospital Association (AHA). This award is presented to organizations and individuals who embody AHA’s vision of living in a society of healthy communities, where all individuals reach their highest potential for health. In fact, so important is the communal aspect of this award, a hospital cannot nominate itself; it must be nominated by others in the community.

Every community has specific needs; it’s not a one-size fits all proposition. Every three years, SEMC, along with Wabasha County Public Health, undertakes a Community Health Needs Assessment which is followed by a Community Health Implementation Strategy. The following health priorities were identified for 2016-2019.

  1. Senior health (emphasis on chronic disease management and fall prevention)
  2. Mental health (emphasis on anti-stigma education and crisis intervention training)

SEMC has looked for ways to address these priorities through active collaboration with local partners and participants in the community. Multidisciplinary work teams use best practice models to develop work plans, performance measures and evaluation tools. It is the collaborative nature of this work that is the key to long term success. The following are some highlights of some of the collaborative work that is underway.

Senior health: Emphasis on chronic disease management and fall prevention

According to a Minnesota Department of Health report, Minnesotans with diagnosed chronic conditions accounted for 83% of all medical spending in the state in 2012.1 Among insured Minnesota adults 65 years and older, 72 percent have at least one chronic condition.2 Noting that health costs are eight time higher for those with chronic disease, Minnesota Commissioner of Health Ed Ehlinger stated, "We cannot afford to treat our way out of this crisis. We must more strongly focus on preventing chronic disease or delaying its progression by investing in healthier communities, public health and primary care.”3

In order to improve the health of older adults, SEMC knows it has to reach beyond the examining room to address their health priorities. Staff work to form collaborative partnerships in the community and to build awareness of local senior health resources. Classes such as the Wellness Support Group is open to anyone touched by a chronic disease such as heart disease, stroke, pulmonary disease and diabetes. The program Living Well with Chronic Conditions is a proven self-management program for people living with chronic health conditions outside of the clinic or hospital and it is hosted by both SEMC and Wabasha County Public Health.

Fall prevention is another area that can improve senior health. According to the Centers for Disease Control and Prevention, falls are serious and costly for people 65 years and older.

Once again, providing the opportunity to learn about fall prevention through education and exercise requires that a whole community works together to provide space, resources and expertise. Strength and balance exercises can make legs stronger and improve balance. The Fit City Seniors class is committed to improving the health of people 55 and older in the community through exercise, education, activities and support. Begun with seed funding from a Blue Cross Blue Shield Prevention Minnesota grant, the class is now self-sustaining and operated through the Fit City Wabasha collaborative. One of the seniors said, “Sessions have improved my physical, emotional and mental well-being.”

Matter of Balance (MOB) classes are designed to reduce the fear of falling and increase the activity levels of older adults. These are held at Faith Lutheran Church in Wabasha. Evidenced-based Tai Ji Quan classes teach better balance through movement and are supported by the WellConnect SE Minnesota partnership - an innovative collaboration of individuals and organizations in Southeast Minnesota focused on optimizing the experience of health and wellness in this region.

Mental health: Emphasis on anti-stigma education and crisis intervention training

SEMC joined the Wabasha County Mental Health Task Force’s campaign “Make it OK” which is a localized version of the national “Make it OK” campaign. The program is aimed at spreading awareness about mental health and erasing the stigma around the issue. The goal of the program is to open up the conversation about mental illness and help communities develop a greater knowledge and comfort with the topic. It is designed around community involvement and one of the central components is a training program that provides community members with the tools and the knowledge they can use in organizations back in their own neighborhoods such as businesses, civic organizations, faith-based organizations, school groups, neighborhood associations, etc.

SEMC will continue to take the health of its communities to heart and they have a continued commitment to participate in these and future collaborative programs and services that promote wellness, prevention, early intervention, and disease management outside of their own walls. Creating healthy communities benefits everyone and allows the medical center itself to target their resources most efficiently for the benefit of their communities.

1 Chronic conditions in Minnesota: New estimates of prevalence, cost and geographic variation for insured Minnesota, 2012. January 2016. Minnesota Department of Health. Page 13.

