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RHQ

Summer 2017

Rural Health Quarterly

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


FirstCare is dedicated to providing

quality health care coverage to our friends and neighbors in

West Texas.

FirstCare.com


CONTENTS //

SUMMER 2017 THE EXPANSION ACT

The Community Health Center and Primary Care Workforce Expansion Act aims to enhance reimbursements for rural providers.

16

REMOTE AREA MEDICAL RAM volunteers provide free health care to the rural poor, but a patchwork of state laws still limits its reach.

18

GROW OR DIE To survive, rural hospitals need to attract more patients, but the demographics don’t add up

20

TEXAS TAKES A LEAP FORWARD

COVER STORY

PROJECT ECHO: HOW KNOWLEDGE-SHARING NETWORKS ARE CHANGING THE WORLD OF RURAL HEALTH CARE

24

SAVE OUR CENSUS

Funding cuts at the US Census Bureau may pose a threat to public health research efforts.

Senate Bill 1107 drops the controversial in-person evaluation requirement for telehealth in Texas. The state cleared a big hurdle with this change, as it was the last major U.S. market blocking the growth of video doctor consultations.

23

PEACE OF MIND How East Texas clinicians, educators and clergy joined forces to bring mental health care to the masses.

30

SEARCH + RESCUE

11

Montana attempts to tackle the alarming rate of suicides in Big Sky Country.

A DENTAL CARE DILEMNA

32

The UND Center for Rural Health drills down into dental care access data with a survey of North Dakota dentists.

A HEALTH PROFESSIONAL PIPELINE

12

37

2  RHQ | RuralHealthQuarterly.com

Education and outreach programs are trying to remedy America’s rural provider shortage.


DEPARTMENTS //

RURAL HEALTH QUARTERLY

Volume 1, No. 3 Summer 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 11-14

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

// PUBLIC POLICY 16-21

// HEALTH TECHNOLOGY 23-29

Research Associate Debra Curti Web Developer Miguel Carrasco

// BEHAVIORAL HEALTH 30-35

// HEALTH EDUCATION 37-43

COMMUNITY HEALTH’S CHANGING LANDSCAPE As demand for their services rise, many community health workers are finding that the nature of their job is changing. As a result, some CHW advocates think the national trend toward certification is a mistake.

40

RHQ CONFERENCE CALENDAR Upcoming rural health conferences across the country.

43

Contributors Janelle Ali-Dinar Sanjeev Arora Matt Bouchonville Mary Darby Coshandra Dillard Nathan Fix Joanna Katzman Miriam Komaromy Mike Lewicki Barbara Mantel Bram Sable-Smith Shawnda Schroeder Jennifer Snead Dava Stewart Bruce Struminger Karla Thornton Cindy Uken Contacts and Permissions Email RHQ at RHQ@ttuhsc.edu. For more contact information, visit www.ruralhealthquarterly.com.

THE LAST WORD Remembering the extraordinary life and legacy of F. Marie Hall.

