Rural Health Advisory Committee Meeting Minutes

Rural Health Advisory Committee Meeting Minutes

Tuesday, September 23, 2008 10 a.m.- 2 p.m.

Snelling Office Park
St. Paul, Minnesota

Members Present: John Baerg (Butterfield), Thomas Boe (Moorhead), Deb Carpenter (Erhard), Thomas Crowley, Chair (Wabasha), Jode Freyholtz (Verndale), Jeffrey Hardwig (International Falls), Margaret Kalina (Alexandria), Diane Muckenhirn (Hutchinson), Thomas Nixon (Deerwood), Rep. Mary Ellen Otremba (Long Prairie), and Nancy Stratman (Willmar).

Members Absent: Dr. Ray Christensen, (Duluth), Rep. Steve Gottwalt, (St. Cloud), Sen. Yvonne Prettner Solon (Duluth).

MDH Staff Present: Jill Myers, Tamie Rogers, Mark Schoenbaum, Angie Sechler, Kristen Tharaldson.

Audience: Virginia Baarzan (Minnesota Academy of Family Physicians), Marnie Burau Kesler (Sen. Prettner Solon), Buck McAlpin (Minnesota Ambulance Association).


New RHAC members Jode Freyholtz and Jeffrey Hardwig were introduced. New RHAC staff Jill Myers was introduced. Chair Tom Crowley gave a plaque of appreciation to outgoing chair Diane Muckenhirn.


John Baerg (Consumer Member) – County commissioners are hearing rumors that the state budget will be short this year; and if that happens, they worry about expenses shifting to counties. Watonwan County has only 12,000 people. The local match was $24,000 in the 1990s and this year it will be $240,000. This money comes from local property taxes. Jail costs continue to be shifted to counties. This forces local public health to cut prevention programs like health screenings, vaccinations, etc.

Thomas Boe (Licensed Health Care Professional) – Tom serves as director of Minnesota State Colleges and University (MNSCU) dental faculty. Starting in 2014, Minnesota will have negative growth in dental professionals due to retirement. Many dentists prefer to live and work in metro areas. We could also see trends of dentists moving from Minnesota to other parts of the country. Minnesota is being proactive about the dental workforce projections by planning for the shortage. Because of the oral health care provider law, the rest of the nation is watching to see what will happen. Appletree Dental received a grant for students/mobile van to provide care to uninsured residents in the Fargo-Moorhead and Hawley areas.

Deb Carpenter (Consumer Member) – Fergus Falls is building a cancer center, which is a high need in the area. Deb is involved in planning a career day on October 16. They are inviting seventh, eighth and ninth graders to teach them about high demand occupations in the area, including health care careers.

Thomas Crowley (Hospital Representative) – St. Elizabeth’s has a waiting list to get into their assisted living apartments. They used to take everyone; now it is more difficult to take those on waiver programs. The hospital subsidizes a mental health program, but still needs to work with the county to maintain these needed services. St. Elizabeth’s recently worked out a relationship with the area technical school to train 10 CNAs to become LPNs via internet courses and clinical experience at St. Elizabeth’s. This is good for recruitment and retention because they offer incentives to repay the costs of education. A recent career day was a success with students showing interest in medical careers. This program actively guides students through medical school preparations and has shown success in encouraging students to choose family practice and come back to a rural community. Records show 30 percent of people at St. Elizabeth’s without insurance are eligible for some type of public program, so staff are doing legwork and follow-up with county social workers to help people through the application process.

Jode Freyholtz (Consumer Member) – Jode has worked in various areas of mental health for 25 years, including chemical dependency, vocational rehabilitation, housing support, etc. She has encountered insurance issues around mental health coverage for people with psychiatric conditions who choose to work. Stigma around mental health is still real and creates the need for travel to access services in rural areas.

Jeffrey Hardwig (Physician Member) – Dr. Hardwig is a practicing psychiatrist and has several concerns about mental health care delivery. These include provider burnout, provider shortages, increases in copays and deductibles, and the cost of medication for those who suffer from mental illness (especially when they hit the “doughnut hole” and stop taking medications). Additional concerns include accepting mental health patients regardless of bed availability, distance of travel tying up ambulances and emergency resources, and the lack of access to children’s mental health services. He would propose a package of care model for children and adolescents including referrals and follow-up based on the complexity of need similar to the DIAMOND project for adults.

Margaret Kalina (Registered Nurse Member) –Margaret provides oversight of a mental health clinic, and the mental health staff are subsidized by the hospital bottom line. She and PMAP are working on an integrated care model with PrimeWest. The hospital in Alexandria continues to have nursing slots available.

Diane Muckenhirn (Mid-Level Practitioner) –A new e-ICU is available in Hutchinson. A recent survey collected nurse practitioner students’ thoughts on being mid-level providers in a rural area. Positives include the chance to become a part of the community, ability to see patients within their family and community roles, and ability to look at the team approach and analyze differences. A main difference is “caring”and maybe there’s more caring because of the nursing background. It makes a difference for staff and patients, yet still can be cost effective. Struggles include a lack of diversity in patient models and challenges to set up experiences in rural areas. Schools try to help, but students also need to network to find rural externships.

Thomas Nixon (Volunteer Ambulance Service Member) –Run volumes have not dropped as much as predicted, but EMTs have seen increases in the number of people who refuse care once they reach a health care facility. Also seeing increases in transports from the Brainerd region to metro because hospitals are short-staffed. AEDs are getting into the hands of the public through churches, banks, first responders, etc. Several people have survived because of AED availability. There has been a recent increase in first responder volunteers. Currently working on a proposal to move a cath lab into the Brainerd area. The county budget is tight and plans to cut home health aides are underway. Gas prices negatively impact EMS services and it is a challenge for smaller services to maintain basic functions. Looking at how to save fuel, buy more efficiently, etc.

