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RHQ

Spring 2017

Rural Health Quarterly

HIV/AIDS Fighting the Stigma in Rural America

A Publication of the F. Marie Hall Institute for Rural and Community Health


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MANAGING CHALLENGES & DISPARITIES IN RURAL HEALTH

The 2017 Rural Health at the Crossroads conference in Amarillo, TX will bring together health care professionals from across Texas and Louisiana to learn and network. This year’s conference will focus on ways to manage challenges and disparities in rural health, including telehealth and community health workers.

• • • • • •

Four pre-conference workshops CEUs for CHW instructors and CHWs CEUs for mental health professionals CNEs for nurses, including Ethics Legislative updates for Texas and Louisiana Poster presentations and awards luncheon

Register online before June 1, 2017 to receive the Early Bird discount. Visit our conference web site for more information and updates:

www.CrossroadsConference.us

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CONTENTS //

SPRING 2017 PREDATORY PRICING The U.S. has the highest cost of health care among industrialized countries without the outcomes to match. Could universal pricing move us closer to universal converage?

11

BREAST CARE How the largest health care collaborative project in the Texas Panhandle is saving lives and changing minds.

12-15

BOOK REVIEW: OUT IN THE RURAL The unlikely story of America’s first rural health center.

OUR SPRING ISSUE A FEW WORDS FROM THE PUBLISHER

Over the last several months, those of us at Rural Health Quarterly have enjoyed a wealth of insights that have helped us better connect with the rural health community. Thank you for all your story ideas, your praise and your infectious excitement. We have big plans for upcoming issues of the magazine, so stay tuned. You won’t BILLY U. PHILIPS, JR. be disappointed. One of the important things we learned, for example, is how much readers enjoy RHQ articles that dig deep into complicated issues. If you feel the same, we have quite an issue for you. Our Spring issue explores the rural HIV/AIDS crisis in depth and with heartbreaking clarity. Our new Public Policy editor, Cameron Onks, deftly walks us through the arcane debates behind Medicaid funding caps and the AHCA. Other stories in this issue describe exciting advances in breast care, veterans care, paramedicine and more. On a more somber note, the rural health community lost a dear friend this past month. F. Marie Hall, the benefactor of our institute, was a visionary leader in West Texas who valued excellence and innovation in rural health care. Ms. Hall’s remarkable story deserves to be told in depth, so that’s prescisely what we intend to do in our next issue. Please reach out if you have any of your own stories to share.

~ Dr. Billy U. Philips, Jr. 2  RHQ | RuralHealthQuarterly.com

16

EXPERIENCE RURAL

Medical students cite personal connections with rural residents as a path to better care.

19

ACCIDENTLY RURAL

A first-year doc finds unexpected joy in rural medicine.

20-22

TEACHING HEALTH CENTERS

Decisions made in DC may put rural training in jeopardy.

23-24

MEDICAID FUNDING CAPS? Why states may have to increase eligibility requirements, reduce coverage or shoulder more of the burden.

25-27

COVER: HIV/AIDS IN RURAL AMERICA To fight the virus, we need to fight the stigma, too.

28-34


DEPARTMENTS //

RURAL HEALTH QUARTERLY

Volume 1, No. 2 Spring 2017

Publisher Billy U. Philips, Jr., Ph.D., Executive Vice President and Director of the F. Marie Hall Institute for Rural and Community Health, Lubbock, TX Editor in Chief Scott G. Phillips // RURAL REPORTS 6-10

// RURAL RESEARCH 11-16

Section Editors Debra Flores—Health Education Travis Hanson—Health Technology Catherine Hudson—Rural Research Ronald N. Martin—Behavioral Health Cameron Onks—Public Policy Copy Editor Melanie Clevenger

// HEALTH EDUCATION 19-24

// PUBLIC POLICY 25-35

Research Associate Debra Curti Editorial Assistant Milina Funderburg

// HEALTH TECHNOLOGY 37-40

// BEHAVIORAL HEALTH 41-43

THINKING SMALL

TELEHEALTH FOR VETS

Why states should embrace acute care hospitals with fewer than 15 beds.

Vetstar partners with Texas Tech to bring mental health care to rural veterans.

35

41

TELEMEDICINE TO THE RESCUE

OUR RURAL OPIOID EPIDEMIC

How I learned to stop worrying and love the 1115 Waiver Project.

A professional counselor’s plea for compassion and community involvement.

37-38

42-43

NEXT GEN 911 SERVICE

CONFERENCE CALENDAR

Pilot project employs telemedicine to connect rural EMS to trauma centers.

Catch up on upcoming rural health conferences across the country.

39-40

44

Contributors Kristine Crane Monya De Gordon Gong Becky Jones Michael Ollove Shawn Parrott Dale E. Quinney Rakhshanda Rahman Sharon Rose Contacts and Permissions Email RHQ at RHQ@ttuhsc.edu. For more contact information, visit www.ruralhealthquarterly.com. Rural Health Quarterly is a free publication of the F. Marie Hall Institute for Rural and Community Health at the Texas Tech University Health Sciences Center.

Spring 2017 | RHQ   3


I’M PAUL GEORGE

RHQ Rural Health Quarterly

Rural Health Quarterly (ISSN 2475-5044) is published by the F. Marie Hall Institute for Rural and Community Health, 5307 West Loop 289, Lubbock, TX 79414, and the Texas Tech University Health Sciences Center (TTUHSC). Copyright 2017—F. Marie Hall Institute for Rural and Community Health.

WHEN I WAS SIX

10 ”

The articles published in Rural Health Quarterly do not necessarily reflect the official policies of the F. Marie Hall Institute or of the Texas Tech University Health Sciences Center. Publication of an advertisement is not to be considered endorsement or approval of the product or service. Rural Health Quarterly is published four times a year and distributed without charge upon request to individuals residing in the U.S. meeting subscription criteria as set forth by the publisher. RHQ ADVISORY BOARD

NBA All-Star Paul George

MY MOM HAD A STROKE

Ogechika Alozie, Associate Professor/Chief Medical Informatics Officer, TTUHSC El Paso Paul Fowler, Director, Office of Strategic Initiatives, TTUHSC Coleman Johnson, Special Assistant to the President, TTUHSC Retta Knox, RN, Hart School-Based Health Clinic, Hart, TX Susan McBride, PhD, RN, School of Nursing, TTUHSC

Learn the signs of a stroke F.A.S.T.

Face drooping Arm weakness Speech difficulty Time to call 911

Linda McMurray, Executive Director at TTUHSC Larry Combest Community Health and Wellness Center Will Rodriquez, Senior Managing Director, TTUHSC Dr. Ken Stewart, Director of Community Development Initiatives, ASU, San Angelo, TX

strokeassociation.org

Dr. Julie St. John, Assistant Professor, TTUHSC Abilene Shari Wyatt, Rural Health Specialist, State Office of Rural Health, Texas Department of Agriculture


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RURAL

REPORTS

ALABAMA //

ARIZONA //

During her second day on the job, Alabama Gov. Kay Ivey abolished the state’s Office of Rural Development.

23 percent of American children aged 2 to 5 years have untreated tooth decay, but in Arizona that number is almost doubled. Among the more rural Hispanic and Native American populations of Northern Arizona the number is even higher.

The shuttered office had garnered attention for implementing the state’s new Baby Box Program to combat Sudden Unexpected Infant Death Syndrome. al.com | 04.12.17

ALASKA //

pbcommercial.com | 03.30.17

ARKANSAS //

RURAL HEALTH REPORTING FROM ACROSS THE NATION AND AROUND THE WORLD

CALIFORNIA // Families in California’s Central Valley are sounding the alarm about the risk of pesticide poisoning after the Trump administration reverses the EPA’s agricultural ban on chlorpyrifos.

Alaska Governor Bill Walker has declared a public health crisis in order to combat the state’s opioid epidemic. The declaration establishes a statewide Overdose Response Program and enables wide distribution of the life-saving drug naloxone, or Narcan.

Arkansas lawmakers have voted to move 60,000 people off the state’s Medicaid expansion plan and adds a work requirement for some others. The proposed changes will lower the eligibility cap from 138 percent of the federal poverty level to 100 percent.

A growing body of research on the pesticide documents the risks for farmworkers and communities. Chlorpyrifos exposure has been linked to autism, lower IQs, and memory problems as well as decreased lung function and reduced fertility.

alaska.gov | 02.15.17

usnews.com | 03.02.17

theguardian.com | 04.17.17

HILDALGO, MEXICO

HARARE, ZIMBABWE UNICEF has donated over 3,000 bicycles to village health workers in Zimbabwe to scale up integrated maternal, neo-natal and child health care for those living in rural areas and hard to reach communities. zimditvnews.com | 04.04.17

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KAIKOURA, NEW ZEALAND

The residents of rural communities in Hidalgo state, north of Mexico City, report multiple diseases ranging from birth defects to conjunctivitis, which they attribute to water pollution caused by sewage from Mexico City being pumped directly into their water reservoir.

New Zealand announced that another $500,000 would be going into Kaikoura and other affected regions to help residents deal with the ongoing trauma of the November 14, 2016 earthquake. The funds go towards free GP visits, support for schools and extending a wellbeing campaign to rural areas.

As many as a quarter of the children born into the 21 lakeside communities have birth defects. Local government has not yet acknowledged any link.

After the earthquake, the Government released a $3.7 million relief package, a fraction of the $12.8m requested by the Canterbury District Health Board.

trtworld.com | 04.12.17

stuff.co.nz | 04.21.17

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What’s news in your neck of the woods? Let us know: Email: Email your rural health news to RHQ at RHQ@ttuhsc.edu

U.S. Mail: Rural Health Quarterly, F. Marie Hall Institute for Rural & Community Health, 5307 West Loop 289, St. 301 Lubbock, Texas 79414

Voicemail: Prefer to call? Leave us a message at (806) 743-9891 FAX: (806) 743-7953

Web: Find more RHQ contacts at ruralhealthquarterly.com or follow us on Facebook at facebook.com/RuralHealthQuarterly.

COLORADO //

HAWAII //

Colorado is bracing for large cuts to rural hospitals as state hospitals face a reduction of up to $390 million in Medicaid funding under a fee Gov. John Hickenlooper suggested in his 2017-2018 budget plan.

Hawaii State Department of Health has issued a fine against the Department of Agriculture for unlawful discharge of animal and human wastewater from their Halawa facility to Halawa Stream.

Critics call the proposed budget cut “unprecedented” and worry that it will result in the collapse of rural hospitals across the state. coloradoindependent.com | 03.09.17

GEORGIA // Yet another rural Georgia hospital, Jenkins Medical Center in Millen, is shutting its doors. Located in one of the state’s poorest counties, Jenkins is the eighth acute care rural hospital to shutter in Georgia since 2010.

Hawaii.gov | 03.22.17

IDAHO //

National Endowment for the Arts is working with the Rural Veterans TeleRehabilitation Initiative to reach patients in rural Florida. The “Creative Forces” program provides arts therapies for veterans dealing with traumatic brain injuries and PTSD.

Georgia declined to expand Medicaid after passage of the ACA, leaving the county rife with uninsured patients. The nearest facility with an emergency room is now in Screven County 20 miles away.

The Lost Rivers Medical Center in Arco, Idaho nearly shut its doors in 2013, but new management has secured financing to help pay for more advanced technology, upgraded facilities and expanded services. The 14-bed hospital serves all of rural Butte County’s 2,501 residents.

broadwayworld.com | 03.28.17

myajc.com | 04.27.17

ktvb.com | 04.27.17

HONIARA, SOLOMON ISLANDS

EDINBURGH, SCOTLAND

FLORIDA //

CHENNAI, INDIA Chennai, a city on the Bay of Bengal in eastern India, is setting up telemedicine centres in surrounding rural areas to allow patients to have consultations with specialist doctors. The initiative will also help collect lab reports and share blood availability status with government hospitals. The number of doctors available per 10,000 people in India is just six, well below the average for most developed countries.

The Solomon Island Ministry of Health has pledged to build new rural health clinics and surgical centers across the archipelago. Currently, only 30% of island births happen at the National Referral Hospital.

A “Support in Mind Scotland” survey has shined a light on mental health problems in Scotland’s isolated rural communities. William and Kate boosted the public profile of mental health this year with their Heads Together campaign.

newswise.com | 10.12.16

who.int | 03.01.17

fginsight.com | 04.28.17 Spring 2017 WINTER SPRING 2017| |RHQ RHQ     77


Rural Reports // ILLINOIS //

MARYLAND //

A recent proposal by Mercyhealth to build a 13-bed “microhospital” in northern Illinois would be a first for this concept in the state, but it’s drawing fierce blowback from neighboring rivals worried about losing patients.

A bill that could expand telemedicine to include counseling for substance abuse disorders is advancing in the Maryland General Assembly. Opioid-related deaths in Maryland have doubled since 2011, and the epidemic is particularly bad in more remote regions of the state.

modernhealthcare.com | 04.24.17

INDIANA // The Indiana Office of Community and Rural Affairs and Purdue University have produced an online data platform called Rural Indiana Stats. Resources available include the economic, health and cultural attributes of rural Indiana counties. tribstar.com | 04.04.17

IOWA // Iowa’s HIV plan for rural areas has been praised in a HHS report and is now a national case study on how to effectively meet the needs of rural residents with HIV. About a third of Iowa residents living with HIV/AIDS live in rural areas. thegazette.com | 03.24.17

KENTUCKY //

cnsmaryland.org | 03.31.17 The least healthy county in the U.S. is in Kentucky, according to the 2017 County Health Rankings recently released by the Robert Wood Johnson Foundation. Of the 30 factors the foundation considered when ranking counties, Breathitt County in eastern Kentucky was ranked last in health outcomes and Clay County was last in overall health risk factors. cnbc.com | 03.29.17

LOUISIANA// Citing “high barriers set before poor, rural, and disadvantaged women,” a federal judge blocked a law that would have led to the closure of two of Louisiana’s last three abortion clinics. news.vice.com | 04.26.17

MAINE //

University of Kansas Health System will pilot a new mobile health app that reduces medical error in cases of cardiac arrest, stroke and sepsis to serve select rural Kansas hospitals. The app offers step-by-step protocols for care. anchoragepress.com | 04.04.17

nytimes.com | 03.27.17

8  RHQ | RuralHealthQuarterly.com

Nurses and union workers from across Franklin County, Mass. walked a picket line together amid ongoing contract negotiations with the Baystate Franklin Medical Center. The hospital is ranked as one of the top 100 rural hospitals in the country by the Chartis Center for Rural Health. recorder.com | 04.27.17

The shortage of E.M.T.s needed to serve Maine’s rapidly aging population has created a bit of a crisis in the state, but an unusual program is turning that crisis into opportunity. Southern Maine Community College is training underemployed immigrants to become emergency medical technicians.

