Grateful

Scientists have begun to chart a course of research aimed at understanding gratitude and the effects on physical and emotional health. They’re finding that people who practice gratitude consistently report a host of benefits:

• Stronger immune systems and lower blood pressure
• Improved resilience
• Higher levels of positive emotions
• More joy, optimism, and happiness
• Acting with more generosity and compassion
• Better quality and quantity of sleep
• Fewer aches and pains
• More likely to take care of their health

At The Center, we have so much to be grateful for every day. 

Kami Norland

“I am grateful for the innovation, inspiration and compassion of the Accountable Communities for Health teams across Minnesota.”

Bethany Adams

“I am grateful for the opportunity to help people who work hard to provide access to quality health care in their communities.”

Angie LaFlamme

“I am grateful for rural providers who are committed to providing quality care to their patients in this ever-changing and challenging health care environment.”

Jere-lyn Fern

“I am grateful for the opportunities that I have had here at the Center and meeting many wonderful people from all the State Offices of Rural Health that we work with.”

Tracy Morton

“I am grateful for 45 states, 1,333 critical access hospitals, thousands of rural communities and countless lives improved with quality care.”

Nicole Clement

“I am grateful to the Federal Office of Rural Health Policy for the dedication that The Center shares with them to the viability of rural hospitals and access to

quality health care.”

Bridget Hart

“I am grateful to witness and be a part of innovation and collaboration that happens every day at The Center!”

Alyssa Meller

“I am grateful for the opportunity to learn from rural communities all over the nation in how they are working together to better the health of their communities.“

Cassandra Rockers

“I am grateful for being able to work with wonderful people both in rural communities and in Duluth!”

Terry Hill

“I am grateful that  our Center has a role in improving the health and wellbeing of rural people across the United States.”

Kim Nordin

“I am grateful for the people who live in rural communities with pride and love. I am inspired by their resilience, creativity and passion for their small towns, reservations and communities!

Joe Wivoda

“I am grateful for the Network Development grantees, especially those that are focusing on behavioral health.”

Debra Laine

“I am grateful for the Network teams who are pioneering a way to change their communities.”

Sally Buck

“I am grateful for the 45 State Flex Coordinators committed to supporting critical access hospitals by improving quality, financial stability and community health.”

Rhonda Barcus

“I am grateful for all the caring folks in health care that help people every day in rural communities, like the one my mom and sister live in.”

Sarah Brinkman

“I am grateful for the 1,600+ small rural hospitals dedicated to making improvements to meet the needs of their communities.”

Phil Birk
“I am grateful for the emergency response volunteers that are first responders in the Iron Range communities where my immediate family lives. I’m also grateful that there are hospitals in Aurora and Ely, Minnesota because Duluth is too far away if my family needs emergency care.”

Becky Gourde
“I am grateful that so many health care organizations are collaborating to improve outcomes in rural areas.”

Memories from a Veteran: Terry Hill

It's Veterans Day 2015, and I'm compelled to begin this blog before it becomes old news. I write this as a veteran of the Viet Nam War, and since it’s a day for remembering, I'll begin by sharing a few of my memories of that war.

Opening memory: The fear begins as I board the plane at Travis Air Force Base, along with 220 other soldiers. We fly in almost absolute silence to the Republic of Viet Nam. We are all scared and apprehensive that we'll never see our families again; that we will come back in a box, or even worse, that we will return gravely wounded and become our family's burden for the remainder of our lives. For much of the ensuing year, the fear is never far away, and occasionally it erupts into sheer terror.

Memory 2:  One month later, I'm deep in the Viet Nam jungle with my First Cavalry colleagues, and after a twenty minute firefight, we cautiously creep forward to examine the results of our fire. A wounded Viet Cong soldier is gasping for air, and his makeshift uniform is slowly turning dark red. I stare into his eyes. They blink several times, and I can see the intense fear of what will come next. Then they stare ahead lifelessly. This is not the body prepared by a mortician for final viewing; this is a body twisted in agony, very much like my own. This boy too had parents and people who loved him, and they will deeply mourn his passing. To paraphrase both Marlon Brando in, "Apocalypse Now", and Joseph Conrad in “Heart of Darkness", this is the "horror".

Memory 3:  It's months later, and back at the fire base near Phouc Vinh, my friend, Rusty, is approaching with a paper bag in hand. Rusty is in his second tour in country and has seen more than 18 months of combat.  Although only a corporal, Rusty is our squad's informal leader; an older guy we can depend on when it matters most. Rusty’s eyes seem to bulge from his face, and as he gets near, he begins raving that he has found the secret of life, the secret that will get us out of this awful war. The answer, he alleges, is in his paper bag. He opens it slowly and I peer inside, recognizing my own face in the mirror that lies at the bottom of the bag. Hours later, Rusty is escorted aboard a helicopter to begin a long journey to a mental health facility in Japan, and I will never see him again. Two months later, another friend has a mental break while waiting to leave country, and makes a similar trip to Japan.

Final memory:  I arrive back at Travis Air Force Base, and process back into civilian life. The previous day, our base was rocketed by the enemy, and later today I'll walk the streets of San Francisco. I'm elated to be safe and back at home, but the yearlong experience will haunt me, and a post traumatic illness will plague me for several years to come.

Looking back today, I see that the entire wartime experience made me stronger and more resilient. I survived, but there are many, many soldiers that returned from that war, and from more recent wars, that have never fully recovered. 

I believe this country must do more to serve those we send into combat; more than the ceremonial rituals that are appreciated, but only begin to provide our veterans the support that they need. We must dramatically improve access to health services for our veterans, and must enlist the VA in more effectively integrating their health services with those of other health care providers.