3 New MDH report finds health costs eight times higher for those with chronic disease, Minnesota Department of Health Press Release, January 27, 2016.


Ascension - St. Elizabeth Medical Center, 1200 Grant Boulevard West, Wabasha, MN 55981, 651-565-4531.


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Program Focus

Resource Facilitation

Serving anyone in the state affected by brain injury


When Theresa "Tess" Wolf learned that her son Bradley had suffered a traumatic brain injury from a self-inflicted gunshot wound to the head, she had no idea where this journey would take her. All she knew is that she wanted to support her son. She soon became his strongest advocate and caregiver as he worked his way through the trauma system in the Twin Cities and was eventually placed in a group home in northwest Minnesota. However, though his initial primary medical needs were met, it soon because clear that Brad was having problems with depression and other life issues. "He hid them very well," Tess said. "Not even his girlfriend knew he was drinking excessively." Tess began looking for explanations about his new behaviors. She found professionals that were knowledgeable about traumatic brain injury at the Minnesota Brain Injury Alliance (MNBIA), the only statewide nonprofit organization dedicated to serving the needs of the estimated 100,000 Minnesotans who live with a disability due to brain injury. MNBIA Resource Facilitators were able to help her understand the many challenges that Brad was facing.

Resource Facilitators answer questions, problem-solve issues, find brain injury support resources, navigate complicated systems, and assist with educating family, employers and professionals about living with a brain injury. After recovering from his initial physical injuries, Brad was struggling with an impaired frontal cortex which was the cause of his new and challenging set of behaviors. A person with a traumatic brain injury often faces a lot of uncertainty during the recovery process and has to transition back to work or school, maintain family and spousal relationships, and cope with ongoing fatigue, headaches and depression. That was certainly the case with Brad who seemed to struggle with emotional control, inhibition and frustration even to the point of being evicted from his group home. Family and staff tried to understand the specifics of his brain injury and support him, but it is often a difficult task. Every case is unique. Resource Facilitators were available to provide confidential support tailored to Brad's specific issues. They were able to guide Tess in identifying supportive housing and community environments that helped minimize Brad’s behavioral challenges.

Resource Facilitation is funded through a contract with the Minnesota Department of Health that makes it possible for every hospital in the state to offer this as a free service to their patients affected by brain injury. Back in 1999, the Brain Injury Association of Minnesota worked in collaboration with five hospitals and four state agencies to conduct the Resource Facilitation pilot demonstration project. The project demonstrated improved patient outcomes, including increased rate of return to work, reduced family crisis and increased family ability to understand and support their family member. That successful pilot project led to the passage of 2003 legislation that made Resource Facilitation available to all people affected by brain injury in Minnesota, regardless of the injury date. Resource Facilitation is now a free, statewide telephone service (800-669-6442) available to persons with brain injury, their family, friends and health professionals. While many participants are referred at the point of discharge from the hospital, anyone can self-refer or be referred by any professional at any point after the brain injury.

A complex health system posed many challenges for the Wolf family. Through Resource Facilitation, MNBIA was able to answer the Wolf's questions and direct them to resources such as local medical providers, the guardianship process, Medical Assistance and case management services. The goal is to provide persons affected by traumatic brain injury with the support they need to transition back into family life, work, school and the community. 

Brad now has a successful placement in a group home in Grant County. He enjoyed living in the city but the rural setting is a much better fit for him. Tess is happy with the care he receives both physically and socially. “I think the thing to remember with people is to care for their social needs. It’s not just about meds and dosages. Having something meaningful in life is of utmost importance,” Tess emphasized. “Training and providing options is important for caretakers like me who have no idea where to go or who to ask.”

Resource Facilitation serve individuals and families that have experienced a broad spectrum of injuries, from concussions to strokes and traumatic brain injuries. Reaching a successful outcome may take a long time and it often involves many ups and downs. Resource Facilitation helps find services that come after primary urgent medical trauma care. And, they help fill the gap between systems of care in major Metropolitan areas and local communities. This is a service for the entire State of Minnesota!

If you are a social service professional and would like to earn CEU's while learning more about traumatic brain injury and stroke, consider signing up for the MNBIA 2017 Lunch & Learn Seminars. The next one, "Latino Culture and their Perspective on Brain Injury," is on September 14. To register, call 800-669-6442.

