Rural Health Advisory Committee Meeting Minutes

Rural Health Advisory Committee Meeting Minutes

Tuesday, November 25, 2008 10 a.m.- 2 p.m.

Snelling Office Park
St. Paul, Minnesota

Members Present: John Baerg (Butterfield), Thomas Boe (Moorhead), Deb Carpenter (Erhard), Ray Christensen (Duluth), Thomas Crowley, Chair (Wabasha), Jode Freyholtz (Verndale), Jeffrey Hardwig (International Falls), Margaret Kalina (Alexandria), Diane Muckenhirn (Hutchinson), Thomas Nixon (Deerwood), Sen. Yvonne Prettner Solon (Duluth), Sen. Julie Rosen (Fairmont), Nancy Stratman (Willmar).

Members Absent: Rep. Steve Gottwalt (St. Cloud), Rep. Mary Ellen Otremba (Long Prairie).

MDH Staff Present: Carol Backstrom, Doug Benson, Jill Myers, Tamie Rogers, Mark Schoenbaum, Kristen Tharaldson, Karen Welle.

Audience: Virginia Baarzan (Minnesota Academy of Family Physicians), Ryan Goedecke (Minnesota Pharmacists Association and University of Minnesota/College of Pharmacy).


New RHAC members Sen.Yvonne Prettner Solon and Sen. Julie Rosen were introduced.


John Baerg (Consumer Member) – The local hospital in St. James is a year old. The architect designed the atrium as a waiting room, but it is not working as intended, so the hospital is putting in temporary partitions. The hospital in Madelia also did major remodeling. John was re-elected as a county commissioner. The main concern of local elected officials is the projected state budget shortfall. They are worried that local public health funding will be cut and preventative services will be lost. Human services cuts would impact people already struggling in this economy, and charity care may be affected.

Thomas Boe (Licensed Health Care Professional) – The U.S. Government Accountability Office recently published a report entitled Medicaid: Extent of Dental Disease in Children Has Not Decreased. The impetus for the report was a 12-year-old boy whose death could have been prevented by a routine $80 tooth extraction. The study found that one in three children participating in Medicaid had untreated tooth decay, and one in nine had untreated decay in three or more teeth. A new pilot program in Moorhead allows dentists to go to schools to do oral screenings and provide fluoride treatments.

Deb Carpenter (Consumer Member) – The October 16 Career Day for junior high and high school students drew 41 youth, including12 in the health care track. The program will be repeated next year. A Department of Labor grant proposal was recently submitted to expand clinical sites and mentoring programs in health care. This includes development of a contextualized curriculum for students planning to enter community colleges.

Ray Christensen (Higher Education Member) – Many summer internship in medicine students were placed in rural facilities this year and the rural physician associate program (RPAP) has 47 students working in rural areas. The UMN-Duluth Medical School is looking at a pilot program to have every medical student do either RPAP or a rural rotation. The rural rotation would require locating sites for 200 medical students for two months a year. The UMN-Duluth Medical School already focuses on rural family physicians, but will change the course structure to seven semesters. The hope is that by training these students in rural areas, there is a greater chance they will choose to work in rural settings. Incentives for rural practice include loan forgiveness program eligibility and scholarships through rural health care systems.

Thomas Crowley (Hospital Representative) – Currently, physician recruitment is the top priority issue. St. Elizabeth’s believes the best opportunities for recruitment are through a “grow your own” strategy. They work closely with students through career days and find opportunities to encourage and support local students. St. Elizabeth’s is experiencing a decline in long term care needs and an increase in emergency room visits. The use of a walk-in clinic for people without insurance is increasing. Overall charity care increased, but there is tremendous support from the community. St. Elizabeth’s is building two new surgery rooms through donations of labor, materials and money.

Jode Freyholtz (Consumer Member) – Six counties in northern Minnesota met to discuss gaps in mental health services. They invited mental health providers and people with psychiatric diagnoses to discuss ways to improve current mental health services. From May to November, mobile crisis teams in the area have served over 100 people with only 15 hospitalizations, so this prevention-focused model is successful. There are concerns among providers that adult rehabilitative services (ARMS) are becoming more difficult to provide because of the high needs and paperwork.