One important improvement would be to make rural vets eligible to receive health services at their local rural hospitals, clinics and mental health facilities. It doesn’t make sense to ask rural vets to travel great distances to VA clinics and hospitals, when appropriate services exist locally. And, we must pay rural health providers fairly for these services.  

If we send young men and women to fight our battles, we must be prepared to provide full access to needed health services when they return.

HIT Myths Debunked!

A few weeks ago I was thinking about all of the myths that swirl around in healthcare IT circles. Many of these myths are heavily ingrained in HIT beliefs, and some are merely misunderstandings. For example, in IT there is a belief that keeping the server room as cool as possible is best for the hardware, yet a study published by Google showed that hard drive failures do not appear to correlate to temperature at all. I keep my personal server room at 75 or so. No hard drive failures yet!

We decided that a blog series on healthcare myths would be fun. Since I started it, here are the HIT myths that I am tired of debunking.

"A single EHR will solve all of our problems!"

Phooey! This is an age-old argument that has gone on for years. Deeper still, is the general IT argument that best of breed solutions are not as cost effective as single-vendor. IT leaders in healthcare often forget that there are more providers than hospitals and clinics. The documentation and ordering needs of providers like behavioral health, home care, hospice, long-term care, and physical therapy. These other providers will likely always be on separate systems, and we will need to communicate with them electronically. Related to this, let's debunk the number-one myth I hear about interoperability!

“We think Direct is a short-term strategy, and we prefer to wait for statewide HIE.”

Balderdash! When folks talk about where we need to be in HIT they usually tell the story of query-based exchange. We talk about getting injured in a far-away state, going to an ER, and all of our medical information from other facilities is magically downloaded into the EHR there. Life is good!

That is a great scenario, and it will happen someday. However, we can use Direct right now to make a difference in patient care! Even providers who do not have an EHR can benefit from Direct by having secure communication with their referring providers. We should be getting comfortable using Direct and eliminating that stupid fax machine! Further, Direct will likely be around forever, it is not a short-term solution! Did we get rid of our phones when email became popular? 

“Patients in our community are too old to access their electronic patient data!”

Flapdoodle! I used to hear this more often than I do now, probably because we are seeing it isn't necessarily true. We have seen many studies that show this not to be the case too. Older patients have more need for medical care and can be very engaged in the healthcare. Also, many older folks use technology to keep up with their family (Skype, Facebook) and have an iPad or smart phone. Further, when we engage the patient's family and caregiver we can get them to access the patient portal nearly every time.

So, since this is a first-in-a-series kind of blog, help me out! What other myths do you hear? What needs to be debunked out there? What other synonyms for "nonsense" do you know?

One HIT Vendor's Perspective

As many of you know, I live in a rural Northern Minnesota town called Hibbing. You may have heard of it as the boyhood home of Robert Zimmerman, who later went on to fame as Bob Dylan. Hibbing is interesting in many ways, and with this being HIT week, you would be surprised to hear that it is home to a Behavioral Health EHR Vendor! IRCS, Inc is a popular Minnesota vendor for behavioral health and I had the pleasure of working with them a few years ago on a couple of projects. Interestingly, they are the only EHR vendor that I know of that has completely re-written their software from the ground up using new development tools! That was an expensive, but wise move that has enabled them to provide cutting edge software via the cloud. This allows them to provide their software to very small offices as well as large centers.

I have invited Chris Freeman, Chief Operations Officer at IRCS, Inc. to discuss their perspective to support issues. This is a topic I often discuss (see my webinar “Vendor Issues Management”) and I think it is important to consider the perspective of the vendor using a Maslow’s Hierarchy of Need model:

At the core is the requirement to sustain the business and avoid liability that could destroy the business. Next is having a profitable business, and that requires keeping and adding customers. Finally, they want to engage their employees and make a difference in the healthcare community they serve. They can’t do any of that stuff at the top with a failing business! It is important to keep this in mind when you wonder why your support issues have not been resolved as quickly as you think they should be!

Now I would like Chris to discuss the perspective of IRCS, Inc. when it comes to support and product maintenance. Take it away Chris!

IRCS, Inc has been in business since 1982 (33 years), and has been primarily focused on Behavioral Healthcare EHR software for the last 20 years.  Our software, Vireo, which Joe refers to in his introduction, is a brand new software, written from the ground up using new development tools.  Vireo was Stage 2 MU certified on Jan 30, 2014 and we were the 3^rd organization (with the 5^th software application) certified.  We believe that communication between the vendor and the customer is of primary importance.  We commonly answer phone calls directly from our customers (no complicated phone system to get stuck in here), so that is generally how an issue starts its life.   I will now share some tips (that dovetail with Joe's webinar “Vendor Issues Management”) to help your vendor get your issues solved in the least time possible.

Issue life cycle:

1) Issue begins life by either a phone call discussion or email.   A tracking ticket is produced to track the issue.

2) We attempt to reproduce the issue.  If the issue contains enough specific information for us to reproduce the issue, we will typically correct the issue within our development environment immediately.  Following that the issue will be corrected in the next release.  For critical issues, we will issue a hotfix. 

3) If the issue does not contain enough information for us to reproduce, we loop back to the customer in an attempt to obtain that information.   This step is what takes the longest amount of time, usually due to scheduling problems (on both the customer and vendor sides).  If we are unable to reproduce the issue or the root cause cannot be identified the issue is canceled.  If we obtain enough information and are able to reproduce the issue we loop back to step #2.

With any vendor, if you want your support issues corrected in the least amount of time possible, do the best you can documenting how to reproduce the issue.  Typically this takes a subject matter expert on the part of the customer, as a normal user does not have the time and/or big picture knowledge to document the information required.   If you do not have any subject matter experts on staff, you need to develop them, as it is our experience that you cannot completely utilize a software application without them.

