Rural Health Network Evaluation

This article was written by Christy Sullenberger, MS, Director of Member Services, NCHN & Rebecca J. Davis, Ph.D., Executive Director, NCHN (Adapted from the Field Guide to Nonprofit Program Design, Marketing and Evaluation) for the “Networking News” monthly newsletter. The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center.

Evaluating the network organization or a specific network program is an essential element of performance and process improvement, as well as overall assessment of effectiveness. Evaluations are used to improve programs, build organizational capacity, demonstrate value, and provide a basis for decision-making. Each element of a program evaluation provides insight into a different aspect of the network organization. Taken together, evaluation is a useful tool for the network leader, Board, stakeholders, and present and future funders.

The evaluation approach you choose guides you in the collection and organization of data, so it is important to develop an evaluation plan early in the process of implementation. In addition, as you begin collecting data, you can conduct an ongoing evaluation, which determines if implementation is going as expected. You may recognize this as part of the Plan Do Study Act cycle of process or performance improvement.

An evaluation may be goals-based, process-based (formative), outcomes-based (summative), or a combination of these. A goals-based evaluation determines whether you are meeting your overall objectives. A process-based evaluation addresses how your program works and highlights operational strengths and weaknesses. An outcomes-based evaluation addresses the benefits of your program to network members and/or the community. A final evaluation will often include pieces of all of these approaches.

Evaluation questions of these three approaches may be:  

• What do I need to know to make program decisions and adaptations?
• What is working well and what is not?
• How well does the program deliver value to members and stakeholders?

Evaluation Process Starts with Measureable Objectives
The evaluation process begins with determining clearly stated and measurable objectives for the program and then moves on to defining measurements of those objectives, collecting data, analyzing the data against program goals and objectives, and then illustrating the connection of the program's outcomes to the network's value.

To determine measureable objectives it is essential to sit down and consider your proposed activities and objectives. One common guideline for developing objectives is the SMART acronym. All objectives should be Specific, Measurable, Attainable, Realistic, and Time bound. Ensure that you have a strong list of realistic goals, achievable objectives, and appropriate activities that link directly to the desired results.

Collecting Data Comes is Many Shapes and Sizes
There are a variety of evaluation methods and models. Each method has strengthens and weaknesses. The important question to answer, is which method will best provide actual data that can be used to determine the effectiveness of the proposed project. An evaluation plan for the proposed project may need to incorporate different approaches. Some basic methods of program evaluation include the following: 

• Questionnaires and surveys: can be analyzed and presented numerically/quantitatively
• Interviews: provide primarily qualitative outcomes and can be conducted in person or on the phone and should be targeted and clear
• Documentation review: can be inexpensive, but may not provide a complete picture
• Focus groups: can provide a range of feedback, but may be slightly difficult to present analytically
• Case studies: can provide an in-depth look at a program and many variables

As you embark on your program evaluation keep in mind that the most important element in the evaluation process is that you start early in the process of implementation and that you are consistent in your collection methods.

Evaluation Resources

• Basic Guide to Program Evaluation (Including Outcomes Evaluation), Free Management Library
• Critical Components of Evaluation by Alana Knudson, Ph.D., National Rural Health Resource Center Evaluation Workshop (August 6, 2014)
• Tools and Strategies for Managing Health Networks: Network Evaluation, NCHN
• Program Evaluation, Rural Assistance Center Online Library
• Aim for Impact and Sustainability, National Rural Health Resource Center/Rural Health Innovations
• Flex Program Evaluation Toolkit, Technical Assistance Service Center (TASC), National Rural Health Resource Center

Rural HIT Predictions for 2015

By Joe Wivoda, Chief Information Officer

Tis the Season...To make crazy predictions in writing that can be tested over the course of the year and checked in one year's time!

As a Formula One racing fan I look forward to the blogs that post not only the predictions for the new season to come, but also the review of how poorly the analysts' predictions were for the previous season. I make my own predictions, but I rarely share them with others. Also, I do not go out of my way to see how well (or poorly) I have done. I have never been a huge fan of grading my work.

Last year I made a few predictions:

• ICD-10 will happen in October 2014 (it didn't)
• 2014 will be the year that everyone will use Direct to exchange health information with providers across the continuum of care (it wasn't)
• Stage 3 will come out and it will rock patient engagement efforts (no rule came out)
• Clinical Quality Measures will be a big focus in 2014, and will drive process improvement efforts in hospitals and clinics (it never happened)

Yikes. Why am I doing this? Oh yeah, it's part of my job and I like it! Anyway, goodbye 2014 and it's difficult to predict ways, hello 2015! I think I got this...

ICD-10
YES, IT WILL HAPPEN! October 2015 will be the ICD-10 change for health care. This will be tough on many hospitals and clinics, particularly in rural. Many STILL do not understand that this is more than training coders and physicians. You need to test, change interface configurations, test, test some more, change processes and test a few more times. This is a big deal, and make sure you take a look at the ICD-10 Implementation Toolkit on our site!

The Meaningful Use Reporting Period in 2015 Will be 90 Days
I am only going on a slight limb here. There seems to be a bunch of concern (me included) about reporting over a full year in 2015. Particularly if this is the first year for Stage 2 for a hospital or clinic, meeting the measures over the 12 calendar months will be difficult. The problem is that the wheels of regulatory change can move slowly (remember the Meaningful Use Flexibility Rule timing?), so get busy on Thursday, January 1 getting those patient engagement and transitions of care numbers up! P.S. It is the right thing to do, and people want this, which means...

2015 Will be the Year of the Engaged Patient
I know, I know. I have been saying this for a couple of years now. A few things have changed though. Nationally we are just more "wired" now. More people have smart phones and decent internet and can access things whenever they want. People are used to buying online, they expect to do business with people who remember their preferences in an electronic system, and they want to have their health information electronically. Ask anyone you know "would you like to have access to your health information, including lab results, physician reports, and other information electronically?" The answer is almost always "yes" or "I wish my physician had access to that information". We are at an interesting, and frustrating time for HIT. Expect to hear from more patients who want access to their information, and want it now. It is their right!