44 Summer 2017 | RHQ   3


Sweets have always been my reward. I want my kids to have authentic food from their culture, which isn’t always healthy. Eating healthy makes me feel like my taste buds are missing out. I have a prime parking spot at work, so why would I walk? Diet soda is as healthy as I get. My stomach just can’t handle healthy stuff. I don’t know how to cook, so I have to stick to simple things like macaroni & cheese. I don’t want to mess with my family’s food preferences. I am too tired to battle with my kids over healthy eating. My kids don’t like salad. My spouse doesn’t like vegetables. If I’m going to a buffet, I want to get my money’s worth. My mother always made me clean my plate, and I can’t break the habit. I have no willpower when it comes to the dessert menu. If I’m stressed, I want something sweet. There are waaay too many delicious foods I want to eat. If I’m stressed, I want something salty. I get bored with the same old food. My kids are picky eaters and I don’t want to make two separate meals. Once I’ve opened a pack of cookies, I figure I might as well finish it. I’ve tried a bunch of different diets and nothing works. I don’t want to become obsessive about every calorie. Eating healthier requires a lot of planning and I just don’t have time for that. The gym is boring. I tried to change my diet before…it was too much effort. I don’t have time to prepare a healthy meal. My taste buds are the way they are. There’s always free food at the office, and I just can’t say no. Fresh food spoils too quickly. I like going out to eat with my friends too much. I eat in the car, so I can’t always find healthy options. Temptation lurks everywhere – I can’t help myself. Special deals and coupons encourage my bad food choices. Vacation calories don’t count. I hate seeing myself in the mirror at the gym. I can’t exercise when it’s humid. I don’t want to get sweaty because I’ll have to redo my hair. It’s too snowy to work out. Vegetables are hard to chop. I walked 86 feet today and I’m already exhausted. I showered earlier, so I don’t want to get sweaty. My couch is too comfy. Taking the stairs is just too time consuming. The fluorescent gym lights make me look pale. My bike shorts give me a wedgie. Working out makes more laundry. My workout videos are all on VHS, and I don’t have a VCR. My tennis grunt isn’t any good. I’m an athlete by proxy, thanks to my fantasy team. My workout would interrupt my TV schedule. I feel sore after working out. My dog doesn’t like to walk. I like cheese too much. Sweat makes me itchy. My gym is like a million miles away. I don’t like working out with people around me. I don’t want to be locked into a gym membership contract. The gym owner is intimidating. Helmet hair isn’t a good look on me. I burn enough calories carrying my purse around. I’m not zen enough for yoga. My sneakers smell like a locker room. The gym is boring. Dessert is my weakness. I’d work out, but I might scuff my shoes. No one will exercise with me so I’m not motivated to go. My husband always makes excuses for not going to the gym, and I think he’s kinda right. I’m not coordinated enough to exercise. I don’t like how my hair looks in a ponytail. I never remember my gym clothes. The gym is boring. If I didn’t have time for lunch today, I definitely don’t have time for the gym. I don’t like the way workout clothes look on me. I’m actually afraid of getting too buff. Working out isn’t a good look for me. I look silly exercising. It’s not convenient. The TV shows they play at the gym are terrible. I don’t like watching people work out; it grosses me out. The gym cuts into my social life. Working out isn’t really me. Exercise should be done in private. And my apartment is too small. I don’t like sweating in front of people. Exercise just makes me hungrier. The gym is way too far from my house. The exercise schedule for workout classes doesn’t fit my schedule. I have a bad blister that makes working out painful. There simply aren’t enough hours in the day. I can’t get motivated to do any exercise, so I’m stuck in a rut. The different exercise class options overwhelm me. I don’t want to sweat where other people sweat. It’s tough to wake up in the morning. I end up just walking around the gym aimlessly. Gym clothes are too expensive. Treadmills are SO boring. I don’t want to run on the street where everyone can see me. I ran out of sports bras. I forgot my running shoes…again. I’ll start working out tomorrow. Sweat makes me itchy. I get enough exercise typing emails. It’s my birthday, so it’s OK to indulge. I’m married, so there’s no need to hit the gym anymore. I’m aiming for the “dad bod.” I’m starting a “mom bod” trend. I consider the walk to my kitchen exercise. I just don’t know what foods to eat . I’ve heard you can burn a lot of calories chewing. My bed is more comfortable than the gym. I don’t want to deprive myself of anything. I’m too carefree to get into an exercise routine. The elevator is faster than the stairs. I’m a busy parent. I need extra fat in the winter to keep me warm. I’m a struggling artist — I only have time for my art. I’m too busy running a business. I’m too busy writing a book. I’m too busy taking care of my family. I like cheese too much. I’m too busy volunteering. I’m too busy trying to build my resume. I tried working out, but I don’t know if I’m doing it right . I’m too busy taking my kids to sports practices, art lessons, school, playdates, etc. I’m too busy doing the housework, shopping, cleaning and looking after the house. I have to help my kids with their homework. It’s genetics. I don’t know where to start with dieting or exercise. I don’t want to interfere with my family’s routine. I tried pilates, but I don’t know if I’m doing it right. The padding in my bike shorts isn’t squishy enough. Once I’ve sorted out my work/life balance, I will figure out my diet and exercise. I can’t pronounce “acai.” I don’t go to the doctor unless something is clearly wrong. I’m not the greatest at taking care of myself; I’m better at taking care of other people. It’s too hard to be healthy during the holidays. The gym is boring. It’s either work or my kids that take up all my time. I don’t like the color of green juice. Vegetables are rabbit food. I heard pizza counts as a vegetable because it has tomato sauce. My family doesn’t like vegetables. Lettuce might as well be grass clippings. I don’t like green-colored food. Kale reminds me of shrubs. It just seems like eating healthy is a trend. I can’t pronounce “quinoa.” Eating healthy just takes too much time. I can’t resist upsizing my meals. I can’t say no to ice cream on a hot day. It would be rude not to eat the cake my neighbor brought me. Bananas creep me out. I don’t feel complete without something sweet after a meal. Snacking helps pass the time. Healthy food is more expensive. Health food stores smell funny. There are no healthy restaurants in my neighborhood. Healthy foods don’t taste as good. I don’t know how to cook healthy meals. I like potato chips too much. The commute is my workout. I would exercise but it just makes me hungrier. I like fried food too much. I like tortillas too much. I can’t start my day without doughnuts. I read that you can become addicted to working out. I can’t text and lift weights at the same time. I don’t like the music they play at gyms. I’ll wait until I make my New Year’s resolutions. The healthy section at my local supermarket is hard to find. If I go to the gym, my cats will miss me. Being super disciplined just kinda harshes my vibe. I get enough exercise through quilting. There’s way too much good TV on this season. YOLO! Going to the gym would require me to change out of my bathrobe. Eating healthy and exercising just seems vain. If I go to the gym, I’m worried people will see my regrettable tattoos. Exercising just takes too much time to organize. I don’t like people telling me what I should eat. I need my food to be fun. The world would be a better place if everyone just ate what he or she wanted. Weights are heavy. Treadmills make me feel like a gerbil. I tried working out once; it was sweaty. I don’t want to waste gas by going to the healthier supermarket. Being healthy has never been a priority. I’m too busy doing house stuff. Animals don’t need to go to the gym, so why should I? What if I miss an email at the gym? I’d rather focus my energy on model trains. Spinach might have worked for that cartoon character, but not for me. I think it’s a conspiracy to get people to eat things they don’t want to. What if I get super fit and my friends don’t recognize me? My hair is too long to exercise. I can’t be around all kinds of buff people. I think that in the future they’ll invent a pill to make everyone healthy. I don’t eat healthy while on vacation, and I always want to feel like I’m on vacation. I don’t want to shock my body. I don’t want to get all buff and then intimidate people at the beach. It just doesn’t suit my hermit lifestyle. I’m just not sure who to listen to – my stomach or my doctor. Exercising just seems so 1980s. What if I like working out too much and I lose my job? I have an addictive personality, and that would probably apply to working out too. If we86 were supposed to eat onlyprediabetes. healthy things, how come bad food tastes so good? million Americans have Know where you stand. I don’t like the names of healthy foods. I have a prime parking spot at work, so why would I walk to work? I like to leave things up to fate.