Variables to document:

1. Type of device and operating system (i.e. Laptop running Windows 7 Professional vs iPad running iOS 9.0.2) and web browser in use (i.e. Firefox 41 vs Chrome 45 vs Safari 8.0.8).
2. User logged in.
3. Release of software in use and Date and Time issue occurred.
4. Steps to reproduce the issue.

If you follow the steps I have outlined above you will give your vendor enough information to be able to reproduce the issue, and your issue will be solved in the shortest time possible.

Thanks Chris! It is great having someone discuss openly how to best communicate issues to a vendor. 

HIT Week and Review of my 2015 HIT Predictions

Happy HIT week! I have been busy talking HIT to a rural network for the last couple of days, and it is exciting to see how we have progressed in the last few years. As a way to check on our progress, I would like to see how I am doing so far on my 2015 predictions I made earlier in the year. I think I am doing a little better than I did last year!

ICD-10

I was right! It did happen on October 1. So far all seems fine, but let’s see what happens when the bills drop.

Meaningful Use Reporting Period in 2015 will be 90 Days

Right again! The BRAND NEW Meaningful Use final rule came out last night and, as most people thought, the reporting period for 2015 is 90 days. No big surprise…

2015 Will be the Year of the Engaged Patient

Hmmm. This one is subjective, and I think I was wrong (again). We are talking more about engaging patients and we are talking less about why patients won’t engage, which is a start. We are building some momentum, and certainly focus on care coordination and other population health management methods will encourage patient engagement, but the groundswell has not occurred yet.

Stage 3 Will Hammer on Quality Measures and Interoperability

See my blog post tomorrow, where I will discuss the Stage 3 final rule. I will discuss this and other areas more, but I don’t think the clinical quality measure and interoperability requirements will be any greater than they are in Stage 2.

mHealth Killer App

I was hoping that an mHealth app or device would emerge that would drive patient engagement and wellness. I was thinking that perhaps the Apple Watch or the Apple Health Toolkit would take off, but so far I really don’t see this as happening this year. I love my Apple Watch, and it makes me more aware of my daily activity, but it just has not taken off yet.

So I got 2/5 correct. Not good, but for a batting average it is awesome! What do you think will happen the rest of the year?

The Center's Growing Team

By: Leslie Quinn, Program Coordinator II

With all of the new programs at The Center, our team is growing…and our office space is bursting at the seams! We asked all of the new staff to answer a list of questions about themselves and we received a mix of funny and serious responses. We want to introduce you to all of the new staff that have joined The Center’s team in the past six months (starting with the newest first):

Paul Luciano, Program Specialist
(started this week – May 2015)

Paul relocated from Vermont and found his dream job. He loves the big lake (he has a view of Lake Superior from his new office) cycling, windsurfing, guitar and strong coffee. The wallpaper on his cell phone is a shot from a recent bike trip (see photo to the right). He said the focus of the work at The Center is great and the people are even better.

Debra “Deb” Laine, Program Specialist 

(started April 2015)

Debra describes herself as “Tenacious, Creative, and Gentle”. She runs a farm on her husband’s family homestead, they have sheep and chickens. She loves that Duluth is “Ever-changing”, the lake, the weather, new things to explore and new adventures. Debra said this is her dream job, “being with like-minded people and working as part of a team.”

Bridget “B” Hart, Program Assistant 

(started March 2015)

“Happy” by Pharrell Williams is the song that best describes Bridget. She loves being outdoors and enjoying all of the seasons in northern Minnesota.  She also loves to read (currently re-reading The Dresden Files by Jim Butcher), playing video games, gardening, hiking and painting wineglasses. Bridget is looking forward to contributing to the many ongoing projects and programs at The Center.

Andy Johnson, IT Coordinator 

(started February 2015)

“Hey, IT Guy” are the three words that best describe Andy…we will try to call him by his real name when we need help! His dream vacation is going to Hawaii, because he has already been to all of the other 49 states. He loves that Duluth has great people, wonderful scenery, changing seasons and delicious local-brewed craft beers. He is sometimes mistaken for Seth MacFarlane. He said, “The staff here is absolutely amazing. Everyone seems genuinely passionate about our mission, and they’re all happy to help each other out”

Sarah Brinkman, Program Specialist 

(started January 2015)

Sarah asked if “Mama” counts as a nickname; her office and cell phone are full of pictures of her adorable son, Wally! Visiting all 50 states is on her bucket list. Her hobbies include playing with her kiddo, reading, curling, getting outside anyway she can (that isn’t too strenuous). Sarah loves knowing that we are working to improve the care people receive across the country.

Cassandra “Cassy/Cas” Rockers, Program Coordinator 

(started December 2014)

Cassy describes herself as “Sarcastic, Caring, and Clumsy”. Her dream vacation is spending a month in Colorado snowboarding or surfing in Hawaii. Outside of work she likes snowboarding, hiking, longboarding, hanging with friends, watching movies, fishing and camping. Note: she is not a morning person. Her favorite part about working at The Center is working with amazing people that are always willing to help answer questions and being by Lake Superior. 

Rural Network Leadership

This article was written by Tim Size, Executive Director, Rural Wisconsin Health Cooperative (RWHC) 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.

This article is abstraction from "Leadership Development for Rural Health" by Tim Size

Leadership is the capacity to help transform a vision of the future into reality.

The significant challenges we face today in healthcare require a form of leadership that is less authoritative and more collaborative. Ronald Heifitz and colleagues at the Stanford Graduate School of Business say it very well. These 'problems require innovation and learning among the interested parties, and, even when a solution is discovered, no single entity has the authority to impose it on the others. The stakeholders themselves must create and put the solution into effect since the problem is rooted in their attitudes, priorities, or behavior. And until the stakeholders change their outlook, a solution cannot emerge.'[1] It is important to not confuse being collaborative with endless stanzas of singing 'Kum By Ya;' collaboration frequently requires strong external catalytic action.

