Rural Health Advisory Committee
Rural Hospital Flexibility Program Advisory Committee

Meeting Minutes

Monday, May 7, 2012
10:00 a.m. - 2 p.m.

RHAC Members Present: John Baerg, Ellen Delatorre, Margaret Kalina, Millicent Simenson, Nancy Stratman, Tom Vanderwal.

Flex Members Present: Stacy Barstad, Rick Failing, Mike Hagen, Mike Hedrix, Barbara Heier, Maria King, Joe Schindler, Lori Sisk, Colleen Spike, Tom Vanderwal.

ORHPC Staff: Craig Baarson, Doug Benson Judy Bergh, Paul Jansen, Cindy LaMere, Nitika Moibi, Mark Schoenbaum, Kristen Tharaldson.

Guests: Judy Bird (Congressman Walz’s office), OJ Doyle (Minnesota Ambulance Association), Kai Hjermstad (Hennepin Technical College), Sharon Josephson (Congressman Peterson’s office), Kent Larsen (TSP Architects), Dennis Mackedanz (Hubbard County Area Community Paramedic Collaborative), Karen Miller (Congresswoman Bachman’s office), Rebecca Radcliffe (Essentia Health), Jason Rusinak (Hubbard County Area Community Paramedic Collaborative), Gary Sabart (TSP Architects), Karen Welle (MDH Health Policy Division).

Welcome and Introductions

Rural Health Advisory Committee (RHAC) chair John Baerg called the meeting to order and asked for introductions from members and guests. Today’s meeting is a joint meeting between two Office of Rural Health and Primary Care (ORHPC) advisory committees. ORHPC staff provided an overview of the RHAC committee. RHAC is a 15-member, governor-appointed committee that addresses statewide rural health issues. It advises the Commissioner of Health and other state agencies. Topics are generally state-focused, with recommendations directed at the legislature and other state-level decision makers.

The Rural Hospital Flexibility program created the CAH designation at the federal level. When Congress created the CAH designation, their intention was to provide more flexibility to rural hospitals who were struggling and for whom federal regulations were not a good fit. The aim is to keep small rural hospitals open to create broad geographic access to health care.

Minnesota’s Rural Hospital Flexibility (Flex) Advisory Committee is made of CAH administrators, EMS representatives, Minnesota Hospital Association, Stratis Health, Minnesota Department of Health regulatory staff, legislative office staff, and other rural health partners. Flex meets quarterly to give advice on how to proceed regarding federal grant activities. Minnesota has the third highest number of CAHs (79 hospitals) and receives the largest Flex grant award in the country. Most of the Flex grant award goes to hospital and ambulance services. Other grants go to partner organizations (MHA, Stratis) to support their work with hospitals and ambulance services. One Flex objective is to work more closely with RHAC to add value to Flex grant activities.

Rural Health System Growth and Consolidation

RHAC priorities include the issue of rural health care delivery system growth and consolidation. The January RHAC meeting included a slideshow looking at rural health systems trends. Over the past 20 years, there are fewer CAHs that remain independent and more CAHs moving towards health system affiliation. Are there advantages or disadvantages to this consolidation for rural hospitals and clinics? RHAC has looked at the data, and chose to look further into the issue.

A student at UMN-Crookston plans to survey CAHs on this topic. A draft of the survey has been prepared with help from ORHPC staff. She wishes to discover the advantages or disadvantages of CAHs' current status (owned, leased, managed or independent). If a CAH changed affiliations recently, she wants to uncover the main drivers behind the decision as well as changes that have occurred as a result of the new health system affiliation. What do RHAC and Flex committee members think would be some important questions to ask through the survey? What are the central questions to be asked about this topic?

Does system affiliation affect patient care? Is it maintained or improved?

  • Can CAHs maintain or add valuable services within the economy of scale and economics that systems may provide?
  • Did the number of specialty services offered increase or decrease?
  • Has population care management changed or evolved?
  • As CAH system affiliations occur, does this change EMS or first responder relationships?
  • What are the oldest areas of the hospital used for patient care? Consider infrastructure investments including remodeling, new building, access to capital for affiliated versus non-affiliated.
  • Is there are difference in affiliated-CAHs' ability to gain capital at a local level?
  • Do affiliated CAHs have the funding needed to carry out their mission over time?

Does system affiliation affect health care workforce recruitment and retention?

