Rural Health Advisory Committee Meeting Minutes


RURAL HEALTH ADVISORY COMMITTEE
Tuesday, March 7, 2008 10:30 a.m.-2p.m.

Metropolitan Mosquito Control Building – Board Room
St. Paul, Minnesota

Work Group Members Present: Sue Alley (Sanford Health Systems); John Baerg (RHAC member); Deb Carpenter (RHAC member); Ray Christensen (RHAC member); Valerie DeFor (Healthcare Education-Industry Partnership); Jacqueline Dionne (Minnesota Department of Human Services); David Hutchinson (Duluth Family Practice); Don Janes (Becker County Human Services); Margaret Kalina (Workgroup Chair, RHAC member); Jean Larson (Minnesota Department of Health-Minnesota Children with Special Health Needs); Diane Muckenhirn (RHAC member); Jim Przybilla (Prime West Health System); Tim Rice (Lakewood Health System); Jeff Schiff (Minnesota Department of Human Services); George Schoephoerster (CentraCare Plaza Family Medicine); Stanton Shanedling, (Center for Health Promotion); Tim Stratton (University of Minnesota-Duluth); Ruth Westra (University of Minnesota-Duluth); Will Wilson (Minnesota Department of Human Services); Gary Wingrove (Gold Cross/Mayo Medical Transport); Marty Witrak (College of St. Scholastica).

Members Absent:  Barbara Brandt (Area Health Education Center, University of Minnesota Twin Cities); Estelle Brouwer (Stratis Health); Tom Crowley (St. Elizabeth’s Hospital); Clint MacKinney (Family Physician for Heart, Disease and Stroke); Lori Sisk (Sanford Health Systems-Canby); Keith Stelter (St. Peter Clinic, Mayo Health Systems).

MDH Staff Present:  Doug Benson, Renee Fredericksen, Tamie Rogers, Mark Schoenbaum, Angie Sechler, Kristen Tharaldson.

Major Themes from March 7, 2008 Work Group Meeting:

The discussion covered a great range of topics. The notes are organized to capture broad observations, major themes and potential criteria for discussing next steps at the May 30 work group meeting. The themes fell into four topical areas:

Broad Observations

“Health care home” is a broader and probably more useful term than “medical home.” Health care home captures a broader range of services that includes prevention. It also may acknowledge the need and potential to improve care and help alleviate physician shortages in rural areas by making greater use of mid-level professionals (e.g.,. advanced practice nurses, pharmacists, nutritionists, school nurses). Particularly in small communities, non-physician providers may know more about a person’s health condition and are likely to be the first stop for health care.

Prevention: Focusing on medical management of illness only tackles half of the health improvement equation: meeting demand with supply, but forgetting that prevention reduces demand. Statistics support the need for unique prevention models in rural communities where high risk behaviors, such as high rates of tobacco use, lack of helmet or seatbelt use, and growing rates of obesity and diabetes, are a concern.
 
Concern about the value and practicality of the health care home model in rural areas: Current proposed criteria in the legislature are process ingredients for establishing and certifying a health care home model. But some rural providers express the need for more evidence of the end goals, outcomes, the value, and cost-effectiveness of this model of care before investing in it.

A Promising Model: Lakewood Health System, a Critical Access Hospital in Staples, Minnesota, recently started using the medical home model targeting chronically-ill patients. Patients at Lakewood are given the option of participating in a medical home, receiving information on what it is, and the benefits of participation. Physicians choose how many patients they will work with and create a care plan in consultation with each one. Electronic health records are used to provide assessments, checklists, protocols and patient education. Clinical information is formatted to allow for search, retrieval and information transfer. Future plans are to hire care coordinators, create a separate triage system for medical home patients, and establish priority scheduling.

Access concerns: Some work group participants expressed concerns that applying the health care home concept in rural areas could be a challenge if it takes on the characteristics of a gatekeeper model. If access to services becomes more restrictive under this approach, current obstacles of distance and availability could worsen in more remote rural areas. Some rural residents may abandon local health care home providers if they believe this model limits their choice of whom to see for health care services.