In Leadership Is an Art,[2] Max Depree offers a model for employer-to-employee relationships based on his experience that productivity is maximized by designing work to meet basic employee needs. His vision of the art of corporate leadership brought employees into the decision-making process. DePree's experience is primarily within the world of the Fortune 500, but many have found him to offer a useful framework for non-profit and public sectors.

While DePree was a successful leader of a Fortune 500 Company, some may describe him as impractical, a common descriptor thrown by the 'pragmatists' at 'collaborators.' Robert Greenleaf offers a suggestion that may be helpful in thinking through this dilemma: "For optimal performance, a large institution needs administration for order and consistency, and leadership so as to mitigate the effects of administration on initiative and creativity and to build team effort to give these qualities extraordinary encouragement."[3]

As the executive director of a cooperative of rural hospitals for more than 35 years, it is easier for me than for many to see rural health through the lenses of collaboration, the opportunities it creates, and the threats it endures as a model for organization and community work. We have adopted and adapted DePree's eight leadership principles as a guide for both our internal and external relationships.

To illustrate these leadership principles, the following is as described in the article Managing Partnerships: The Perspective of a Rural Hospital Cooperative. [4]

1. There Is Mutual Trust
Develop relationships based primarily on mutual trust so that the cooperative goes beyond the minimum performance inherent in written agreements. "While responding to a rapidly changing market in 1984, the implementation in six months, from scratch, of a rural-based health insurance company in Wisconsin was only possible due to the prior existence of a basic level of trust among the key actors."

2. Commitment Makes Sense
Participants may join a cooperative to explore its potential; they remain only if they perceive that they are receiving a good return on their investment of time and money. "RWHC offers a broad array of shared services from which hospitals pick and choose according to their individual needs; commitments are made because they have been structured in a way that attempts to maximize the 'fit' for each individual participant."

3. Participants Needed
Each organization must know that it is needed for the success of the cooperative. "It is a major mistake to ever take for granted the participation or commitment of any member. The RWHC communication budget is ample testimony to the importance of early and frequent communication and consultation."

4. All Involved in Planning
The planning is interactive, with the plan for the Cooperative being the result of, and feeding into, the plans of the individual participants. "One theatrical but powerful example of ignoring the need for local input and preferences involved the Cooperative within months of its incorporation in 1979. Two regional health planners were practically driven from the bare wood stage of Wisconsin's historic Al Ringling Theater after their presentation of a unilaterally developed plan for local consolidations and closures. The plan was not implemented and did not contribute to further discussion of how rural healthcare in southern Wisconsin could be improved."

5. Big Picture Understood
Participants need to know where the organization is headed and where they are going within the organization. "RWHC has a motto: 'Say it early and keep saying it.' A number of RWHC's more significant initiatives, such as improving rural hospital access to capital, various quality improvement projects, and advocacy for major education reform within the University of Wisconsin's health professional schools has been multiyear if not indefinitely long efforts."

6. Participants Affect Their Own Future
The desire for local autonomy needs to be made to work for the Cooperative through the promotion of collaborative solutions that enhance self-interest. "When RWHC began operations, many observers were highly skeptical about whether or not it would last, let alone make any real contribution-that rural hospitals' traditional need for autonomy would prevent any meaningful joint activity. Some shared services have been undersubscribed as hospitals have chosen local options when, at least from the perspective of RWHC staff, a cooperative approach offers a better service at a lower cost."

7. Accountability Up Front
Participants must always know up front what the rules are and what is expected of them. "Discussions at RWHC board meetings are frequently comparable to customer focus groups and equally valuable. Participation in all Cooperative shared services requires a signed contract, not so much as to permit legal enforcement, but to ensure that all parties in the partnership have thought through upfront the expectations of all the participants."

8. Decisions Can Be Appealed
A clear non-threatening appeal mechanism is needed to ensure individual rights against arbitrary actions. 'The use of the cooperative strength of RWHC hospitals has been used to enforce an appeals process in a variety of circumstances, including a potential breach of contract by a large health insurer; individually, few could have justified the necessary prolonged legal challenge to enforce the contract but through concerted joint inquiry into the legal options available, further legal action became unnecessary."

In summary, leadership is the capacity to help transform a vision of the future into reality. Individuals who can and will exercise leadership are like a river's current-a part past where we now stand, a part yet to come. We have an ongoing need to remember and to look toward the next 'generation.'

The full text of this article is available at Leadership Development for Rural Health

About
RWHC has been providing affordable and effective services to healthcare organizations since 1979. RWHC is owned and operated by thirty-nine (39) rural acute, general medical-surgical hospitals. The Cooperative's emphasis on developing a collaborative network among both freestanding and system affiliated rural hospitals distinguishes it from alternative approaches. RWHC offers a variety of programs and services to its members as well as to other clients across the nation. RWHC is a current Rural Health Network Development Grantee of the Health Resources and Services Administration, Federal Office of Rural Health Policy. RWHC staff served in early leadership roles and continues to be an active member of NCHN (National Cooperative of Health Networks).

[1] Size T. Special Issue of the North Carolina Medical Journal: Contemporary Issues in Rural Healthcare (in honor of James D. Bernstein), January-February Issue 2006.

[2] Heifitz R, Kania J, Kramer M. Leading Boldly. Social Innovation Review. 2004;Winter:25.

[3] DePree M. Leadership is an Art. New York, NY: Dell 1989.

[4] Greenleaf RK. Servant Leadership. New York, NY: Paulist Press, 1977:60.

[5] Size T. Managing partnerships: The perspective of a rural hospital cooperative. Health Care Manage Rev 1993:18(1):31-41.