KANSAS //

MASSACHUSETTS //

MICHIGAN // The water quality in Flint has been of high interest in recent years, but rural areas around the state are also struggling to provide safe drinking water. Michigan leads the nation in number of private wells, and officials from the Michigan Department of Environmental Quality report levels of lead near or above the action level across the state. greatlakesecho.org | 02.21.17


MINNESOTA // A report from the Minnesota Hospital Association shows that rural hospitals across the state repeatedly lagged those in urban areas in terms of median operating income from 2012 to 2015. Whereas the median operating margin for rural hospitals during the time period ranged from 0.2 percent to 2.4 percent, the median margin for urban hospitals ranged from 3.2 percent to 4.2 percent. startribune.com | 03.24.17

MONTANA //

NEW MEXICO //

Montana lawmakers have rejected a $400,000 request to expand a state program to train doctors. Seventeen Montana counties have no primary-care physicians. Doctors said the money would be used to expand training in rural areas and to establish a psychiatry residency.

Primary care providers from 10 rural health care centers in New Mexico were recently connected with endocrinologists, nurses, diabetes educators and others in order to become local experts at managing complex diabetes at their centers.

greatfallstribune.com | O2.20.17

NEBRASKA // Nebraskans worry an attempt to slash funding for abortion providers could force health clinics throughout the state to cut services or close. The proposal could also mean less funding for clinics that specialize in reproductive health but don’t provide abortions. usnews.com | 04.30.17

The “Endo ECHO” program consisted of weekly video conferences and mentoring on specific cases. healio.com | 04.03.17

NEW YORK // New York has enlisted AmeriCorp to help fight rural opioid abuse. Volunteers will partner with The Rural Health Network of South Central New York to connect addicts with services and educate the public. binghamtonhomepage.com | 04.07.17

MISSISSIPPI // NORTH DAKOTA //

The Mississippi Rural Physicians Scholarship program, created in 2007 with the goal of training homegrown physicians to provide care for small towns, is starting to pay dividends. As of April 2017, 11 doctors have graduated from the program and 25 more are expected to begin work this summer. foxnews.com | 04.24.17

NEVADA //

At Children’s Mercy Kansas City, 26 of the hospital’s 47 pediatric specialties are now offered via a telemedicine network that serves rural Missouri.

Advanced practice registered nurses would be authorized to sign myriad health-related forms under a bill heard recently by a Nevada state Senate committee. Senate CoMajority Whip Joyce Woodhous explained that the bill would make the system more efficient, particularly in rural areas.

newsobserver.com | 01.18.17

reviewjournal.com | 03.31.17

MISSOURI //

A University of North Dakota report estimates a potential statewide physician shortage of somewhere between 260 to 360 professionals by 2025. The UND medical school is offering incentives for medical graduates to pursue residencies and careers in rural communities. bismarcktribune.com | 03.24.17

OKLAHOMA // Oklahoma’s current budget deficit could shut down or downgrade the status of as many as 42 rural hospitals in the state. ktul.com | 01.13.17

Spring 2017 | RHQ   9


Rural Reports // PENNSYLVANIA //

WEST VIRGINIA //

State legisalors have re-introduced a bill that would eliminate the requirement that Pennsylvania nurse practitioners get business contracts with doctors before treating patients on their own. Proponents say the aim of the bill is to make primary care more accessible to residents, particularly in rural areas.

A $1.3M grant awarded to Marshall University will support more than two dozen community health workers who will work with high-risk diabetes patients in coal country. Partners in the grant are health insurance companies, with the long-term goal of providing reimbursement that sustains community health workers’ employment.

The PA Medical Society, which represents the state’s physicians, opposes the bill. wearecentralpa.com | 03.21.17

SOUTH DAKOTA // Dr. Marlys Luebke has been named the South Dakota Academy of Family Physicians 2017 Family Doctor of the Year. She is the first woman to receive the honor. Dr. Luebke champions the expanded use of telemedicine to provide care to remote areas of the state. grandforksherald.com | 02.24.17

TENNESSEE // According to a recent report from the Tennessee Hospital Association, 61 hospitals are among the largest employers in rural parts of the state. In Hancock County, one of the least wealthy counties in the state, the hospital employed 34 people who earned $1.7 million in income in 2015. The 61 hospitals have a combined economic impact of $994.7 million and support 15,654 jobs. tennessean.com | 03.31.17

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TEXAS // The Texas House approved a bill that would require health insurance providers to offer the same coverage and benefits for mental health and substance abuse conditions as they do for medical and surgical care. Lawmakers have pledged to make serious changes to how the state offers mental health services, particularly in rural communities. dallasnews.com | 04.05.17

UTAH // The Georgetown Center for Children and Families and the National Council of La Raza reports that 23.4 percent of Hispanic children in Utah are uninsured — that’s nearly two and a half times the national rate. kutv.com | 04.04.17

VIRGINIA //

herald-dispatch.com | 02.04.17

WISCONSIN // Wisconsin state legislators have proposed a package of legislation to support the state’s rural residents. The Rural Wisconsin Initiative includes programs to support economic development, education, broadband expansion, workforce training and rural health care. hhnmag.com | 04.10.17

WYOMING // The Wyoming Health Department will use tobacco settlement funds to fund suicide prevention training since the Wyoming Legislature cut a large portion of suicide and substance abuse prevention money in the 2017 session.

Researchers at the University of Virginia School of Medicine are are testing an online program called Pos4Health to reach people living in rural areas of the state who are failing to take their HIV medications. The program addresses the need for social support when living with HIV.

Wyoming has long had one of the highest suicide rates in the country. Experts have offered various explanations for the high numbers, from the state’s independent culture — which they say can discourage people from asking for help — to limited resources in rural communities.

virginia.edu | 03.21.17

trib.com | 04.28.17

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Rural Research //

NEGOTIATING DRUG PRICES

PREDATORY PRICING C THE U.S. HAS THE HIGHEST COST OF HEALTH CARE AMONG INDUSTRIAL COUNTRIES WITHOUT THE HEALTH CARE OUTCOMES TO MATCH. COULD UNIVERSAL PRICING MOVE US CLOSER TO UNIVERSAL CONVERAGE?

Obamacare was designed to make health care affordable. Ironically, premiums for health insurance increased by 25 percent in 2017, much higher than the increase (7.5 percent) in 2015, and the problem is particularly pronounced in rural areas of the country. Now the GOP is debating a new health care bill, but no one seems confident that it can make it through both houses of Congress. While politicians Dr. Gordon Gong from both parties continue to argue about who should pay BIOSTATISTICIAN America’s health care bills, few have focused on the crux of F. Marie Hall Institute the issue: the high cost of care. for Rural and Community Health care costs increased 63 percent from 2011 to 2016 Health, Texas Tech Univerwhile worker’s earnings and inflation increased only 19 persity Health Sciences Center cent and 6 percent, respectively. From 1999 to 2009, health insurance premiums went up 131 percent. The current political climate provides an opportunity for health care reform research that focuses, first and foremost, on controlling the cost of health care. Steven Weissman, a former hospital president in Florida, sent President Trump a petition to end predatory pricing in the healthcare industry. “The biggest problem in healthcare is that there is no pricing at all,” Weissman said. For example, a lab may charge $10 or $400 for the same blood test, and a bill for hospitalization for chest pain can range from $3,000 to $25,000 or more. The price, Wiseman said, is based on how much money hospitals can shake out of their patients’ pockets. We have the highest cost of health care among industrial countries but our outcomes are well below the average. Americans pay more than two-and-a-half times the average of 33 developed countries, according to HuffPost contributor Peter Emerson, and our life expectancy is lower than many of them. If we cut costs by half, then the two parties may stop fighting. Americans may be willing to provide care to everyone, including the poor, if the costs are not too high for the middle class to cover themselves. Jimmy Williams, Acting Director of the Office of Payer and Provider Relations at the Texas Tech University Health Sciences Center, agrees that there is really no such thing as universal pricing anywhere in the U.S. Two hospitals in the same city may charge different prices for the same service, although the price is typically the same for all patients within a hospital. Williams concedes that, in general, U.S. hospitals charge patients too much. It is more reasonable, he says, for everyone in the U.S. to pay medical services at the current Medicare (if not Medicaid) rate. Research on health care cost controls is needed. LabCorp, which provides lab test for the whole of the U.S., may provide us with a good model for uniform pricing. Reducing the number of U.S. insurers to single digits might also help by reducing administrative costs while keeping competition in the market. The expansion of telemedicine and community health workers in the health care workforce might also reduce health care costs. One thing is clear. If the health care industry does not address the ever-rising cost of care, Washington will almost certainly do it for them.

BY CARMEN HEREDIA RODRIGUEZ, KAISER HEALTH NEWS

iting budget-busting drug costs, a California lawmaker wants state health programs to band together to negotiate better prices with drug companies. Assemblymember David Chiu (D-San Francisco) has introduced a bill that would strengthen intra-agency collaboration on drug cost-saving strategies.

“Californians and Americans are frustrated with the lack of progress around drug prices,” Chiu said, citing the uproar over EpiPen and hepatitis C medications. He said state agencies should pool their efforts “so that we can leverage that consumer power and get the best deal for our money.” While the proposed California Drug Costs Reduction Act does not mandate that various California health programs such as Medi-Cal or Covered California purchase drugs together, it would require administrators of those programs and 17 other state agencies to convene twice a year to strategize about ways to keep costs down. Through the California Pharmaceutical Collaborative (CPC), state officials would consider a uniform state drug formulary and look at paying for drugs based on the value they bring to the health system. The proposal so far has no registered opposition. Priscilla VanderVeer, a spokeswoman with the drug company trade association Pharmaceutical Research and Manufacturers of America (PhRMA) had no comment on the proposal. Other states such as Massachusetts have bulk purchasing programs for drugs, according to the National Academy for State Health Policy. And Oregon and Washington have joined together to create a bulk purchasing program. It is one of five multi-state pharmaceutical programs in the country, according to the National Conference of State Legislatures.

WINTER 2017 | RHQ   11 WINTER Spring 2017 SPRING WINTER 2017| |RHQ RHQ     11 11


Rural Research //

ACCESS TO BREAST CARE FOR

WEST TEXAS

ABC4WT

OVERVIEW // THE ABC4WT PROJECT The Access to Breast Care for West Texas (ABC4WT) project conducted by the Texas Tech University Health Sciences Center Breast Center of Excellence targets the underserved and underinsured population of the the Council of Government 1 region of West Texas for delivery of breast health education, screening, and comprehensive cancer care. The project has matured into a comprehensive community-wide collaboration that lends itself to development of a replication model for statewide dissemination and implementation.

B

BY RAKHSHANDA RAHMAN, M.D., ET AL.

reast cancer is the most commonly diagnosed cancer among women in the United States irrespective of ethnicity, the most common cause of death from cancer in Hispanic women, and second most common cause of cancer deaths among all other ethnicities. In 2012, the incidence of breast cancer in Texas was 110.8/100,000 and mortality rate was 21.11/100,000 according to the Center for Disease control1 and Texas cancer registry. These numbers are worse for the Council of Government 1 (COG-1), which was the target area for the original Access to Breast Care for West Texas (ABC4WT) project. The ABC4WT project was designed specifically for the COG-1 milieu of the Texas Panhandle. This community is largely comprised of medically underserved communities facing ethnic (specifically Hispanic), socioeconomic, and geographic barriers that compromise access to healthcare and result in low rates of mammographic screening leading to late stage diagnosis. Initially funded by CPRIT in 2010, ABC4WT received continuation funding in 2014 to add cervical cancer screening. The success of the ABC4WT project has led to a dissemination effort so that other regions can replicate the project in their communities and reduce the disease burden from breast cancer.

// SECRETS TO SUCCESS

EFFECTIVENESS OF THE ABC4WT PROJECT

The strengths of the ABC4WT project lie in specific strategies which focused on development of comprehensive community-publicprivate partnerships to bridge knowledge/awareness gaps at the community level, access barriers at the ‘for-profit’ and ‘non-profit’ provider level, and delivery systems gaps at the processes and accountability structure level. The successfully implemented evidence-based strategies that form the basis of the ABC4WT replication model fall into two categories: community engagement (to address knowledge gaps, cultural milieu, and attitude towards breast health) and collaborative public/private partnerships (to address access gaps).

The ABC4WT project is the largest healthcare collaborative project in the Texas Panhandle, comprised of extensive partnerships between one multi-campus university (Texas Tech University Health Sciences Center), 7 community-based organizations, and 10 private service providers throughout the 26 counties of the COG-1 via contracts, memoranda of understanding and informal networks. These partnerships have resulted in a breast healthcare delivery system that is credited with a significant drop in late stage of breast cancer at diagnosis in the area.

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REPLICATION AND SCALABILITY The breast healthcare delivery system established by the ABC4WT project via extensive community-public-private partnerships has generated several components that can be packaged for replication not only for breast health programs across Texas, but are also scalable to other healthcare needs that disparately affect the underserved communities. The uniqueness of this project is its comprehensive nature that addresses the entire spectrum of breast healthcare including education, prevention, screen-


AWARENESS AND EDUCATION // The impact of ABC4WT project in the Texas Panhandle includes an increase in knowledge of breast cancer risk factors and common breast symptoms, an increase in awareness regarding available resources and an increased understanding of the relationship between early detection and better treatment outcomes. The impact also includes the transfer of knowledge to peers and the next generation.

// 18,921 DIRECT CONTACTS BREAST CANCER DISEASE BURDEN // Another critical impact of ABC4WT project includes an increase in the breast cancer screening rate and in the use of preventive counseling and preventive therapy. The region also saw a decrease in late-stage diagnosis and an increase in the rate of trial participation by breast cancer patients.

// 4,902 MAMMOGRAMS & DIAGNOSTIC SERVICES SYSTEMS CHANGES // The ABC4WT project also resulted in the establishment of an Interdisciplinary Breast Fellowship program, a mobile clinics to offer service in targeted locations such as homeless shelters, an increase in specialty consult clinics in distant counties and a reduced no show rate from 47% to 14.7% for screening.

// 58 PRECURSORS AND CANCERS DIAGNOSED INTANGIBLE OUTCOMES// The success of the ABC4WT project also results in some benefits that are harder to quantify. Namely, an increase in trust between public, private, and community organizations; an increase in community pride and focus on the principle of self help; the development of new networks and partnerships for a variety of community-based projects; and a reduction in health care disparities in an oft-neglected and underserved region.