Stage 3 Will Hammer on Quality Measures and Interoperability
This is probably my easiest, and safest prediction, because we have been hearing about it for a while. Stage 3 of Meaningful Use will include a ton of requirements around Clinical Quality Measure (CQM) reporting and public reporting of the data, along with a method of "graduating" from the Meaningful Use program if you are getting good scores. Also, with the "Cromnibus" bill that passed a couple of weeks ago, there were provisions for ONC to remove certification for EHRs that do not play well with others. That's a sign of things to come, and I have heard many rumblings that FTC and ONC are taking a long, hard look at some of the practices that EHR vendors have done, particularly in rural, to make interoperability more difficult in favor of single-vendor communities.

Security Breaches, and HIPAA Fines, will Grow Dramatically in 2015
There have been a number of high profile security breaches in 2014, all of which were preventable. The pilot HIPAA audits that OCR did in 2014 will be expanded, and there will undoubtedly be many fines handed out for poor security practices at health care providers and business associates. More malicious code and data ransom attacks are what I predict, unfortunately. Beef up (and for goodness sake UPGRADE) those firewalls!

mHealth Killer App
Finally, I think there will be a killer app that will really take off in 2015. Mobile Health (mHealth) and wearables, like the FitBit or Apple Watch, will provide all sorts of opportunities to assist providers. Consider that a patient can now show the physician their heart rate throughout the day, and with the amount of data that can be stored now, why not show the entire heart rhythm for a several day period? Chronic disease management, particularly diabetes, will soon have a number of apps and devices ready for market that can automate the collection of critical medical data. Wearables and other mobile-enabled devices will change how patients see their health, respond to the health and even access their health care. We need to be aware and prepare for this mHealth revolution!

There, I put it out there. These are industry-wide predictions that will affect rural HIT the most, or that rural providers need to consider now to be prepared. There are other things that will happen next year, but I am afraid to say too much. You may think I am a fortune teller!

Happy New Year!

HIT and Rural: Why it isn't "Small Urban"

By Joe Wivoda, Chief Information Officer

The word "tractor" can be interpreted in a couple of ways, depending on where you are from. In a suburban neighborhood a "tractor" may be a John Deere, have four wheels, and have a seat and steering wheel. In a rural setting a "tractor" could still be a John Deere, have four wheels (or more) and a seat and steering wheel, but would look different and do very different work! The same goes for Health Information Technology (HIT) in urban and rural, the two can be different!

Rural Tractor

Urban Tractor

There has been a trend of larger integrated delivery networks offering their electronic health records (EHRs) to rural hospitals as a way for those rural hospitals to save some money and simplify the exchange of information for referrals. This may not be as simple and straightforward as it sounds, and the results may not make sense for the rural hospital.

For example, because staff at a critical access hospital (CAH) often have to wear many hats, there can be unique workflow requirements that an urban EHR may not be able to accommodate. I worked with one CAH that had a difficult time finding Pharmacy Technicians. They paid their Ward Clerks to get trained and certified as Pharmacy Technicians. This was a brilliant idea that made the Ward Clerks more valuable, solved a critical problem for the CAH and created a vexing problem for the EHR vendor! The urban EHR that the CAH was using did not have the ability to have staff in multiple roles (Ward Clerk and Pharmacy Technician are different roles in a role-based security model that most EHRs use), and why should it? This would likely never happen in an urban hospital, yet this is common at rural hospitals. They ended up having to use two logins, two passwords and some loss of efficiency because the EHR could not accommodate the two roles.

The benefits of exchange with an urban hospital or delivery network can be important, but often overstated. A higher proportion of rural patients are referred to home care, family practice providers, long-term care and other local providers than large urban centers. Implementing the same EHR at the urban and rural setting, with administration occurring centrally, will likely create barriers for the local providers to exchange with the local CAH. As an industry we have made health information exchange too difficult, particularly for those providers that are not eligible for meaningful use. It really is not that hard to exchange clinical information today using Direct, C-CDA and other technologies, yet hospitals and clinics seem to be struggling to make this happen. By moving the management and strategy for the EHR further from the CAH it makes it all the more unlikely that non-physician providers in particular will be approached to exchange information for patient care. We will continue to use FAX and envelopes laid on the chest of transferred patients. By using an EHR designed for rural, and managed by local staff, it is far more likely that real health information exchange will occur in rural settings.

Rural is not small urban! They do have different needs, processes and workforce challenges. The EHRs built for rural often take these issues into account. By "shoehorning" EHRs designed for urban hospitals into rural we can introduce less efficiency and create unsafe practices. Consider some of the challenges you face at your rural hospital and how a one-size-fits-all approach may not be best.

So, I am going to go plow my 10 acre field with the lawn mower and cut the grass with my Ford 2000 loader. Wait...

Cream of the Crop: A Personal Story of Life-Saving Rural Health Care and EMS

By Margo Kulseth, Information Specialist

Margo, Age 6

The importance of rural health care was proven to me in dramatic fashion at a tender age. It was September 1977 on my family farm in southern Minnesota, the epitome of rural America. I was six years old and had just started the first grade. My friend Jill and I were talking on the phone about which of Charlie’s Angels we liked best when suddenly I heard the running lawn mower outside my house make a strange sound and stop abruptly accompanied by a terrifying scream.

Now that almost 40 years have passed, the details of this traumatic day have blurred in my mind, but the emotion still comes back quickly as I recall the chain of events as best I can. I was a painfully shy, timid kid, so I think I talked to Jill about what I heard for a bit and wasted precious time before I hung up the phone, went to the door and opened it a little to peek outside. What I saw is something no child should ever experience.

My mother was lying on the ground with her leg bloody and mangled. Despite the pain and fear she must have been feeling, my mom told me later she was trying to be strong and stay calm so as not to scare me. I stood there in the doorway, too shocked and afraid to go to her, something I feel ashamed of now.