The First Rural Health Hackathon

By: Terry Hill, Executive Director, Rural Health Innovations

Last month I spoke at the first rural health care hackathon ever held in the United States. “Hacking Rural Medicine” was sponsored by the Frontier Medicine Better Health Partnership, a network of rural hospitals, and was held on the campus of the University of Montana in Missoula, MT. The concept of the “hackathon” comes from the technology industry, and consists of bringing a diverse group of people together to brainstorm solutions to common problems, to form new teams to pursue solutions, and ultimately to create change and spread innovation. The leader responsible for coming up with the idea and carrying out the implementation of the hackathon process, is Monica Bourgeau, the Frontier Medicine Partnership’s Chief Operating Officer. She was intrigued by the concept, appealed to the Massachusetts Institute of Technology (MIT) for assistance, and then embarked on more than six months of planning to make it happen. MIT was an enthusiastic partner throughout the process and contributed students and other experts to help facilitate the event.

 

Terry Hill

More than 150 participants registered for the Montana hackathon, representing a diverse background and skill set from 15 states. Friday evening was reserved for a full agenda of speakers, with presentations ranging from five to fifteen minutes. I was one of the fortunate few given fifteen minutes to set the rapidly evolving health care landscape. The basic message I conveyed was that transformational change is taking place, moving the health industry from volume- to value-based payment. Rural health providers must begin now to find their place in the changing value-based health system. Other speakers provided a similar message, and still others noted the strengths and assets of rural America, and declared that innovation can be done quicker and better in rural settings.

Saturday saw the participants discussing issues and problems in an open space setting, and then break out into diverse teams to propose solutions and plan action strategies to carry out the associated work. One group, for example, worked on ideas and strategies to generate needed data for population health management. One of the participants commented, “We can’t expect miracles from a three day event, but we’re hoping that some IT innovator will be able to develop a prototype solution to something we've all been wrestling with for months. That’s how progress has come in this industry; one person building on the ideas of another.” Another group, led by primary care physicians, developed strategies to bring joy and meaning back to medicine and other health care work. The idea was that besides the bad outcomes for patients and their communities, health care providers have also fallen victim to a health care system that has been stressful and often led to disillusionment. Ideas ranged from education, to integrative health methods, to teamwork, and mutual support and networking.

Hacking Rural Medicine Attendees

The hackathon is organized like a competition between teams, and on Sunday the nine teams that formed on Saturday presented their plans of action. Judges assessed the innovation and practicality of each team’s proposal and awarded 1st, 2nd, and 3rd place prizes. A crowd’s favorite award was made as well. First place went to the group planning to build a more practical, accessible rural health information database. Organizer, Monica Bourgeau, said the competition was only one fun aspect of a more serious hackathon purpose, “We’re hoping that besides the innovative ideas and action strategies, one of the outcomes of this event will be to begin partnerships and personal connections that will live and produce results long after the event…That’s what’s really exciting to me.”

My own observation is that this Hackathon provides an excellent model of how to bring community stakeholders together to solve urgent rural health problems. Already similar events are being planned in three other states, and it may be something individual rural community hospitals might want to contemplate as well. One of the primary challenges rural hospitals face today is how to most effectively work with their communities and other health providers in their service area. The need is crucial, partially to maximize the use of available hospital services, but also because in a value-based reimbursement system, providers will also be responsible for services outside of their hospitals. And, with the rural hospitals being challenged more than ever before, it’s an ideal time to seek partners, collaborators and innovators from nontraditional sources. The old adage, “All of us” are a lot smarter than any one of us” has never been truer.

For more information about the Hackathon, contact Terry at thill@ruralcenter.org or go to the Hacking Rural Medicine website. 

YouTube Video of Terry Hill’s Opening Keynote 

YouTube Video from Day 3 of the Hackathon and Prizes 

Top Five Reasons Why the Swing Bed Program is Vital to the Long-Term Viability for Critical Access Hospitals and Rural Healthcare

By: Terry J. Hill, Executive Director, Executive Director, Rural Health Innovations, a subsidiary of the National Rural Health Resource Center, a non-profit organization and Mark Lindsay MD, Medical Director, Allevant Solutions

1. Significant Equity Gaps in Rural vs Urban.  Access to healthcare is a basic human right. Rural patients are sicker, more likely to suffer from chronic disease, not only have reduced access to primary care but also specialty care. Eliminating cost-based reimbursement for swing bed services in critical access hospitals (CAHs) would place countless rural facilities at risk of closing, this would not only severely limit access of rural residents to post-acute services but place these residents at risk of losing access to care across the care continuum. The 1997 Budget Act was one of the most important legislative efforts to narrow the tremendous gap in equity that has existed and continues to exist in rural communities as it relates to access and scope of services available. Efforts to return to the prospective payment system for swing bed usage in CAHs undermines the intent of the original legislation and does not acknowledge the present gaps and disparities that continue to exist in U.S. and rural healthcare.

2. It is important to focus on Value Equation, not just cutting costs when contemplating reduction of services in rural healthcare.  Rural healthcare is a very different model of healthcare delivery. The Value Equation takes into account quality, patient safety, service excellence, and cost over time. It is also vital for healthcare delivery to be equitable with adequate access to all. More than half of all post-acute services today are provided in skilled nursing facilities. Although excellent care is provided by many skilled nursing facilities (SNF), Medicare post-acute care literature as a whole reveals CAHs provide higher quality of care than the SNF care setting. CAHs that provide Medicare beneficiaries with post-acute care have demonstrated readmission rates as low as single digits compared to 20% in SNFs (Lindsay 2013). This gap results in with costs in the billions of dollars. Shifting more of these vulnerable patients from CAH swing bed programs to SNFs will not likely result in improved overall value. The Value Equation for CAH swing bed program should be defined by the following:
Value = Quality Outcomes + Patient Safety (culture) + Service Excellence/ Cost over time