Major Themes

  • Workforce 

Role of primary care physicians and other providers: At the heart of current primary care delivery is physician-directed coordination in rural areas. To some extent, other providers, such as pharmacists, nurse practitioners or EMTs, are also known as points-of-contact for health care in rural communities. Participants suggested work remains to delineate how responsibilities of a health care home model would be distributed in rural locations. For example, a patient is discharged after an acute myocardial infarction. Who will be most appropriate for helping the patient with medication management, cardiac rehab, and lifestyle maintenance over the long term?  

If providers are given the opportunity to work at the top of their license, changes in practice will automatically occur. For some providers, working at the top of their license is not satisfying, so the health care home needs to be something everyone will want to participate in, which will likely stimulate health care workforce retention. The key will be to decide where you need doctors and where you do not. A rural advantage is teams of care providers already know one another and often have established working relationships thereby more willing to take on different roles.

Physician directed care could/should be responsible for initial engagement while care coordinators could/should be responsible for health maintenance and disease management. Some concern was expressed over whether patients/families will perceive this model of care delivery as a hand-off to lower quality care for the sole purpose of reducing costs.

Workforce shortages and workforce affects of health care home model: Regardless of who leads a health care team, workforce shortages exist for all health care professions in rural communities. Is it possible that implementation of the health care home concept will intensify already existing workforce shortages in rural areas? Will the concept of health care home decrease the number of physicians needed or increase the need? This question is relevant to all health care professions in rural areas. It is most likely the health care home concept will lessen demand for health care workforce in the long term. However, in the short term, it will probably increase health care workforce needs. 

Need for a coordinated team and community approach: Rural demographics may call for a different level of professional expertise in health care services to be available (e.g., gerontology). The primary educational system presents opportunities for prevention (immunization, sports activities requiring physicals) and could serve as health care homes for children. However, school nurses are also in short supply in rural areas, often covering many schools and primarily serving children with special health needs (medical management) instead of advancing health promotion. Opportunities also exist with mobile workforce, such as ambulances and EMTs.

Education and dialogue will be required for both providers and patients to accept the value of the health care home model. Provider peer support and education will be needed to educate and encourage solo practitioners in rural areas to evolve and adopt the health care home model.

  • Continuity of Care/Coordination of Care

Patient-Centeredness: The concept of “patient-centeredness” commonly means that health services are coordinated across the continuum so the patient’s needs are met as seamlessly as possible. A central goal of health care homes is to provide the capability to create a health care delivery system that is less fragmented and more patient-centered. Financial support of the components within the health care home model can ensure care coordination occurs (see reimbursement section of this document). The rural health care system’s ability to coordinate beyond just referral will be different and diverse across the state, so building in flexibility in any health care delivery model will be integral. There may be the need to look at models of collaboration between medical and prevention services. In some rural areas, public health and human services care coordination is already key and only requires a doctor's signature for services.

Burden on physicians: Rural providers must be skilled in a wider range of care (e.g., emergencies/trauma, obstetrics, geriatrics) covering all needs with a minimum number of providers in a safe manner. Because of these multiple demands, some physicians may not be able to assume this additional coordination role. Patient compliance is also a consideration when it comes to referrals.

Service Integration:There will be a need for institutional/organizational development and support among rural health care providers along with the recognition of existing rural culture and precedent for how systems previously worked together to coordinate care as expected. 

It is important to remember the conventional medical home model shows the local health care delivery system integrated within larger, community-wide systems of support, and to look at existing community systems as part of an overall care plan. However, health care services in rural areas are not always integrated with local community resources. Health care services occurring in schools or home settings would require coordination with the health care system and change communication practices.

Community Resources: The health care home model must embrace and maximize existing community resources to meet patient needs in rural areas. In rural communities, different levels of informal and formal support systems with different entry points, need to be recognized and incorporated into the new model. Additional rural points of connection include churches, schools and mobile workforce (e.g., ambulances/EMTs, home care workers). There will be a need to educate these entities on the health care home concept.

The informal support network of family members plays a significant role in the current health care home model. A particular rural phenomenon is the shrinking number of extended family members given the exodus of younger generations to urban areas. To fill the gap, more formal systems of support (i.e., nursing homes, home health services and Area Agencies on Aging) should be incorporated into a new rural delivery model.