  • What is the current physician-admitting profile and what will it be in 5 years? Does ease of physician recruiting increase within systems?
  • What are the affiliations or relationships with physician groups in town? CAHs should try to understand local hospital-clinic-physician relationships (employee, contracted, freestanding clinics, affiliated clinics, etc.).
  • For hospitals that are newly affiliated, is there “merger pain” around the reshuffling of staff or financial systems? Are there adequate resources to support changes in personnel or technology?

Does system affiliation affect a CAH’s ability to maintain compliance with reporting or other requirements of health reform? Does it affect a CAH’s financial situation?

  • Does system affiliation help CAHs maintain compliance?
  • Are there financial changes prior to affiliation versus after affiliation? Consider Medicare cost reports for CAHs as a source of data for this project.
  • For CAHs that remain independent, where do they get compliance information? Part of the answer is ORHPC, MHA or Stratis. As health systems expand and there are fewer independents, what is the role for ORHPC, MHA or Stratis in terms of consulting with health systems?

Does system affiliation affect local governance or community perceptions of the hospital?

  • Has system affiliation made a difference in local decision-making?
  • Could identify a local newspaper to get a sense of the community view of a hospital before and after system affiliation. Ask a hospital CEO paid by a health system and they have a certain line. Answers may be different from an outside or public view.

What are characteristics of hospitals that plan to stay independent?

  • Are you exploring consolidation or system affiliation? Where do you see yourself in 5-10 years?
  • What are the drivers? Ask about the reasons hospitals would want to affiliate or not.
  • See trends toward systemization, but some CAHs plan to stay independent. The survey could look at two tracks: affiliated/planning to affiliate, independent/planning to maintain independence.
  • When were hospitals affiliated within the last 14 years? May need to target hospitals with a recent change and independents.

Is the justification for the CAH program impacted by increasing trends towards system affiliation?

  • It is important to recognize the evolving role of CAHs over the past 14 years. The initial idea was a triage system to get emergency care at CAHs, and then ambulance services would bring patients to the next intermediary or larger hospital. Has the philosophy of CAHs changed over 14 years and is there still a need? Has the role of CAHs changed as far as health care delivery is concerned?
  • Heading towards regionalization, will federal decision makers question the need for a CAH financial safety net? If the current cost-based system goes away, low-volume CAHs may not be viable in the eyes of regional health systems. These trends may have unintended consequences.

What are additional survey considerations?

  • Need to keep the survey length reasonable. What information would be the most useful?
  • A big challenge for survey development will be wording. We need to ask the right questions to get the answers we are looking for. It would be easy to put out a survey that creates little clarification and prompts more questions. Have other states done a survey like this?
  • Illinois studied the characteristics of their CAHs as they adapt for the future. What prompted the study? What are the main findings? Could discuss this with their Flex program coordinator.
  • Should part of the survey be directed at systems? What does the CAH program mean to systems regarding their idea to invest?
  • A good approach may be to survey a small group of CAHs over time. Could start with a few hospitals that have recently affiliated and follow them over a 5-year period.

Report Out on Northwest Region Community Forums

ORHPC did a series of community forums in 2008. The state was divided into four quadrants and we met with hospital staff, local EMS, public health, community stakeholders and consumers in each region. The forums encouraged discussions about health care delivery in each region and included a SWOT analysis (strengths, weaknesses, opportunities, threats) of the local health care system. ORHPC staff summarized the information to create objectives for the Rural Health Plan, a requirement for the Flex grant.

ORHPC staff decided to reconvene these forums in 2012. They started with two forums in the Northwest Region in Park Rapids and Thief River Falls. Representatives from local EMS, public health, hospitals, aging services and consumers were present. ORHPC staff summarized the themes from these forums. These themes can be used to inform the CAH community health needs assessment process. They can also help to address long-term regional planning.

Themes from the Park Rapids Community Forum:

  • Transportation issues
    • Transportation is a major barrier to primary care access.
    • Transportation gaps include: to and from medical visits, from hospital after EMS run, transports between hospitals, follow-up appointments.
    • Funding for transportation services is declining. There are also jurisdictional issues between health facilities, EMS, other first responders and law enforcement. This is especially complicated regarding mental health patients.
  • Mental health
    • Lack of mental health workforce, specifically for adolescent and pediatric patients.
  • Home health
    • Reimbursement declining; changes ability to stay at home.
  • Discharge planning
    • Assume person picking up patient will provide care, but this is not always the case. Need plan for continued care and clarity on provider roles.
  • High Medicaid and uninsured patients
    • A huge issue for this population is dental care. The region is overwhelmed with a large patient load for free/reduced dental care. The free dental clinic receives patients from 25 counties in Minnesota. Local private dentists cannot make that business model work.
  • EMS Services
    • EMS volunteerism is decreasing and new models of how to attract volunteers are needed.