Kulseth Farm

I was fortunate that day and every day of my childhood to have my grandparents, my dad’s parents, living right next door on the same farm but in a different house. It was where my dad had grown up. After my parents were married, they had built our house on the same property as my dad and grandpa farmed the land together. So on this day, my mom hollered at me from her spot on the ground to get my grandma. For whatever reason, maybe because I was too scared to advance past the front door, I ran back inside the house to call my grandma on the phone rather than running over to her house, which is what my mom intended. This is yet another source of embarrassment for me as my mom must have thought I was not going to get help.

As luck would have it, I picked up the phone and heard a conversation in progress. Back in those days, we had party lines that were shared among neighbors. I recognized the voices as those of our pastor at the small country church about a mile away and another neighbor. Filled with uncertainty and indecision, I think I hung up and picked up the phone a few times before finally mustering the courage to interrupt them, something I had been taught not to do. I said this was an emergency and I needed to use the phone, at least one helpful skill I must have learned at some point. Our pastor, recognizing my voice, asked what was wrong, and I told him Mom was hurt. He hung up and headed over to our house.

Meanwhile, I called my grandma and told her Mom was lying outside and needed help. At this point, I didn’t understand what had happened, and in my six-year-old mind, my theory was that our neighbor’s big, loud, black dog named Chopper, of whom I was terrified, must have attacked my mom. So I think this is what I told my pastor and my grandma. They probably were skeptical and didn’t know whether to believe me, and I can’t blame them.

I must have gone back to the doorway to report back to Mom that I had called Grandma, but she had not come out of her house yet. My dad was picking corn that day, and Mom told me to go get him. At some point, my younger sister, age three, ended up with me. She had been playing or watching cartoons, I suppose, and heard the commotion, or maybe Mom told me to get her. Mom said to hold my sister’s hand and take her along to get Dad. She reminded me as I had heard many times before, growing up on the farm, not to go close to the dangerous spinning auger on Dad’s machinery.

I was wearing white socks, and I asked if she really wanted me to run across the farm in them with no shoes because I knew they would get dirty, which seems silly now but a valid question for a people-pleaser child, I suppose. Of course she reassured me it was okay this time. Again, my lack of urgency is embarrassing, but I have to remind myself of my youth, inexperience and timid demeanor at the time.

So my sister and I, hand-in-hand and shoeless, ran toward my dad, who was by the tractor with a wagon full of corn being dumped into the elevator and deposited into the corn shed. We got his attention while staying a safe distance away from the farm equipment as we had been taught, and he must have known something was wrong by the look of us. He turned off the machinery, and I’m not sure what I said, but somehow I conveyed that Mom was in trouble, and he needed to come quickly. By the time we got to Mom, my grandma had come out to investigate and must have called 911. Then she took my sister and I back into our house and wouldn’t allow us to go near the windows. Soon the ambulance arrived, stabilized and transported my mom to the critical access hospital closest to our home.

I learned later, of course, it was not Chopper who attacked my mom. She had been using a riding mower on the hill on which our house is built, and in an attempt to trim the grass close to the hedges, she had an accident that caused her leg to slip into the blade of the running mower. When she tried to stand up, she heard the bone break, so she dragged herself up the hill to where she could call for help. She ended up being transferred to a larger hospital in Mankato, Minnesota, where she had multiple surgeries over the next several months. My sister and I stayed with friends and neighbors sometimes while she was recovering, but we had fun playing with her wheelchair and crutches.

As an adult, I understand the severity of this medical emergency much better than I did at the time. What if my mom had been unconscious? What if she hadn’t been able to get my attention or that of anyone else? What if she bled to death? Farm accidents happen quite often, and sometimes they are fatal because no one else is around to witness the emergency or to get the victim to proper health care in a timely manner, or the transportation time to the nearest facility is too long. It may take longer to get to the victim also.

Mom's 70th Birthday
August, 2014

I am so grateful for the critical access hospital and ambulance service that was available for my mom that fateful day. Without them, I could have lost her. That is a thought so overwhelming, I can barely grasp it. How vastly different would life have been for my sister and me to grow up without our mother? Luckily, aside from a slight lingering limp, Mom is in reasonably good health today, and we had a party in August to celebrate her 70th birthday. My mom is one reason I am a proud advocate for rural health care.

Margo and Mom 2014

Should Rural Hospitals Use Social Media?

By Leslie Quinn, Program Coordinator

Who? What? Where? When? Why? How? I will answer all of these questions for rural hospitals wondering about social media. Let’s start with the why…

Why?

Social media is a FREE marketing tool! Yet only 26 percent of hospitals participate in social media. Why should you get on board?

• It provides a venue to communicate with patients, partners and your community
• Recruit and retain both providers and patients by showcasing your hospital
• Stop the outmigration of patients who are able to drive right past your rural hospital to the next urban center
• Attract the younger population (biggest users of social media) to come to your hospital and become lifetime patients
• Monitor what is being said about your hospital on social media and have the ability to respond

Who?

More people are using social media than you might think; yes, even in rural areas. Your patients and potential patients are on social media. Approximately 83 percent of adults age 33 and younger currently use social media. Internet users age 74 and older comprise the fastest growing segment, with 16 percent now using social media. Your competitors are on social media too!

What?

Show your social media network who you are, the organization, employees, services and more by posting pictures and stories of your facility, staff, community and events. Inform your social media network of available services at your hospital, wellness events at your facility or in your community and job openings. Social media users also find health information on the internet, so you can use social media channels to get patients more involved in their health and health care. You can ask questions to get feedback from you social media followers. Do not post any identifiable health information about patients, to be HIPAA compliant. If you want to post a story or picture of a patient, make sure they sign a consent form.

Where?

There are many social media websites, but the most popular for hospitals are Facebook, Twitter, YouTube and Blogs.

Source: http://thesparkreport.com/infographic-social-mobile-healthcare/?utm_source=pr&utm_medium=email&utm_campaign=infographic

Facebook has 1.15 billion users, making it the largest social media site. Facebook users can “like” your company page, which enables them to see when new content has been added. Facebook allows you to share messages, links, photos, videos, documents and more. Facebook users can interact with you by liking, commenting or sharing your posts.
Examples of rural hospitals utilizing Facebook:

• Transylvania Regional Hospital, Brevard, North Carolina
• Union General Hospital, Farmerville, Louisiana
• Tallahatchie General Hospital, Charleston, Mississippi
• Johnson Memorial Health Services, Dawson, Minnesota
• PeaceHealth Ketchikan Medical Center, Ketchikan, Alaska

You can also keep up with us on The Center's Facebook page.

