Rural Health Advisory Committee Joint Meeting with the FLEX Advisory Committee

Meeting Minutes

Tuesday, May 21, 2013
10:00 a.m. - 2:00 p.m.

RHAC Members Present: John Baerg (RHAC chair), Ellen De la Torre, Daron Gersch, Margaret Kalina, Nancy Stratman

Flex Members Present: Brian Carlson (Flex chair), Pam Biladeau, Rick Failing, Ann Gibson, Barb Heier, Karen Miller, Scott Reiten, Joe Schindler, Bethany Schneider, Karla Wang

ORHPC Staff: Craig Baarson, Judy Bergh, Darcy Dungan-Seaver, Rachel Gunsalus, Cindy LaMere, Tom Major, Nitika Moibi, Mark Schoenbaum, Kristen Tharaldson, Will Wilson

Guests: Virginia Barzan (Minnesota Academy of Family Physicians), Bridget Rassett (Minnesota Dental Association), Rebecca Radcliffe (Essentia Health)

RHAC and Flex program overviews
Kristen discussed the role and activities of RHAC and indicated that the committee has been doing a lot of work with health reform. The RHAC committee tends to focus on state policy and program development. Judy discussed the role and activities of the Flex committee, which is updating its membership. The Flex committee tends to focus on federal policy. Mark discussed the complementary roles of the two committees.

MNSure presentation (Mario Vargas)
MNSure, Minnesota’s new health insurance exchange program, will begin open enrollment in October 2013. MNSure is one part of the Affordable Care Act (federal health reform). MNSure language is moving away from “Obama Care” or “exchange.” It is purposefully using the word “marketplace.” This means constituents – individuals and families - can select quality health care coverage.

Mr. Vargas explained that MNSure is a marketplace to find, compare, and choose quality health care coverage. It utilizes an image of a nonprofit website (.org) to have a more friendly, open and accessible feel. The “one stop shop” interface is modeled after the Massachusetts insurance exchange.

Question: What level of out-of-pocket expenses would someone have to pay? This is a concern for hospital CEOs who are trying to afford payroll expenses.
Answer: It depends on what kind of plan they choose. It is all speculation at this point. Mr. Vargas cannot yet say exactly how the subsidy program will work.

Follow-up idea: FLEX staff could facilitate meetings for CAH administrators with the Minnesota Hospital Association closer to October 2013.

SIMS grant presentation (Diane Rydrych)
The State Innovation Model (SIM) grant program was established by the Centers for Medicare & Medicaid Services (CMS). It funds selected states to become laboratories of innovation to achieve the Triple Aim. How do we lower costs, improve the patient experience and improve quality outcomes simultaneously?

Minnesota was far enough along in our health care reform efforts to become a testing state. Other testing states include Arkansas, Maine, Massachusetts, Oregon and Vermont. Minnesota received $45 million for a SIM testing grant. This includes a six-month planning period from April 1 through September 30, 2013. Implementation of the Minnesota Accountable Health Model starts October 1, 2013.

Minnesota is testing this model to address a range of issues, including fragmented care and gaps in care for mental/chemical/behavioral health patients. This model moves us towards new ways of paying, as health care is largely still a fee-for-service world.

How do we integrate all types of health to improve population health? Minnesota is a leader in measuring quality through its state quality reporting system (SQRMS). We are seeing improvements in quality. However, there is a lack of alignment and differences in how payers are looking at risk adjustment and population management. The medical system often views clinical care and preventive care as two different streams, and they do not come together well. The Minnesota Accountable Health Model will address this issue while building on foundations already in place:

  • SQRMS (state quality reporting)
  • Medicaid Accountable Care Organization (ACO) demonstration
  • e-Health initiative
  • Health Care Homes (250 certified with 25 new certifications each quarter)
  • Community care teams
  • State Health Improvement Program (SHIP)/Community Transformation Grants (CTG) (state health improvement programs)

Question: One of your SIM goals is to get coordinated care for all, but the health care home (HCH) system is tiered based on severity of chronic illness. Do you have a plan for how to fix this payment methodology? How do we get the cash flowing/resources allocated where they are most needed?
Answer: We are concerned about coordination of care for all patients. A SIM multi-payer alignment task force will begin to have these conversations.

Question: How does the SIM grant money facilitate rural health care transitions? Many rural facilities will not jump into an Accountable Care Organization (ACO) right away. How can rural providers prepare for what is coming?
Answer: There have been a few proposals for rural ACO-type models. How we pioneer ACO models in rural areas follows the same concept – coordination of care with providers – even if it differs from a formal ACO. How can we improve the patient experience through rural ACOs? That is one of the goals.