Themes from the Thief River Falls Community Forum:

  • EMS recruitment issues and need for coverage
    • It is not always guaranteed that volunteers are available. If local EMS does a run to Grand Forks or Fargo, large distances need to be traversed. When out on a long-distance run, who will provide service locally?
  • Recruitment challenges
    • More remote area, so “grow your own” is important approach.
    • Because the region lacks community colleges, it is more difficult to draw from a local student base.
  • Environment Health
    • Local public health receives requests to survey sites of concern, but feel it is out of their area of expertise. This is especially true with health hazards within households (asbestos, mold, garbage houses). Whose responsibility is it? Who takes the call, does the survey, etc? Who is trained and able to perform these tasks?
    • Counties or local public health cannot afford, nor do they need, a full-time person to take on these tasks. To address this specific need in the region, forum participants suggested an idea to train high school science teachers to do environmental assessments.
    • When these situations involve child endangerment, local EMS or law enforcement is involved. When these situations involve adults with mental health issues, who is qualified or appropriate to handle the situation?
  • Mental health
    • Whose responsibility are mental health patients when they are in crisis?
    • Patients end up incarcerated with mental health issues. Should this happen or is there another facility to provide services?
    • A past CAH innovation grantee formed a consortium in Becker/Mahnomen/Norman counties to address psychologist shortages in their area. They developed a wide range of opportunities for psychologists to train in their rural area. Ten people have utilized the program and all ten currently practice in outstate rural areas. This model to support mental health workforce could be replicated or revisited.

Rural Health Policy Issues Discussion

RHAC looks at the whole rural population and rural health system from a policy perspective. The Flex committee looks at core rural health care services from a hospital perspective. How do the RHAC work plan priorities line up with Flex program concerns? Are there additional issues to consider?

  • Technology to keep aging populations in their homes.

In rural areas, there may not be home health coverage. The health provider travel time to a home may take longer than the patient assessment. Technology is one option to cut costs. This topic could be addressed through two parts of the RHAC work plan: 1) Aging, Dementia and Long-Term Care;  and 2) Successful Wellness Models for Rural Communities.

There are financial barriers to home-based technologies for aging populations. Funding for technology must be within a “cap.” If it cannot be funded, it does not work. Insurance companies have pulled out of coverage for home monitoring equipment, though the devices save money overall and patients satisfaction is high.

There are regulatory barriers to home-based technologies for aging populations. There is no reimbursement for supervisory visits, so some providers use Skype to reduce costs, but not sure that will be allowed. When patients do not need skilled nursing, but do need support to stay in their homes, they often do not meet specific criteria for reimbursement. There is incongruence between the regulatory and financial constraints and what is best for individual patients.

From a state policy standpoint and prevention standpoint, the state could save a lot of money with increased use of technology to keep elders in their homes. It is happening on a piecemeal basis, but could be addressed statewide from a buying-power and research perspective. The State of Minnesota is developing a set of essential health benefits. It might be timely to recommend coverage of home-based technologies for aging health services. The VA is doing a lot of this work to implement home monitoring in patients’ homes. They may have rural models that are affordable. The Northwest Region of Minnesota might have a model to address this. Most counties do not offer home health services, so it is provided through hospitals contracts with local public health.

  • Health Reform Environment

CAHs need to be better prepared for Medical Home implementation and incentives. There is a need to address barriers to rural EHR implementation and meaningful use. Barriers to system-wide implementation (including hospitals and clinics) should be considered. EHR implementation creates cash flow issues for rural hospitals.

CAHS need to be better prepared for changing expectations for quality reporting. Hospital reporting at state and federal levels is complex. There are monthly, quarterly and annual requirements. Many CAHs add technology and staffing to accomplish reporting requirements. Need to find ways to streamline compliance and reporting requirements. A new concern when it comes to reporting is that hospitals are responsible for patients poor behavioral choices related to quality. In the future, this could lead to patient discharge for poor health indicators in order to achieve success on quality measures.

EMS leadership

Tom Vanderwal, FLEX member and RHAC volunteer ambulance service member, presented information about the need for leadership development in rural EMS agencies. Tools and training are needed for rural EMS personnel to be successful leaders. Financial management, public speaking, and volunteer recruitment and retention are important skills to develop in rural EMS leaders.