Twitter has 500 million users that. You can “tweet” updates in 140 characters or less. Twitter users can “follow” your twitter profile to subscribe to your tweets. Tweets may include short messages, links, photos or videos. Twitter users can reply to your tweet or forward your tweet to their followers by “retweeting.” Hashtags (#) are used heavily in twitter to group similar tweets based on a keyword or topic area.

For example, the official hashtag for National Rural Health Day is #powerofrural.

We're also tweeting on The Center's Twitter feed.

YouTube has 1 billion users who post and watch videos. You can post videos to market your hospital and showcase your facility and staff or for patient education. YouTube users can watch, comment on and share your videos.
For example, Baptist Health Medical Center in Herber Springs, Arkansas produced a CAUTI Awards Winning Video.

Blogs have 329 million users. Blogs are growing in popularity with individuals and corporations. Nearly 40 percent of US companies use blogs for marketing purposes. Blog readers can follow your blog by signing up for email notifications when a new blog post is available.They can comment on your blog post or share the link to your blog post with others.

The Mayo Clinic is consistenly ranked #1 for hospitals using social media, one example is their Sharing Mayo Clinic blog.

LinkedIn has 277 million users and is a professional, business-oriented social media site. LinkedIn users can connect and network with colleagues, classmates and “follow” company pages. LinkedIn allows you to share messages, links, documents, photos and job postings with users.

For example, Jamestown Regional Medical Center in Jamestown, North Dakota uses their LinkedIn company page for recruitment, retention, services and hospital news.

You can connect our staff on The Center's LinkedIn profile.

Each social media site has a help center to answer any questions you may have with setup and use. You can also attend social media webinars and trainings to learn more. Self-help books are also available.

When?

There is no time like the present. Start making a plan now to incorporate social media into your marketing strategy. Make sure someone is responsible for actively posting to all social media accounts that your organization creates. A good goal would be to post at least once per week to LinkedIn, daily to Facebook and multiple times per day to Twitter. YouTube and Blogs are used to publish larger content, so it is not necessary to post as frequently. Someone should also be responsible for replying promptly to posts and questions, both positive and negative.

How to Start:

• Check out your local partners and competitors to see what they are doing on social media
• Decide which social media sites you want to start with. Choose one or two and expand later if they are successful. Start small – don’t get in over your head.
• Create an internal social media policy for employees that includes company policy and disclaimer as well as employee guidelines. Example: Mayo Clinic Social Media Guidelines for Employees
• Decide who is in charge of posting and managing social media sites
• Use your logo as the profile picture on all social media sites for brand recognition. You can also use a professional quality staff photo as the cover photo.
• Include hospital address, contact information, website, mission, vision and marketing slogans in the information sections 
• Promote links to your social media sites in the media and on hospital communications, including employee e-mail signatures. Encourage (but do not require) employees to interact with the company’s social media pages; it will encourage other followers to be more interactive.
• Set goals and monitor progress

Sources:
Healthcare Friending Social Media: What Is It? How Is It Used, and What Should I Do?
Social Media Toolkit from the Alabama Office of Primary Care and Rural Health

The Center's Wellness Program: Walking the Walk!

By Kim Nordin, Program Coordinator

We not only talk the talk, we walk the walk!

Happy National Rural Health Day week! At the National Rural Health Resource Center (The Center), we will be celebrating with a group walk and healthy food potluck on Thursday. Check out our Facebook page for photos! As a national leader in rural health, we at The Center recognize the importance and responsibility of being a best practice model for all things health.

This is the seventh month of our workplace wellness program, and today, I’m thinking about worksite wellness programs, which are a form of preventative health and can greatly impact a rural community’s health. I outlined The Center’s Wellness-a-thon in my last blog post, if you’re interested in learning more about it.

Joe and Margo, part of Team Centerites,

during a 5k benefiting the local YMCA

youth program. This was their 

first 5k and they rocked it! 

My favorite part of the Wellness-a-thon has been the weekly challenges. These weekly challenges target key wellness focus areas and challenge staff to try something new, learn something new, or focus on an aspect of health that we may not always think about.

“The weekly challenges put all aspects of wellness on your daily radar.” 

The main driver of our program and the reason I am so passionate about the importance of workplace wellness programs is that the future health care business model is based on patient value. The goal is to minimize the cost of care and enhance the overall health status of a given population by providing care (or supporting wellness) at the EARLIEST point in the care continuum. This approach redefines health care as an activity that includes far more than sick care and acute interventions. Worksite wellness programs are a good place to start.

“Healthy hospitals are a cornerstone of a healthy community.”

What better place for worksite wellness programs than hospitals, which are often the biggest employer in rural communities? They play an important role as respected leaders and role models in health and wellness in the communities they serve. If rural hospitals build a sustainable support system for employee health and wellness, the impact on the rural community’s population health is huge.

Angie, Alyssa, Kami, Joe and me, during one of our quarterly wellness activities: A surrey bike ride on the lake walk! Note: It’s more of a workout than it looks! 

Worksite wellness at The Center is having a positive impact as the program reaches its seventh month. We have engaged in several weekly challenges, and staff members track their progress in one master spreadsheet, which allows us to see our progress as a group.

Some weekly staff challenges:

• Workplace humor week - send a co-worker something funny
• Participate in a random act of kindness
• Positivity challenge week – read the tips provided and challenge yourself to take on a more positive attitude
• Schedule one health related appointment
• No cell phone use while in your vehicle
• Walk/bike to work
• Drink at least 8 glasses of water per day
• Participate in a fitness class
• Take the stairs (Our offices are on the 3rd and 4th floors)
• No sugary (soda) beverages during work

Recently, I sent a out survey to evaluate the program in a short five-question format. Staff members were asked to use a Likert scale of 1-4 where 4= Love it!, 3= It’s good to have, 2= It could be better, and 1= Total waste. 11 out of 17 (65%) of our staff responded. Overall, the wellness program was scored a 3.44 out of 4, which is pretty good for our first seven months!