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. Copyright 2017—F. Marie Hall Institute for Rural and Community Health. 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 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, Ph.D., RN, School of Nursing, TTUHSC Linda McMurray, executive director at TTUHSC Larry Combest Community Health and Wellness Center Will Rodriguez, senior managing director, TTUHSC Ken Stewart, Ph.D., director of Community Development Initiatives, ASU, San Angelo, TX 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 //

Black babies died at three times the rate of white babies in Alabama in 2015. The state’s overall rate is 8.3 – one of the highest in the nation. Officials have launched a pilot program in three rural Alabama counties to make preventive care available to uninsured women.

The only two insurance companies offering individual health plans on federal exchanges in Arizona have filed paperwork to continue selling coverage in 2018. Blue Cross sells in 13 mainly rural counties and will maintain a similar set of plans next year.

al.com | 06.18.17

ALASKA //

usnews.com | 06.13.17

ARKANSAS //

Alaska is seeing a surge in diseases connected to injecting drugs, particularly hepatitis C. Health officials say drug users in rural areas of the state don’t have regular access to clean syringes, which drives up the likelihood of re-use or needle sharing.

Arkansas has the third highest maternal mortality rate in the country. State Rep. Greg Leding has proposed a Maternal Mortality Review Committee to improve maternal care for women in Arkansas, particularly in remote areas of the state.

alaskapublic.org | 06.28.17

nwahomepage.com | 06.16.17

NORTHAMPTON, AUSTRALIA

ETHIOPIA

The Sporting Shooters Association of Australia raised nearly $13,000 last month for the Regional Men’s Health Initiative with a community feral animal hunt, mostly rabbits and foxes.