3. CAHs Perform Better than Urban Hospitals and SNFs in Important Areas.  CAHS actually outperform SNFs and urban hospitals in virtually every measure in culture of safety and HCAHPS surveys. High quality post-acute care requires teamwork, communication, and collaboration and there is a strong link of clinical outcomes to a positive culture of safety. There is also strong data in the literature that lower nurse staffing ratios are linked to morbidity and mortality. Shifting rural patients from CAH swing bed program (location with highest culture of safety scores and higher staffing ratio) to SNFs (location with lowest culture of safety data and lowest staffing ratios) is not likely to provide higher value. It is important to take into consideration that CAH swing bed patients are potentially sicker than SNF patients and it is more likely that these patients would not likely be accepted by SNFs but would more likely continue to reside in acute care facilities at higher costs associated with a higher specialty mix of providers. CAH swing bed programs have a number of services that are not typically available to SNF patients such as on-site physicians, respiratory therapy, laboratory, radiology, and most importantly the ability to address an acute change in condition. Ouslander reported that more than ½ of the hospital readmissions from SNFs could have prevented if adequate services and processes were in place to address an acute change in condition (Ouslander 2010).

4. Swing Beds Help CAHs Provide Long Term Viability for their Communities. The greatest strength that CAHS provide today is the breadth of primary care services to care for more patients locally across the care continuum. Medicare costs per capita are lower in rural hospitals compared to urban hospitals. One of the challenges that CAHS face today is a shrinking inpatient census. In fact the average daily census in CAHs across the country is under four. The ability to utilize swing beds for CAHS not only reduces the Medicare costs per patient bed day in these facilities, but increases revenues and margins that can help support population health, wellness, and other services. Since 2010, 48 critical access hospitals have closed. Many times CAHs are the primary economic drivers in their communities. Closures not only mean lack of access to quality care or delayed treatment but also loss of jobs.

5. Mayo Post-Acute Care Program, a new model of care focusing on the value of the CAH in the healthcare continuum. The Mayo Post-Acute Care Program was developed in an attempt to address the quality gap that exists with inadequate high quality post-acute care pathways that results in excessive acute care hospital stays, costly readmissions, bottlenecks and reduced acute care hospital flow. The Mayo program established Transitional Care programs in 11 CAHs in MN, WI, and IA and also included ventilator programs in MN and WI. The Mayo Post Acute Care Program resulted in very high quality outcomes, teamwork scores, patient satisfaction, and reduced excessive acute care hospital lengths of stay, readmissions and bottlenecks. CAH swing bed programs have become a preferred discharge destination for Mayo Clinic. The Transitional Care program not only has increased high quality post-acute care pathways but has increased the overall capabilities of the CAH care teams to care for more patients locally across the care continuum. CAHs provide greatest value through breadth of services, allowing majority of patients to be cared for locally, and can be an essential down stream flow for acute hospital complex patients in need of high quality post-acute care, a major gap in our present healthcare system.

Sources: 
Lindsay, M. E. (2013). Mayo post-acute program and care continuum. Patient flow: Reducing delay in healthcare delivery. In R.W. Hall (2nd Ed.), International Series in Operations Research and
Management Science, 206: 447-472.

Ouslander, J. G., Lamb, G., Perloe, M., Givens, J. V. H., Kluge, L., Rutland, T., .Saliba, D. (2010). Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs. Journal of the American Geriatrics Society, 58(4):627-635.

Santa Cruz County Adolescent Wellness Network: Taking integrated vertical networking to a new level

This article was written by Cassalyn David, Network Director, Santa Cruz County Adolescent Wellness Network 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.

Even before the Santa Cruz County Adolescent Wellness Network (AWN) had a name or knew what an integrated vertical network was, it was exemplifying cross-sector collaboration. The first connections began between the schools and community organizations that wanted to eliminate disparities by promoting health literacy and healthy lifestyles for youth.

Early on, network members had ambitions beyond just creating a fitness or health literacy program that would last a few years. They saw the need for a lasting, holistic adolescent wellness infrastructure and wanted to be part of the budding nationwide movement for youth empowerment. Grant funding for school health initiatives can be very ephemeral and narrowly service-focused, so the Rural Health Network Development Grant Program has been key to AWN sustainability. With Federal Office of Rural Health Policy (FORHP) support and connections to other rural health networks and national resources, AWN has been able to set and achieve ambitious goals for our infrastructure and services. We could not have accomplished this if we had continued to work in silos. Our broad and well-connected coalition has been our key to success.

Member connections
Since we operate in a rural, small town atmosphere, it is both possible and necessary to have members that are well-connected throughout the community. Chris Bachelier, the representative from the County Superintendent of Schools, has been with the network from the very beginning. She is central to our school partnerships, serving as our liaison with every level of the school system. Through her we have fantastic buy-in from the County Superintendent of Schools, connections with all of the health and wellness programs housed in her office, and personal connections with individual school administrators and health and fitness staff.

Chris has facilitated many of the Network's key projects. Teachers, school health staff, and administrators are some of the busiest people I know, but Chris knows how to find time with them. For our school-linked health care planning, Chris helps the Network understand school and district-level needs and constraints. In order for AWN to reach our goals for school-primary care linkages, we need to be listening to everyone from the front-line service providers to the Superintendent. She conducted key informant interviews with school health staff that answered many of our questions. It was inspiring to hear about the service these nurses and nurse aides provide their students and validated many of the ideas we had about ways we could make their jobs easier. They know it is best in the long run if you can serve the 'whole child,' because they see every day how social and environmental factors are impacting student health. We learned about the challenges families face in accessing health and social services, and are working to create a seamless system of referrals across these disciplines.