The Minnesota Brain Injury Alliance is a 501(c)(3) organization. 2277 Highway 36 West, Suite 200, Roseville, MN 55113-3830. Phone: 612-378-2742.

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Workforce topic

Understanding the landscape of primary care providers in rural Minnesota

Readers who have a stake in rural health care won’t be surprised to learn that the vast majority of all health care providers in Minnesota are employed in the metropolitan areas of the state. In 2016, for example, 81 percent of dentists, 79 percent of primary care providers, and 84 percent of licensed mental health providers were employed in Minnesota’s urban centers including the Twin Cities, Duluth, Rochester, and St. Cloud. Of course, we would expect that most of the health care providers will be employed where most of the people are. But the distribution of health care workers is not uniform even after adjusting for population size, as shown in Figure 1 below. Here we see the number of people–per–provider in a region, also known as the population–to–provider ratio for physicians, physician assistants (PAs), and advance practice registered nurses (APRNs) across the state. Theoretically, all else being equal, rural physicians, PAs, and APRNs have at least twice the number of people to care for compared to their urban counterparts. This is consequential because providing accessible high quality care becomes challenging as patient panel sizes increase.

Figure 1: Minnesota population-to-provider ratios, primary care providers, 2015-2016

Data Sources: Minnesota Boards of Medical Practice and Nursing. The Minnesota Department of Health geocodes addresses of providers to determine what type of region they are working in.

Rural shortages among specialty physicians are especially serious: based on Board of Medical Practice data from 2016, there are less than five OB/GYNs, pediatricians, psychiatrists, and general surgeons, and only approximately 13 internal medicine specialists across all of rural Minnesota. We know that these shortages affect the way physicians practice in rural areas. For example, in MDH’s 2016 Physician Workforce Survey, we asked physicians the question, “How often do you provide care that a different specialist might otherwise provide if they were available/accessible?” Figure 2 displays the responses from the nearly 17,000 Minnesota physicians who responded to this question, and shows that in rural areas, nearly half of physicians say they fill such care gaps either “frequently” or “all the time” compared to approximately 22 percent of urban physicians.

Figure 2: “How often do you provide care that a different specialist might otherwise provide if they were available/accessible?” (N=16,986 physicians)

Data Source: 2016 MDH Physician Workforce Survey

In which parts of rural Minnesota are health care provider shortages the worst?

Figure 3 provides a partial answer to this question. Again, we use the population-to-provider ratio as a relative indicator of workforce shortage, but Figure 3 shows this indicator across five regions of the state, by provider type. Shaded boxes indicate where the population-to-provider ratios are even higher than the statewide rural average, indicating even worse access to these providers. The data show that each region has areas of both strength and weakness. For example, in the rural parts of central Minnesota (which includes regions surrounding St. Cloud but excludes St. Cloud and its immediate vicinity) the per capita number of physicians and PAs is higher (better) than average for rural Minnesota, but the per capita number of APRNs and RNs is lower (worse). Likewise, in rural Northeast, the per capita number of physicians and all nurses is higher than average, but PAs is lower, suggesting that PAs may not be as easily used to shore up the physician workforce, as they do elsewhere.

The region that appears to have some of the worst shortages in the state is the rural Northwest region. This is a large region, stretching from Fargo/Moorhead in the lower western edge, to Bemidji in the center, up to the Canadian border, and including both the White Earth and Red Lake reservations. Again, keeping in mind that all rural areas of the state face shortages, the shortages in rural Northwest appear to be particularly severe. There is a substantially higher population-to-provider ratio of physicians, APRNs, and RNs in Northwest than in other rural areas. The rural Southeast region (surrounding, but excluding, Rochester) also has worse-than-average shortages of physicians and PAs.

Figure 3: Regions of worse-than-average workforce shortages based on population-to-provider ratios

Rural Region





Rural Central





Rural Northeast





Rural Northwest





Rural Southeast





Rural Southwest





All rural areas of Minnesota





Data Source: MDH’s analysis of licensing boards’ business address data. Numbers in bold represent the condition when the population-to-provider ratio in that region is larger than the same ratio for all rural areas of the state.