// 26 COUNTIES SERVED Spring 2017 | RHQ   13


ing, multidisciplinary cancer care, and survivorship with inclusion of quality of life concerns and research participation with a specific focus on the barriers faced by underserved populations. More importantly, this model prospectively tracks each patient served until final disposition. Reaching underserved populations with the end goal of increasing screening rates that translate into reduction in mortality is challenging at best. Organizations and institutions catering to populations with the highest needs often do not have the resources to design, test, and implement new programs addressing these concerns. An evidence-based replication model such as the ABC4WT project guide would allow these institutions and organizations to offer comprehensive services to their communities with minimal trial and error, maximal cost effectiveness and access to experienced personnel for training and troubleshooting while being able to measure the impact of their program. The ABC4WT project has been active in the Texas Panhandle since August of 2010 and has resulted in lowering the late stage of breast cancer at diagnosis and an increase in the screening compliance rate from 57% to 59.2%. Overall, ABC4WT made 1.6 million indirect contacts and almost 19,000 direct contacts through publicprivate-community level partnership during last 5 years as a result of the coalition training and process maps that we propose as replicable products. These processes provided almost 5,000 clinical services, and detected over 1,000 abnormalities in this vulnerable underserved population. Most importantly, the 58 cancers that were diagnosed and had no funding for treatment were appropriately connected with resources and each received comprehensive multidisciplinary cancer care and survivorship by the program institution with 54% clinical trial participation and 100% follow up. The project team is ready to build dissemination products out of this project based on principles of dissemination. 14  RHQ | RuralHealthQuarterly.com

In 1962, Rogers published his standard work “Diffusions of Innovations”. A literature review on dissemination of health care innovations by Van der Linden showed that this book, reprinted in 1971, 1983, and 1995, is still leading subsequent papers and books in this field. That is why in the beginning of our research we used Rogers’ concepts and models to address known issues with dissemination of health care innovations. Rogers distinguishes five critical factors with influence on the speed of diffusion: 1. Relative advantage 2. Compatibility 3. Simplicity 4. Trial ability 5. Observability The first factor relates to the relative advantage for the professional who uses the innovation. As mentioned above, the areas serving the most underserved populations are least equipped with resources to develop innovative projects. Therefore, a successfully piloted project with accessible resources offers a relative advantage for professionals in these regions. The second factor is the degree with which the innovation is applicable within the existing organizational structure. Since our model is a partnership between several different organizations, it lends itself to be adjusted in a variety of organizational structures, and is in fact, the strongest component of our model. The third factor is the simplicity of the innovation: are a few or many factors and processes involved to diffuse the innovation? The strength of this proposal is that it can be adjusted to any scale, small or large, depending on the goal of the end-user. It is important to note, however, the community-public-private partnerships remain the cornerstone of this proposal. Trial ability, the fourth factor, has to do with whether the innovation can be diffused in small steps versus major reorganization of the system. TTUHSC has already successfully replicated the model with a second service of cervical health in the Texas Panhandle (trial with a new service) and on another campus, San Angelo

1.6 MILLION Indirect Contacts *social media, TV, radio, newspapers and newsletters

(trial with a new geography /population). The fifth factor, observability, relates to the degree the effects of the innovation are visible for professionals. The prospective electronic data tracking is an important component of the proposed project which would allow for measurable outcomes. Keeping these factors in mind, several strategies are recommended for development of a successful dissemination product. These strategies have been assembled in a dissemination planning tool by the Agency for Healthcare Research and Quality (AHRQ). The components of the ABC4WT replication model are developed utilizing the “Dissemination Planning Tool” proposed by AHRQ as follows:

DISSEMINATION PRODUCTS ABC4WT offers a comprehensive program utilizing multiple platforms for end users. For the purpose of developing a replication model, specific products are identified to be developed with two main objectives: (i) addressing Roger’s critical factors for successful dissemination mentioned above, and (ii) applicability to priority areas of greatest need such as geographic and/or financial disparities pertaining to cancer incidence and mortality, to target the underserved populations. COALITION BUILDING TRAINING The ABC4WT coalition was built on several evidence-based strategies such as the “Six Thinking Hats System” designed by Edward De Bono for group discussion and individual thinking involving six colored hats that utilize the principles of parallel thinking for groups to plan projects or proposals in a detailed and cohesive way, aiding the development of common vision and strategies. This module will be


packaged as a part of pre-service training and staff selection. Other critical training elements in the ABC4WT project included evidence-based coalition sustenance strategies such as annual refresher training for (i) re-evaluating and simplifying the mission, (ii) team building focusing on flexibility of networking opportunities for stakeholders and customer service mindset, (iii) transformational leadership, (iv) re-evaluation of working structures and process maps with “Hits” and “Misses” approach (v) enhancing satisfaction with coalition activities designed to retain and recruit new partners. These elements will serve as ongoing consultation and coaching, facilitative support for program evaluation, administration, and systems intervention. ABC4WT has expertise in training personnel (Rahman, MD and Felts, M.Ed.), and developing modules that can be packaged as a structured stepwise Coalition Building Training Program. This is the most important aspect of the replication model because community coalitions, composed of a diverse group of community members who are committed to effecting change, are successful in engaging community partners in health improvement. The collaborative work of a coalition is more effective than the efforts of individuals or individual groups because it comprises of partners representing multiple sectors, reduces duplication of effort, and uses various resources to accomplish a common goal. However, we observed during administration of the ABC4WT program that re-messaging and annual training was essential to keep up the tempo, enthusiasm and accountability of the collaborative. This program will also provide the process maps, event checklists, application forms and other resources built by the ABC4WT project. WOMEN INSPIRING, SERVING AND EDUCATING (W.I.S.E) CURRICULUM Several evidence-based approaches were utilized to develop a cadre of women from diverse cultural back-

grounds to enhance breast health education and awareness in the community. Utilizing the local community members as educators to account for cultural nuances from a diverse community is shown to enhance the effectiveness of the message. Consistent with key tenets of community-based participatory research, the ABC4WT project developed a 5-module breast health curriculum at a 6th grade reading level to specifically target the level of understanding and education of the underserved community. This curriculum went through several developmental phases including collecting questions from focus groups; identifying language for consistent understanding; use of appropriate data sharing tools, and testing understanding by 6th grade students. In addition, it specifically focuses on culturally-tailored components (for Hispanic, Somali, and Black communities) as evidence supports that this aids communication and that cultural awareness by the educator can lead to close relationships with attendees. OUTCOME TRACKING DATABASE The actual goal of the entire project is to enhance cancer screening and early detection as well as to complete the loop of care by documenting the final disposition for each patient. Secondarily, it is also important to document the basic demographics of the clientele so that the healthcare delivery systems can be adjusted for needs. Lastly, since these projects are funded by local, state or federal agencies (CPRIT in case of ABC4WT), it is important to gather real time information to ensure appropriate use of resources/funding and for audits to document that the population cited in requisition as the target is indeed the target of the project. This can be an arduous task when dealing with multiple providers across large geographic areas with multiple electronic systems. Data sharing can be a problem if proper HIPAA compliant strategies are not employed. The ABC4WT project has developed a database for tracking information

in real time. It not only allows us to keep track of all outcomes for quarterly reporting but enhances patient care because of the flagging system to track patients until final disposition is entered. The development of this database was a time and resource intensive effort; however, it has made the process of breast healthcare delivery very efficient. In fact, local hospitals often rely on our database for reporting their outreach activities for Commission on Cancer (COC) accreditation.

POTENTIAL END USERS Breast cancer is a public health problem by its sheer incidence and mortality. Therefore, there are several different public, private, and community-based institutions with a common goal of prevention and early detection of breast cancer. The ABC4WT project was developed initially as a community collaborative project and several unorthodox partnerships were created that allow the replication model to be used by a variety of healthcare settings as well as many different types of clinicians and administrators. The ABC4WT replication model can be used in organizational settings such as: (i) Texas-based community organizations, e.g. National Association of Social Workers, Hispanic Health Coalition, Intercultural Cancer Council, Rio Grande Cancer Foundation, Latinos in a Network for Cancer Control, etc., (ii) Government organizations /programs, e.g. Breast and Cervical Cancer Screening program, Delivery of Health Services Reform Incentive Plan etc., (iii) Academic health institutions, e.g. various campuses of Texas Tech University Health Sciences Center and University of Texas etc. The ABC4WT replication model can also be used by professionals such as: (i) clinical specialists, e.g. breast radiologists, family physicians, advanced practiced nurses, breast surgeons, medical oncologists, nurse navigators, primary care physicians etc., (ii) administrators e.g. managers of imaging centers, rural clinic managers, board members of community organizations, clinical practice mangers, etc. Interested end users can contact the Breast Center of Excellence at the Texas Tech Health Sciences Center for replication of our program in your area. Our team and products are ready to assist you every step of the way.

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Spring 2017 | RHQ   15


Rural Research //

OUT IN THE RURAL THE UNLIKELY STORY OF AMERICA’S FIRST COMMUNITY HEALTH CENTER “Few will have the greatness to bend history itself, but each of us can work to change a small portion of events. It is from numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends Catherine Hudson forth a tiny ripple of hope, and crossing each other from a million different DIRECTOR FOR RURAL centers of energy and daring those ripples HEALTH RESEARCH build a current which can sweep down F. Marie Hall Institute the mightiest walls of oppression and for Rural and Community resistance.” Health ~ Robert F. Kennedy

O

ut in the Rural: A Mississippi Health Center and Its War on Poverty is a historical account of the birth of the nation’s community health care program and gives readers a proper introduction to Dr. H. Jack Geiger, founder of the Tufts-Delta Health Center in rural Mississippi. It is a story one man’s vision of health care and how it led to the opening of the first rural community health center (CHC) in America. Set during the civil rights movement, author Thomas J. Ward Jr. takes a look back in time to when America was not so great. A time in America’s history when separate and unequal treatment was the norm. A time when the poorest among us were those who for generations had provided free labor to this country’s economy. A time when many African-Americans in the south had lived beyond their usefulness on farms and plantations and were victims of their circumstances. The book includes many compelling photos, but perhaps the most telling of the times is the one selected for the cover. It provides a haunting glimpse into the living conditions and the plight of the people who were all but invisible. Dr. Geiger saw health and human rights as inseparable, stemming from his experiences as a visiting medical student in South Africa in the 1950s. He used this knowledge to bring health care to impoverished people in Mound Bayou, Mississippi. In Dr. Geiger’s mind, the concept of community health was a merger of public health and clinical medicine, teaching the people how to take a more active role in their own health. War was indeed waged on poverty through this Mississippi Health Center via the approach taken to improve the quality of life of the many sharecroppers in the region. The health center was not only concerned about the health of the people, but it was a launching pad for economic development. The center utilized health services as the route of entry to social

16  RHQ | RuralHealthQuarterly.com

change and addressed issues such as environmental (living) conditions, nutrition, economic attainment and self-sufficiency. Not quite a rags-to-riches story, but Out in the Rural chronicles the development of how a cooperative was formed which empowered the people by giving them the opportunity to earn a living for themselves by teaching them new skills or showing them how to utilize the ones they already possessed. There are now over 9,000 CHC’s in America and it is amazing to think it all started with this one. Out in the Rural is a must read for health professionals and history buffs alike. Thomas J. Ward is the chair of the History Department at Spring Hill College in Mobile, Alabama. He is the author of numerous works on both African-American history and the history of health care, including his first book, Black Physicians in the Jim Crow South. He lives in Spanish Fort, Alabama with his wife and three sons.

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Health Education //

EXPERIENCE RURAL COMMUNITY ENGAGEMENT KEY TO PROVIDING ADOLESCENT MENTAL HEALTH CARE On the Western Slope of Colorado in the North Fork Valley lies a small rural town called Paonia. It’s a small community of just over 1,400 residents rich in history, agriculture, talented athletes and scholarly students alike. I think back to when I grew up in Paonia and, at that time, I could not have PROGRAM MANAGER, told you what set my rural Colorado YOUTH ENGAGEMENT hometown apart from any other rural TRAINING INITIATIVE American community. I never gave F. Marie Hall Institute much thought to the health care of others for Rural and Community beyond my experience that people just Health took care of each other and invested love and energy into each other’s lives. That and the fact that sports was my life, just as I imagine is true for a great many rural teenagers. Sure, we had problems just like everyone else, but I was likely not mature enough to notice or just wasn’t paying attention. Flash forward nearly two decades when I’m passionate about the mental health care of adolescents, especially in rural communities. I think back and honestly couldn’t even tell you if there were counselors in my town. There had to be, right? Nevertheless, I wonder what sets one rural community apart from another when it comes to the mental health of teens. I’m think about small farming communities like Littlefield, Texas, a town situated 36 miles northwest of Lubbock with just over 6,000 residents, more than four times the size of the town I grew up in. Many commonalities exist between Littlefield and Paonia, including a strong commitment to agriculture, community, and natural resources such as oil and coal. But one major difference stands out to me, and it is difficult to understand. According to the Colorado Department of Regulatory Services, Paonia, Colorado boasts at least 15 mental health and substance abuse service providers in its 1,400 resident community, a ratio of 93:1. According to the Texas Department of State Health Services, the over 6,000 resident community of Littlefield, Texas lists only two active mental health and substance abuse service providers. That’s a ratio of over 3000:1. Thinking beyond the city level, Paonia sits in Delta County with near 30,000 residents, including at least 26 more mental health service providers actively listed with CDRS. Lamb County, Texas, however, has over 13,000 total residents and includes only two additional providers for a

total of four in the entire county. Sure, providers could travel from all around to deliver the necessary services to these rural communities, but why is that even the situation we’ve arrived at? Why is Paonia so much different than Littlefield? According to the American Psychological Association, 60% of rural residents live in mental health professional shortage areas. Couple this with the other struggles rural residents face, like the stigma likely to occur based on a lack of anonymity in small towns, and it’s a recipe for adolescent health disparity. Instead of creating barriers to care, we should be exploring ways to break down the barriers that make it so difficult for rural residents to receive the help they desperately need. Why does a small rural Colorado town boast so many more providers than a much larger community in Texas? It can’t be as simple or insignificant as a change of scenery or a pay differential. I’m not sure there are any direct answers to this question. More importantly, I’m not sure debating over the reasons that there are diverse disparities across the country is the best use of our time and energy. Instead, let’s look at solutions for bringing these services to the rural communities of America. At the heart of working with rural communities is engaging with rural community members. The act of engaging with others implies an emotional commitment. It’s one thing to actively engage with people in the process of doing business. What if we took things a step further and remembered that the people are the community? Being a part of that community is essential to having an effective relationship with its members. Take, for example, a medical university in New York whose medical students spent time in rural communities as part of their medical education. They cited connections with community members outside of a clinical setting as a primary means of improving outcomes in rural health care. These avenues of engaging people increase satisfaction on personal and clinical levels. There’s something special about rural communities. What I value most about going back home is that people genuinely care about my wellbeing and take an active interest in my life outside of the services we can provide each other. Perhaps bringing better adolescent health care experiences to rural communities is about experiencing rural community at its roots. Get out there and experience rural community.

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Spring 2017 | RHQ   19


Health Education //

// SHASTA The Shasta profit primary California. A residents of

20  20  RHQ RHQ| |ruralhealthquarterly.com RuralHealthQuarterly.com


A FIRST-YEAR RESIDENT FINDS JOY AFTER A MATCH DAY NIGHTMARE

Accidentally Rural BY MONYA DE, M.D.

A COMMUNITY HEALTH CENTER Community Health Center is a nonhealth care system based in Redding, regional hospital, Shasta serves rural far Northern California.

aron Zaks, a family medicine intern (first-year resident) at Shasta Community Health Center in Redding, CA, did not set out to practice medicine on the Sacramento River, deep in the shadow of the Cascades foothills where Chinook salmon spawn. In his final year at Touro College of Osteopathic Medicine in the California suburb of Vallejo, Zaks had interviewed confidently at several residency programs in urban and suburban areas of California. His goals were simple; make good on his four years of undergrad at UC-Berkeley and his four years of medical school. He wanted a family medicine residency, maybe near home in Benicia—maybe Contra Costa hospital, where he was born. But the annual residency match threw a wrench in all that. The hospitals where Zaks had interviewed had too many qualified candidates, and he ended up with no job for a frightening few days. He had to enter the SOAP (Supplemental Offer and Acceptance Program), an update to the old “Scramble.” Both are essentially a “Hunger Games”-like battle for the scant number of unfilled residency spots in far-flung areas. “You wake up Monday morning,” he remembers. “You have until noon that day to gather your application. At noon it’s sent to all the residencies [that have openings]. Then you start getting calls from various program directors. It’s kind of a lot of big-name people. And they say, “Why do you want to come to Tennessee?”