Organizational culture
Every organization has its own systems and culture, and AWN has the additional layer of working across disciplines. The challenge for me has been to recognize the differences both between and within health, education and nonprofit service sectors. I actually made the mistake of assuming the three school district boards and administrations would have similar procedures and requirements for our partnership agreements. Fortunately, my members are experienced and supportive.

Talented evaluation
Another advantage for AWN is having an experienced evaluator. Rebecca Drummond is the Program Director for Family Wellness at the University of Arizona Mel and Enid Zuckerman College of Public Health. Rebecca has unique experience in the realms of coordinated school health and youth health systems, having served on the Board of Directors of the Arizona Public Health Association, chairing the School Health Section, and as a board member and President of the Arizona School Based Health Care Council, a state affiliate of the national School Based Health Alliance.

Both Rebecca and Chris have backgrounds that span health and education, so they are excellent at bridging the disciplines. They can relate to the teachers and be champions for schools' role in student wellness, despite funding and time constraints. This showed when AWN created the first-ever implementation and analysis of School Health Profiles at the county level in Arizona. School Health Profiles is a CDC survey that tracks school health and wellness policies and practices. AWN wanted to know where our local schools stood in comparison to their peer institutions and best practices. Through careful outreach, AWN obtained an excellent response rate. Even the process of distributing the surveys and results helped the school health movement gain momentum in our community.

A long history of integrated vertical networking
As a Network Director, it makes my job easier to have respected member organizations and well-connected representatives to provide wisdom and practical guidance. The impetus that brought partners together from the beginning was supporting schools' health and wellness efforts and creating a holistic paradigm for serving and empowering youth. It would have been more difficult if we had started in a narrow mindset and decided later on to expand to include schools. Our mission, vision, goals and programs were conceived and continue to evolve with this broad coalition at the table. To keep them at the table, we are challenging ourselves to continue providing valuable services for our members and community.

About

The Santa Cruz County Adolescent Wellness Network (AWN) is a group of local agencies that has been working to promote and improve adolescent wellness services through collaboration, education, and advocacy since 2007. The current partner organizations are Mariposa Community Health Center, the lead and fiscal agent, along with Southeast Arizona Area Health Education Center (SEAHEC), Santa Cruz County School Superintendent, Community Intervention Associates, Pinal Hispanic Council, Circles of Peace, and the University of Arizona Cooperative Extension Santa Cruz County. The Arizona State Office of Rural Health provides Technical Assistance. The AWN is a place for partners to collaborate and share resources to identify and respond to adolescent wellness needs. Our mission is to promote adolescent wellness through advocacy, education, and collaboration with schools and community organizations serving youth, ages 12-25. The AWN is funded by a Rural Health Network Development Grant through the Health Resources and Services Administration, Federal Office of Rural Health Policy. AWN has been an active member of NCHN (National Cooperative of Health Networks) since 2010.

Ready…Set…Go! Designing an Effective Practice Search

By Angie LaFlamme, Senior Program Coordinator

Angie wrote this blog post for the National Rural Recruitment and Retention Network (3RNet) blog representing the National Rural Health Resource Center as the Minnesota Member of 3RNet.

When should I start my job search? This may be the question I am most asked from physician residents and advanced practice provider students. The answer is…right now! Although you may not want to begin site visits until closer to the end of your training, it’s never too early to begin thinking about what type of practice you want to have, as well as the community in which you want to live. By starting your job search early, and knowing what to pay attention to during your residency internships and student rotations, you will be better equipped to begin your practice search.

A really great way to begin determining your preferences is to create a list of “Must Haves”. These are details about both a practice and a community that you feel strongly about and will help frame your job search.

Practice Setting

Determine what type of practice setting that interests you; private or group practice, single specialty or multispecialty group. Maybe a hospital or an academic setting is more appealing to you. Keep in mind each of these practice settings will offer a different type of work experience.

Workplace Culture

Do you have any religious or ethical considerations? Do you want to work with a particular patient mix, how busy do you want to be and is the practice compatible with your family situation? Perhaps you’re interested in finding a group of older, more experienced physicians who can be a mentor or would you prefer a younger physician group who may share similar interests and values? Also, be sure to ask about provider satisfaction within the practice.

Geographic Location

Define what you want and need in a community with regard to housing, schools, shopping, entertainment and recreational activities. When it comes to your location preference, it’s imperative to have a clear understanding of what you like to do and where you want to live.

Technology

Understand how technology is transforming health care. Recognize the various types of technology that you anticipate needing.

Compensation

With the amount of educational debt that new providers have, this may seem like it should be the most significant item on your list. And while I agree that this area is important, I want to stress that it shouldn’t be the most influential. Never pre-select practice sites on compensation alone, as money shouldn’t be a factor until you’ve completed your site visits and are offered a job. It’s also important to consider the entire compensation package. This includes salary, incentives, benefits and signing bonus, etc.

Now that you’ve determined your list of “Must Haves”, you are ready to begin your practice search and site visits. Once you’ve narrowed your search to a handful of communities/facilities that you’d like to visit, there is much to consider to effectively evaluate each opportunity. Here is a list of areas to explore and assess:

Services

Will you have access to services such as x-ray, lab, home health, hospice, physical therapy, occupational therapy, chiropractic, speech therapy, etc.?

Patient Volume

How busy is the practice? Can you see patients at your own pace or will you be expected to see a certain number of patients per day?

Formal Relationships

Are there any agreements in place in regard to specialist referrals? Is there a particular hospital that you must admit to?

Specialists

Are there specialists employed by the facility or are their visiting specialists?  Does the facility utilize tele-medicine for any of their specialty care?

Care Coordination

Is the clinic a certified health care home? What is the clinic’s team approach to care coordination within the community? Learn how their focus on patient centered care across the continuum of health care has supported their patient’s quality of care.