SIM core resource investments include: (1) expansion of Medicaid Health Care Delivery System pilots (HCDS) and other ACOs in the market; (2) providing additional data/analytic capacity and health info technology resources to other providers; (3) grants for health information exchange. We have come far with electronic health records but do not know much about the kind of data systems being used or what data they are collecting. We are doing assessments to get to the point of integration. We want to provide support to providers to transform care that they deliver.

Question: How do we integrate new providers into care? What’s the role of community paramedics, birth doulas, community health workers and advanced dental therapists? Who else needs to be at the table? What data do they need from us or others to make initial assessments?
Answer: SIM program staff will create task forces as advisory bodies. The real work of the grant starts in October. One of the biggest challenges is to coordinate this grand vision for where health care is going, while making sure we are realistic about what we can do in three years.

Question: How much of the SIM grant is allocated to IT?
Answer: There is $2 million in grants for health information exchange, and additional funding for baseline assessments, roadmap development, and data analytics development. The Governor’s Health Reform website has these details. ( http://mn.gov/health-reform/SIM/ )

Question: On the data analytics side, will the SIM grant improve access to data (e.g. Medicaid data)? Do you envision that hospitals will have access to that data?
Answer: For SIM, we are in the planning stage. The Minnesota Department of Human Services (DHS) is looking at HCDS and giving them access to better data reporting systems. Outside of SIM, we are working on data reporting and want SQRMS to be much more accessible.

Question: Rural health has big access issues around mental/behavioral health. If you are looking for a pilot project, incorporate behavioral health into a telehealth situation where a psychiatrist can use telehealth connections to allow rural patients to access psychiatry. Currently there is a nine-month wait list.
Answer: We are looking at possible pilots, including access to behavioral health services and integration with other health services. My presentation did not touch on behavioral health homes, which is another new area of development.

Legislative Session Wrap Up (Mark Schoenbaum)
The state legislative session ended just 12 hours ago. The Health and Human Services bill was done relatively early. Items that RHAC and FLEX committees may be interested in:

  • Health Insurance Exchange – the legislature put in place pieces at the state level that are needed to connect with provisions in the ACA that will go live in January 2014.
  • Medicaid expansion – required action at the state level.
  • New type of affordable health plan (basic health plan) – the legislature synched up the MinnesotaCare program (which has been available for 20 years) with the new federal affordable plan. They created a transition period where MinnesotaCare will be more affordable, removing things like the $10,000 cap on hospitalization, which has been a goal for many years.
  • State HHS bill- Minnesota will begin paying for doula services, which addresses a recommendation from the RHAC Rural Obstetrics report. Minnesota will also invest $750,000 to expand mental health crisis response teams, an action supported by RHAC to support mental health crisis response in rural areas.
  • MERC –  this program was cut in 2011, and was restored this year. Part of restoring the funding included new rules for distribution that intend to make more of the pool available for small and rural sites.
  • Mental Health  – funds are newly available for mental health first aid training, and screening brief referral intervention. Medicaid will now be covering mental health peer coverage services. Previous RHAC member Jodie Freyholtz-London is active as a mental health peer counselor.
  • Rate increases – dental and nursing home services will see rate increases through the Medicaid program. Outpatient services will be bumped up 3 percent and physician services may be bumped up 5 percent, resulting in improvements to Medicaid patients on the outpatient side.
  • Nurse staff ratios – mandated nurse staffing ratios on hospital were not passed, but there is a new 2015 data transparency reporting requirement. It will include prospective (What is your staffing plan?) and retrospective (What staff actually worked?) staffing reports.
  • Diagnostic imaging – a provision from 2012 regarding diagnostic imaging that required rural facilities to be separately accredited was removed this year.

Statewide Alzheimer's and Dementia Planning (Olivia Mastry, Emily Farah-Miller and Pam Van Zyl York)
The genesis for the ACT on Alzheimer’s Project was a 2009 state mandate for an Alzheimer’s Disease Working Group. This was a Governor-appointed group of 20 members. An additional 80 volunteers were involved. After 16 months of discussions, the group produced a legislative report. The state did not allocate funding for implementation. The ACT on Alzheimer’s group was formed to do real ground-level work on a day-to-day basis. This work is largely volunteer-based, many of whom have had personal experiences with dementia or Alzheimer’s disease. The collaboration sets rules to stay focused on a common agenda, monitor and share progress toward the following goals:

  • Identify/invest in promising approaches (do what actually works)
  • Increase detection and improve care (only 50 percent of those with dementia are diagnosed)
  • Sustain caregivers (specific recommendations to sustain caregivers)
  • Prepare communities (help communities equip at local level)
  • Raise awareness and engage community

Community readiness is the key to progress. Creating community leadership and advocacy for Alzheimer’s readiness requires a grassroots strategy facilitated by external experiences and resources, but managed and driven by community-based advocates. Community readiness is achieved through three broad strategies:

1. Tackling the fear of the known/unknown about Alzheimer’s that prevents discussion.
a. What is the impact of Alzheimer’s in our community?
b. What can we do for those affected by it so that their life is easier?
2. Making conversations about Alzheimer’s disease pervasive in communities.
a. What happens when you help the caregiver?
b. What happens when you implement a transitional care model?
3. Providing critical support and resources that foster community readiness for the disease.
a. First Tool = providers. Flow chart to diagnose, might show that there is something else that’s going on that is treatable.
b. Second Tool = care coordinator. What do I need to do?
c. Third Tool = community capacity. Needs to be equally strong as clinical capacity.
d. Fourth tool = caregiver. Companion piece for the caregiver.

Walker is the first pilot site to implement all action phases. Aging services worked with community members to test the new tools and identify priorities for their community. ACT on Alzheimer’s is looking for new rural pilot sites and will partner with RHAC to get the word out about the dementia toolkit.

Question: Are there rural-specific issues or challenges to consider when doing this community organizing work?
Answer: Rural care givers often travel further distances to care for loved ones. This incurs greater costs for caregivers. Also, long-distance care giving is more common in rural families. Therefore, resources for caregivers to find the help they need for their loved one and themselves is an important consideration.

Health Information Technology Issue Brief (Karen Soderberg)
Ms. Soderberg presented new e-Health assessment results focused on three settings: ambulatory clinics, hospitals and nursing homes. It focuses on adoption of electronic health records (EHRs) and utilization of EHRs, including computerized provider order entry (CPOE); and health information exchange (HIE).

EHR Adoption
Nearly all Minnesota hospitals have implemented EHRs with little variation between rural (95 percent) and urban (97 percent) settings.  Similarly, EHR implementation in clinics is strong in both rural (80 percent) and urban (79 percent) settings. RUCAs were used to demonstrate that adoption rates are comparable across large rural, small rural and isolated rural clinics. About two-thirds of nursing homes have installed EHRs with rural adoption (64 percent) lower than urban adoption (74 percent).

EHR Utilization
The number of hospitals and clinics using clinical decision support tools has increased since 2010, and previous gaps between urban and rural rates have declined. In 2012, 45 percent of rural clinics routinely used more than three clinical decision support tools, up from 34 percent in 2011. Statewide, 93 percent of pharmacies e-prescribe and there is no difference between urban and rural pharmacies. Rural clinics e-prescribe at a slightly lower rate (76 percent) than urban clinics (86 percent), mostly due to rural clinics who do not have EHRs.

Computerized provider order entry (CPOE) is an area of geographic disparity with full implementation in rural hospitals (42 percent) much lower than in urban hospitals (82 percent). CPOE is fully implemented in about 50 percent of CAHs with an additional 33 percent having achieved partial implementation. Most clinics are effective users of CPOE with rural (72 percent) and urban (79 percent) clinics using CPOE for 80 percent or more of orders. Nursing homes have the lowest rates of CPOE of rural (28 percent) and urban (22 percent) settings.

Health information exchange (HIE) is high with 84 percent of CAHs and 98 percent of non-CAHs exchanging health information. Rates of exchange with unaffiliated providers and other settings are much lower. HIE rates are lower for clinics with 52 percent of rural clinics and 60 percent of urban clinics doing some type of information exchange. Nursing homes have the lowest rates of HIE of rural (35 percent) and urban (40 percent) settings.

Next steps for HIT analysis include how clinics/hospitals are responding to implementation. Barriers in this area include staffing issues in rural facilities, high costs, lack of leadership and rural staff responsible for multiple roles.

Strategic Plan Initiative for ORHPC Advisory Committees (Darcy Dungan-Seaver)
The Office of Rural Health and Primary Care (ORHPC) staff various advisory committees, including FLEX and RHAC. We want to make sure that we work as effectively with our rural partners as we can. You may be contacted to help us assess/survey areas you feel need improvement and which areas are going smoothly along with asking for ideas to strengthen the advisory capacity of our committees.

Meeting Adjournment
Meeting is adjourned at 2:00 p.m. The next RHAC meeting will be September 2013.

Updated Friday, 09-Aug-2013 14:31:53 CDT