One of those calls came from the faculty at Shasta Community. Zaks says, “I couldn’t impress anyone else [on the phone] the way I could with them, because I wanted to go to Redding.” He had never lived in a rural community. Still, it was Northern California. He had already experienced the Midwest during a mandatory med school rotation in Tulsa. He wanted to be near home. Before he knew it, Shasta had said yes, and he was packing his bags for a county with a grand total of 178,000 people. “For the first month, I was just trying to keep my head above water,” says Zaks. “Being an intern is significantly more demanding than being a second- or third- year. I work close to 80 hours a week many times.” Luckily, he has several Touro classmates in his intern class, which helped to ease the transition. Most, like Zaks, are from suburban communities. Like all SOAPing medical school graduates, he had to shake off the perceived stigma of being the last chosen for the intern class. “I didn’t tell a lot of people that I SOAPed. I kept it essentially a secret. It was a big thing that I wasn’t proud of.” Living in his new bucolic setting has been healing. “It’s beautiful out here. There’s nature, mountains, skiing in every direction, but Redding’s got a little bit of a city feel to it.” In between long shifts, he runs or hikes. On being a physician for the many rural communities surrounding Shasta, he says, “You think you’d see a lot of spider bites and raccoon scratches and those kinds of really rural problems,but it’s not really that. People have the same problems as they do everywhere else. They all show up in the emergency room.” The biggest adjustment? “How spread out everything is. You’re continually running into pretty major transportation challenges. If we want to refer someone to a higher level of care…we don’t have a pediatric ICU. If a child is intubated and ventilated, he needs to get down to Sacramento, which is 160 miles. Kids get airlifted. “There are a lot of people that live in Susanville, Happy Valley, all these little towns that are spread out. Things that are accessible to people in other places aren’t accessible there; if you’re talking about seeing a physical therapist, it might be an hour and a half out. Home health nurses can deliver IV antibiotics, but all those things are reduced when you’re out in the mountains. If you have a heart attack, it’s 60 miles for an ambulance to get out to you. Everything’s a little more inaccessible. We have a whole team of social workers and case managers that coordinates discharges, follow up, getting canes and walkers. It’s something the hospital does well.” His residency tries to address the homelessness in the area despite the distances. “Our program director goes out in the HOPE van out to the homeless and provides a lot of treatment for wounds and 22  RHQ | RuralHealthQuarterly.com

SOAP...is essentially a ‘Hunger Games’-like battle for the scant number of unfilled residency spots in farflung areas. things like that. In some cases, we can get them the medications that they need.” Then there are all the slightly scary firsts of being a brandnew doctor. “First baby, first circumcision, your first injection into the knee or shoulder. That’s a little bit difficult and nerve-wracking. But we’re first in line for procedures. We’re often the first assist on surgeries. In other programs, you have a lot of ER residents, surgery residents, orthopedic surgery residents, everyone trying to do a lot of procedures.” The friendly atmosphere of the hospital is another huge plus. “It’s a small-town feel when it comes to the doctors and specialists. You get to know all of them. I feel comfortable, most of the time, sending a text message to a specialist if I have a quick question. Other hospitals, they have larger residencies, and there’s not as close a feeling. You walk around this hospital and know a lot of people.” Will he be a career rural medicine doc? “I’m keeping myself open to being talked into staying around here. I just want to be a straightforward family medicine doc, seeing adults and teenagers. One of the best things about family medicine is, you can go anywhere. And when you’re talking about rural docs, youre talking about family medicine. You can’t do nephrology without dialysis; you can’t do [interventional[ cardiology without catheterization.” In other words, true rural medicine means being a generalist. Gratitude flows through his voice, and you sense that Zaks understands how the SOAP could have gone so much worse. “My favorite thing is that I’m actually a doctor. It took a few months, but I can introduce myself as a doctor and take care of people and do the job of a doctor. You can tell overall that I’m having a good time. Family medicine is what I wanted to do , and this is the place that is letting me do that.” He makes a request, proudly. “Tell the fourth-year medical students that residencies in Redding—Shasta and Mercy family medicine—are really good.” Take that, SOAP.

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Health Education //

TEACHING HEALTH CENTERS

BUDGET DECISIONS IN DC MAY PUT RURAL DOCTORS’ TRAINING IN JEOPARDY

I

n nearly two years as a medical resident in Meridian, Mississippi, Dr. John Thames has treated car-wreck victims, people with chest pains and malnourished infants. Patients have arrived with lacerations, with burns, or in a disoriented fog after discontinuing their Michael Ollove psychiatric STATELINE medications. Pew Charitable Trusts Thames, a small-town Mississippi native, said the East Central Mississippi HealthNet Rural Family Medicine Residency Program has been “exactly what I was looking for.” Unlike the vast majority of doctors, Thames sought a residency in a rural clinic instead of in a teaching hospital because his ambition is to practice in the sort of place where he grew up, where doctors are scarce. He wants to be able to handle anything that comes through the door, from infections to gunshot wounds to a woman who might deliver a baby any second. But budget decisions in faraway Washington, D.C., may make it more difficult for Thames and other doctors who want to practice in small towns or underserved cities. Under the Teaching Health Center Graduate Medical Education program, which is part of the Affordable Care Act, the federal government dispenses grants to community health centers to train medical residents. The goal of the program is to address the shortage of primary care physicians in rural and poor urban areas.

But under current law, the federal government will stop funding the program, which serves nearly 750 primary care residents in 27 states and Washington, D.C., at the end of September. Without congressional action, it might be shut down. “The program is absolutely doing what it is designed to do, which is to put doctors in underserved areas like ours,” said Darrick Nelson, the director of Hidalgo Medical Services’ teaching health center program, which is training six residents in Lordsburg, New Mexico. The teaching health centers have received bipartisan support in the past. But supporters worry that because the program is new, relatively small, and not as well-known as other federally funded doctor training programs, it might fall through the federal budgetary cracks. “The greatest threat to the teaching health centers is the dysfunction in Washington,” said Dan Hawkins, a vice president at the National Association of Community Health Centers, a research and advocacy group.

EARLIER CUTS Bipartisan support didn’t protect the program from earlier cuts. In 2010, Congress allocated $230 million over five years, or about $46 million a year. But when it approved a two-year extension in 2015, it reduced funding to about $43 million a year. That reduction was enough to cause some of the teaching health centers to train fewer residents. Some have closed. Studies have found that most physicians end up practicing close

to where they did their residencies. But most teaching hospitals are located in urban centers, far from rural regions with acute doctor shortages. Poor urban neighborhoods also have difficulty attracting physicians. The American Association of Teaching Health Centers, a nonprofit advocacy group, said the ACA residency program is having the intended result. According to the organization, 55 percent of teaching health center graduates practice in underserved areas (http://aathc.org/ know-the-facts/), compared to 26 percent of those who graduate from hospital-based residencies. “The program is doing exactly what we wanted it to do,” said John Sealey, director of medical education for Authority Health in Detroit. More than 60 percent of residents who graduated from teaching health centers in Detroit go on to practice in medically underserved areas, many of them in Michigan, he said.

PROGRESS IN MONTANA RiverStone Health, a health care provider in Billings, Montana, was a teaching health center even before the federal program began. RiverStone started training residents in 1998, after partnering with two local hospitals. “The state was completely reliant on recruiting from other areas, which was clearly not working as well as it should,” said Roxanne Fahrenwald, a RiverStone vice president. Fifty-one out of 56 Montana counties have shortages of primary care doctors, according to the federal government.

Spring 2017 | RHQ   23


With the federal money awarded to it under the ACA, RiverStone has been able to add one medical resident a year to its program, bringing its number of residents to 24. About 70 percent of RiverStone graduates have remained in the state.

PRIMARY CARE Supporters also argue that teaching health centers expose residents to the types of ailments and health disparities, such as higher rates of obesity, diabetes and heart disease, that they are likely to encounter if they practice primary care in underserved areas. “In a community health center, most of the patients are going to 24  RHQ | RuralHealthQuarterly.com

present with conditions or ailments more common to a primary care practice, whereas those in the hospital will be sicker, with more acute needs,” said Shawn Martin, a vice president at the American Academy of Family Physicians. The residents in teaching health centers do spend some of their time training in hospitals. They must complete hospital rotations in surgery, inpatient care, obstetrics and gynecology. But health center residents also see what many hospital residents never do. In Washington, D.C., for example, medical residents at Unity Health Care Inc. often work in jails,

homeless shelters and HIV/AIDS clinics. Those receiving care at such sites would bear the brunt of the impact if federal money for the health center residency program disappears. “I’m very nervous,” said Eleni O’Donovan, director of the teaching health center program at Unity. “The program is not sustainable without that funding.” This story was first published by Stateline (http://www.pewtrusts. org/en/research-and- analysis/blogs/ stateline/2017/04/24/rural-doctorstraining-may-be-in-jeopardy), the daily news service of the Pew Charitable Trusts.

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Public Policy //

MEDICAID FUNDING CAPS? IF ‘REPEAL &REPLACE’ CAPS MEDICAID, STATES MUST SHOULDER THE BURDEN OF CARE For the first time since 1929, the GOP controls the White House, the Senate, the House, and most governorships and state houses. Never before, in most of our lifetimes, have Republicans been in a better position to coordinate and advance legislation at both the state and federal level. So it came as a surprise to many when disagreements between moderate and conservative factions within the party resulted Cameron Onks in the Republican replacement to ATTORNEY the Affordable Care Act (ACA), the F. Marie Hall Institute American Health Care Act (AHCA), for Rural and Community Health being pulled from the House floor only moments before a vote could be taken. As Speaker of the House Paul Ryan explained after pulling the bill, “doing big things is hard” and “moving from an opposition party to a governing party comes with growing pains.” Although it is unclear when or if a new bill will make its way through both the House and Senate, whenever Republicans do reconcile on a revised AHCA, it is sure to include a key feature that appeared in the original AHCA and received little opposition from either conservative or moderate Republicans: caps on federal contributions to Medicaid. But just what are Medicaid funding caps, what do they mean for the states, and how will they affect Medicaid coverage for the millions of Americans receiving coverage under our current laws?

WHAT IS MEDICAID? WHO PAYS FOR IT? Medicaid provides health care coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. The program is funded jointly by the states and the federal government, and administered by the states, according to federal requirements. As of December 2016, approximately 69 million Americans were covered by Medicaid, with children comprising nearly 49 percent of all enrollees. Last year, Medicaid cost taxpayers $582.9 billion, of which, the federal government paid $364.3 billion (62.4 percent), and states paid $218.6 billion (37.5 percent).

Under our current Medicaid laws, eligible individuals have an entitlement to coverage and states are guaranteed federal matching dollars with no pre-set limit. This means that for each dollar a state spends on Medicaid, the federal government will spend a dollar to match, without a limit; and individuals covered by Medicaid are able to receive treatment regardless of preexisting conditions. This system protects Medicaid services implemented by the states in the event of an unforeseen increase in Medicaid enrollment or costs and ensures those individuals covered by Medicaid receive the treatments they need. Although unlimited federal match and the entitlement to coverage have dramatically increased Medicaid enrollment, coverage, and benefits over the last seven years, not everyone agrees with the current system. Proponents of Medicaid reform contend that unlimited federal match and the entitlement to coverage cause poor state planning, unchecked spending, and wasted federal dollars. Federal contributions, they argue, should be capped. This would allow the federal government to fix the annual cost of Medicaid and limit federal Medicaid spending over time while incentivizing efficiency by removing the financial safety net for the states. But there’s a tradeoff. While capping federal contributions to Medicaid would make federal spending more predictable and achieve federal budget savings, it would also shift the costs of Medicaid to the states and likely eliminate many services as well as the entitlement to coverage.

WHAT ARE MEDICAID CAPS? Caps to federal Medicaid contributions may be accomplished by a variety of means; however, all caps to federal Medicaid contributions are based on the same process. A fixed amount of money is granted by the federal government to the states to address a broad range of issues. The states are then free to create and implement programs to address those issues using the federal funds as they see fit (within broad federal guidelines). The contributions are considered “capped” because rather than increasing based on Medicaid expenses, the federal funds are fixed and do not exceed a set limit in a given year. Caps are typically implemented in one of two ways: block grants or per capita/per enrollee caps. Under a block grant system, each state would receive a predetermined, fixed amount of money each year for its Spring 2017 | RHQ   25


entire Medicaid program irrespective of enrollment; that base figure would then be increased by a specific amount each year, typically tied to inflation of the medical care component of the consumer price index. The base amount of the grants is not necessarily tied to enrollment, costs, or program needs, and instead may be determined using spending data from previous years or an arbitrary combination of factors. Once a base amount has been determined and the funds are allocated to the states, it is then up to the states to create programs and decide how block granted funds are spent (within broad federal guidelines). Under a per capita cap, rather than provide a set block of funds for the entire Medicaid program irrespective of enrollment, federal funding for each state is determined based on an amount provided per enrollee. The federal government begins by determining a base amount to be paid to the states for each individual enrollee. The base amount per enrollee is then multiplied by the total number of enrollees in a given state to arrive at a total grant amount for the state for a given year. Like block grants, the base amount for annual per-enrollee spending is established using spending figures from previous years or a combination of factors that affect population health and the cost of care. Unlike block grants, per capita grants grow along with enrollment and allow for the creation of separate classes of enrollees, such as children, the elderly, and the disabled. Once a base amount has been determined and the funds allocated to the states, it is then up to the states to decide how per capita funds are spent. For example, under the original text of the AHCA, beginning in 2020, the federal government would have established a limit on the amount of funding it provides the states for Medicaid using a per-enrollee cap. The cap for each state would have been determined by calculating the average per-enrollee cost of medical services for most enrollees who received full Medicaid benefits in the state in 2016. The Secretary of Health and Human Services would have then increased the average per-enrollee cost for each state by the growth in the medical care component of the consumer price index. With both block grants and per capita caps, federal savings are achieved by limiting the rate at which grant funds grow so that federal Medicaid spending is kept at levels less than under current Medicaid laws. Over time, as per-enrollee Medicaid expenses grow at a faster rate than the amount of federal funds available, states will be forced to increasingly rely on their own tax dollars to support Medicaid programs. If a gap develops between the amount a state needs to meet its Medicaid expenses and the amount provided by the block grant or per capita allotment, the federal government will not contribute additional funds and it will be up to the states to choose between making up the difference, increasing eligibility 26  RHQ | RuralHealthQuarterly.com

requirements or reducing services.

