Rural Health Advisory Committee Meeting Minutes
Friday, September 23, 2011, 10 a.m.-2 p.m.
Members Present: John Baerg, Ray Christensen, Tom Crowley, Jeff Hardwig, Rep. Larry Hosch, Margaret Kalina, Sen. Tony Lourey, Diane Muckenhirn, Tom Vanderwal
Members Absent: Tom Boe, Jode Freyholtz-London, Rep. Steve Gottwalt, Sen. Julie Rosen, Nancy Stratman
MDH Staff: Paul Jansen, Jill Myers Kemper, Mark Schoenbaum, Kristen Tharaldson
Guests: Virginia Baarson (Minnesota Academy of Family Physicians), Ronay Bjerke (pharmacy student), Linda Hinz (Rep. Hosch aide, MSW student), Maggie Kading (pharmacy student), Tom Larson (pharmacy professor), Elana Nelson (pharmacy student), Jessica Tonder (pharmacy student), Kaitlin Yost (pharmacy student).
Jeff Hardwig – Dr. Hardwig is a general psychiatrist in International Falls. Essentia Health is moving to a new mental health model. Availability of a nurse practitioner and psychologist will expand mental health coverage for the area.
Sen. Tony Lourey – Sen. Lourey is a new RHAC member. He represents a very rural area in northeast Minnesota including the I-35 corridor between the metro area and Duluth. He was elected to the Minnesota Senate in 2006 and currently is serving his second term. He is the new DFL lead on the senate health and human services committee following Linda Berglin’s departure. He is aware of mental health services access issues in his area.
John Baerg – Watonwan County has about 11,000 people and is very rural farming area. John has served as county commissioner for 15 years, has been on the local hospital board for 12 years, and has served on the school board and county health and human services committees. Currently the county is struggling with poor water quality issues.
Tom Vanderwal – Tom is a new RHAC member. He serves as a leader in one of the eight regional EMS groups in Minnesota. He will represent volunteer ambulance services on RHAC. He also serves on the FLEX committee.
Diane Muckenhirn – Diane is a nurse practitioner in Hutchinson with 26 years of experience in nursing. Preceptorships for nurse practitioner students are advertised through the Minnesota Board of Nursing website. A new phenomenon is home care agencies in the metro area are making house calls at any time or day of the week. There is high demand for urgent care at home for pediatric and geriatric homebound patients. The providers have collaborative agreements with clinics. Psychologist and physicians are also available for house calls. Diane wonders if this trend will reach rural areas and if it could be turned into a rural model.
Tom Crowley – Tom has worked at Saint Elizabeth’s in Wabasha for 40 years. He helped to develop programs in the areas of dialysis, home health and mental health. Physician recruiting is a big issue in the area. It is especially difficult to recruit obstetric providers. Saint Elizabeth’s has a “grow your own” workforce philosophy and is keeping in touch with three local students who are applying for medical schools. County commissioners wanted to discontinue county home health programs, but agreed to a public/private partnership to continue to serve about 100 individuals with low incomes. These include Medicaid patients and veterans who would fall through the cracks without home health services.
Ray Christensen – Dr. Christensen is a family physician and cofounder of the Gateway Family Health Clinic in Moose Lake and assistant dean for Rural Health at the University of Minnesota Medical School Duluth campus. New medical students at UMN-Duluth are going into family practice in greater numbers, including 52 percent of graduates last year. This shift is supported by curriculum changes, availability of rural preceptorships, and student opportunities to work in various communities and hospital systems.
Margaret Kalina – Margaret serves as Director of Patient Services and Chief Nursing Officer at Douglas County Hospital in Alexandria. She is active in the Minnesota Organization of Leaders in Nursing, which helps expand or create nursing education programs. New nursing graduates are having difficulties finding jobs. This may be linked to generally low hospital census figures. A health reform focus on avoiding adverse events and readmissions will likely continue to lower in-patient census numbers.
REVIEW OF 2009-2011 WORKPLAN PRIORITIES
The Rural Health Advisory Committee was initially formed in the early 1990s in reaction to Minnesota Care program changes. Rural legislators wanted to make sure they had a way to identify needs and concerns of rural areas.
The workplan review provides an opportunity to look back and plan ahead. Rural health trends drive this work, so the top issues identified will be RHAC’s main focus for the next two years. The main products of RHAC are policy recommendations aimed at the Commissioner of Health, other state agencies and state legislators. (See workplan accomplishments and recommendations follow-up handouts.)