Care coordination is especially important for special populations, such as American Indians, migrant workers, newer immigrants, and seasonal residents moving from one area to another.

Health Assessments/Care Plans: Health assessments provide a starting point and care plans provide the roadmap for navigation.

  • Technology 

Broadband and Internet Issues: Given the unequal access to broadband and other electronic technology, some work group members questioned the assumption that all rural residents will obtain and use internet technology to interact with providers. Work group members also identified the need to appropriately reimburse providers who communicate remotely with patients and other providers.

Telehealth: Technology offers great potential and growing capacity for reducing the amount of distance for patients to visit or consult with their physicians.  However, any electronic infrastructure expansion among providers has to be in lockstep with reimbursement improvement and financing. Some technology is in place, but it is not being utilized. 

Portable equipment: There is a real need for portability of equipment since rural providers may be working in several areas.

Electronic health records (EHRs) challenges among small rural hospitals are:

  • Having a standard platform that makes it possible for communication with other hospitals, providers.
  • Funding initial, start-up costs for EHR implementation
  • Training of staff
  • Having technology staff.
  • Sharing basic infrastructure across a region
  • Having economies of scale
  • Knowing if major computer companies, like Google, will provide an effective free/low cost platform for EHRs as they are claiming.
  • Reimbursement and Financing

 Though supportive of finding better ways of providing a consistent level of primary care across the state, some expressed concern that requiring a standard, uniform set of criteria for defining health care homes may require rural health care providers to do additional work and/or independently finance expensive changes. Basic health care infrastructure needs to be maintained since is fundamental to the delivery of primary care services.

Infrastructure challenges: Some small and low volume providers will have financial challenges making the investments in technology and quality improvement measurement and reporting systems required to operate as a health care home. These challenges will include:

  • Initial investment capital for capital purchases and start-up training and support
  • Ongoing operating expenses for both technology and support
Inverted incentives:   To the extent that implementing health care homes reduces hospitalization, some members expressed concern that this new model may be financially detrimental to small hospitals, given the current reimbursement system’s structure of paying for volume and intensity. Even with financial incentives, this occurs occasionally, so better alignment is necessary.

Start-up investments needed:  Implementation of health care homes in rural Minnesota is likely to require additional tools, such as peer support and education on the beneficial nature of health care homes in order for rural providers to evolve and adopt the evaluation and quality measures expected. have access to state grants and other support to help them move ahead.

Stigma still exists around utilization of certain services in rural communities, (i.e. as mental health), and it would be easier to provide seamless care if stigma is reduced through physical changes in infrastructure.

Paying a range of community resources for care coordination:  In many rural communities with limited services, providers such as pharmacists, EMTs, nursing homes and others are relied on as primary care access points because there are no traditional clinics. Participants suggested allowing reimbursement for other players so they can take on the coordinator role in rural areas. 

  • Overall Key Challenges, Principles and Criteria

Reasonableness – Are expectations and the details of the model reasonable from the cost perspective of providers and/or patients? Must every rural provider adopt all components of the model or are there options short of adoption of the entire health care home model?

Feasibility – Does the infrastructure exist? Can financial incentives be aligned? Will the model achieve initial intent and anticipated outcomes?

Acceptability – Culture change is required for both provider and consumer. The value of this particular delivery model must be clear to all involved.

Time – Members expressed concern that under legislation under discussion in March, 2008 that proposed health care home implementation by July 1, 2009, rural concerns may be overlooked. Some suggested it be implemented in stages. (Note: Final legislation begins payment of care coordination fees on January 1, 2010.)

Unintended Consequences – In a market-based system, there are winners and losers. For rural areas, the permanent loss of a provider is not an option. There should be a concerted effort to bring all providers on board considering the level of quality improvement and safety recommended by the IOM.

Critical Mass – If Fee-For-Service Medicaid is the only payer, the health care home model will not work for rural Minnesota. Currently, there are no overwhelming commercial interests supporting this new model.

Meeting adjourned at 2:03 p.m.

The next Rural Health Care Delivery Workgroup meeting will held on Friday, May 30, 2008 at the Mosquito Control Building from 10:30 to 2:30 p.m.

 

Updated Tuesday, November 16, 2010 at 12:28PM