Rural Health Advisory Committee Meeting Minutes


RURAL HEALTH ADVISORY COMMITTEE
Tuesday, May 19, 2009 10 a.m.-2 p.m.

Meeting/Videoconference/Teleconference: Snelling Office Park

Members Present: Deb Carpenter (Erhard); Ray Christensen, (Duluth); Thomas Crowley, Chair (Wabasha); Jeffrey Hardwig (International Falls); Margaret Kalina (Alexandria); Diane Muckenhirn (Hutchinson).

Members Absent: John Baerg (Butterfield); Thomas Boe (Moorhead); Rep. Mary Ellen Otremba (Long Prairie); Jode Freyholtz (Verndale); Rep. Steve Gottwalt (St. Cloud); Thomas Nixon (Deerwood); Sen. Yvonne Prettner Solon (Duluth); Sen. Julie Rosen (Fairmont); Nancy Stratman (Willmar).

MDH Staff Present: Liz Carpenter, Kristine Gjerde, Jill Myers, Tamie Rogers, Mark Schoenbaum, Kristen Tharaldson, Karen Welle.

Presenters: Ron Brand (Minnesota Association of Community Mental Health Programs, Inc.), Liz Carpenter (e-Health Initiative - MDH), Karen Welle (ORHPC - MDH)

Audience: Virginia Baarzan (Minnesota Academy of Family Physicians); Diane Mandernach (SISU Medical Solutions, LLC); Colleen Sauter (7 Medical Systems).

MEMBER UPDATES

Deb Carpenter (Consumer Member) – Fergus Falls hospital (Lake Region Healthcare) is on track with building a new cancer center; scheduled for completion by year end. Involved in an area grant from the Minnesota Department of Education that will increase the number of students enrolled in health career courses and increase the number of people entering the profession with a degree.

Ray Christensen (Higher Education Member) – Thank you to rural hospitals for support of medical and pharmacy student program. The Rural Physician Associate Program (RPAP) student numbers were reduced for next year due to limited funding. Students and sites were disappointed. Both University of Minnesota medical schools have experienced fewer applications than in the past, thought to be a nationwide trend, although the quality of applications is still high. Some Area Health Education Centers are coming off of funding grants. Stress is in finding a way to be financially viable, particularly in rural areas.

Thomas Crowley (Hospital Representative) – Wabasha building two new operating room suites. The Capital Improvement Grant award and contributions from the Wabasha community have resulted in $1.2 million for the new operating rooms. Farmers are planting the “Field of Dreams” - 40 acres of beans surrounding the hospital campus. All of the farming supplies, equipment and work is donated, and all of the proceeds go to the hospital. Nine CNAs from long term care are going through LPN program. Training our own has paid dividends. Have not had to use a nursing agency and many students continue to expand their nursing careers. Just implemented large part of EHR with nursing and physicians. Nurses feel that the checks and balances have made it easier to assess patient risk.

Jeffrey Hardwig (Physician Member) – The Children’s Depression Care Initiative is moving forward nicely, working with child psychiatrists, pediatricians, family practice physicians, and the Minnesota Department of Human Services. This project involves a number of ways to enter the system through initial screening and depression screening using children’s depression inventory in a medical or mental health clinic. Score is presented to provider, where they may refer for an acuity and complexity assessment. Based upon the complexity, follow-up plans and scheduling are determined. Local team will provide care and may refer for further care. It creates a local system to deal with children’s depression. This initiative is similar to the DIAMOND project for adults. Three pilot projects are planned with one in International Falls.

Margaret Kalina (Registered Nurse Member) – Alexandria is using an e-Health grant to look for a way to interconnect services and maintain privacy. Douglas County Hospital is adding 80,000 sq. ft. Some decreases in patient census have been experienced lately.

Diane Muckenhirn (Mid-Level Practitioner) – Hutchinson continues to experience community layoffs. Nurse practitioner (NP) students being precepted were granted loan forgiveness. Recent NP students have not been aware of this program. We need to make sure that they are aware of this program. Advanced Practice Nursing programs are concerned whether they may fill their program due to lack of PhD prepared nursing faculty to support the programs. NP journals are mentioning that NP needs to be disease prevention and health promotion based, yet the CPT codes do not reflect codes for billing to include these items. Need outcome measures to be coded. All NPs will need to be doctoral trained by 2012.

COMMISSIONER’S UPDATE

Presented by Mark Schoenbaum, director of ORHPC, for Scott Leitz, asst. commissioner of the Minnesota Department of Health.

The legislative session ended yesterday; we are waiting to see what legislative and governor actions will follow. A few policy changes of interest to RHAC include:

Workforce:

  • Physician assistants will now be licensed instead of registered; each physician can supervise up to five physician assistants.
  • Pharmacist authority to adjust medication under protocol was enacted.
  • Mid-level practitioner, dental therapist legislation passed: Dental therapists will function under direct supervision of a dentist, and the advanced dental therapist can be supervised indirectly. First graduates of the new dental therapist programs are anticipated at the end of 2011 or early 2012
  • Appropriation made to the commissioner of the Minnesota Department of Labor & Industry to help returning veterans, who were military medics, transition through paramedic training.

Policy action:

Mental Health Crisis Teams are in place throughout the state and serve as a great resource to communities. New language allows the 911 system to dispatch the teams in response to an emergency call.

Spending decisions:

  • Legislature appropriated matching funds to allow the state to compete for stimulus funds: This will allow MDH to seek EHR loan funds from stimulus package.
  • National Health Service Corps has state federal partnership program that funds some loan forgiveness slots, $120,000 funds matched by legislature, to allow eligibility.