HOW DO CAPS AFFECT THE STATES? Currently, the federal government provides unlimited matching funds to the states for Medicaid. In return, the states are required to cover certain people and services. Removing the unlimited federal match and implementing caps will have a significant impact on the states’ budgets as well as the services they provide. While states will be allowed greater leeway in how they spend their funds, the cost of flexibility may be a reduction in services, an increase in eligibility requirements, and/or repeal of the entitlement to coverage. One of the most immediate impacts of federal funding caps for Medicaid would be the reduction and redistribution of federal funds away from lower income states. There is significant variation in federal Medicaid spending across the United States due to each states’ decision to accept or refuse the Medicaid expansions offered under the ACA as well as the states’ unique health care needs, policies, and economies. The poorer, sicker states typically receive more federal funds per capita than their healthier, wealthier counterparts, and are at greater risk of sudden economic downturn or spikes in enrollment. For example, the federal government pays approximately 75 percent of Mississippi’s annual Medicaid expenses, but pays only 50.1 percent of the annual Medicaid expenses for Virginia and 56.1 percent for Massachusetts. Implementing caps would reduce the federal funds flowing to the poorer states while simultaneously increasing the states’ Medicaid expenses (if they maintain services at their current level). Many state government officials are displeased with the proposal to cap Medicaid funding while maintaining the entitlement to coverage; to appease these officials, legislatures have proposed allowing states the right to eliminate the entitlement to coverage or implement waiting lists and increase eligibility requirements. Although many states insist they would not cut services, at a time when state budget committees are already under pressure to cut spending, the poorer states will inevitably be forced to cut services, implement waiting lists, or increase eligibility requirements to compensate for the reduction in federal spending. Conversely, the redistribution will reward wealthier, healthier states who would see less of their federal taxes used to support Medicaid programs in low income states. The effect of these redistributions is that as states are left to reduce or expand Medicaid services based on their unique financial capabilities, regional health disparities will begin to arise throughout the country.

INCREASED FLEXIBILITY? A key argument in favor of capping federal contributions to Medicaid is that caps will increase efficiency and reduce


waste by allowing the states greater flexibility in how they create and implement Medicaid programs using federal funds. However, our current Medicaid laws are already quite flexible and it is difficult to see how greater efficiency will be achieved without significantly reducing coverage, increasing eligibility requirements, or eliminating entitlements. Under our current laws, states design and implement Medicaid programs in accordance with federal guidelines and may elect to participate in a number of optional programs. Federal guidelines implement minimum standards for eligibility, benefits, premiums, cost sharing, and provider payments and delivery systems. States are required to cover low income children, families, seniors, and individuals with disabilities who meet the federal poverty requirements. States then have the option to expand coverage to children, pregnant women, and adults at or above 138 percent of the federal poverty line (FPL), as well as seniors and disabled people over the age of 75, working people with disabilities, the medically needy, and people experiencing need of long-term care up to 300 percent SSI. All states have elected to cover children at or above 138 percent FPL; and 32 states have elected to expand coverage to adults at or above 138 percent FPL. For both minimum and optional benefits, states determine the amount, duration, and scope of covered benefits, subject to the requirement that coverage be sufficient to achieve the program’s purpose. States also have significant leeway to charge premiums and implement cost sharing for certain Medicaid enrollees, structure the delivery systems used to provide services, and determine provider payments. Should states feel the need to implement a program or payment method beyond the guidelines or state options, federal law provides Section 1115 waiver authority, which allows the Secretary of HHS to waive certain requirements in Medicaid matching funds for purposes not otherwise allowed under federal rules. If the states are still unsatisfied with all of the options described above, they are allowed to use Medicaid funds as premium assistance to purchase private insurance rather than providing direct coverage. Given the already broad latitude enjoyed by the states when creating and implementing Medicaid programs, and the existence of federally supported state options to expand coverage, any additional state flexibility would be achieved by allowing the states to reduce benefits, increase eligibility requirements, increase premiums and cost sharing, or impose additional program requirements for participants. These proposals would reduce the number of people covered by Medicaid, reduce the services provided to covered enrollees, or require additional out of pocket payments for enrollees. Due to political nature of the Medicaid program, it is

unlikely that any legislature will attempt to implement these proposals in any meaningful way with regard to the elderly, disabled, or child populations. Since these groups represent the largest portion of Medicaid costs, reduction of benefits or increased eligibility requirements for other groups, such as low income adults, will have little effect on the overall efficiency of the Medicaid program.

WHAT’S NEXT? So what does all of this mean for you? As we look ahead for Congress to craft the revised AHCA, it is important to keep in mind that any future iteration of the AHCA will very likely include caps on federal contributions to Medicaid. Implementing caps will eliminate unlimited federal match and replace it with a fixed sum to be paid to the states annually. Due to limited state budgets, without funding from other sources to account for the difference, removal of unlimited federal match will result in a reduction in Medicaid services, increased eligibility requirements, and/or the elimination of the entitlement to coverage. Due to the broad flexibility the states currently enjoy, it is doubtful that caps on federal contributions to Medicaid would increase flexibility or efficiency sufficiently to justify the overall negative impacts that caps would have on the states and the populations they serve. Therefore, any proposal that includes block grants or per capita caps must include some additional measures to compensate for the negative impacts those funding systems would cause. It is important to keep in mind that the issues raised above are influenced by a number of factors: what categories of program spending and eligibility are included in spending limits, which year’s spending is used as the base and what growth factor is used to increase the caps over time, how much flexibility is granted to the states to make changes to their programs, and how to treat the optional expansion of coverage under the ACA. These are all very important considerations that will affect how federal caps operate. Much of whether you consider caps to federal contributions to Medicaid to be good or bad is predicated on what your goals are. If your goal is to reduce federal spending, caps will accomplish this, albeit at the cost of reducing services and coverage. If your goal is to maximize services and coverage, caps will do the exact opposite, and will actually reduce coverage and benefits. As always, the devil is in the details; until we know more about how the revised AHCA will structure and implement the factors discussed here, any proposal that touts caps to federal Medicaid contributions as the golden ticket to fixing Medicaid funding should be taken with a grain of salt.

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Spring 2017 | RHQ   27


Public Policy //

T

he little brown church in Nashua, Iowa, has a certain notoriety. In the mid-1800s, a music teacher passing through the town wrote a song about a church that he envisioned there. It was a perfectly prophetic gesture.

A few years later, a church was erected on that very spot—even though its parishioners had never heard the teacher’s song. Ever since, the church has been a special place—and a popular destination for weddings. As of August 2014, over 74,000 had taken place there. One of those was Tami Haught’s. On November 27th, 1993, just two days after Thanksgiving, she married Roger in a joyful ceremony. But unbeknownst to the guests, the newlyweds harbored a dark secret: Roger had AIDS, and Tami had HIV. “The doctor said to cancel [the wedding] because [Roger] wouldn’t live,” Haught said. Roger had been diagnosed with AIDS a few months before, on August 4th. Tami was diagnosed with HIV on August 23rd, the day before her 25th birthday. Roger lived for almost three years after his diagnosis. He died about two months before the birth of their son Adrian. In those three years, Roger and Tami chose to love each other. But in the outside world, they suffered a lot—especially from the stigma. “Back in the 90s, if you had cancer, people cared. If you had AIDS, people judged,” Haught said. Roger was diagnosed with HIV in 1984, but shortly thereafter, following a car accident, his bloodwork came back with a false negative for HIV. Wanting to believe that he didn’t really have HIV, Roger didn’t question those results, and never mentioned his previous HIV diagnosis

28  RHQ | RuralHealthQuarterly.com

You should not be dying from HIV in this day and age.... The folks who are dying are dying from inadequate care—late diagnosis, or not accessing care once they’ve been diagnosed. - Carolyn McAllaster, Director of the Duke HIV/AIDS Policy Clinic

to anyone—not even his fiancé. “I didn’t have time to blame him,” Tami said. “I had slept with him without having the conversation. I had put myself at risk.” “It was a heterosexual foolery that we didn’t have to worry about it, because we were straight, or didn’t do drugs,” Tami continued. “It was a rude awakening, and proof that HIV doesn’t discriminate.” Like much of the American public during the late 80s and 90s, Roger’s own family struggled to understand HIV/AIDS and accept that he had it. What made Roger’s situation worse is that he himself never really accepted it, Haught added. “He was a redneck, homophobic cowboy, and he absolutely hated living with AIDS,” Haught said. Tami and Roger moved back to Roger’s native rural Texas briefly after their wedding because that’s where he wanted to


THE HIDDEN EPIDEMIC FIGHTING THE STIGMA OF HIV/AIDS IN RURAL AMERICA BY KRISTINE CRANE

live, but they didn’t find adequate support there, and Roger didn’t want to go to the doctor and risk being seen. So they moved back to Iowa where he could be somewhat anonymous. He was treated two hours away from Haught’s hometown, at the University of Iowa Hospitals and Clinics in Iowa City, a university town. They told everyone except their families that he had cancer. Three or four months before Roger died, he told Haught that he couldn’t keep fighting. “Finally, it was emotionally as well as physically that he was tired. And passed away.” The death certificate says he died of kidney failure. “But what the death certificate doesn’t show are all the mental issues,” Haught said.

SEEDS OF STIGMA Haught will always remember the day she disclosed her HIV status to her family: February 10th, 1993. A couple of months after her wedding. “It’s a day that my sister will never forget,” Tami said. “I disclosed it in probably one of the absolute worst ways. I came home. I had gotten some flyers and brochures [on HIV/AIDS]. I threw them on the coffee table. [I said] ‘Roger has AIDS. I am living with HIV. I don’t know how long I will live. I’m tired, and I’m going to bed.’ Spring 2017 | RHQ   29


“They sat there in shock,” Tami continued. “My brother stood up and gave me a hug and said: ‘No matter what you need, we love you. We’re here for you.’ Some people are disowned. I was very lucky that I’ve always had their support.” That was especially true because they were living in a punitive social environment. Several states, including Iowa, had criminalization laws against people for not disclosing their HIV status to partners. “In order to get Ryan White funding, states had to prove that if somebody was intentionally propagating HIV, they could be prosecuted,” Tami said. The Ryan White Care Act, also known as the AIDS Prevention Act of 1990, was designed to improve the care of people with HIV/AIDS, especially those without insurance. To receive funding, states had to enact disclosure laws, which thirty-three states did. “Iowa’s was the most punitive,” Tami said. “In Iowa, if you could not prove you had disclosed your status, you were sentenced to 25 years in jail and put on a sex offenders’ registry.” But proof of disclosure was difficult, not least because the burden of proof was always on the person with HIV, Haught said. As a result, the law sometimes became a weapon against people with HIV. “People stayed in abusive relationships,” Haught said. “[Partners would say things like], ‘If you break up with me, I will tell police that you did not disclose your status.’” The laws were also enacted at a time when there was limited medical knowledge about the disease and how it is transmitted. “In Texas, someone got thirty years for spitting at a corrections officer,” Haught recalled. “You cannot get HIV from spitting.” Haught dealt with discrimination head-on in Iowa while she was raising her son. She first ran into it when she went to introduce herself at his preschool. “The first time I went to meet [the teachers], they didn’t want to shake my hand,” she said. Haught had a case manager who guided her through those early years of disclosing her HIV status in school environments. For example, she agreed not to make homemade treats at preschool—and to be fair, all the other parents agreed they also wouldn’t make treats. “Luckily, Adrian didn’t have any issues until eighth grade,” Haught said. “A friend of his came over and made fun of Adrian. He said his mom had AIDS and was going to die.” Haught called the boy’s father, who made him stop. But still, the seeds of that stigma—along with Haught’s fear of her own death—stayed with her. 30  RHQ | RuralHealthQuarterly.com

“I never imagined that I would live long enough to see [Adrian] graduate in 2015,” Haught said. “I was a blubbering mess. On December 27th of this year, he made me a grandma.” Haught said that she began living to live—instead of die—about twelve years ago. She was at the dentist, and the hygienist cleaning Haught’s teeth scolded her lightly for not flossing her teeth every day. “She said, ‘In ten years, when you start losing your teeth, you will regret it,’” Haught said. “I knew the diagnosis was that we were living longer, healthier lives, but I just never believed it having lived through the loss of my husband.” “But it was the trigger for me to think about what I was going to do if I didn’t die,” Haught said. What she did was throw herself into activism.

THE EVOLUTION OF A CAUSE Haught started an advocacy group in 2006 called PITCH, which stands for Positive Iowans Taking Charge. They now have about 125 members, with various support groups throughout the state and an annual wellness summit. “Some people say they look forward to it every year,” Haught said. “It’s the only time they can be themselves and ultimately admit they have HIV. The rest of the year, they live in silence.” Haught also became involved with a national group called SERO, which is focused on ending inappropriate criminal persecutions of people with HIV. They are helping to repeal, state by state, criminalization laws that are rooted in a poor understanding of HIV transmission. Most laws do not consider that correct and consistent condom use as well as the use of antiretroviral therapy reduces the risk of transmission to a negligible level. The National HIV/AIDS Strategy, released by the White House in 2010, also called attention to the problem of HIV criminalization, and the CDC has encouraged states to revisit these laws. The American Psychological Association has spoken out against HIV criminalization, recommending the repeal or reform of these laws so that they only punish HIV positive people who intentionally engage in behavior that is risky for transmission. On its website, SERO lists several recommended actions for HIV positive people to protect themselves, including having sexual partners sign disclosure forms and saving all written communication should it be questioned. So far, two states have reformed their laws: Iowa and Colorado. In 2014, Iowa replaced the 25-year flat prison


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sentence with a tiered sentencing system, depending on the circumstances of HIV transmission. “I was actually speechless,” said Haught, who between 2012 and 2014 served as community organizer for CHAIN (Community HIV/Hepatitis Advocates of Iowa Network). Five days later, 200 activists came to Iowa to celebrate—and to ceremoniously cut off the ankle monitors on two HIV positive Iowans who had been forced to wear them under the old law. Last May, Colorado became the second state to reform its laws. “We’re working in other states to make progress,” Haught said, who as SERO’s organizing and training coordinator travels around to different states lobbying legislators. “It’s really tough in the South,” she added.

