Rural Health Advisory Committee

Meeting Minutes

Tuesday, September 25, 2012
12:00 p.m. - 2 p.m.

RHAC Members Present: John Baerg, Tom Boe, Ray Christensen, Tom Crowley, Ellen Delatorre, Daron Gersch, Margaret Kalina, Jackie Osterhaus, Millicent Simenson, Nancy Stratman, Tom Vanderwal

ORHPC Staff: Judy Bergh, Laura Grangaard, Paul Jansen, Nitika Moibi, Mark Schoenbaum, Kristen Tharaldson, Will Wilson

Guests: Virginia Barzan (MAFP), Rachel Gunsalus (RHAC summer intern), Rebecca Radcliffe (Essentia Health), Jessica Tonder (PharmD resident)

Welcome and Introductions

This is the first meeting for three new RHAC members. Dr. Gersch is a family practice physician from Albany. Ms. Osterhaus is a physician assistant from Paynesville. Ms. Simenson is an LPH and SHIP coordinator for Leech Lake Health Division. Today’s agenda includes a combination of reports and projects, traditional business, and setting priorities for the year.

Report out on Regional Community Forums

RHAC staff shared information from the northeast regional community forums, include top issues of concern and what is going well. Themes in “areas of concern” include transportation, mental health transports and bed availability, long-term care and legislative understanding of implications of health reform for rural Minnesota. Themes in “what is going well” include collaboration and EHR implementation.

Similar issues arose in northwest community forums, including mental health transportation and distant geography, EMS transport/law enforcement, leadership in EMS, and the need for volunteers. Another highlighted issue was long-term care services struggle with staffing and reimbursement, and how they are affected by the need for home health care services.

Ms. Stratman commented on a forum attendee’s struggle with getting the proper training requirements to become a nursing home administrator. She noted that the majority of courses are available online through UMN-Crookston and are entirely online through another state program. People also can get practicum credit for past long-term care experience.  The requirements are rigorous, so these options might help people out.

The forums make it clear that the systems for handling mental health issues in rural areas are lacking resources. Mental illness is an issue for nursing home beds, too.  Nursing home staffs spend 90% of their time on 10% of the patients with complex mental and physical needs, while reimbursement is not adequate. Nursing homes care for high-need non-elderly residents because there is nowhere else for them to go. Nursing home RARE data shows that mental health is the #1 reason for readmissions.

Transportation is another issue of common concern. County human services and Medicaid no longer pay for volunteer transportation except for a loaded mile/trip. If a patient needs to travel to see a specialist, the volunteer driver is reimbursed only when the patient is in the vehicle. This causes volunteers to quit and the elderly to rely on high-cost taxi services. Finding transportation for people who don’t drive or don’t have support is an issue, especially after hours. For emergencies, an ambulance can get people to the ER, but leaving is an issue. This is reflected in the EMS data that shows a lot of runs are inter-facility no load runs. Transportation challenges led one county to hire a specialist physician on a weekly or monthly basis and limit patient choices rather than find transportation solutions. It is difficult to assess how transportation limits access to primary care in rural areas.

Rural Health Environment Scan

RHAC members were asked to scan the environment of rural health and describe issues that are pre-peak, peak, or post-peak in terms of rural priorities for improving health:

Pre-peak/Incoming:

  • Healthcare Reform
  • Medicare/Medicaid Reform
  • Telemedicine
  • Virtual Hospital
  • Healthcare Team
  • Genetic Counseling in Primary Care
  • Care Coordination
  • Rural Workforce
  • Equipment updates
  • EMS/Community Paramedics
  • Health Care Home
  • ACO's
  • Long Term Care reimbursement
  • Aging Population
  • Rural Hospital Closing
  • Increase in Patient Volume
  • Prevention (SHIP/CTG)
  • Wellness Centers

Peak/Hot issues:

  • Transportation
  • Hospital Changes
  • Workforce Shortages
  • Health Care Homes/Primary Care
  • Mental Health Access
  • Access to care
  • Payment issues/Reimbursement
  • End of life discussions
  • Chronic Illnesses
  • Volunteers in EMS Leadership
  • Age Shift/Demographics
  • System Level Focus
  • Transportation Issues
  • Lack of trained medical interpreters
  • EHRs/Meaningful Use

Post-peak/Outgoing:

  • Personal Communication
  • Interpretive Services
  • Cultural Competency
  • Rural OB
  • Nursing Home
  • Access to care
  • RN workforce in rural
  • Trauma System
  • Health Care Home
  • Telemedicine
  • Access to technology

After the exercise, RHAC members were asked to share their reflections and thoughts. Mr. Crowley wondered if our state is doing enough to prepare for the age wave and needs of the aging population. Mr. Baerg was surprised about a lack of concern regarding electronic health records implementation. He would like to know if there are differences in rural-urban EHR adoption rates or broadband access. It was noted that a lot of peak issues are systems-oriented rather than technology-oriented. Is this a shift in focus for rural?

RHAC Work Plan: Update on 2012 Activities to Date
Updates were provided on the following work plan topics:

1. Rural Obstetrics Work Group. RHAC members reviewed the work group recommendations. Clarification was needed on ‘recommendation E’ related to residents’ work hour restrictions. Although residents have fewer hours on the floor and fewer deliveries with the new law (100 deliveries now versus 300 deliveries under old work hour restrictions), in the end, they must feel comfortable performing deliveries with less experience. Residents develop no concept of what it’s like to work long hours. Work hour restrictions also create challenges to staff coverage because residents may have already worked too many hours in one week to fill in on shifts. Nurse practitioners and physician assistants are filling in, but young physicians do have a different mindset about work/life balance.

