Rural Health Advisory Committee

Meeting Minutes

Tuesday, September 17, 2013
10:00 a.m. - 2:00 p.m.

RHAC Members Present: John Baerg, Thomas Boe, Raymond Christensen, Thomas Crowley, Ellen Delatorre, Daron Gersch, Rep. Clark Johnson, Margaret Kalina, Jacqueline Osterhaus, Rep. Joe Schomacker, Tom Vanderwal

RHAC Members Absent: Sen. Tony Lourey, Sen. Julie Rosen, Millicent Simenson, Nancy Stratman

ORHPC Staff: Judy Bergh, Darcy Dungan-Seaver, Katie Schleiss, Anne Schloegel, Mark Schoenbaum, Kristen Tharaldson, Will Wilson

Guests: Lynn Barr (National Rural ACO), Virginia Barzan (Minnesota Academy of Family Physicians), Pam Biladeau (Emergency Medical Services Regulatory Board), Matthew Collie (Minnesota Department of Health), Mary Fischer (Southern Prairie Community Care), Jim Pryzbilla (Prime West Health), Diane Rydrych (Minnesota Department of Health), Karen Welle (Minnesota Department of Health)

Welcome and Introductions
Welcome to the newest members of the Rural Health Advisory Committee, Rep. Joe Schomacker (Minnesota House of Representatives) from Luverne, Minnesota and Rep. Clark Johnson (Minnesota House of Representatives) from North Mankato, Minnesota.

Rural ACO Models Panel

Lynn Barr, National Rural ACO (NRACO)

  • Seeking to eliminate outcome disparities (improve access, reduce costs) between health care in rural and non-rural settings though utilizing technology, process improvement, patient engagement and informatics.
  • Benefits include model transformation from fee-for-service to fee-for value, financial protection (fixed costs to participate in the program and slow-moving transformation process), data-driven transformation of care delivery to improve community health, patient satisfaction and retention, multiple payer mix and promoting clinical integration skills across the continuum of care.
  • ACO reimbursements for mid-level providers - Nurse Practitioners (NPs) and Physician Assistants (PAs).Patients need to see a physician at least once per year in order to gain access to the community.
  • Volunteer ambulance services are not attached to a health care system, but still hospital based.

 

Southern Prairie Community Care: The Development of a Rural Care Model (Mary Fischer, Southern Prairie Community Care)

  • Focus of Southern Prairie Community Care is to build a strong primary care network, emphasizing Health Care Home concepts (MDH certification process), strong physician engagement, and patient/family engagement to fullest extent possible.
  • Community pharmacists have a strong public health presence.
  • Accountable Rural Health Community Health Networks (ARCH Networks) manage the total cost of all services and access funding and services from multiple arenas.
  • Coordinate primary care, MH, dental and social services through a single health care home, developing regional health information exchanges and promoting population health to address community needs.
  • Success factors needed for care networks in the future – engaging patients in their own health and chronic conditions, looking beyond traditional medical services to provide things that patients need to be healthy like transportation, housing, etc. and coordinating all services needed through health care homes, and using electronic medical records.
  • Need meaningful engagement at the Board level of local providers and community leaders, chronic disease management in the system, and engagement of all county-provided services, actively engaging partnerships in the community.

 

Accountable Rural Community Health (Jim Pryzbilla, Prime West Health)

  • “Tyranny of the Exam Room” – need high patient volume in order for business to be sustainable, but biggest barrier is lack of beneficiary enrollment.
  • Debate on use of fee-for-service payment structure or value-based structure, with questions on how to align the incentives for who gets paid.
  • Ongoing issue on managing complex patients (such as schizophrenia, complex mental illness, chronic conditions with low adherence to treatment), whether home visit nurses can administer oral medication, and use of other low-cost, patient-centered and personal interventions to prevent costly re-hospitalizations.

 

SIM Grant Project Lead (Diane Rydrych, Minnesota Department of Health)

  • Works on Health Care Delivery System (HCDS) payment structures and implementing new Accountable Communities for Health (ACHs) – capacity for greater data sharing and health information technology investments.
  • Promotes efforts to work with community organizations to create ACHs that will integrate medical care with behavioral health, public health, LTC and social services within a total cost of care model.
  • Seeks to move providers along a continuum of development to a fully integrated model, with providers and communities working together.

 

Rural Health Advisory Committee Previous Work Plan Outcomes

WPP1: Regional health systems have consolidated in recent years in large parts of rural Minnesota. As a result, numerous rural hospitals and other providers are now owned or managed by fewer large systems. In addition, systems have acquired control of additional hospitals. Rural question: What are the implications for these changes for the health of rural Minnesotans and the place of rural health institutions in their communities, both positive and negative? How do health reform pressures and rapid implementation of health information technology impact this landscape?

Outcomes: RHAC meeting presentation at Upper Midwest Rural Health Research Center (January 2012); Legislative panel presentations at MHA, MPhA, and MRHA (November 2012); CAH survey on Rural Hospital System Growth and Consolidation (May 2012); Issue brief on Rural Hospital System Growth and Consolidation (January 2013); RHAC meeting presentation on Roadmap to a Healthier Minnesota (January 2013); RHAC meeting presentation on Health Care Homes (March 2013); Joint FLEX/RHAC meeting presentations on MNsure (May 2013), SIM grant (May 2013), and HIT issue brief (May 2013).

WPP2: Forty percent of all deaths in the U.S. are attributed to four behaviors – drinking, smoking, poor nutrition, and inadequate physical activity. Rural rates of these behaviors are often higher than in metro areas. Rural angle: Rural communities need to identify community resources, tools, web sites and guidelines for implementing prevention strategies around obesity and chronic disease prevention.