THE LAW THAT ALMOST TOOK DOWN AN OLYMPIAN In March, Haught was lobbying in Florida, the state with the highest number of HIV diagnoses. It is fourth in the nation for people living with HIV/AIDS. Darren Chiacchia, an equestrian who won the Bronze medal in the 2004 Olympics, is one of those people. Chiacchia, who lives for part of the year on a horse farm in North Central Florida (and the other part in upstate New York) also knows first-hand the challenges of Florida’s HIV criminalization law and the stigma surrounding it. In 2009, Chiacchia’s former lover Chandler decided to take revenge on Chiacchia for ending their four-month relationship: Chandler filed a report to the Marion County Sheriff ’s Department claiming that he had found out about Chiacchia’s HIV status only one month before. Had that been true, Chiacchia would have violated Florida law by having had sex more than once without revealing his HIV status to his partner. Chiacchia says he told Chandler about his status on their first date. “His [Chandler’s] reaction was, ‘True love will prevail,’” Chiacchia said. But the relationship was rocky from the start, and every time Chiacchia tried to end it, Chandler threatened him with: ‘Don’t do this. Your life will be over as you know it.’ The twist in the story is that there were times that Chiacchia questioned his own truth. “He [Chandler] almost had me convinced that I hadn’t told him,” Chiacchia said. A near-fatal horse accident in 2008 had left Chiacchia 32  RHQ | RuralHealthQuarterly.com

with Traumatic Brain Injury, which often comes with deep memory lapses. Incidentally, it was while hospitalized for the accident that Chiacchia found out he had HIV. “It didn’t really freak me out,” he said. “It was just something that had to be taken care of.” While recovering from the accident, Chiacchia fell into his relationship with Chandler. He was vulnerable, and his brain, he said, was “very malleable.” It was only when Chiacchia, who’d made millions as a professional athlete, was sliding into bankruptcy to defend his case, that he began to recover his memory. To make sure his tax returns were up to date, he did his own forensic accounting, collecting the restaurant and country club receipts. That unlocked his memory about the night he told Chandler that he had HIV. He reconstructed that night, and went back to the restaurant where he’d taken Chandler. “I sat at the same stool at the end of the bar. I ordered my same favorite cocktail. I ordered my same favorite meal, and then afterwards I pulled into the same vacant parking lot where it all happened,” he said. At that point, the case might have just ended up being a case of conflicting reports, but Chiacchia had a few other factors in his favor: “Florida statute reads that the person must be informed,” Chiacchia said. “So what about the three other people who told him [my HIV status] instead?” They all testified in favor of Chiacchia. Also, to sue someone for HIV-related crimes, Chiacchia explained, HIV transmission must take place. “He [Chandler] gleefully reported himself negative,” Chiacchia said. In February, after eight years of legal battles and debt, the Florida assistant state attorney dropped all charges against Chiacchia. It was the start of the biggest horse show of the year in Marion County, known as the horse capital of the world. It is Florida’s fifth largest county, as well as one of its most rural. Chandler had suffered stigma living there during the eight years of his legal battles. He was in earshot of comments like, ‘They’re a couple of queers. They belong in jail anyway,’ Chiacchia said. His livelihood training equestrians and buying and selling prize horses suffered. “People were quick to judge. My life as I knew it was over,” Chiacchia said. “That’s the stigma we’re talking about.” That all changed when his case was cleared. “The week the news hit was the first day of the horse show, and I think I got twenty-five hugs from people,” he said. “That was amazing.” Chiacchia still has his horse farm in the thicket of


athlete, living the American Dream, and this law almost took me down,” he said. “Think about all the other people out there.”

THE DEEP SOUTH: THE PERFECT STORM FOR HIV

Olympic equestrian Darren Chiacchia

Florida’s horse country. He’s grooming ten future champion horses and training young equestrians from all over the world, who in exchange help him out on the farm where he keeps an array of sheep, donkeys, chickens and dogs. He’s always been a hustler, he said. Starting from the moment, when as a twelve-year-old delivering newspapers, he was first mesmerized by horses at the race track in Buffalo, New York, where he grew up. Since then, he’s tenaciously pursued his dreams—even in the face of the accusations. His main concern with the HIV criminalization laws is that they empower accusations, he said. “They also give people a false sense of security that someone wouldn’t do that,” meaning not reveal their HIV status. “Imagine a father telling his daughter not to worry whether she’s pregnant because it’s a guy’s responsibility.” “The law suggests one’s sexuality is someone else’s responsibility,” he said. “People who don’t know their own status are the worst risk group.” According to the CDC, 13 percent of HIV positive people in the U.S. over age 13 don’t know their status. Chiacchia said he wants to get more involved with education efforts now that the burden of his trial is over. He’s acutely aware that most people with HIV similarly accused might not have had the resources to fight such a battle. HIV, especially in rural areas, disproportionately affects the poor. “I’m an upper-middle class, white male, an Olympic

AIDS activist Kathie Hiers remembers when the scope of the HIV/AIDS crisis in her home state of Alabama hit her. She was doing a home visit in Choctaw County, a deeply rural county with just under 14,000 inhabitants. Hiers was visiting a mother and her two daughters—all of whom were HIV positive. The older daughter was pregnant, and the younger one had pneumonia. The younger one sat facing the open oven door. She had a towel over her head to capture the heat, since they couldn’t afford to heat their home. A few weeks later, she died. “Unfortunately, we just didn’t get her into care in time,” Hiers said, adding that all three women, who developed full-blown AIDS, had not been in regular care. “They were sharing their medications with their boyfriends, thinking that would keep them from getting it. They weren’t getting the proper dosages,” Hiers added. Poverty, lack of access to health care, pervasive stigma, racial inequalities and a high rate of STIs (sexuallytransmitted infections)—which make it easier to transmit HIV—have made the rural South “the perfect storm for HIV,” Hiers said. “Alabama is 50 percent plus rural, and it is exceedingly difficult to serve these people adequately,” Hiers added. According to a recent report by the Center for Health Policy and Inequalities Research at Duke University, the South has had the highest number of HIV diagnoses for over a decade. Of the 17 states comprising the South, the nine that make up the Deep South are particularly afflicted. In 2013, 40 percent of the country’s HIV diagnoses occurred in the Deep South, which accounts for only 28 percent of the U.S. population. The states in this region include Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee and Texas. African-Americans in the South are also disproportionately affected by HIV. In 2013, 53 percent of the diagnoses in the Deep South were in African-Americans, compared to 44 percent in the U.S. The Deep South has also traditionally had the highest death rates for people with HIV. Between 2008 and 2013, 43 percent of deaths in the U.S. attributed to HIV were in the Deep South, according to the report. “You should not be dying from HIV in this day and

Spring 2017 | RHQ   33


age,” said Carolyn McAllaster, the Director of the Duke HIV/ AIDS Policy Clinic. “If you’re on treatment, it’s a chronic illness with normal life expectancies. The folks who are dying are dying from inadequate care—late diagnosis, or not accessing care once they’ve been diagnosed.” “The higher death rates are telling the story better than any number that we have,” she added. Also, people with HIV in the rural Southeast were more likely to have an AIDS diagnosis within a year of being diagnosed with HIV, according to the report. One of the problems is that rural areas in the South lack physicians. According to the report, 40 percent of HIVspecific providers are in the South, where 44 percent of the country’s HIV positive people are. Transportation issues also disproportionately affect people in rural areas. Some patients don’t have cars and can’t get to clinics—and they don’t want to ask for help lest people find out about their status. “If they don’t have a car, stigma can kick in,” McAllaster said. Stigma persists amongst providers as well, McAllaster added. “Primary care providers do not want to prescribe PrEP because they think it will encourage risky sex,” she said. PrEP, or pre-exposure prophylaxis, is a preventive medication for people who are at substantial risk of HIV. McAllaster likens likens the resistance to PrEP to the resistance to birth control pills because “they think she’ll sleep around.” For similar reasons, sex education is not taught in schools in much of the South, which ultimately leads to unsafe practices, Hiers said. In Alabama, the number of young people with HIV has increased from one in four to one in three. To overcome some of these hurdles, Hiers, the CEO of the nonprofit AIDS Alabama, has been working to get help and resources for HIV positive people in all of the state’s 67 counties. She started a telemedicine initiative so that people can be seen remotely—and privately. “We’re learning that people would rather [our offices] not be located at health departments. A lot of peoples’ relatives work at the health department, and people are afraid of losing confidentiality,” Hiers said. Local initiatives like this also help offset a disparity in funding at the national level for the rural South. “A lot of the resources go to the big, urban areas,” McAllaster said. “A lot of our advocacy is around getting resources to the rural areas and smaller cities.” Hiers added that certain urban areas like New York and San Francisco have almost ended the epidemic. “I tell my colleagues in bi-coastal areas that they will never end the epidemic in the U.S. without dealing with the South,” she said. The updated National HIV/AIDS Strategy (NHAS) targets the South, with the goal of reducing HIV diagnoses by 25 percent within five years. 34  RHQ | RuralHealthQuarterly.com

THE FUTURE OF HEALTH COVERAGE Hiers breathed a sigh of relief when Trumpcare failed to pass in late March. “Nothing about it was good for people with HIV,” she said, adding that the Affordable Care Act gave many HIV positive people a window of opportunity to access affordable healthcare and medications. “Definitely the ACA helped people with HIV, even if they weren’t in states that expanded Medicaid,” she added. As an example, in Alabama—a non-expansion state—five percent of people with HIV signed up for the exchanges, she said. In expansion states, Medicaid coverage for people with HIV increased six percent between 2012 and 2014 nationwide. In those same states, the uninsured rate of people with HIV dropped six percent, according to the Kaiser Family Foundation. Haught said that the ACA also gave her access to more physicians. “For the first time in twenty years, I was able to go to doctor five minutes from home, and I get all my medications from one source,” Haught said, adding that before the ACA, she would drive five hours round-trip just to see one doctor. She is worried that any changes to the ACA will negatively affect people living with HIV. “[Losing coverage] impacts adherence. If affects our lives. If we don’t get our medications, we will die.” “I’ve seen that death,” she continued. “I wouldn’t wish it on anyone.” While no one can predict the changes coming around the corner, one thing is certain for HIV activists: “It’s not the right time to pull back in resources,” McAllaster said. “We’ve made some real advances in fighting this epidemic.” Just a few days after the AHCA was sent back to the drawing board, activists were celebrating some of those advances—and advocating for more—at AIDS Watch. On March 28th over 650 people from 34 states gathered in Washington D.C. to educate members of Congress about their needs. “I went to something that really choked me up,” Hiers said. “It’s a new wave of what’s coming.” The presentation was called “Undetectable Equals: untransmittable,” and featured discussion of three major studies that have shown that HIV-positive people who are virally suppressed cannot transmit HIV. That knowledge should help revamp states’ criminalization laws, she said. But the more profound impact might be an internal one to people living with HIV, she added. “It was so moving to see HIV positive people change their perception of themselves. They don’t have to think of having sex as a loaded gun anymore. It’s really an encouragement for people to stay on theirs meds.”

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Public Policy //

SMALL RURAL HOSPITALS

WHY STATES SHOULD SUPPORT CRITICAL CARE HOSPITALS WITH FEWER THAN 15 BEDS

A

labama currently has eight counties with no hospital. Over the past six years, Alabama has had five rural hospitals close. This is tied with Georgia for the second highest number of rural hospital closings among all 50 states. Texas, with nine, has had the most rural hospital closings. Many Dale E. Quinney rural residents and EXECUTIVE DIRECTOR others interested Alabama Rural Health in rural health care Association are asking if there is a model health care facility that can provide care similar to that received in a hospital in counties with no hospital. One possibility is the Freestanding Emergency Department which is a new type of health care facility that is now authorized in Alabama. This is basically a hospital emergency department that is not attached to the hospital. Two requirements for this facility limit its possibilities in meeting the needs in rural counties. It cannot be located more than 35 miles from the parent hospital and must be directed by an Emergency Medicine physician. A second possibility is the Critical Access Hospital (CAH) which was first authorized under federal law in 1997. A CAH is certified under Medicare conditions that differ from those for acute care hospitals. A CAH cannot have more than 25 inpatient beds; must maintain an annual average length of stay of no more than 96 hours for acute inpatient care; must offer 24-hour, 7-day-a-week emergency care; and must be located in a federally-recognized rural area. Critical Access Hospitals are encouraged to focus on providing care for common conditions and outpatient care, while referring patients with other conditions to larger hospitals. In return, this type of hospital receives cost-based reimbursement

from Medicare, instead of standard fixed reimbursement rates. This can enhance the financial status of many rural hospitals with larger percentages of Medicare patients. Critical Access Hospitals have not been as financially feasible in Alabama as in many other states. Alabama currently has only four. There are 30 Critical Access Hospitals in Georgia and 32 in Mississippi. Currently, there is a state requirement in Alabama that acute care hospitals must have a minimum of 15 beds. Given current restrictions on inpatient stays, many rural hospitals do not have a daily census of patients that would require 15 inpatient beds. The federal requirement for critical access hospitals is that there be 25 or fewer authorized beds. There is no required minimum number of beds. There is a federal requirement that a critical access hospital must first be an acute care hospital and then convert to a critical access hospital. A new hospital cannot be opened as a critical access hospital. With Alabama’s requirement that acute care hospitals must have 15 or more authorized beds, a new hospital must be constructed with a minimum of 15 beds, even if there is no need. The current financial crisis among many of Alabama’s rural hospitals may make the time right for Alabama to take a look at our regulatory requirements for acute care hospitals to consider allowing our rural areas to have hospitals with fewer than 15 beds. These facilities could operate as acute care hospitals or convert to critical access hospitals without being required to have more beds than they can realistically expect to need. This could be done as a change in regulatory requirements for acute care hospitals or by authorizing a new type of hospital – the Small Rural Hospital. Several states already have rural hospitals with small numbers of authorized beds,

including Tennessee and Mississippi. The Johnson County Community Hospital in Mountain City, Tennessee is a 2-bed critical access hospital with 78 employees that operates at a profit when the annual critical access hospital payment is received. The emergency department at this facility treats patients with minor conditions and sends them home, stabilizes patients with more serious conditions for transfer to a larger hospital, or keeps those who should be observed overnight. The emergency department utilizes telemedicine and an emergency department staffing service. There is a certified rural health clinic affiliated with this hospital. Major services such as radiology, other scanning, laboratory, and therapy is provided. This small hospital even provides obstetrical service. The Greene County Hospital in Leakesville, Mississippi is currently a 3-bed critical access hospital that is being expanded to seven beds in a county that does not have a single physician. This hospital has 55 employees and is also operating at a profit. There is a 60-bed nursing home attached to this hospital and it has a certified rural health clinic. The services provided at this hospital are quite similar to those in Mountain City except that telemedicine is not being utilized and the emergency department is staffed by four advanced practice nurses who commute from Mobile, Alabama to provide this coverage. Advanced practice nurses cannot provide this coverage in Alabama, though there is some discussion about considering this coverage to hold down costs during early morning hours when patient traffic is light. Can small rural hospitals like these provide part of the solution to our rural hospital crisis? One thing for certain is that continuing to allow rural hospitals to close is not part of the solution.

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Spring 2017 | RHQ   35


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Health Technology //

TELEMEDICINE TO THE RESCUE HOW I LEARNED TO STOP WORRYING AND LOVE THE 1115 WAIVER Tumbleweeds rolled past in windy West Texas as we travel US Highway 87 from Lubbock to the bustling small town of Lamesa. It is a two-hour round trip to meet with staff of the rural hospital and specialty clinic to check in on their telemedicine program. Melanie Clevenger and I represent the Becky Jones Telemedicine Division and the TexLa Telehealth Resource Center within the F. Marie PROGRAM MANAGER, TEXLA Hall Institute for Rural and Community F. Marie Hall Institute Health at the Texas Tech University Health for Rural and Community Sciences Center. The Medical Arts Specialty Health Clinic is one of the sites we serve in some of the vast rural areas of West Texas. The news was not good. Multiple roadblocks had stalled their telemedicine program and kept them from services to area patients they had planned as part of their participation in Texas’ 1115 Waiver Project. In February of 2016, 72 telemedicine visits were needed by October to meet Year 5 Project goals. Staff explained that there had been several challenges including connectivity and availability of cardiologists willing to provide the service. Melissa Matlock, 1115 Waiver Coordinator and Communications Director, and Albert Acosta, Director of Radiology, Medical Arts Specialty Clinic and Coordinator for Telemedicine, gave us the details about lack of physician availability and firewall issues trying to connect with a Lubbock clinic.