A motion was made to pass the Rural Obstetric Work Group recommendations by Mr. Christensen, seconded by Ms. Stratman, and passed unanimously. It was noted that members would like to see the report shared widely in rural communities and with the legislature.

2. Health System Growth and Consolidation. RHAC staff shared preliminary responses from a CAH survey on this topic. Next steps include an issue brief with additional analysis from the survey.

3. Medication Therapy Management and the Role of Rural Pharmacists. Research has been compiled on this topic. Next steps include an issue brief publication.

4. EMS Toolkit. This resource is currently in its first version and will be online shortly. Next steps include work with regional EMS boards and other stakeholders to improve the toolkit and share it widely. It is meant to address volunteer leadership transitions. Turnover occurs so often that many may not know this is available. They can use these resources to budget, recruit new volunteers, ask for county funds, etc.

RHAC Work Plan for 2012-2013 Activities

RHAC staff shared two options for approaches to the work plan for upcoming activities. Plan A is the approach that has been used for several years, which includes a staff focus on work group activities (planning, research, report and recommendations). This approach allows for extensive analysis of a single issue of importance. Plan B is a new approach designed to engage RHAC members more directly in work related to their areas of interest. This approach may allow for more agility (direct or timely actions) and focus on several work plan areas simultaneously.

Under Plan B, teams would form around each work plan priority area. Each team would have at least one RHAC member lead and a RHAC staff lead. Together, they can prioritize and plan for work in each area. The role of the RHAC lead is to provide a vision for the team. Plan B requires more direct input from RHAC members. It allows staff to engage RHAC members’ interests at the same time.

If RHAC is trying to enact policy change, is more robust or very specific work (Plan A) a better approach? Legislators are going to read bullet points/shorter stuff, not long reports. Other people besides legislators do look for more depth. An important role of RHAC is to make recommendations.  Plan B shifts the goal to fewer, more specific recommendations in multiple areas. Teams working on all work plan priority areas can promote the central focus to improve the quality of rural health care.

RHAC members voted unanimously for Plan B. RHAC staff walked through the current work plan priority areas to see which areas should remain on the list, and to ask for RHAC team members for each area. Recruitment for RHAC team members for each work plan priority area will continue after this meeting.

Work Plan Priority Area RHAC member team RHAC staff lead

1. Health Reform - Things are happening fast. Need to provide a rural voice on ACOs, medical hoomes and other aspects of reform.

 

Gersch, Crowley, Kalina, Osterhaus

Paul

Partners: MAFP (Virginia)

2. Health Promotion & Wellness - Lots of good models and partnerships exist in rural. Need increased awareness of good models and resources for rural communities.

 

Baerg, Delatorre, Simenson

Kristen

Partners: SHIP/CTG

3. LTC & Aging - Highlight poor reimbursement, staffing issues (LPNs), technology & home monitoring. Also need for community supports.

 

Stratman, Crowley Kristen

4. EMS Leadership - Increase visibility and awareness for rural EMS leadership issues. Follow up on EMS Toolkit 2.0.

 

Vanderwal

Paul

Partners: MAA (Debbie)

5. Rural Obstetrics - Follow up on specific recommendations around statewide trainings and access to obstetric care/referral system for AI populations.

 

Simenson

Kristen

Partners: Mary Jo, Wendy (Bemidji), IHS

6. Mental Health Response to Emergencies - Address access, barriers, silos, funding regulations for testing prerequisites to admit people. Need documentation of issues and collections of best practices around: (1) transportation and (2) crisis response.

 

 

Kristen

Partners: Interagency Council on Transportation

7. Rural Workforce Shortages - Governor's Task Force recommendations, primary care, specialty care, diversity, nursing home-hospital staff sharing.

 

  TBD

The previous priority area around medication management and rural pharmacists was dropped from the RHAC work plan. A new priority area for rural workforce shortages was added. Workforce issues are a prominent theme. ORHPC can provide updates on health care workforce reports specific to Minnesota. The Governor’s Task Force work group on workforce should have updates by the end of the year.

Regarding education planning, how do we keep people in both primary care and rural health? We know some things that work: exposure to rural experiences, encouragement to explore options, and keeping people local while getting their education.

Ms. Tonder, a pharmacy resident, shared that people have good experiences when they are exposed to rural health as pharmacy residents, but when they do not have roots or a place to stay, it’s difficult to convince them or make it easy for them to experience this. Her ideas for what is needed include:

  • Exposure, education, and people understanding what rural health really is
  • More support in place for people to try out rural settings
  • People in charge of programs who understand and are willing to champion rural health, not look at it condescendingly
  • Incentives for people to experience rural health care, because exposure of students is a good way for people to learn and be supported

ORHPC Updates

The Rural Health Conference was a great success this year. The RHAC work group session on rural obstetrics was well received and a promising number of students interested in OB attended. Several ORHPC grant application cycles begin this fall, including FLEX and hospital planning grants. The Governor submitted a CMS Innovation Grant related to federal health reform. The Governor’s Workforce Task Force will be releasing workgroup recommendations soon. RHAC could consider putting some energy behind supporting those workforce recommendations.

Adjourn

The meeting adjourned at 2 p.m. The next RHAC meeting will be on November 27 at Snelling Office Park – Red River Room. This meeting will include a legislative panel of health association representatives.  Upcoming meeting dates in 2013 include January 29 (videoconference 9-11:30 a.m.), March 26 (in person 10 a.m.-2 p.m.) and May 21 (in person 10 a.m.-2 p.m.).

Updated Wednesday, October 31, 2012 at 12:34PM