EMS and trauma designation bill passed, which delineates where and when ambulances take patients, starting in July 2010.

PRESENTATION

American Recovery and Reinvestment Act: What’s in it for Minnesota Rural Health?  (Karen Welle and Liz Carpenter)

Update and highlights:

  • MDH has a top level e-Health unit, located in the Health Policy Division.
  • e-Health includes a public-private collaborative to advise the commissioner of the Minnesota Department of Health.
  • Two mandates exist in Minnesota state law:
    • 2011 mandate for e-prescribing
    • 2015 mandate for interoperable EH
  • Workgroups have developed a statewide plan for e-Health implementation. See Model for EHR system (slide #5)
  • There is little information about assessment at present regarding barriers to adoption
  • Minnesota has invested $8.3 million in e-Health grants and $6.3 million in 0 percent loans, targeting funds to rural and safety net providers.
  • Support of $5.4 million in telehealth broadband initiatives in Greater Minnesota.

ARRA Key Provisions

  • HITECH Act
  • Medicare and Medicaid HIT incentives
  • Grants to states and tribes to promote HIT and EHR
  • Office of National Coordinator for HIT (ONCHIT)
  • Grants to states require matching funds from the state: 2011 at 1:10; 2012 at 1:7; and 2013 at 1:3
  • Competitive grants will be available to states and tribes for loan programs to assist with EHR technology, enhance EHR use, train personnel, and improve secure exchange of information. Match required: 1:5.

Medicare HIT incentives

  • Incentives are available to hospitals and individual providers that are “meaningful users.”
  • Meaningful user:
    • Using EHR technology
    • Demonstrates information exchange
    • Reports clinical quality measures
  • Incentives become penalties in 2015.

The MDH priority is to position providers to be eligible for maximum incentive Medicare and Medicaid dollars. 

PRESENTATION

Telemental Health in Minnesota: Progress & Challenges (Ron Brand)
Mental health, workforce and information technology are three of the RHAC’s top priority issues. Combining the three led to a request for input from Ron Brand, of the Minnesota Association of Community Mental Health Programs (see presentation PDF: 523KB/32pgs).

Discussion and comments
Thanks were extended to Ron Brand for the Association’s role in this foundational work. The group expressed the hope to have a children’s psychiatrist available to remote areas in the future. The requirement for broadband capability is a large obstacle to obtaining this service, and has been addressed for some through the FCC grant. Positive aspects of telemental health included a reduced no-show rate, estimating that a drop of only 6 percent would pay for the monthly costs.

Discussion of potential RHAC priorities and projects was initiated. Items brought up to be addressed included: mental health policy such as credentialing, interstate relationships and training; mental health access; and availability of child psychiatry services. Telemental health requires extensive training. There are mental health staff across the state, but who and where they are is unknown. We should look at mechanisms to maximize resources.

Suggestion was to take a look at broad telehealth issues and potential, rather than just mental health. Using telehealth in disease management areas was also suggested. Good infrastructure is key to successful telehealth. We might look at what is currently working in the state. Telemedicine has followed corporate relationships as a feeder of patients, but mental health services do not supply customers. But when working well, telemental health reduces customer numbers. It was also suggested that the DIAMOND project for adult mental health be looked at as a potential telemental health project.

MDH UPDATES (Mark Schoenbaum)

Health reform: Margaret Kalina (Alexandria) and Virginia Baarzan (Minnesota Academy of Family Physicians) are involved with MDH health reform activities. RHAC has done a lot of work on health reform, including health reform impact and implications to rural health. Question to be answered: How to develop health reform that is sensitive to rural needs?
                       
Stratis Health is working to keep the process rurally relevant. PPS hospitals must currently submit quality data to Medicare, and CAH participation is voluntary.

State Health Improvement Program: Applications are in and under review. No decisions will be made until the budget is finalized.

Health Care Home: Much progress has been made and proposed rules for Health Care Home participation are out for public comment. Patient and clinic readiness assessments for health care homes are now being conducted, particularly on clinic side. A demonstration project was just released with initial lessons learned. Cautionary note: it takes much longer to transform clinic settings.

RHAC Mental Health Subcommittee: Opinion was expressed that segregated mental health and physical health produces adverse outcomes. Carve outs unique to mental health result in a separate managed care system with restrictive access and reimbursement. Members would like to propose a mental health impact statement on rural health care. Discussion was held whether this issue is only rural or larger than RHAC. Comment was made that this not only rural, but that it certainly is a rural issue. The group agreed to convene a subcommittee to review mental health issues in rural Minnesota. The group will meet by phone over the summer. All RHAC members are invited to attend. The primary members include: Ray Christensen, Jode Freyholtz, Jeff Hardwig and Senator Prettner Solon. Kris Gjerde (MDH) will convene the group.

Conference: The Minnesota Rural Health Conference will be convened in Duluth June 15-16; expenses for RHAC members are covered by ORHPC.

Workforce:  MDH is analyzing and collecting new information on professions. Data collection will soon start for social workers and psychologists.

RHAC meetings:  MDH staff is thinking through more permanent ways to allow remote access. Please send your thoughts and opinions our way.

Meeting Handouts

NEXT MEETING

The next RHAC meeting is scheduled for Tuesday, September 29, 2009 at the MDH Snelling Office Park, St. Paul. 

The meeting adjourned at: 2:05 p.m.