A short presentation provided context for current rural health issues. Our planning process needs to consider workgroups of the Governor’s Health Reform Sub-Cabinet and the Minnesota Department of Health Commissioner’s Office.
|Governor’s Health Reform Sub-Cabinet – Interagency workgroups|
|MDH Priority Work Groups|
|Community-oriented Primary Care||Community value of Statewide Health Improvement Program (SHIP)||Public Health Accreditation|
DEVELOPMENT OF 2011-2013 WORKPLAN
A group brainstorm gathered ideas on current rural health trends and concerns:
- MENTAL HEALTH
Mental Health First Point of Contact. County sheriffs have shown great interest and involvement in advocating for a better mental health first point of contact system. They need tools to access mental health services in their area to divert individuals with mental health issues to hospitals instead of jails. This is especially important for emergency situations. Mental health crisis protocols for providers are important in health care settings. This allows a framework for providers to meet quarterly to discuss cases and revise local protocols as needed.
Promising models for mental health first point of contact, such as regional Crisis Response Teams and telehealth capabilities in emergency vehicles, could be developed and promoted. Additional partners may be needed to address mental health first point of contact issues: The Minnesota Psychiatric Society, NAMI, local police, sheriff and EMS.
There may be a need to institutionalize a governing body to address rural mental health first point of contact issues. Statewide data on first point of contact could be used, including the EMS regulatory board report on mental health emergency transports, which included hospital database information. It is estimated that half of all ER visits for mental health are not truly emergent. Need other modes to address this issue including mobile, telehealth and collaborative practices. One promising model is in the Alexandria area. Need to identify grants and maximize local resources.
On call practitioners in hospital emergency rooms, especially those in remote rural areas, need tools to locate emergency mental health contacts at county, regional and state levels. Telehealth options and best practices for integration of county-level mental health communication systems could be developed. Better communication systems are needed to facilitate coordination among law enforcement, emergency services, social services and health care providers.
Role of Pharmacists. Pharmacists can play a more central role in managing mental health patients. Psychotropic drug interactions are hard to predict. Pharmacists can consult with primary care providers who lack access to a psychiatrist. They can play a broader role to educate patients and medical staff.
Nursing Home Closings. Supports for aging in place are needed to keep people out of nursing homes. Nursing homes need to be integrated with communities to demystify the aging continuum of care. When a nursing homes closes, this increases the distance between patients and their family and friend networks. Nursing homes are the costliest settings for end of life care. Nursing home patient trends include decreased length of stay (less than 130 days) and extremely old or frail patients who need high levels of care. Rehabilitation patients of all ages are admitted to nursing homes for the financial benefits. Are there incentives to build behavioral units in nursing homes? It seems there are financial disincentives to invest in nursing homes even for modern needs. Nursing homes are often a financial liability for rural hospitals.
Nursing Home Quality of Life Issues. Quality of life and dignity are important issues at the end of life. A shortage of nursing assistants with huge caseloads (regulations allow up to 20 patients) and poor pay result in overall decline in quality of care for nursing home patients. Nurses working in long term care often leave due to the physical toll on their bodies and the stress of the job. There are pay disparities within job classes (nursing home versus hospital).
Dementia. There are a lot of partners working on the issue of aging in general, and Alzheimer’s disease and other dementias in particular. An Alzheimer’s Disease Working Group published a report in January 2011. The aim was for Minnesota to be the first state in the nation prepared for the baby boomer wave of Alzheimer’s. (Alzheimer’s Association Minnesota-north Dakota Chapter is online) RHAC member Rep. Steve Gottwalt worked to pass related legislation in 2011 for better data collection and reporting on Alzheimer’s. The bill, H.F. 200, also supports a learning collaborative for screening and education on best practices regarding identification and management of dementia patients. Best practices for early recognition and treatment, mentors for those with early diagnosis and their families, and support groups for caregivers could be considered jumping off points for rural specific work on this issue.
Wellness programs. There are free and low-cost wellness programs available in communities for elders. However, the elderly, their caregivers and community volunteers need help connecting to these services. A statewide database of locally available wellness programs for the elderly would save care providers the time of locating these services on their own. It could also be a place to share best practices and local adaptations to broader programs.
Rentals from housing with services. There is concern about new legislation requiring a consultation with the Minnesota Council on Aging before elders can rent from a housing with services (HWS) facility. The consult is required regardless of payer type. Some see it as an invasion of privacy or government interference. On a more practical level, it is problematic to assume there are safe or secure housing alternatives in rural areas for elders who are denied through the consultation process.