Jeffrey Hardwig (Physician Member) – Development of a children’s depression care package aims to provide better access and quality of care to children with depression. It was inspired by the DIAMOND project, an evidence-based best care management program for outpatient adult depression based on a collaborative care model. This integrated model involves screening, triage and planning for optimal care. Dr. Hardwig’s role in this effort is to make sure the model is rural relevant and covers the uninsured.

Margaret Kalina (Registered Nurse Member) – The supply of nurses in Minnesota has improved in recent years. Although nursing is not ‘recession proof,’ many nursing jobs are available. A bonding project passed in July will create more private hospital rooms for Douglas County Hospital. Physician recruitment remains a top issue and the hospital struggles with how to recruit physician specialists. Charity care in the ER has doubled in the last three months.

Diane Muckenhirn (Mid-Level Practitioner) – Hutchinson area high school instructors met with doctors, nurses, chiropractors, EMTs and others to discuss how to get students on the right track for health care careers. The American Academy of Nurse Practitioners is discussing the medical home concept and the importance of nurse practitioners as primary care providers.

Thomas Nixon (Volunteer Ambulance Service Member) – The central Minnesota regional ambulance service reports increased run volumes even though hospital intake is lower. Although gas prices are lower, they are still considering more efficient vehicles. Current emergency vehicles get 9 to11 miles per gallon, and it is expensive to replace these fleets. The national registry of EMTs is in the process of realigning titles of emergency personnel. Currently, states use their own titles; they are trying to make changes so training levels are clear and uniform across the country.

Sen. Yvonne Prettner Solon (Senate Majority Member) – Sen. Solon is a practicing clinical psychologist in Duluth and sits on the Duluth Graduate Medical Education Council. The majority (70 percent) of graduates work in rural areas. UMN-Duluth could train more with additional capacity and sites. The Legislature passed major health care reform last session and now is ready for implementation and working on public health goals.

Sen. Julie Rosen (Senate Minority Member) – Sen. Rosen’s legislative district includes Blue Earth, Faribault, Martin, Waseca and Watonwon counties in southern Minnesota. The aging of the population in these counties is significant, and disparities exist based on geography. The 13 long term care facilities in this district are all experiencing negative operating budgets and staffing shortages. The Senate Health Care Budget Committee will have a lot of work to do in the next session. Legislators are proud of the bipartisan effort to move health care reform ahead, but a lot of work remains to figure out how to encourage innovation while accomplishing savings.

Nancy Stratman (Long Term Health Care Member) – Long term care is busy trying to anticipate the needs of boomers as they age. The Willmar nursing home and hospital are struggling with low patient census issues. They are involved in the Stratis Health palliative care initiative. The COLA (cost of living adjustment) was recently distributed. Minnesota has equalized rates and they must charge the same regardless of insurance type.


Carol Backstrom, assistant to the commissioner for health reform, presented information about the health reform work since passage of the bill last May. They are using Triple Aim principles from the Institute for Healthcare Improvement as a framework for health reform implementation. MDH is on target with the timeline to complete its work in four areas:

  1. SHIP – The Minnesota Legislature approved $47 million for this initiative. MDH is defining grant requirements (including the match requirement) and will issue a Request for Proposal (RFP) in February 2009. Local public health is required to collaborate with partners who have a track record with health promotion and prevention activities. Although the grant will go to local public health, it must be used to collaborate with partners and identify creative local approaches.
  2. Cost and Quality Transparency – RFP areas include quality measurement, encounter data, baskets of care, and analytical work for peer grouping. The areas for “baskets of care” are not determined yet. Dr. Hardwig suggested children’s mental health care as one area.
  3. Health Care Homes – This area includes a focus on outcomes and measurements of success to determine standards. The outcomes need to be measurable and address overall cost of care. There will be a statewide capacity assessment for readiness to implement health care homes. This will determine if health care providers and consumers understand the concepts around health care homes.
  4. Other workgroups – Reports from the Workforce Shortage Study Group and the Oral Health Practitioner Work Group are due January 15, 2009.