RURAL HEALTH REPORTING FROM ACROSS THE NATION AND AROUND THE WORLD

COLORADO // Provider rates in rural parts of the state, free-standing emergency rooms and opportunistic drug pricing are contributing to the rising costs of Colorado health care, the Colorado Commission on Affordable Health Care said in its third and final report. The panel recommends more widely publicizing what rural providers are charging not only so patients can better shop for care, but also so providers can know what their competitors are charging. gjsentinel.com | 07.01.17

6  RHQ | ruralhealthquarterly.com

ABUJA, NIGERIA

A community health clinic completed with the assistance of the United States government has been commissioned in a rural suburb of Abuja.

The United Kingdom announced its plan to provide £90 million of support for Ethiopia over the next four years. The programme will enable over 3,000 mostly rural health centres to provide quality family planning services.

The initiative funds wellbeing projects like the Working with Warrior’s DVD and the annual Talk to a Mate Footy Round. Both projects are a bid to curb the shocking number of rural Australian men taking their lives through suicide each year.

The clinic was initiated by the Jikoko community in Bwari Area Council of the Federal Capital, but the project stalled until the U.S. government offered $10,000 grant assistance from the U.S. Ambassador’s Small Grants Program for Children Orphaned by AIDS and other Vulnerable Children.

newbusinessethiopia.com | 07.11.17

avonadvocate.com.au | 07.09.17

premiumtimesng.com | 07.07.17

6  RHQ | RuralHealthQuarterly.com


m

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.

CONNECTICUT //

HAWAII //

Connecticut has the second worst rural transportation system in the country, according to a new report.

An $800,000 grant-in-aid will enable Hamakua-Kohala Health to build a new clinic on the site of the old infirmary in rural Honokaa. Due to mold and termite damage, the infirmary could not be renovated.

Thirty-nine percent of Connecticut’s rural roads are rated in poor condition, and the rate of traffic fatalities on rural roads is nearly double the fatality rate on all other roads in the state.

GEORGIA //

westhawaiitoday.com | 07.07.17

A rural Georgia hospital that was about to close for lack of funds will stay open after all.

IDAHO //

A new study claims that proposed funding cuts to Medicaid would hurt rural Floridians the most. 57 percent of Florida’s rural and smalltown children receive health insurance through Medicaid versus 44 percent of their urban counterparts.

The company that owned Jenkins Medical Center in Millen, Ga. had announced in April that it would shut down the facility with a 24hour emergency room and send patients to a sister hospital 20 miles away. Instead, with days to go before the June 24 shutdown, a Florida-based investor purchased the hospital

Blue Cross of Idaho announced it will remain in the 2018 individual market, offering on and off exchange qualified health plans in every county in Idaho, regardless of population size. Blue Cross of Idaho will add three more plans to their existing offering for a total of nine in 2018.

wusfnews.wusf.usf.edu | 06.07.17

myajc.com | 06.19.17

ktvb.com | 04.27.17

MANITOBA, CANADA

IRELAND

ctnewsjunkie.com | 06.28.17

FLORIDA //

KARNATAKA, INDIA The Health Ministry in Karnataka in the southwestern region of India is inviting doctors to quote their own pay package to serve patients in rural areas. The proposal comes after officials had exhausted all other avenues to overcome the shortage of specialists in government hospitals in rural areas. As the bids arrive, the health ministry will negotiate with applicants, say health ministry officials.

The Manitoba government is moving ahead with a large-scale transformation of the province’s emergency medical services system that includes closing more than a dozen EMS stations in rural Manitoba.

A staggering number of rural Irish GPs — up to 50 percent in some in counties— are due to retire within seven years. Funding cuts made under emergency legislation in 2009 have severely affected general practice, doctors say.

citytoday.news | 07.04.17

cbc.ca | 06.29.17

independent.ie | 07.12.17 Summer SUMMER2017 2017| |RHQ RHQ     77


Rural Reports // ILLINOIS //

MARYLAND //

The rural community of Dixon, Illinois, is attracting statewide attention for a program that emphasizes quick access to treatment for drug offenders rather than letting them languish in jail. Supporters argue that early intervention is less costly than waiting.