Uneven workforce distribution is a persistent problem, and making full use of health professionals already in place is as important as adding new providers for rural areas. Solutions include capturing the potential for team-based care and coordination to stretch the reach of current providers, incentivizing primary care over other specialties by increasing reimbursement rates and loan forgiveness programs for rural primary care providers, increasing the use of telehealth and coupling physician rural recruitment efforts with spousal career support services to increase chances of retention.

Based on physicians’ practice addresses, geographically coded by MDH.

Teri Fritsma, Lead Healthcare Workforce Analyst, Office of Rural Health and Primary Care. 651-201-4004

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RHAC Member Profile Ann Bussey

Improving access and availability to prevention and wellness programs in rural communities

Some say that U.S. health care is both “the best of times and the worst of times”; others describe it as a dynamic national laboratory of simultaneous policy implementation and testing. Within this challenging environment is rural health with its own complexities. Rural Healthy People 2020, opened its 2015 publication with the following statement:

“Living and working in rural America should not have dire or significant implications for health status. Rural residents still lag in health status in comparison to their urban counterparts. This knowledge lends itself to a great urgency for addressing rural health disparities, above all, to improve the quality of life for those who choose to call rural America home."

What an interesting time to serve as a consumer member on the Minnesota Rural Health Advisory Committee (RHAC)! I was asked to share my background and thoughts with you.

I am a retired health care administrator from a large integrated health system, and now serve as an adjunct faculty in the Rural Health MBA program with the College of St. Scholastica, as well as a community facilitator and volunteer in the Hibbing/Side Lake area where I live. It is truly a new journey for me to approach health from the role of a rural community member, while at the same time, preparing students for rural health leadership and participating in RHAC.

The good news is that there is a growing awareness of community needs by local stakeholders through the revised community health assessment process. Community health providers and state agencies are focusing funding and efforts to improve the built environment, while improving access and availability to prevention and wellness programs for rural communities. The “push” is definitely on from health providers and agencies.

The question is...”if you build it, will they come?” What is the “pull” from rural communities? What are the dynamics in rural communities for engagement in programs that improve health? How do we focus on the appropriate promotion and resourcing with rural communities to implement evidence-based activities that improve health? How do we focus on the needs of the person served in rural communities? Are we involving community persons served in our process similar to health care involving patients in the “Include Always” approach? How do we put our finger on the secret sauce of each rural community?

My questions arise from serving as a community facilitator for the restoration of a senior fitness program in the Hibbing area. It was difficult aligning the resources and the funding around common goals of health equity for older adults, not only for rural access to fitness centers, but also for rural access for evidence-based fitness programs. The learning is that a built environment without evidence-based programs may not help us achieve desired health outcomes. Another learning is that a community secret sauce can be as simple as a “group of ladies in town”. Our Hibbing ladies are a coordinated and respected group, demonstrating resolve and commitment. One of our major challenges was the lack of awareness that an older adult population comprises the largest percentage of rural communities; however, an older population is not often prioritized since the future of rural communities is dependent on strategies to recruit and retain younger adults and families. Another challenge is the need for a common community leadership framework, one that has clearly articulated health strategies, goals, measures, and implementation principles for rural communities.

The human side of no action is failing health for older adults with increased falls and worsening of chronic diseases, and most importantly, loss of hope that older adults in rural communities matter. We are a community that desired to “pull” in a program, developing and aligning resources regionally vs seeking resources only from our local community. It took two years, and for some, it was the rest of their lives. How do we build leadership and dialogue for achieving both a “push” and a “pull” within our rural communities?

I look to you “to improve the quality of life for those who chose to call rural America home”. The Rural Health Advisory Committee is integral to developing health policy, best practice and service delivery models to benefit rural Minnesota. Please contact me or other members of the Committee with your insights, initiatives and models. And thank you for your interest in my story., PO Box 54, Side Lake, MN 55781. Phone: 218-393-6824.

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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

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Comments? Contact or call 651-201-3863.

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.
Updated Tuesday, 21-Nov-2017 10:30:11 CST