- RURAL HEALTH CARE TRANSFORMATION
Rural Integrated Care Systems. Many trends are changing the way rural health care is organized and delivered. Primary drivers of these trends include federal health reform (ACA), state health reform (health care homes, quality reporting), accountable care organizations (payment mechanisms changing), and large health system takeovers of rural areas (regionalization, renaming organizations or affiliations). Is there a role for independent practitioners in rural areas? How can they be organized in rural areas and be viable? Need to identify models for affiliation and expansion. Need to support and connect with local public health on care coordination on county-based provider teams.
Fee-for-service payment mechanisms allow the worst quality medical practices to make the most money. When physicians see patients, they should worry most about health outcomes. Need to remove barriers through a team approach and eliminate turf wars. Robert Wood Johnson has a demonstration project for best practices for med/surgical teams and this model could be adapted for rural primary care. Incorporating social workers as well as methods to manage paperwork and insurance are necessary components.
Statewide Health Improvement Program (SHIP). Retirees and baby boomers need timely options for nutrition, exercise and wellness. To capitalize on SHIP, need to aim at baby boomers. Successful health promotion for school-aged children includes “walking school bus” (children within one mile of school walk together with parent/grandparent two times daily) and “bicycle school bus.” These safe routes to school programs are zero to low cost and can be implemented at local schools. There are policy issues that need to be addressed such as gym school classes being optional. Local farmers markets and farm to school programs are also good models to promote. Workplace physical activity could be further promoted. Partners in this effort are SHIP program staff (MDH), Local Public Health Association (LPHA) and Area Health Education Centers (AHEC).
Role of APRNs. Many older physicians have not experienced a model of practice that includes Advanced Practice Registered Nurses (APRNs). Right now, there is an oversupply of APRNs. Nurse practitioners need to market themselves and demonstrate their versatility. RHAC should make sure wordage in reports is inclusive of APRNs.
Access to Medication Therapy Management Services. Need to link Medication Therapy Management (MTM) by pharmacists to all other services. Although elders make up 12 percent of the population, they consume 33 percent of all medicines. With diabetes in the American Indian population, pharmacists can improve outcomes and the process for managing medications. The Fond du Lac model could be looked at for promising practices. Rehospitalizations are a growing concern. MTM has shown success in avoiding readmission in the first thirty days, which is especially important with cardiac patients. With mentally ill patients, including dementia and delirium in the elderly, MTM can help to keep people stable. Telehealth applications for MTM can be best utilized in rural areas.
No pharmacy shortage designation. Currently there is no shortage designation for pharmacy in rural areas. Pharmacy graduate students at the University of Minnesota are developing a model for this designation.
Pharmacy data. The ORHPC does not currently collect pharmacy workforce data. The Board of Pharmacy or the University of Minnesota may be collecting pharmacy workforce data.
Community Paramedic. The community paramedic pilot program to develop and test a curriculum was partially funded by ORHPC. The Shakopee Mdewakanton Sioux community and Scott County Medical Director Dr. Michael Wilcox led the pilot program. Minnesota is the first state to recognize the community paramedic provider in law.
Leadership. The volunteer EMS community needs to develop leadership to address Scope of Practice and other issues at the legislature.
Telehealth Billing. Agencies through the continuum of care need approval to get paid for providing telehealth services. There needs to be a way to get speedy approval and clarification on reimbursement policies for all providers.
Community Health Workers (CHWs). Analyze how this newer provider type is being used in rural areas or with rural populations.
Jill Myers Kemper is leaving ORHPC for a new position. Kristen Tharaldson will be lead staff for RHAC and Paul Jansen will provide data analysis on RHAC projects.
One consumer position remains open for 2011 appointments. Six positions will open in 2012 and will be posted through the Secretary of State website.
New RHAC members will receive orientation materials electronically. They may also be asked to be interviewed for the ORHPC Quarterly newsletter.
The meeting adjourned at 2 p.m.
RHAC members will be asked to participate in a conference call in November to finalize the draft RHAC work plan for 2011-2013.
Our next meeting will be held jointly with the Partnership Council (formerly the Health Education-Industry Partnership/HEIP) in Bloomington on Thursday, December 8 from 10 a.m.-2 p.m. An agenda will be sent out prior to the meeting.