THE 1115 WAIVER The Texas Healthcare Transformation and Quality Improvement Program is a Section 1115(a) waiver demonstration that was approved by the Centers for Medicare and Medicaid Services (CMS) on December 12, 2011. The waiver has funded Delivery System Reform Incentive Payment (DSRIP) projects intended to enhance access to care, improve the quality of care, and improve the cost-effectiveness of care. Funding is a combination of federal and local money. The projects are focused on Medicaid and indigent patients. The Texas Health and Human Services Commission (HHSC) Medicaid/CHIP Division was tasked with management and oversight of the Program. The five year project was set to end on September 30, 2016 unless an extension was approved. Texas developed a regional model that includes a diverse mix of providers. Regional Healthcare Partnerships (RHPs) were formed across the state with one organization within the RHP serving as the “anchor” that coordinates projects

within the region and submits proposals to HHSC. Each RHP includes a variety of participating healthcare entities such as hospitals, community mental health centers, public health agencies, and academic medical centers. DSRIP projects have been directed toward four activity categories: 1. 2. 3. 4.

Infrastructure Development Program Innovation and Redesign Quality Improvements Population-based Improvements

Infrastructure development involved expanding capacity for primary and specialty care and included specific project guidelines to introduce, expand, or enhance telemedicine/telehealth, and, more specifically, use the technology to improve access to behavioral health services. Program innovation and design projects were intended to improve care models and processes such as Medical Homes and the Chronic Care Management Model. Category 3 quality improvements will assess the effectiveness of the projects in the previous two categories through measurement of outcomes. Category 3 plans were to start no later than year 4 and are currently in progress so the real impact of the program in terms of outcomes is still to come. Population-based Improvements in Category 4 will be based on quality data reported through hospitals.

MEDICAL ARTS HOSPITAL Medical Arts Hospital planned to implement a telemedicine program in the Specialty Clinic to provide expanded specialty referral services and expanded access for rural residents. Based on a Needs Assessment, the target population was established cardiology patients being seen for routine appointments through telemedicine. The benefits to the hospital system were many. Telemedicine services improve access, decrease time and fuel costs driving significant distances for healthcare, and reduce lost productivity when patients or family members must take time off from work to spend at least half a day getting to and from an appointment for specialty services unavailable in the community. The value of successful implementation to the hospital district based on 1115 Waiver funds was up to $1,869,879. Medical Arts Hospital, like many rural hospitals, struggle with operating on smaller profit margins while providing a valuable service to the community and area. Those supplemental funds were not something they could afford to lose. Spring 2017 | RHQ   37


Our meeting with Albert Acosta started a whirlwind of coordination to meet the telemedicine encounter number of 72. After learning that the TTUHSC Texas Tech Physicians Center for Cardiovascular Health had some capacity and a physician willing to use telemedicine to see patients in Lamesa, the Telemedicine Division and TexLa Telehealth Resource Center provided technical support and trained staff. Cardiologist Dr. Scott Shurmur agreed to try telemedicine. It was a new experience for Dr. Shurmur but he quickly became comfortable with use of the technology. TTUHSC Telemedicine coordinated clinics with Mr. Acosta and staff. By October, 72 patients in Lamesa had been seen by Dr. Shurmur via telemedicine. Medical Arts Hospital reached their goal… and the celebration was on! In addition to 1115 Waiver funding, the Medical Arts staff have seen other evidence that the program has been successful. “It’s something else we can offer to serve our community,” Mr. Acosta told Telemedicine staff. He gave examples of the impact on patients. One 90 year old woman, who speaks only Spanish and does not drive, would likely not have the means to make the two hour round trip to Lubbock and would not have had the follow-up care. He gave examples of patients that must use the Medicaid transportation services bus to travel to Lubbock for healthcare. It is an all-day affair when everyone must wait until all patients taking the trip are seen at different clinics and different times during the day. Using an Impact Calculator developed by the South Central Telehealth Resource Center, the 72 patients saved more than 134 hours travel time and approximately $767.00 in fuel. Goals for FY2017, Year 6 of the 1115 Waiver Project, require 141 telemedicine visits and Mr. Acosta hopes to continue and grow the Telemedicine program and include additional services. How do patients feel about the technology? Patient satisfaction data was collected for the telemedicine clinic and demonstrates: • • • •

Satisfaction with the service at the Telemedicine Clinic 95% Agree or Strongly Agree Would use the Telemedicine Clinic again 94% Agree or Strongly Agree The Telemedicine Clinic met healthcare needs 95% Agree or Strongly Agree The Telemedicine Clinic adds to the quality of care available to me in the community 95% Agree or Strongly Agree

TELEMEDICINE FOR RURAL TEXAS The 1115 Waiver projects have been implemented in many rural and underserved areas in Texas. Lamesa is representative of many areas in the 131,000 square mile area of primarily rural West Texas – the service area for TTUHSC Telemedicine. It is the county seat of Dawson County, designated as rural, a Healthcare Professional Shortage Area (HPSA) for primary care and mental health, and a Medi38  RHQ | RuralHealthQuarterly.com

cally Underserved Area (MUA). Since the nearest tertiary facilities are 60 miles away, Medical Arts serves as the hub of healthcare to more than 83,000 residents in the area. Of the 254 counties in Texas, 133 are rural. Forty seven have no hospital and 68 have one hospital. Sixty-four are considered frontier with less than 7 people per square mile. Thirty-two of the frontier counties are border counties. Sixteen percent or 3.2 million Texans live in rural areas. Sixty-eight percent of the 254 counties in Texas are all or in part primary care HPSAs. Eighty percent of Texas counties are HPSA for mental health. Rural health is different and requires innovation to bridge gaps in care. Rural residents tend to have lower income and are less likely to have healthcare coverage than their metropolitan counterparts. There are significant health disparities. Rural adolescents are more likely to use alcohol and smoke cigarettes. There are higher rates of hypertension and suicide. Death rates after myocardial infarction are higher in rural areas. There are often vast distances to travel to reach needed care. In this environment, telehealth has played a key role in 1115 Waiver projects to overcome challenges and enhance access to care. Telemedicine maximizes the use of existing health care professionals by allowing them to remotely diagnose, monitor and recommend treatment for patients located in rural areas. According to current HHSC reports, 14 percent of active projects involve telehealth. Telehealth is a tool used to expand primary care and specialty care, provide patient navigation and health promotion, and educate the existing healthcare workforce. Sixty-two percent of the projects involving telehealth concentrated specifically on behavioral health in response to severe mental health care worker shortages in both rural and metropolitan areas of the state. Through the DSRIP or 1115 Waiver Projects, Texas has increased Medicaid enrollment and made more care available to the Medicaid and uninsured populations, populations that represent high costs to the healthcare system. Medical Arts Hospital in Lamesa is just one of many successful examples using telehealth to integrate primary care and mental health services, increase access to mental health services and specialties in remote and rural areas. Numerous studies have associated telehealth with improved access to care, improved quality of care, while decreasing costs but more data is needed. Outcomes reported from the Texas 1115 projects will add to the body of knowledge of outcomes associated with telehealth. In April, 2016, HHSC has received confirmation from CMS that a 15-month waiver extension has been approved, though a longer extension will continue to be negotiated. The TexLa Telehealth Resource Center is a federally funded program designed to provide technical assistance and resources to new and existing Telehealth programs throughout Texas and Louisiana. The TexLa TRC strives to continually evaluate Telehealth programs in these two states for effective delivery of Telehealth services, efficiency, sustainability, and patient satisfaction. The project described was supported by grant number G22RH30359 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS.

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Health Technology //

NEXT GENERATION 911 A TELEMEDICINE MEDICAL SERVICES PILOT PROJECT FOR TEXAS Have you ever stopped to think how much better healthcare could be if all technology available was utilized? Could technology help reduce healthcare cost or even improve outcomes? Can technology decrease the need for long trips to visit a specialist or even get medical care in a Frontier county? Could integrating technology Sharon Rose improve preventive care whether it be at home, school, work, or any environEMS TELEMEDICINE ment? It was once said “If we can dream PROJECT MANAGER it – we can do it!” Utilizing technology in F. Marie Hall Institute for Rural and Community different ways takes commitment from Health various stakeholders willing to look for solutions and not giving up at the first sign of problems. The Next Generation 9-1-1 Telemedicine Medical Services Pilot Project is one such project. Created and funded by Texas House Bill 479, the Texas Commission on State Emergency Communications (CSEC) and Texas Tech University Health Sciences Center (TTUHSC) were asked to establish a pilot project which would place telemedicine equipment in Emergency Medical Service (EMS) units. Not only did the project specify EMS units, but EMS units in rural areas. Texas defines a rural area as a county with a population of 50,000 or less, or a large, isolated, and sparsely populated area of a county with a population of more than 50,000. Of the 108 counties in the TTUHSC service area, the large majority of those counties are considered rural areas.

Large geographic area – 131,459 sq. miles, which is larger than New York, New England, and the District of Columbia combined

The main objective of the pilot project is to demonstrate whether telemedicine technology will work in the EMS environment and maintain connectivity with area Trauma Facilities in the same area while at the scene and while traveling down the road to the Trauma Facility. The main obstacle will be overcoming connectivity issues due to the vast distances between scene of incidence and closest trauma facility. Due to the type of incidents in this region, it was decided to look at trauma, cardiac, and stroke runs to be able to determine the outcomes and cost of these incidents.

THE PILOT PROJECT TTUHSC began the project by doing a needs assessment of the rural providers and hospitals in the West Texas region. We identified numerous EMS providers and Trauma facilities in the area and decided to start in a 9 county region around Midland, Odessa, and San Angelo, the heart of the oil production boom. This region was considered due to the increase in oil production which has increased traffic in this region. There has been an increase in the number of traffic accidents as well as major trauma incidents in this area over the past few years.

WHY RURAL AREAS? Let’s take a look at the health care issues West Texas counties face every day. • • • • • •

21 West Texas Counties have no physicians – 6 only have Nurse Practitioners 32 counties have no hospital 75% of the region is more than 90 miles from a Level 1 trauma center access The population is more likely to be poorer, sicker, and uninsured It is difficult to recruit and retain educated healthcare personnel There is an increased rate of fatalities and injuries due to the nature of the workforce

Spring 2017 | RHQ   39


TTUHSC began by contacting all the EMS providers in the identified 9 county region to set up a project work group to participate in the development of protocols, data collection forms, and training. An initial meeting was held to introduce the project to all the EMS providers in this region. After the question/answer session, most of the EMS providers were enthusiastic about the project. The next step was to get the Trauma Facilities in the area to participate and form a Clinic/Hospital workgroup. TTUHSC initially met with the Trauma Coordinators from Shannon Medical Center - San Angelo, Midland Memorial Hospital, and Medical Center Health System – Odessa. TTUHSC set up meetings with stakeholders of each facility (Trauma Coordinator, administration, Emergency Department Medical Director) to present the project. The EMS and Clinic/Hospital workgroups were brought together to evaluate equipment, from two different vendors, specifically developed for installation into ambulances. TTUHSC submitted a Request for Proposal in order to solicit bids from all interested agencies. After receiving four different bids, staff from TTUHSC and CSEC evaluated the proposal’s and awarded SwyMed the contract in early August, 2017.

BARRIERS TO PROGRESS Even with enthusiastic EMS providers, the project hit several barriers from the Trauma Facilities in the region. Due to staff/ leadership changes, not all stakeholders present for the presentation causing communication issues, and lack of time/staff to invest, none of the Trauma Facilities in the region were willing to participate at this time. TTUHSC and CSEC went back to the needs assessment done early in project and decided to look at EMS providers and Trauma Facilities around the Lubbock service area. TTUHSC contacted Medical Arts Hospital EMS and set up a meeting to present the project information. The EMS providers were very excited about the project and suggested getting the Hospital ED on board. After several discussions with the COO, the ED Medical Director did not see the project as beneficial to their service line. However, the EMS service was still interested. TTUHSC next contacted Scurry County EMS – Snyder and Cogdell Memorial Hospital – Snyder. A presentation meeting was set up, which was well received with many questions. Fortunately, the EMS Medical Director and ED Medical Director was the same physician. Both organizations were interested in participating in the project. Getting contracts signed and executed and equipment purchased and delivered, installation of the EMS units took place in early February. The EMS staff were very excited and even had a visit from the local flight crew. Once the equipment was installed, the EMS Director and Unit Supervisor were trained by SwyMed and responsible for training the rest of the staff. Once the software was downloaded in the EMS office, the Unit Supervisor and TTUHSC project manager drove out to two known “dead” zones in Scurry County. The first zone was Camp Springs which is 16.3 miles north40  RHQ | RuralHealthQuarterly.com

MAP OF SCURRY COUNTY

east of Snyder. The ambulance was pulled over to the side of the road and attempts were made to connect to the EMS office. Unable get a connection, the ambulance started back towards Snyder. Approximately 2 miles towards Snyder, we were able to get a connection with the EMS office. The second zone was Lake J.B. Thomas dam located 12 miles southwest of Snyder. Once the ambulance reached the dam, we were able to get a good audio and video connection with the EMS Office. The information was discussed with SwyMed and we will try to utilize a booster to get connectivity in these areas. The next steps for Scurry County is to get Cogdell Memorial Hospital software downloaded and ED staff trained to use it. Once available, another trip in the ambulance back to the dead zones will be done to make sure we can get a connection with the ED. Once we can get good connectivity, we will go live with runs and start data collections.

THE ROAD AHEAD TTUHSC has made contact with University Medical Center – Lubbock with interest in participating in the project. Pending getting equipment and software installed and staff trained, Scurry County will be able to connect with University Medical Center. TTUHSC will be able to install equipment in the Medical Arts Hospital EMS and get implementation in Lamesa. TTUHSC is awaiting contracts from Andrews County EMS and Permian Regional Medical Center to participate in the project as well. We have made contact with Medical Center Health System – Odessa to set up a meeting to get the appropriate stakeholders together to present the project again. Once TTUHSC gets more EMS units and Trauma Facilities implemented, data collection will start with information received from each entity regarding type of run, connectivity issues, and time taken to get to correct facility for treatment. We can then look at the outcomes and cost to see if there is an impact with this technology. We can also look at other appropriate programs which could develop from just having this technology available.