Technology/Electronic Health Record (EHR)

Where is the practice at in implementing their electronic health record and are they meeting the Meaningful Use criteria? Do they have a health information technology team and/or any physician champions? What are they doing to increase patient engagement? Are they utilizing data from the EHR for quality or process improvement activities? Does the facility utilize any telemedicine services? How about the use of mobile devices? Mobile devices have transformed many aspects of clinical practice and have become the commonplace in many health care settings.

Affiliations/Networks

Is the clinic affiliated with a health system or part of a network? These types of relationships can provide additional resources, education, experts, equipment and financing.

Infrastructure

What is the condition of the facility? Are there any recent or pending renovations in progress? Is there adequate space, equipment and staff?

Performance Expectations

What is the scope of practice required? What is the call schedule and is it equitable among all providers? Are the any supervisory or administrative duties required of you? Is the facility a preceptor site?

Organizational Structure

Is the practice physician-owned or health system? Who manages clinic operations and how is the organization governed? Is there a medical director and/or a board of directors? Who will do your performance reviews and approve your time off?

As you consider everything involved in finding the right practice opportunity, the key is to start early. The process is relatively time consuming so take the time necessary to create your vision of “must haves” and then ensure that it corresponds with reality. And remember…interviewing is an ideal opportunity for you to learn about new employment opportunities, visit new geographic areas and meet new people. Use these visits as your compass in selecting the perfect practice.

For more information on beginning your practice search contact Angie LaFlamme at 218-727-9390, ext. 222 or visit the National Rural Health Resource Center website.

Telehealth...Friend of Foe?

This article was written by Toniann Richard, Executive Director, Health Care Collaborative of Rural Missouri 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.

At the Health Care Collaborative of Rural Missouri (HCC), having encountered both challenges and successes, we unequivocally say Friend!

The HCC is a rural health network, committed to improving the health status of underserved populations in a three county area. HCC was formally established in 2006 following a three year period of working informally together to address area health care needs. The purpose was to ensure that the health care needs of all citizens in our service area were met, particularly the needs of the under- and uninsured. Since forming, our focus has been to develop and implement programs that are responsive to the documented health needs of county residents, with specific health status indicators as benchmarks for progress on addressing those needs. Of course, this was how we embarked on our telehealth journey in 2011.

HCC applied for and received a United States Department of Agriculture (USDA) Distance Learning and Technology grant with network partner Lafayette Regional Health Center (a critical access hospital). We purchased several telehealth units for the rural health clinics as well as one for the emergency department and outpatient clinic. The initial project was focused on integration of mental health services with HCC's network partner Pathways Community Health, a Community Mental Health Center.

Initially we had several bumps in the road. Let's start with the obvious...high speed internet. Our network is located in a very rural part of Missouri - think dial-up connectivity. So, step one was finding a connection that was both fast enough and affordable for all of our partners. We began by partnering with an information technology vendor who understood the value of purchasing connectivity in rural Missouri. We then applied for Universal Service Administrative Company funding and were granted reduced-cost connectivity.

With the connectivity problem overcome, we developed another problem...firewalls. The point-to-point connection from A to B was a much bigger hurdle than we could imagine. There were two firewalls, along with the bridge firewall at the HCC office. It took three information technology consultants, a technology vendor and multiple staff from the network and network members to get the problem solved, multiple times. Each time the firewall changed for the members, we had to bring the consultant team back together to troubleshoot the problem yet again. It is an ongoing challenge for us, but we have learned how to work together to meet the requirements for connectivity.

The next phase of our project was even more interesting. HCC had made a decision in 2012 to apply for a new access point (Community Health Center) funding for our network. HCC was awarded this designation in late 2013 and one of our first orders of business was to launch our own telehealth project, which focused on behavioral health. We were so excited to launch this program because there is a major lack of mental health providers in our area and psychiatry is definitely a major shortage. We partnered with long-term friend of HCC, Pathways Community Mental Health, for a behavioral health consultant (face-to-face) and a psychiatrist (telehealth). As a result, Pathways is paving the way for telehealth statewide. On average, they currently do 3,000 telehealth visits per month with over 30 of those visits being for HCC.

You must be asking yourself, "But what do the patients think?" Well, I am glad you asked! Pathways conducts annual patient satisfaction surveys with their telehealth patients. We were proud to learn that their overall satisfaction was over 90% and over 20% would choose telehealth as their form of treatment. This tells us that telehealth is being accepted more and more across rural America.

Last but never least, during implementation we were also working on policy. Senate Bill 262 was introduced in 2012 and passed in 2013. Senate Bill 262 prohibits health carriers from denying coverage for a health care service on the basis that the service was provided through telemedicine if the same service would be covered when delivered in person. This was a major hurdle for rural Missouri and it is one of the areas where Missouri set the tone for the rest of the Midwest.

We look forward to our next step in telehealth, which will be the addition of a new unit at our second health center and plans to develop a comprehensive, vertical telehealth network with our partners.

About HCC

The Health Care Collaborative of Rural Missouri (HCC) has a mission to "Cultivate partnerships and deliver quality health care to strengthen rural communities." Since its inception, the HCC has developed into a comprehensive rural health network, with a wide variety of health, social services and community partners that provide health and wellness prevention and treatment programs for all citizens in our service area, and focused on the health care needs of low-income, under- and uninsured residents. The HCC's strength lies in developing collaborative relationships, utilizing the strengths of individual organizations to develop programs and services that are larger than any one organization. HCC is the first rural health network to receive HRSA's Bureau of Primary Health Care 330 funding to operate a community health center. HCC has been an active member of NCHN (National Cooperative of Health Networks) since 2010.  

  
(Picture source: http://telehealth.med.miami.edu/what-is-telehealth)