Positive comments about the program: 

• It’s (The Wellness-a-thon is) very comprehensive. I enjoy the tips and wellness updates on Sharepoint.
• My own (health) patterns have improved, but in actuality less than my intention. I continue to appreciate the shared goals!
• Nice to have comradery. There could be more support between staff.
• I'm more mindful of specific wellness habits: e.g. not driving/texting
• It helps me be more conscious of things, though I haven't changed behaviors (at least permanently) because of it
• Down 15 lbs. and adding some muscle since December 2013 by committing to exercising
• I enjoy the weekly challenges and sharing info on Sharepoint
• We all work so hard on multiple projects which can be isolative (including extensive travel), however maintaining rapport and trust with coworkers is critical. The activities have promoted a positive morale and trust/communication.
• I really, really liked it. I liked the focus on all types of health and I must admit that if there was a day I was tempted not to exercise, I would because I wanted my points. The individual coupled with group goals was brilliant!
• I think every office needs some sort of wellness and "morale" committee that plans regular activities like this. Because our organization is rooted in health, it is especially imperative. The activities have been very creative and fun. The reminders on Sharepoint are also great, especially the list of reasons to be grateful and positive. Thank you for making this a priority.

Since the inception of the program, all but one staff member participated. With that participation rate, we will definitely continue the program. I’d like to kick off the next year with health risk assessments and health screening for all employees. Everyone will start the year with a personal health goal and a way to measure it. This will help us to track our accomplishments.

I’m proud of our program. We’re having fun and taking care of our minds and bodies! Can you say that about your workplace?

Rhonda, Kami, Leslie and me, enjoying a mid-day yoga class in the courtyard of our office building. Wellness Warriors!

Celebrating Rural, Celebrating Access to Care!

By Rhonda Barcus, Program Specialist

Imagine the stress…your greatest loved one has received a cancer diagnosis which requires frequent treatments…four rounds of chemo and then seven weeks, five days a week of radiation. The closest service is over 80 miles round trip. In addition to the emotional and physical uncertainty of a cancer diagnosis, you are now dealing with the challenge of getting your loved one to treatment! I am celebrating today because that did NOT happen to me.

The first part is all true. My greatest loved one was diagnosed with cancer this summer, did go through four rounds of chemo, and has begun seven weeks, five days a week of radiation. We however, are so fortunate to live in a rural community that has a satellite center for cancer treatment. When she finished chemo and we began planning for radiation, we weren’t sure there were services available where we live. My loved one told me if we had to travel that distance every day, she would refuse further treatment.  I’m not sure she would have gone through with that, but I am glad we never had to make that decision.

This summer was a more difficult journey than we ever expected. What looked like a cut-and-dry diagnosis and treatment ended up being worse than expected. In the midst of the worry, I often stopped to be grateful. We had insurance; we had a car to get to treatments; and we had caring friends and family. And above all, I thought over and over how much harder the summer would have been if every treatment and every doctor visit required that 80 mile trip.

So today, during the week-long celebration of National Rural Health Day, I’m celebrating The Power of Rural. The “power” is profound. It’s not just about convenience and easy access, but at a deeper level, it can be about who not only survives, but also thrives.

Hospital Management in the Ever Changing World of Health Care

By Terry Hill, Senior Advisor for Rural Health Leadership and Policy

We all know that change is the new constant in healthcare. Many rural hospitals are considering options for aligning with other hospitals and/or health systems. Rural hospitals also face periodic changes in leadership and are challenged to find the right CEO. A good first step might be to identify a selection process or a model that has proven to be a best practice for others.

Recently, I interviewed Lynne Cunningham from Studer Group, who has just completed a successful assignment for a public hospital board in rural Alabama, which resulted in the successful identification of a new management partner for the hospital. The following are highlights from this conversation.

Q:  Today's healthcare leaders need an advanced level of skill to meet the continuous changes now so common in the industry. The future of organizations in healthcare relies heavily on making the right leadership choices to manage this environment. What steps should a board/executive team ponder when they realize they need a new approach to management? Would you consider your recent work a best practice?

A:  Good question. Yes, I would consider it a best practice. I think it’s important to “begin with the end in mind” as Stephen Covey would say. The board and executive team need to have serious conversations about the range of options they are willing to consider and the values which are important to them regardless of the choices they will entertain. I think there are four questions for the selection committee to consider:

1. What results are you looking for?
2. What type of individual are you looking for in a new executive?
3. What culture do you want to promote?
4. What values must an organization have if they are looking for a new management company?

Q:  How do you thoughtfully make the decision?

A:  There are some logical steps to take in making a thoughtful decision.

• Organizational Assessment

This first step diagnoses your organization’s strengths, opportunities, vision and environment. During the assessment, your consultant will want to talk to executives, board members, community leaders, providers, hospital leaders, and employees. The deliverable from the organization assessment should be a research report with specific recommendations. These recommendations will make it easy to move to a job description for a new CEO or to a request for proposal (RFP) for a management company.

• Prioritize Your Candidates

Review a side-by-side comparison of the proposals you receive. The proposals you’ll get (or the resumes for CEO candidates) will be long. It’s best to use a board created decision-making matrix, which prioritizes the key attributes for success that your organization is looking for, and compare candidates/proposers across these variables to prioritize those that meet your requirements.

• Use Behavioral-Based Interviewing

Conduct telephone interviews with all viable candidates using behavioral-based questions that help you see how your candidate or proposing organizations have responded to a particular situation in the past. The best indicator of future performance is past performance! Send the interviewees additional questions in advance that need to be answered in these telephone conversations.

• Update Your Side-by-Side Comparison

Continue to update the side-by-side comparison and then conduct in-person interviews with final candidates. Ask the candidates/proposers to focus their in-person presentations on critical factors that will be used to make the final decision.

• Use the Decision-Making Matrix

The decision-making matrix will help you quantify your reaction to candidates or various management companies. As the final interviews are conducted, have each member of the selection team use the decision-making matrix as their guide for evaluation.