How do we create an EMS leadership model for small agencies in Minnesota? What gaps should this model address?

  • Recruitment and retention. This was documented in the 2002 RHAC report “A Quiet Crisis: Minnesota’s Rural Ambulance Services at Risk” and it remains a central issue.
  • Lack of appropriate leadership training. How can leaders be identified and trained appropriately?
  • No transition plan for future leaders.
  • No mentorship from current to next leadership.
  • Unstable balance sheets.
  • Poor or absent fundraising abilities.
  • Few if any rural techniques for best practices for the small agency.
  • First responder agencies are not charging for their services.

What are the greatest challenges for rural EMS agencies?

Rural volunteer leaders differ from their full-time counterparts. About 65% of northwest region ambulance agencies are volunteer. 100% of organized first-responder agencies are volunteer. Lack of trained leadership means small and volunteer leaders have no formal training.

Reliance on a volunteer base may not be sustainable into the future. Gen X and Gen Y are willing to volunteer with things they believe in, so are we addressing their interests? Many people want to remain volunteers. When they are too regulated or given too much direction, they may indicate it is not worth it.

Aging communities in rural areas are more prevalent than in the past. Retirements and migrations to the central lakes region will create larger volume in the future. Coverage areas for some rural EMS agencies are extremely large. As primary service areas enlarge, EMS agencies will drop out and there will be less agencies overall.

Rural EMS recruitment is affected by “war stories” from the field. Instead need to tell stories of how EMS helps people. It is not just blood and guts (5-10% of runs); instead it is about helping grandma or connecting with the local community. Need public service messages or county government to understand value. As budgets are cut, EMS responsibility will fall on fire/rescue squads and law enforcement.

Financial and fundraising issues are challenging for EMS and first responders. There is a wide spectrum of abilities, with some poor billing practices or limited capability to do agency billing. They are unsure how to ask for funding and that could be addressed through online tutorials.

What are some solutions for rural EMS agencies?

It may be possible to train the baby boomer population as first responders. They could be responsible for their neighborhood or retirement community. To do this, EMS agencies would need to rethink shift lengths.

Leadership training can be tailored to the needs of small and volunteer EMS agencies. There are varied models of leadership in place including part-time paid, full-time paid, hospital based, private or on call. How do you tailor EMS leadership training for people coming from varied backgrounds? Need to instill a mentorship philosophy in current and future EMS leadership including a how to model.

Leadership tools need to be easily accessible and useful for small and volunteer EMS agencies. Need a presentation template for local government meetings to explain what EMS does, how it’s funded, and benefits for the local community. Need a one-page template for funding requests to present at a township or county board meeting. It is important for first responder groups to be honest about financial needs. They may need to explain run volumes and the volunteer base, including a current roster and years of service for each member. If a requested amount is too much, ask local government what they can give.

Need a standardized duplicable recruitment/retention tool for current leadership. Need to tailor this tool for programs that have very few runs each year. There is a Minnesota Ambulance Association project to train returning veterans in EMS/first response. Are there collaborative ventures between fire and EMS? Some places there is overlap as they want to train young people do be versatile, but others are siloed. There are core families that take on volunteer first-responder duties in communities. EMS agencies could develop family or generational recognition for local service. Best practice models for small and volunteer EMS agencies need to be exchanged throughout the state.

Community Paramedic Updates

OJ Doyle provided a short history of the Community Paramedic model. The idea for Community Paramedics was generated in New Mexico as a way to meet unmet health care needs in rural areas. A Creighton University professor studied the New Mexico pilo and found problems with it, yet other countries started implementing the model. In the U.S., pilot projects with Community Paramedics have demonstrated effectiveness as well as cost savings.

The development of the Community Paramedic model in Minnesota started with a legislative proposal three years ago. Flex grant money was used to develop the Community Paramedic training curriculum and to field test the curriculum in partnership with the Mdewakanton Sioux community. EMS partners continued to do groundwork to promote the model and focus on unmet needs or target groups of underserved people to reduce unnecessary use of EMS and emergency rooms. This fit the need to provide health care in an efficient and cost-effective manner.

The first legislative victory was passage of the Community Paramedic Law in 2011. This established a new provider type and defined training requirements. The second legislative victory was legislation to make Community Paramedics reimbursable under Medical Assistance. This occurred in 2012 and places emphasis on patients who are “frequent fliers” in emergency rooms. Minnesota is the first state in the nation to put Community Paramedic in law and first to have mandatory reimbursement.