For Maryland’s rural areas, the opioid epidemic is a serious drag on government and medical resources. In the past two years, Western Maryland Health has spent nearly $1.5 million in additional costs from opioidrelated patient treatment.

wqad.com | 06.19.17

INDIANA // Indiana state health commissioner Jerome Adams has been nominated to serve as U.S. Surgeon General. Adams was integral to addressing an HIV outbreak in rural Indiana by convincing then-Governor Mike Pence to provide a free syringe exchange.

KENTUCKY //

heraldmailmedia.com | 06.11.17 In a move the state says would save money but cut another 9,000 people from Medicaid, Kentucky Gov. Matt Bevin is seeking a waiver from the federal government to change the state-federal health plan. Kentucky has the nation’s largest number of rural medicaid expansion enrollees as allowed under the ACA. The proposed changes are aimed at reducing that number. courier-journal.com | 07.07.17

newsweek.com | 07.06.17

IOWA // Residents at the Iowa Veterans Home in rural Marshalltown can now begin to see their care providers and specialists via telemedicine without leaving the facility. IVH is also expanding the program to reach to the Iowa City VA and the Des Moines VA.

MASSACHUSETTS // A partnership between Baystate Health and the University of Massachusetts medical school in Worcester is slated to bring prospective doctors to train at the Baystate Franklin Medical Center with the hope some may focus on rural medicine and choose to establish their practices in the area. recorder.com | 05.26.17

LOUISIANA // Louisiana’s health secretary is exploring the possible use of a little-known, 1910 federal patent law to force down the price of hepatitis C medications. Louisiana has 35,000 people with hepatitis C who are relying on the state for care. kansas.com | 07.10.17

timesrepublican.com | 06.13.17

MICHIGAN //

To address the need for nurses in rural communities, Kansas Wesleyan University and Salina Area Technical College are launching new programs to expand nursing education.

Many more Maine children in both urban and rural areas of the state are considered at high risk for lead poisoning under updated rules that are prompting an increase in home inspections.

A new Michigan telemedicine law imposes new telehealth practice standards, including restrictions on prescribing controlled substances. The law was not universally supported, even among pro-telehealth proponents, as they pointed out that telehealth-based care “has already been thriving in Michigan without legislation.”

ksal.com | 06.19.17

bangordailynews.com | 07.06.17

natlawreview.com | 12.27.16

KANSAS //

8  RHQ | RuralHealthQuarterly.com

MAINE //


MINNESOTA // The College of St. Scholastica has been awarded a $1.4 million, two-year grant from HRSA to fund the Rural Academic Practice Partnership. The RAPP initiative will improve health outcomes for people living in rural communities of Minnesota through the placement of nurse practitioner students in rural settings and by expanding educational opportunities for rural care providers. css.edu | 07.06.17

MONTANA //

NEW MEXICO //

Life Flight Network and Blue Cross Blue Shield of Montana have reached a new network agreement after lawmakers passed a bill that required it. The legislation came after Montana residents complained that they were getting hit with bills for tens of thousands of dollars for “out-of-network” medical flights.

Pregnant women living in northern New Mexico have to cross over sixty miles to deliver their babies with a doctor or midwife. Women in Tucumcari have to travel almost an hour and a half to Clovis for delivery. In Santa Rosa, women have to go to Albuquerque, which is nearly a two hour drive. More than half of the physicians in the state are in Bernalillo County.

usnews.com | O6.29.17

NEBRASKA // Nebraska lawmakers are looking to increase mental health services in rural areas of the state that lack psychologists, psychiatrists and counselors. A state-funded internship program to attract more behavioral and mental health students is under consideration. dailyprogress.com | 07.09.17

kunm.org | 06.30.17

NORTH CAROLINA // The University of North Carolina at Chapel Hill School of Medicine has been awarded a $1.5 million grant to establish clinical experience for health professions students in rural areas of the state. wraltechwire.com | 07.05.17

MISSISSIPPI // North Mississippi Health Services has formed a clinically integrated network with the aim of providing quality, reducing costs, increasing patient satisfaction and increasing provider happiness. The Tupelobased health system serves 24 mostly rural counties in the northeast corner of Mississippi and a few neighboring counties in Alabama.