Outcomes: Published updated version of “Health Status of Rural Minnesotans” (September 2011); RHAC meeting presentation on State Health Improvement Program (SHIP) and Community Transformation Grants (CTG) programs (January 2012); Legislative panel presentation at Local Public Health Association (November 2012); RHAC members advise on promotion of rural prevention models that work (June 2013).

WPP3: Many state partners are working on the issue of aging and Alzheimer’s disease. Elderly rural Minnesotans need access to health care and housing services in their communities. Rural questions: What are challenges to improving dementia care in rural Minnesota? Which long-term care workforce and infrastructure challenges are unique to rural areas?

Outcomes: RHCA members letter of support for Sen. Franken’s Ride Act (October 2012); Legislative panel presentation to Aging Services of Minnesota, NAMI (November 2012); Joint FLEX/RHAC meeting presentation on Statewide planning for Alzheimer’s (May 2013); RHAC member presented on aging issues at Rural Health Conference (June 2013); Regional community forums to discuss workforce shortages and pay gaps in long-term care (August 2013); work with ACT on Alzheimer’s leadership group to identify rural communities that have done work on palliative care or aging services care coordination to pilot a dementia toolkit (August 2013); Article on ACT on Alzheimer’s dementia toolkit adoption in Walker, MN (September 2013).

WPP4: The current generation of rural EMS leaders is moving closer to retirement and recruiting new leaders is problematic. Community paramedics are an emerging profession in rural areas. Rural angle: How do rural EMS leadership challenges affect the viability of rural ambulance services and patient access? How can community paramedics fill gaps in rural EMS services?

Outcomes: RHAC meeting presentations on Stroke Awareness in Rural Hospitals (March 2012), EMS leadership (May 2012), and Community Paramedic Update (May 2012); EMS toolkit version 1.0 with focus on retirement and retention, funding and finances (August 2012); Legislative panel presentation to Minnesota Ambulance Association (November 2012); EMS toolkit version 2.0 with focus on leadership and management resources (January 2013); RHAC meeting presentation on Behavioral Health Update (March 2013); RHAC members letter of support for Gov. Dayton’s proposal to fund additional Mobile Crisis Response Teams (October 2012); Regional community forums to discuss possibilities for Community Paramedics training and employment in rural areas (August 2013).

WPP5: While access to obstetric services is imperative for rural women, there is a shortage of obstetric providers in some parts of rural Minnesota. Rural angle: What happens when there is a lack of obstetric services in rural areas? What training is necessary to support current and future rural obstetric providers?

Outcomes: Rural obstetrics workgroup meetings (February 2012 and March 2012); RHAC meeting presentation on rural obstetrics recommendations (March 2012); developed strategies and policy recommendations (April 2012); RHAC adoption of eighteen recommendations (May 2012); Presentation to Wadena-Todd-Cass county public health staff (June 2012); RHAC members/workgroup members presented at Rural Health Conference (June 2012); RHAC members/community letter of support for Minnesota’s doula bill (April 2013); American Indian doula presentation at Rural Health Conference (June 2013); published “Rural Obstetrics Report” (September 2013); RHAC staff presentation “All Our Babies: Improving Rural Birth Outcomes” at Community Health Conference (September 2013).

RHAC Workplan: Rural Health Issues Identification

Work Plan Curve Activity

Testing Phase:

  • Health Promotion and Wellness (community approaches)
  • Heart Disease programs

Pre-Peak Phase:

  • Scope of practice issues
  • Future of EMS (volunteers)
  • Community paramedic program
  • MNSure

Incoming Phase:

  • Concerns about possible defunding of CAHs
  • Mental Health programs
  • SIM Grant
  • Primary care physicians/Specialist physicians gap growing
  • Minimum wage
  • Dementia and end of life care
  • New roles for non-medical professions

Peak Phase:

  • Dental
  • Pharmacy
  • Provider shortage
  • Rural Workforce
  • CAH Model
  • HCH Model

Post-Peak Phase:

  • Rates of utilization of long term care
  • Acute care and emergency care
  • EMR/HIT

Outgoing Phase:

  • Volunteerism with EMS

Recycling Issues:

  • Language Barriers
  • Cultural competency
 

RHAC Workplan: Prioritization and Approaches to Top Issues for 2013-2015

  • Workforce
    • Primary care versus specialization
    • Scope of practice issues
    • New professions (community paramedics, dental therapists, community health workers, doulas)
    • Minimum wage
  • Health Reform
    • ACOs
    • SIM Grant
    • MNSure
  • Access
    • Language interpreters/cultural competency
    • Oral health care
    • Pharmacy/prescription management
    • Mental health care
  • Health Promotion
    • Rural community approaches
    • Cultural competency
  • Institutional redesign/Care redesign
    • HCH
    • ACOs
    • CAHs
  • Aging services in rural communities
    • Dementia
    • LTC options
    • Palliative/hospice care
  • Volunteerism/community resources
    • EMS
    • Aging baby boomers
    • Transportation

    ORHPC Updates

    ORHPC staff will prepare letters of support for federal government officials (Senator Al Franken, Senator Amy Klobuchar, Senator Harry Reid, Senator Mitch McConnell, Senator John Boehner and Senator Nancy Pelosi) to express disapproval to proposed changes in Critical Access Hospital designations. Recommendations from the Inspector General seeking to modify state designations of certain hospitals as “necessary providers” could end CAH designation status for 62 of 79 of Minnesota’s Critical Access Hospitals.

    Adjourn

    The next Rural Health Advisory Committee meeting will be on Tuesday, November 19 from 10 a.m. - 2 p.m. in St. Paul, Minnesota.



Updated Wednesday, 13-Nov-2013 14:34:13 CST