EMS taxing districts can be used broadly as funding mechanisms for local EMS services. They create an opportunity for rural areas to have two divisions for EMS response: advanced life support (for emergent cases) and community paramedics (for preventive or low-intensity cases). There are three taxing districts currently in existence in Minnesota and others areas are interested in this approach.

Kai Hjermstad was in the first class of Community Paramedic trained through the Mdewakanton Sioux pilot. He is now working with Hennepin Technical College to develop their Community Paramedic training program. They received a Minnesota Job Sharing Grant to train 100 Community Paramedic in three years. There are 12 graduates in the current class. They will complete 96 hours of classroom training and 196 hours of clinical training at various Twin cities hospitals. They can apply for their Community Paramedic certificate in August. The next class starts in June and depending on grant funding, the program may have 100 students enrolled. Community Paramedics must have at least two years of paramedic experience to apply for a training program. Community Paramedic curriculums will eventually be developed for four-year and master's-level programs.

Kai is currently the only person officially working as a Community Paramedic. He works at a free clinic doing immunizations every other week and works in the field doing low-cost and preventive interventions. He works to reduce hospital readmissions by making sure patients are taking medications correctly. Community Paramedics are especially helpful for home-bound or autistic patients. The focus is more on primary care and getting to know patients than on emergency care. Community Paramedics get to know the local public health infrastructure and community members.

Current reimbursement for Community Paramedics through medical assistance is 90% of physician assistant costs. Other payers will likely come on board when costs savings are documented. The biggest savings are in the areas of transport, emergency room and physician services. There is not a lot of equipment or technology used at this point. Community Paramedics are mainly involved in providing basic primary care services.

Jason Rusniak and Dennis Mackedanz provided an overview of the Hubbard County Area Community Paramedic Collaborative. Cass County is the only county in Minnesota without a hospital. Attempts were made to establish a hospital, but there are logistic challenges with patient care and long patient-transport times. Earlier this year, North Memorial Ambulance Services was awarded a Flex grant to train Community Paramedics in the Park Rapids area and to assist St. Joseph’s Hospital with their Community Health Needs Assessment (CHNA). A key part of the Community Paramedic curriculum is training on the CHNA process to identify gaps in service areas. The Hubbard County Area Community Paramedic Collaborative will connect Community Paramedics with local public health and hospitals to help them with CHNA requirements. This will also inform a plan for Community Paramedic deployment in the area.

Clinical requirements for Community Paramedic training address the current skills a paramedic knows and can utilize in non-emergent settings. As clinical requirements are further defined, the Hubbard County Area Community Paramedic Collaborative will use this to create a job description unique to the area to address the local customer base. Around mental health, Community Paramedics can help to fill gaps. Many patients don’t need ambulance transport, but could undergo procedures that Community Paramedics can do onsite. Another aim for the Hubbard County Area Community Paramedic Collaborative is to build a new career ladder for EMS. For aging or experienced paramedics, or those with injuries who cannot lift patients, the Community Paramedic profession may be a good fit.

At this point, there are two ways to access Community Paramedics: through 911 or primary care providers. When 911 is called, EMS and Community Paramedics respond to the site. If a Community Paramedic provides the necessary service, EMS personnel are freed up and ready for emergent cases. Community Paramedics can also be worked into a patient’s primary care plan. After a patient is discharged, primary care providers can use Community Paramedics for home visits. In the future, the model could include hospitals or clinics using Community Paramedics for follow-up care or emergency home health. Patients who may benefit from this model include mental health patients who require medication checks, those recently discharged from a hospital, or repeat patients with special health care needs. Community Paramedics have to operate under physician supervision and cannot prescribe meds.

The long-term vision includes strategies to use Community Paramedics to stabilize rural ambulance services. With a consistent funding source for ambulance personnel to do non-emergent care, this will provide base level of funding for rural ambulance services as well as overall costs savings to health systems. Some EMS personnel already work in emergency rooms or hospitals in between runs. These people need training and this gap might overlap with Community Paramedic curriculums. Integration of care makes a difference and understanding roles from the street to the hospital is an important part of this training. The Hubbard County Area Community Paramedic Collaborative model will help demonstrate effective use of this new emergency response professional.

Meeting Adjourned at 1:55 p.m.

The next RHAC meeting will be September 25, 2012 at Snelling Office Park, Red River room from 10 a.m. to 2 p.m. The next Flex meeting will be in September, date and time to be determined.

Updated Monday, June 11, 2012 at 05:13PM