 Lance Ross – Minnesota Ambulance Association (MAA): The MAA is hoping to avoid cuts this year and will request an increase of $1.55 million to support existing programs. Other issues of importance include the primary seatbelt law, trauma system transports, and the use of medical resource control centers to relay information to hospitals as used during the Republican National Convention.

Kari Thurlow – Aging Services of Minnesota: Last year, Aging Services passed a community consortium pilot project bill to be implemented in 2009. It is designed to incentivize community services, local government, primary care and long term care to fill gaps in communities. It will fund up to three pilot projects (with one in rural and two in urban areas) and hopes are to identify and replicate successful approaches.

Sue Stout – Minnesota Hospital Associatio (MHA): MHA is not asking the Legislature for funding, but hopes to keep current funding levels stable. Along with increases in uncompensated care, hospitals are seeing a significant drop off in patient census numbers and are experiencing layoffs.

Kathy Huntley – Minnesota Rural Health Association (MRHA): A top issue for MRHA is universal insurance starting with children and eventually covering all Minnesotans. Long term care is an important part of rural economies and the need to age in place is key. Standards for certification of medical interpreters are needed. Another priority area of MRHA is to require Rural Opportunity Assessments (ROA) when planning new state initiatives.

Liz Carpenter – Minnesota Pharmacists Associatio (MPhA): MPhA is assessing barriers to implementation of the e-prescribing mandate to go electronic by 2011. Other issues of concern include pharmacy practice act updates, Medicaid pharmacy reimbursement, and possible legislation on continuous quality improvement programs. Federal issues being addressed this year include recognition of pharmacists as providers under Medicare Part B, inclusion of pharmacists in National Health Service Corp (NHSC) and exemption for pharmacies from durable medical equipment (DME) accreditation.

Sara Noznesky – Minnesota Medical Association (MMA): MMA is concerned about cuts to General Assistance Medical Care (GAMC) and MinnesotaCare and are preparing for the health care access fund to be raided again this year. The viability of clinics in rural areas is shaky, especially when considering patient mixes (percent of patients on Medicare and Medicaid), cuts or adjustments to reimbursement (20 percent cuts by 2010), and issues collecting reimbursement from patients with health savings accounts (HSAs). MMA is supportive of the medical home concept and increased access to primary care


After review of the report, RHAC members recommended the following changes to the draft Rural Health Care Delivery Workgroup report:

    1. Phase-in the health care home concept. Start with primary building blocks and add other components later. Allow time to address variability in readiness and resources through a phase-in process.
    2. Add RHAC’s definition for “medical home” and/or “health care home” informed by the national models, Minnesota’s health reform bill and the Minnesota Academy of Family Practice (MAFP).
    3. Complete the list of “ancillary” professions to include volunteers, transportation, etc.
    4. Make it clear that a lack of EHRs should not prohibit health care home participation.
    5. Reimburse for time (care conference) versus intensity of time. This has system-wide implications versus solely applying to the health care home concept, but it will impact the success of the health care home model and also impacts dental and related professions.
    6. Investigate and include ideas larger health care systems are using regarding collaboration and communication across sectors or systems
    7. Combine several of the financial assistance recommendations. Instead of “few incentives,” it should read “disincentives” to current collaborative efforts.
    8. After certification of medical homes, ensure there is a process for evaluating and retooling the certification standards as we experience the use of them. Use a “rapid cycle” technique to make improvements ongoing.
    9. When the report is complete, send it along with a letter to Tom Daschle, new secretary of Health and Human Services, to highlight RHAC’s work on health care home.


    President-elect Obama’s communication with the NRHA prior to the end of the election cycle shows he has a rural health plan as well as a rural agenda covering technology, agriculture, health care and other areas.

    RHAC staff will organize a conference call to nominate the RHAC chair-elect.


    The next RHAC meeting will be Tuesday, January 20, 2008, via videoconference.

    Meeting adjourned at 1:55 p.m.