• Select the Best Candidate/Company

By using the decision-making matrix, it typically will be clear which candidate/proposer is the best fit.

• Gain Board Concurrence

Once the selection committee has agreed on their recommendation, gain board concurrence on this recommendation.

Q:  Okay, so the process to select a successful candidate/proposer has been completed. Isn’t that when the hard work really begins? How do you negotiate for success?

A:  You’re right, now we get the lawyers involved as you either:

• Enter contract negotiations to finalize an employment contract for approval by the board, or
• Enter contract negotiations and due diligence to finalize a management contract

If everyone has been engaged throughout the process, these negotiations are apt to proceed smoothly. Due diligence with a new management company may take 90 days or more, but contract negotiations and some transitions can occur simultaneously.

Q:  Is there anything else you’d consider a critical success factor?

A:  Yes, I think a well thought-out strategic communications plan is essential. It’s likely that a lot of internal and community stakeholders are aware that you are about to make a decision. Once the choice has been validated by the board, implement a comprehensive strategic communications plan to internal and external audiences. Control the message to the greatest extent possible. I’d suggest the plan include:

• E-mail blast to employees and providers

Cascade the same message to all employees and providers to reduce variance in what your target audience is exposed to.

• News release to the public

Transparently share information with the community and proactively position the “why” behind your action as a mission-driven decision.

• Town hall meetings with employees and providers

The consistency of the message is maintained when employees and providers are hearing from the same executives in multiple meetings. In today’s electronic environment, one of the sessions can be videotaped and posted on the organization’s intranet. Unlike the e-mail blast, these town hall meetings provide an opportunity for employees and providers to ask questions and hear directly from those in leadership about how the change may impact work at the facility.

• Community meeting open to the public

As a critical community resource, your community members will want to know about changes at their hospital or with their providers. Give them an opportunity to hear from executives and the board and to ask clarifying questions.

Yes, this is a lot of work, but I really think the planning and organization will pay off in support for your decision.

The Medicare Rural Hospital Flexibility Program Reaches Sweet 16

By Sally Buck, CEO

It is an exciting time for the Medicare Rural Hospital Flexibility (Flex) Program state grantees and partners as we recognize the program has reached its sweet 16, which is to say 16 years in existence. The Flex program was born as part of the Balanced Budget Act of 1997 to provide funding to states for the designation of critical access hospitals (CAHs) in rural communities and allows hospitals to be reimbursed on a reasonable cost basis for inpatient and outpatient services provided to Medicare patients. There are now 1,326 CAHs in the Flex program that play an essential role in sustaining rural health care.

The National Rural Health Resource Center (The Center) has the pride of a parent seeing their "child" reach this milestone of 16 years. Terry Hill, former Executive Director of The Center, was involved in the initial development of the Flex Program with the Federal Office of Rural Health Policy (FORHP) to support small rural hospitals in the conversions, development of networks, quality improvement and financial stabilization. Through a contract, The Center established an innovative technical assistance model: Technical Assistance and Services Center (TASC) in 1998 to provide information and education about Flex to the state grantees and their partners. 

In the infancy, TASC supported the states with development of rural health plans and creating "any necessary provider" rules, financial feasibility tools for assessing conversions. Through the toddler years, TASC provided state Flex grantees with education on cost reports, establishing networks for care transitions and quality improvement. It’s hard to imagine, but when we started, we didn’t have webinar technology, and the webpages were often static pages without search functions.

By the 10 year mark, the Flex program had moved into CAHs with swing beds to accommodate post acute care services. The "any necessary provider" rules reached their sunset, and conversions to CAH status dramatically declined. Flex programs and TASC mobilized to support CAHs to trauma designations through emergency medical services (EMS) and CAH training and regional planning. With a decade of experience, TASC, the Flex Monitoring Team (FMT) and state Flex programs worked together to provide CAHs with more data about the financial, quality and community engagement status within their state and nationally. Hospital Compare was launched by the Centers for Medicare & Medicaid Services (CMS), and although CAHs weren't required to report quality, hundreds of performance indicators became more important for all hospitals.

As the Flex program reached the awkward stage of the teenage years, the grantees adapted to new reporting requirements, and outcome-focused work plans. CAHs were watching the transformation of health care payment models evolve without a small volume option. A new initiative, the Medicare Beneficiary Quality Improvement Program (MBQIP) was introduced by FORHP in 2010 to increase quality reporting by CAHs with rural relevant measures and data to spur quality improvement efforts. This was a critical activity as CAHs were experiencing some bullying about their performance. With MBQIP, the Flex program has dramatically increased quality reporting by CAHs and states have implemented  a number of initiatives to improve patient safety, satisfaction and patient outcomes.

Now at 16 years of age, Flex is developing a vision of what it will become in the future as a mature program and what impact Flex, with over 1,300 CAHs, will have on rural health care in the U.S. and the thousands of communities served. With the changes in health care delivery and payment, the Flex Program needs to continue to share best practices, learn from peers and experts to ensure small rural hospitals can continue to improve care and the health of rural communities and reduce costs. Happy Sweet 16 to the Flex Program, and best wishes for many more successful years to come!

                                                                                                                          

Walk a Mile in your Funder's Shoes

By Margo Kulseth, Information Specialist

“Walk a mile in my shoes.” This familiar idiom was the advice given to an audience of rural health grantees, grantors and stakeholders in Kansas City, Missouri on September 30, 2014 at the Federal Grant Writing Workshop during the keynote session by Kim Moore, President of the United Methodist Health Ministry Fund. “In order to write a good grant application, we must think like the grant funder,” said Moore. What does the funder want to accomplish in awarding this money? What will motivate the funder to choose my application?

Kim Moore

Moore shared the following tips for grant seekers:

1. Consider the “lens” of the funder and write the application in those terms

• What aspect of health care is the funder’s focus? Disparities? Social determinants? Social justice? Cultural competency?