Mary Ellen Otremba (House of Representatives Member) –While working on her re-election campaign, she has encountered many calls of concern about health care.

Nancy Stratman (Long Term Health Care Member) – Concerns about many CNA openings. They are leaving jobs because of the high cost of gas. The Care Center of the Future forum featured a panel of WWII, Baby Boomer, Generation X and Millennials. All had different ideas of how to structure long term care. Looking at neighborhood-based concepts for delivery of care. Residents will be interviewed as a new part of the Minnesota Department of Health (MDH) survey process. Willmar nursing home is one of 10 facilities chosen for a new palliative care project. This initiative is being led by Stratis Health in partnership with Transitions and Life Choices, the palliative care program of Fairview Health Services.


Scott Leitz, Assistant Commissioner of Health, presented information about the health care reform legislation passed in May 2008. Goals are to reform the delivery system, expand health care access, make the system more transparent, and improve overall health. Important sections of the bill include:

  • SHIP (Statewide Health Improvement Program)
  • Health care home model supported through payments
  • Measurement and transparency in payment reform using common quality measures and implementation of a statewide quality incentive program
  • Provider peer group information using data to get a sense of costs versus quality
  • Baskets of care so providers could set price for common procedures (births, hip replacements, etc.)
  • Consumer engagement: How do we engage them to care about differences in quality and cost, lifestyle improvements, etc.

The RHAC work plan priorities are highly interrelated and reflective of health care discussions at the capitol this year. Anticipate a lot of workgroup activity to inform the process. Legislators would like a lot of rural involvement and input. Workforce is a central issue. We must ensure we have the right number and levels of providers to deal with primary care and nursing shortages. Care delivery models and reimbursements need to change. Innovations in rural areas need to be supported through funding, technology and training. To achieve financial stability, Medicare and Medicaid need to be supportive of integrated care models.

In the area of quality, Minnesota does well relative to other states, but when comparing outcomes-to-cost with other countries, we do poorly. We need to build on opportunities for prevention and care delivery quality improvements. This includes wider use of health information technology. Its more than EHRs and needs to address the general use of emerging technologies to support better care. To address the social conditions underlying the push for better population health, SHIP will require a local needs assessment and give multiple community players a role including schools, community-based services, etc. and use evidence-based strategies that work at the local level.


The following suggestions were made as considerations for the existing RHAC work plan:

    • Need to gather ideas for “growing your own workforce” at the local level; ideas to include (1) internet training programs (2) how to make dollars unencumbered (DEED does sectoral grants-could they focus on health care?)
    • Nurse practitioners face barriers to practicing at the top of their license and need to have full access to be a primary care provider (being addressed by workforce shortage workgroup and RHAC will look at recommendations from this group at the January RHAC videoconference)
    • Behavioral health “carve outs” rather than being part of total budget are huge barrier
    • Landscape of EMS volunteers in rural areas
    Rural ability to measure QI; methodology needs to be factored differently (this was a recommendation in rural health care delivery report)
    • Update to the Rural Health Status report; want to look at key areas for improvement (dental health, seat belt use, smoking, etc)
    • Dental health profile (contact Dr. Colleen Rickle, Metro State)
    • Veterans health – specifically, brain injuries

    The RHAC work plan priorities were ranked according to level of urgency and importance.  The priorities for the next year, in order are:  workforce, rural health delivery model, personal and population health, financial stability, information and communications technology, and quality improvement.


    The workgroup reviewed the draft health care home summary and shifted their focus to connections among primary care/specialty care/community systems. Workgroup members will review recommendations and a draft report at the final workgroup meeting on Oct. 29.


    Mark Schoenbaum, Office of Rural Health and Primary Care (ORHPC) director, discussed the recently released study from The Access Project showing that America’s farm and ranch families pay top dollar for health insurance that inadequately covers their needs and causes them significant financial risk. Nearly a quarter of farmers and ranchers say health care costs cause financial problems, and 20 percent of farm families had outstanding debt from medical bills.

    Two legislatively mandated work groups are being coordinated by staff in the ORHPC. The Health Workforce Shortage Study Work Group “shall study changes necessary in health professional licensure and regulation to ensure full utilization of advanced practice registered nurses, physician assistants, and other licensed health care professionals in the health care home and primary care delivery system.” The commissioner will make recommendations to the legislature in this area by January 15, 2009. More information on the work group is online.

    The 2008 Minnesota Legislature passed legislation establishing a new oral health practitioner discipline, licensed by the Board of Dentistry and working under the supervision of a dentist. The Oral Health Practitioner Work Group will advise the commissioner of health on recommendations and legislation to specify the training and practice details for oral health practitioners and report to the 2009 Legislature. MDH and the Board of Dentistry must report the work group's recommendations and proposed legislation to the Legislature by January 15, 2009. More information on the work group is online.

    Jill Myers, ORHPC program planning supervisor, presented information about the 2008 Minnesota Rural Health Plan. The plan will be updated per federal requirements and will focus on four goals: (1) ensure a strong, integrated rural health care system; (2) ensure a sound rural professional health care workforce; (3) foster improvements to rural health access and quality; and (4) support the use of health information technology and telehealth delivery in rural communities.


    Kristen Tharaldson, ORHPC planner, presented information about the 2007 Critical Access Hospital survey (CAH) of language access services. While the majority of CAHs provided some type of language access service (oral, written or signage), only 41 percent had staff designated to work on language access service issues. The full report is online.


    The next RHAC meeting will be Tuesday, November 25, 2008, at the Snelling Office Park. A legislative panel will present on issues for the 2009 session.

    Meeting adjourned at 2:05 p.m.