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CARING FOR HIV+ VETERANS

Behavioral Health //

TELEHEALTH FOR VETS

VETSTAR PARTNERS WITH TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER TO BRING MENTAL HEALTH CARE TO RURAL TEXAS VETERANS

It is not just our obligation to care for military veterans. It is an honor. There is a significant amount of discussion about the responsibility of the Veterans Administration and the federal government to care for returning soldiers. However, taking care of people requires a total community investment. The expectation that the VA alone can provide total care for all the veterans is an unrealistic Ronald N. Martin expectation. LPC, THE TWITR PROJECT The Veterans Health Administration in the United F. Marie Hall Institute States currently provides treatment at 1,233 health care for Rural and Community facilities, including 168 VA Medical Centers and 1,053 Health outpatient sites. In 2016, the Veterans Health Administration operated 243 Mental Health Residential Rehabilitation Treatment Programs with 8,034 beds at 113 VA Medical Centers. From 2001-2012, during the Iraq and Afghanistan wars, the military deployed 2.4 million personnel. Nationwide, it was estimated that almost 730,000 of the returning soldiers would have a mental health condition that requires treatment. In Texas, it was estimated that 70,000 would need mental healthcare, followed by California at 63,000, and Florida at 50,000. It is estimated that fewer than 50% of these individuals received any mental health treatment. The latest data compiled by the VA estimated that by September 2017 there will be 21,065,561 veterans nationwide and 1,665,401 will reside in Texas. At least 40 percent of veterans live in rural areas. To address the gap in services to veterans in rural West Texas, the Texas Tech University Health Sciences Center and the F. Marie Hall Institute for Rural and Community Health recently partnered with VetStar to leverage telemedicine counseling services to veterans in a twenty county area. The project’s goal is to have a variety of veteran-dedicated mental health options available based on the needs identified when the veteran and/or family member are engaged by the Pathfinders or present themselves for assistance. The primary services offered by South Plains Veterans Telemedicine Services consist of outreach and assessment, evaluation by a Licensed Professional Counselor (LPC), creation of a short and long term treatment plan for each veteran, and treatment or referral for treatment. The Institute currently has a similar model that has been used in rural schools and was designated as a best practice in rural schools by the Texas House Select Committee on Mental Health. The program is the Telemedicine Wellness Intervention Triage and Referral (TWITR) Project. Students are identified and screened for risk-based behaviors in schools then provided telepsychiatric services by TTUHSC Psychiatry over a telemedicine link. Through the telemedicine link to services, the F. Marie Hall Institute for Rural and Community Health and VetStar will have the capability to reach out to veterans in rural communities at various convenient locations, at Starcare offices, or those incarcerated and provide them with mental health treatment, referrals, and resources to ensure each veteran has the ability to access and receive adequate treatment regardless of his or her access to transportation.

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BY CARMEN HEREDIA RODRIGUEZ,

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KAISER HEALTH NEWS

r. Michael Ohl of the Department of Veterans Affairs’ (VA) Iowa City VA Health Care System is creating a model titled Telehealth Collaborative Care to improve the quality of care for Veterans who live far from specialty clinics. TelehealthCollaborative Care uses videoconferencing to connect rural Veterans with human immunodeficiency virus (HIV) with VA specialists. Approximately 18 percent of the 26,000 veterans under VA care for HIV live in rural areas. These veterans have limited access to high-quality, HIV specialty clinics. “Veterans should have easy access to HIV testing and state-of-the-art HIV care regardless of where they live,” said Ohl, an infectious disease specialist. “We know that compared to their urban counterparts, rural veterans with HIV enter care with more advanced illness, are less likely to receive the latest advances in HIV treatment, and have lower survival rates. We want to change that.” Ohl’s study explores rural veterans’ interest in using video telehealth at close-by, VA community-based outpatient clinics (CBOCs) to maintain their ongoing care. CBOCs serve as satellite clinics for large VA medical centers. Veterans can telecommunicate, via video at CBOCs, with an HIV specialist at the larger facility. HIV pharmacists, psychologists, and nursecare managers may also be included in videoconferences. A nurse onsite with the veteran at the outpatient clinic can administer treatment if prescribed by the specialist.Veterans can also meet with their primary care physician onsite. The primary care clinic and specialty care clinic can then communicate to determine how best to co-manage the veteran’s care. The coordinated process lifts a major travel burden off rural Veterans. In 2010, rural veterans with HIV were an average of 86 minutes by car from the closest infectious disease clinic versus 23 minutes on average for urban veterans. Rural veterans were also less likely than their urban counterparts to use specialty care. The Telehealth Collaborative Care study, which involves approximately 800 veterans, is focusing on rural areas near San Antonio, Houston, Dallas and Atlanta, each of which has a VA hospital with an HIV specialty clinic.

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Behavioral Health //

OUR RURAL OPIOID EPIDEMIC A PROFESSIONAL COUNSELOR’S PLEA FOR COMPASSION AND COMMUNITY INVOLVEMENT Prescription drug abuse is a powerful addiction, and addiction rates are steadily increasing across the country. People are losing the battle—and their lives—daily. And these people are not just faceless strangers. They are Shawn Marie Parrott our friends and our LPC, THE TWITR PROJECT neighbors. They F. Marie Hall Institute are the people we for Rural and Community love. Health As a professional counselor who has worked in the field of addiction for many years, I find it heartbreaking to watch this epidemic unfold. I’ve always taken immense pride in my work with individuals struggling with addiction. I have always assumed a degree of ownership over their struggles, along with a dedication to passionately assist them on their road to recovery. I like to think many of those I’ve treated are now living healthy and productive lives, lives free from the pain they once endured when they came to me for help. Now I’m not so sure. Today, U.S. opioid addiction continues to increase at an alarming rate, and research conducted by the U.S. Department of Health & Human Services indicates that deaths from prescription opioids have more than quadrupled since 1999. Drug manufacturers and distributors carry a large part of the burden for this public health crisis. Beginning in the 1980’s, opioid derivative drugs were advertised and marketed as safe and nonhabit forming. Doctors believed what they were being told, and patients thought they were being prescribed a miracle drug that alleviates pain without consequences. Opioids are widely popular due to their effect on the brain. The chemical compo42  RHQ | RuralHealthQuarterly.com

sition of the drug attaches itself to nerve receptors that control pain reduction and increase feelings of euphoria. Once a person becomes physically and psychologically addicted, the brain becomes consumed with the drug, leaving a person struggling with intense urges to repeat. Withdrawal symptoms are also extremely difficult to cope with, leading to a vicious cycle. Specific examples of prescription opioid drugs include hydrocodone, oxycodone, morphine, fentanyl, and codeine. They are all extremely addicting; fentanyl, however, is by far the most dangerous of the group. Fentanyl was originally intended to treat the pain of cancer patients, but it has been frequently misused and prescribed for conditions not originally intended. According to the National Institute on Drug Abuse, fentanyl is 50 to 100 times more potent than morphine. It is widely abused illicitly, and it is responsible for countless overdose deaths. America’s rural communities have been among the most affected by opioid abuse and overdose deaths. By way of explanation, researchers cite lengthy distances to urban resources, high rural unemployment and poverty rates, and high rates of chronic illness. Rural populations are older, an older populations are at particularly high risk. Chronic health problems and years of access to prescription opioids have done untold harm to America’s older rural population. Fortunately, experts around the country are now focused on highlighting the vulnerability of our rural regions to drug abuse and overprescription. A study published recently by the CDC explores the ramifications of prescribing practices. Findings suggest that long term chronic abuse correlates highest with longer days of access to the prescription drug. The length of time a person is

exposed to the drug following an acute injury or illness contributes to an increased possibility of dependence over time. Distance to adequate care facilities further aggravates the problem. When people are in a life and death situation, they need assistance quickly, but lack of transportation continues to be a serious issue. Treatment centers are also scarce and costly, leaving this valuable resource out of reach for many. In short, obtaining drugs—prescription or illicit— is often easier for rural folks than obtaining other kinds of professional help when they need it. In a combined effort to combat these problems, federal and state agencies have begun to focus on preventative and harm reduction strategies. Physicians and medical professionals are becoming more aware of the alarming rates of addiction, and numerous states are using database systems known as PDMPs (Prescription Drug Monitoring Programs). PDMPs monitor patients’ access to certain scheduled drugs and allow physicians to track the prescribing history of patients. The information provided can highlight highrisk patients which can turn into a recommendation for drug treatment programs before a patient’s drug use escalates. Telemedicine services are also becoming more readily available in rural areas. Technology that provides remote access to medical professionals is bridging a gap that allows treatment for medical and psychiatric conditions. Improved overall health leads to less pain and addiction, in addition to increased hope. A more recent strategy is to allow pharmacies to provide access to a schedule III drug called Naloxone without a prescription from a physician. Naloxone is a fast acting antidote for an opioid overdose. Swift action is vital for a person


who is in a medical emergency from the dangerous effects of a drug overdose, and rural citizens are in more danger without access to this life saving medication. Additional Medication Assisted Treatment options include access to treatment programs that provide Methadone and Buprenorphine to patients. These two drugs are used to assist a patient in managing the symptoms of withdrawal from the drug they are addicted to, thus reducing the urges and craving to get high. According to SAMHSA, a combined approach to treatment that includes medication assistance, counseling and behavioral therapies are optimal to the recovery of opiate drug addiction. Sadly, these costly programs are scarce. Legislation enacted in other states includes the 911 Good Samaritan Law. The intent of this law is to de-criminalize the act of addiction and provide immunity for illegally obtaining drugs. It does not provide immunity for other illegal drug related activities, such as distribution of illegal substances. Many states are going in this direction in hopes of allowing people to feel more comfortable asking for help. Addiction has undoubtedly touched the lives of most Americans. Directly or indirectly, we are all affected. I’m grateful to all my clients who have taught me so much. I’ve always said, “Teach me. I’m here to listen.” So they did, and I continue to hope and pray for their wellbeing. Strategies for battling the addiction epidemic need to include increased community involvement and connectedness. We must work together to create programs designed to combat drug addiction and to provide drugrelated education that can empower people to ask for help. We motivate others to invest in their own recovery by teaching them that we are listening and invested in their needs. People need people. We don’t strive in solitude. At least, not for long.

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THE WELCOME MAT

UNC INITIATIVE WILL COMBAT OPIOID USE DISORDERS AND OVERDOSES ///////////////////////////////////////////////////////////////////////////////////

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BY UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL

new research initiative at UNC-Chapel Hill will seek to combat the opioid epidemic by helping to reduce barriers to rural physicians treating opioid use disorders in North Carolina. The project is the first focus of a new effort to increase North Carolinian’s access to specialty care through an innovative medical education model that gives rural health practitioners access to training, experts and resources not usually available to them. The UNC Extension for Community Healthcare Outcomes for Rural Primary Care Medication Assisted Treatment (UNC ECHO for MAT), in collaboration with University of New Mexico Project ECHO, will reduce barriers to primary care providers offering medication assisted treatment (MAT) to persons with opioid use disorders and reduce deaths from accidental overdose in North Carolina, which exceeds the national average and has been steadily increasing over the past 10 years. “One effective way to combat opioid addiction and thereby opioid overdoses is MAT,” said Sherri Green, a research fellow at the Sheps Center for Health Services Research and assistant professor in the Gillings School of Global Public Health. “There is both a shortage of MAT providers, especially in rural counties, and a need to support MAT providers through case-based learning, practice supports, and a collaborative community response with treatment and other social and medical supports for patients receiving MAT.” The UNC-ECHO for MAT will seek to better understand what prevents primary care providers from offering MAT in their practices, evaluate strategies to overcome those barriers, and work closely with providers and community and state partners to expand access to MAT with associated community supports in 22 rural and underserved counties. The three-year, $2.9 million project is funded by the Agency for Healthcare Research and Quality

Some of the barriers to physicians providing MAT include lack of training for primary care providers, concerns about a patient’s ability to follow through with treatment, workload practice resource limitations, isolation or lack of support for the practitioner, difficulties in connecting patients with community treatment resources, and stigma associated with substance use disorders and use of MAT. The UNC ECHO team will collaborate with Local Management Entity-Managed Care Organizations for mental health and substance use disorder services (LME/ MCO) staff and providers, Community Care of North Carolina, the Governors Institute, AHECs and the NC Harm Reduction Coalition to address these concerns. The project will offer participating providers continuing medical education (CME) credits to be certified as MAT providers, physician to physician case consultation, CME through teletrainings and tele-case conferences to help implement a MAT program, as well as practice based office staff support. The research team will track how many practitioners prescribe MAT and the effectiveness of provider level interventions to reduce barriers to providing MAT. “AHRQ has provided North Carolina with a unique opportunity to leverage the good work and knowledge of many partners working across systems in the state, from behavioral health to public health, concerned about and invested in finding solutions to this public health crisis,” said Green. The Centers for Disease Control estimated the national opioid overdose death rate for 2014 to be 9.0 per 100,000. In 2014, 45 counties in North Carolina had overdose death rates over 9.0 per 100,000. According to the North Carolina Division of Public Health, 1,101 people died in 2012 from unintentional poisoning in the state, with 92 percent of all unintentional poisoning deaths being drug or medication related.

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RHQ CONFERENCE CALENDAR

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heck out our list of rural health conferences, and let us know if you’re hosting one so we can help spread the word. Email us the details at RHQ@ttuhsc.edu. 2017 Rural Medical Education Conference May 9, 2017 San Diego, CA www.ruralhealthweb.org 22nd NRHA Health Equity Conference May 9, 2017 San Diego, Ca www.ruralhealthweb.org NHRA Rural Hospital Innovation Summit May 9-12, 2017 San Diego, CA www.ruralhealthweb.org 40th Annual NRHA Rural Health Conference May 9-13 2017 San Diego, CA www.ruralhealthweb.org American Telemedicine Association International Meeting and Exposition May 22-25, 2017 Orlando, FL www.americantelemed.org Oklahoma Rural Health Conference May 25-26, 2017 Norman, OK www.rhao.org Critical Access Hospital Conference June 6-7, 2017 Minneapolis, MN www.eidebailly.com National Rural Institute on Alcohol and Drug Abuse June 11-15, 2017 Menomonie, WI http://www.uwstout.edu Indiana Rural Health Conference Jun 13-14, 2017 French Lick, IN www.indianaruralhealth.org Dakota Conference on Rural and Public Health June 13- 15, 2017 Minot, ND ruralhealth.und.edu Minnesota Rural Health Conference June 19-20, 2017 Duluth, MN minnesotaruralhealthconference.org Rural Health at the Crossroads June 21-23, 2017

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Amarillo, TX crossroadsconference.us Wisconsin Rural Health Conference June 21-23, 2017 Wisconsin Dells, WI www.wha.org NHRA State Rural Health Association Leadership Conference July 11-12, 2017 Nashville, TN www.ruralhealthweb.org NHRA Rural Quality and Clinical conference July 11-12, 2017 Nashville, TN www.ruralhealthweb.org Arizona Rural Health Conference July 25-26, 2017 Flagstaff, AZ crh.arizona.edu National Organization of State Offices of Rural Health Annual Meeting Sept 6-7, 2017 Savannah, GA nosorh.org

NRHA Rural Health Clinic Conference Sept 26-29, 2017 Kansas City, MO www.ruralhealthweb.org NHRA Critical Access Hospital Conference Sept 27-29, 2017 Kansas City, MO www.ruralhealthweb.org Maryland Rural Health Conference Oct 5-6, 2017 McHenry, MD www.mdruralhealth.org West Virginia Rural Health Conference Oct 10-13, 2017 Canaan Valley, WV wvrha.org National Association of Rural Health Clinics Fall Institute Oct 17- Oct 19, 2017 Indianapolis, IN narhc.org Oregon Rural Health Conference Oct 18-20, 2017 Sunriver, OR www.ohsu.edu

National Association for Rural Mental Health Sept 6-8, 2017 San Diego CA www.narmh.org

New England Rural Health Roundtable Nov 15-16, 2017 Bartlet, NH newenglandruralhealthroundtable.wildapricot.org

Nebraska Rural Health Conference Sept 20-21, 2017 Kearney, NE nebraskaruralhealth.org

Tennessee Rural Health Conference Nov 15-17, 2017 Pigeon Forge, TN www.rhat.org


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Profile for Rural Health Quarterly (RHQ)

Rural Health Quarterly 1.2 - Spring 2017  

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Rural Health Quarterly 1.2 - Spring 2017  

HIV/AIDS in Rural America • Predatory Pricing: Could Universal Pricing Move Us Closer to Universal Coverage? • Access to Breast Care for Wes...