2. Understand the rules and limitations of the grant

• They can be complex and the same language may mean different things to different people

3. Do not fight the rules and limitations of the grant

• Some of the limitations may seem unfair, but you are very unlikely to persuade the funder to change the grant

4. Do not assume your project is not what the funder is looking for

• It may not be obvious at first glance, so dig deeper
• Go to Grant Makers in Health at www.gih.org to find funders interested in health in your state or region

5. Respect the process laid out by the funder as you would like to be respected as the applicant or grantee

• Do not go over someone’s head in an attempt to get funding

6. Give the information on a level your funder understands and needs

• Do not be too brief so as to leave questions and doubts in the mind of the funder, but don't be facetious either

7. Show how you will leverage limited funds to create significant impact

• The biggest challenge of philanthropy is creating positive change with limited resources
• How will not completing your project be more costly in the long run?

8. Show how your project is likely to be sustainable beyond the term of the grant

• Funders want to provide short term money that will have a long term impact (NOT vice versa)
• Include a plan for how your project will continue once the money runs out (Hint: Do NOT say it will only continue by seeking other grant sources unless you have very likely ones in mind)
• The purchase of equipment or training people how to do something new are good examples of sustainable use of grant funds

9. Show the funder the risk of investing in your project is likely to pay off with lessons learned that can be shared and used by others

10. Create a strong evaluation plan

• How will you know your project is successful?

11. Create measurable outcomes

• Do not over- or under-promise
• Measurement should be commensurate with project scale
• What is your cost per unit of service?
• What is the quality of work?
• Will people be healthier or happier because of your project?
• The data should grow out of the work and inform the grantee of whether the project has been successful
• Outcomes should be logical, appropriate and likely to occur
• If XYZ happens, we will be happy about it and celebrate it

12. Have a dissemination plan for the project results

• Are you going to write a report? Hold a webinar? Put the results on a website? Convene a conference or workshop?
• Collaboration and sharing of lessons learned is one of the best ways to use grant funds wisely
• Most problems cannot be solved in siloes
• Bring all the stakeholders and their resources together for sharing

13. Point out the secondary benefits of the project

• Will the project establish new working relationships? Develop a new and improved culture? Cross boundaries of traditional roles?

14. Include support letters from involved entities expressing their endorsement of your project if possible

• Do not create such a negative picture of the need that you lose the opportunity
• Balance the need description with the assets realistically available in the community

15. Discuss in advance how the grant award will be announced

• Be careful to handle the process legally and within the guidelines of the funder

16. Become known by your funder beyond the written application

• Get to know your funder personally if you can
• Learn about each other

Mr. Moore told the audience, “Your work is more than a job. It’s a personal passion to advance the rural health system.” It is the same with funders. Most want to do more than give away money. They develop learning communities for grantees, hold webinars, conferences, workshops, provide technical assistance and generally want to see their grantees succeed and create positive change that can serve as examples for others to follow. Funders want partnership with and among their grantees.

The benefits of collaboration cannot be overstated. Grantees in the rural health arena or any other must align with and build on each other’s work. It is not just about getting and giving money. Success will come from aggregating resources, sharing, learning and disseminating together. Perhaps if we attempt to walk a mile in each other’s shoes, it will help us to appreciate and capitalize on our common goals for the greater good of improved rural health care.

Kim Moore presenting at the Federal Grant Writing Workshop in Kansas City, Missouri on September 30, 2014

RHPI: End of the Journey

by Terry Hill, Senior Advisor for Rural Health Leadership and Policy

Listening to Jerry Garcia this morning singing about a "long, strange trip," brought to mind the impending conclusion of our Rural Hospital Performance Improvement (RHPI) project journey in support of rural hospitals in the Mississippi Delta Region. Beginning with an initial hospital consultation in Tallahatchie County, Mississippi in 2000, the National Rural Health Resource Center (The Center) and its many partners supported 323 onsite hospital projects in eight states between 2001 and 2014, and put on hundreds of educational events.

Funding was provided by the Health Resources and Services Administration's (HRSA) Federal Office of Rural Health Policy (FORHP). We are grateful for their stellar leadership as well as the many contributions of our state partners, including state offices of rural health and state hospital associations. Our original corporate partner was the Mountain States Group, and our deep appreciation goes to their staff and to our stellar cadre of consultants too numerous to mention.

We have also had an amazingly dedicated staff here at The Center. They have worked hard to bring excellence to every aspect of the RHPI program, including measurable outcomes, education and customer service. And finally, we are grateful to the many hospital leaders in the Mississippi Delta Region that we have come to know and have proudly served over these many years. They are the real heroes of our journey, and their accomplishments have been documented by Dr. Eric Scorsone on three separate occasions, as returning $3, $11, and most recently $7 in hospital improvement, for every $1 invested in RHPI by the federal government.

In an era of value-based healthcare, we at The Center, are most proud of the documented value our RHPI program brought to more than 200 rural hospitals and the communities they serve. As we wrap up the RHPI project, we thought you might enjoy a few "fun facts" about the work done to support the Delta states:

• From 2001 to 2014, RHPI supported 323 onsite hospital projects
• Financial Operational Assessments were the most requested project with 110 completed
• Strategic Planning was second most requested and 37 projects were supported
• 170 different hospitals were eligible for onsite projects and 127 facilities took advantage of the opportunity
• A Return on Community Investment (ROCI) analysis completed in 2014 indicated that for every $1 invested in RHPI, a return of $6.8 was generated 

Health IT In 2024: Time to put on your futurist hat!

By Joe Wivoda, Chief Information Officer

National Health IT Week 2014 has been a blast for me! I have blogged every day and tweeted about it as well @WivodaRural. I spoke with people in my community about the importance of patient portals and convinced quite a few people to sign up and access their health information. We even made signing up for a patient portal (or a family member’s) one of our wellness challenges at The Center! Life will be so much less exciting when HIT Week is over. Insert sad face here.

Regardless, this is the final HIT Week blog, and what is a blog series without a wild prediction for the future? I have been blathering on about how we are in the “bag phone” stage of HIT, and now it is time to imagine what life will be like when we are in the “iPhone” or “Android” stage of HIT. Well beyond Meaningful Use, when patient access to data is universal and expected. Data is easily shared among providers. Welcome to 2024!

Ten years from now, patient engagement will not be a buzz word, it will be just another way we access health care. Primary care visits will begin with accessing our mobile device. Thanks to interfaces with wearable devices such as watches and glasses, the provider can see our heart rate, temperature, Sp02, respiration, and other vital signs over the last several weeks. If we have a chronic condition, such as diabetes, there will be a near-constant monitoring of our blood glucose levels. Since this information can be stored indefinitely (storage is essentially limitless) and computing power is significantly greater than today (Moore’s law will have broken down, but still…) most providers will be notifying their patients when the data indicates that there may be a problem. No longer will we need to call the clinic, they will call us when our data indicates there may be something wrong.

Telemedicine will be commonplace. What we may call an “e-visit” today will just be a “visit” to the provider. Primary and specialty visits will utilize technology that is at our fingertips to provide the right care at the right time, and most often at the patient’s home or office. Simple, inexpensive peripherals will be able to monitor our vitals and likely be able to perform common lab tests. Imagine doing your own urinalysis in the “comfort” of your home.

Apps on your smartphone will be able to utilize powerful centralized systems like IBM's “Watson” to diagnose complex diseases. Already apps like iTriage can be very useful for simple diagnoses, so imagine where we will be in 10 years!

A few years ago, a futurist told me that we might be 10 years away from having a “tricorder” from Star Trek: A device that can be held up to a person that can “sense” what physical disorders may exist. There is now an X Prize for just such a device, so I expect in 10 years that invasive testing will be rare. Instead we will walk in a “phone booth” (Remember those? They are collectible now.) that will analyze our vitals and other things to determine what ails us.

This is a long way from where we are in 2014. Consider that the cores of most of our EHRs were written 20 years ago or more, so we do have a long way to go. Increased data analytics, more complete data capture, and huge data repositories that include DNA data will be required in the future. This isn't science fiction; we are well on the way to be able to do these things. In fact, I am probably being much less imaginative than I could be. What do you think National HIT Week 2024 will be like?

Rural is Not Small Urban: Issues in Rural HIT

By Joe Wivoda, Chief Information Officer

Recently, someone asked me what I thought the major issues were with Health Information Technology (HIT) in rural hospitals and clinics. I get this question quite often, and I realized I have never blogged on this before! Since it is National HIT Week, and I am blogging daily, what better time is there to blog about rural issues? Some of these barriers apply to urban facilities but are amplified in rural, kind of like in an urban yard, you might expect to see a push mower, while in my yard, there is a Ford tractor. Or something like that. My metaphors have been weak lately.

Workforce

Access to qualified HIT staff is still an issue in many rural areas. Networks and systems typically have HIT staff, but many CAHs and Rural Health Clinics (RHCs) make do with a local personal computer consultant or someone who has some basic troubleshooting skills. It is rare to have a skilled HIT person working at a standalone CAH or RHC, but when there is, the facility is typically far ahead of those without HIT talent.

It can be the same issue for clinical HIT staff. When the electronic health record (EHR) is put in, there usually will be some sort of “super user” that needs to be assigned. They are responsible for implementation and internal support moving forward. Most CAHs and particularly RHCs can’t afford to have someone partially dedicated to maintain and support the clinical side of the EHR, so a talented nurse who is the super user will often need to step back into nursing full time, and the EHR gets neglected.

Cost of Upgrades

Particularly this year, with the new Meaningful Use certified technology requirements, EHR upgrades have been very expensive. I am aware of several CAHs who have had to pay more than $200,000 to implement the 2014 versions of their EHRs. Additionally, many of these upgrades require re-implementation of several core features, like computerized physician order entry (CPOE). The new rule allowing delays in Stage 2 does not apply if you merely can’t afford it. This can be a difficult expense to justify, particularly when the financial incentives are coming to an end.

Transitions of Care

I have written about this in a couple of other blogs. Of all of the Meaningful Use Stage 2 measures, I feel this is the most important for making a difference in the communities we serve. Patients need this, and our referral partners are begging for this!

The Stage 2 requirements around transitions of care and summary of care records has been difficult for rural facilities. Many of them do not fully understand their referral patterns, which is a critical step. Also, many CAH referral partners are either not eligible for meaningful use and do not have the capability to receive continuity of care documents (CCDs) (long term care, home care/hospice) or they are not interested/motivated to work with the CAH/RHC to exchange the information (urban tertiary/quaternary hospitals and specialists). To achieve the stage 2 measures, it will be necessary to overcome these hurdles, but more importantly, it is the right time to solve the problem of poor information flow for referrals. We are harming patients every day by not solving this!

Clinical Quality Measures

Generating electronic Clinical Quality Measures is difficult even when you have qualified HIT staff, and with the workforce shortage in HIT/Clinical IT at most rural facilities, this can be nearly impossible. It isn’t that they just need someone who can extract the data either, because it is typical that either the data is not collected, or it is not collected in a uniform manner. The act of attempting to generate clinical quality measures electronically will always result in process improvement opportunities. Just take a look at how your facility is collecting smoking status. I bet it is being collected in multiple fields and may not even be discrete. Now try doing a report on falls…

ICD-10 Preparation

ICD-10 is coming. Most CAHs and RHCs have done little about this, and if they have, it is just the training of providers and coders. There is much more HIT work to do prior to converting to ICD-10, including testing with payers and interface testing. Now would be a good time for me to plug our ICD-10 Toolkit. Free to download!

Health Reform Preparation

Rural health has been slow to understand and implement technology to support health reform. In particular Health Information Exchange (HIE), data repositories and reporting technologies are not in place or being considered. This goes back to workforce and also awareness of the implications of moving from volume to value. Health reform is here; our payment models will be changing; and HIT is a core foundation piece for being able to operate under the new models.

These are a few of my thoughts. No, the sky is not falling. Yes, we can remove these barriers. It just takes some focus and new ways of working. That isn't easy, but we need to make the changes to survive and thrive in a world where the rules are changing rapidly.

Speaking of rapid change, tomorrow is my last blog entry for HIT Week, and it will be a doozy! I will be putting on my futurist cap and discussing what HIT will look like in the next several years. Tweet me @WivodaRural, and give me some of your thoughts. This will be fun!