NORTH DAKOTA // A program to train nurse practitioners at North Dakota State University was awarded a $513,992 grant to help prepare family nurse practitioners to serve rural areas. North Dakota has 55 health care shortage areas.

NEW HAMPSHIRE //

bismarcktribune.com | 07.02.17

fiercehealthcare.com | 06.28.17

Centene Corp. says it will offer insurance plans to 25 mostly rural counties in the state who would otherwise have no insurer on the ACA exchange in 2018.

New Hampshire ranks No. 2 in the nation, behind West Virginia, for the number of opioid-related deaths. It ranks No. 1 for fentanylrelated deaths per capita. The state’s rural context, lack of treatment funding and high prescription rates are cited as contributing to its opioid epidemic.

kansascity.com | 06.30.17

usnews.com | 06.28.17

MISSOURI //

OKLAHOMA // Through the Heartland OK project, Oklahoma officials are working in 13 rural counties to reduce patients’ risk for heart disease and stroke through care coordination. swtimes.com | 06.27.17

Summer 2017 | RHQ   9


Rural Reports // OREGON //

WASHINGTON //

In rural Oregon, nursing homes remain a key fixture in health care, providing what no other residential facility can — around-the-clock nursing care. Yet nursing home operators say state policies are to blame for weakening rural nursing homes, which by virtue of their location face higher costs. Some nursing home operators say state workers steer consumers away from rural nursing homes or press residents to move out sooner than they should.

According to a new report, residents in rural areas of Washington state are more likely to be food insecure, become obese, get diabetes and be uninsured. They also have less access to homecare, hospice services, and care providers. The report recommends two main areas of focus: supporting the creation of publicprivate partnerships and working with technologists.

eastoregonian.com | 07.04.17

SOUTH CAROLINA // After the loss of hospitals in two South Carolina counties, the establishment of a freestanding emergency department is being heralded as a way to provide health care to rural residents. The new 24/7 facility will be funded through a one-time, $3.6 million Transformation Fund Grant. thetandd.co | 06.17.17

SOUTH DAKOTA //

TENNESSEE // Meharry Medical College and Middle Tennessee State University are joining forces to tackle the state’s rural doctor shortage by creating a fast track from undergraduate to medical school. Students would attend three years at MTSU, earn a bachelor’s degree and then go straight into three years of medical school at Meharry, A $750,000 pot of state funding would offset their tuition. tennessean.com | 06.21.17

TEXAS // With Texas Gov. Greg Abbott’s signature, Texas became the last state to allow physicians to connect with new patients via telehealth.The law put an end to the two-year legal battle between Teladoc and the Texas Medical Board (see page 23). mhealthintelligence.com | 05.31.17

Better access to telemedicine oversight for chemotherapy infusions is available in the rural communities of Armour and Vermillion, South Dakota through a HRSA grant awarded to Sanford Health.

VIRGINIA //

According to the South Dakota Comprehensive Cancer Plan, in the year 2010, cancer surpassed heart disease as the leading cause of death in South Dakota.

Through the use of telemedicine and telestroke in rural care, the University of Virginia reduced 30-day hospital readmission rates by 40 percent for patients with heart failure, acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, stroke, and joint replacement.

yankton.net | 07.02.17

mhealthintelligence.com | 06.23.17

10  RHQ | RuralHealthQuarterly.com

stateofreform.com | 06.15.17

WISCONSIN // A state cap on non-economic damage awards in medical malpractice cases in Wisconsin has been ruled unconstitutional by a three judge panel. The Wisconsin Hospital Association criticized the decision, arguing it could make it harder for patients in rural areas to find treatment. wrn.com | 04.10.17

WYOMING // Wyoming has received more than $25 million for mammogram machines and other medical equipment since 2010 from a national nonprofit that works to improve rural health care. When the program started, the Leona M. and Harry B. Helmsley Charitable Trust identified seven states that received the smallest amount of health care philanthropy. Wyoming, which has some of the most expensive medical care in America and has just 26 hospitals, was one of those states. trib.com | 07.17.17

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CALL FOR PRESENTATIONS //

Rural Research //

SAVE OUR CENSUS

FUNDING CUTS AT U.S. CENSUS BUREAU MAY POSE A THREAT TO RESEARCH

W

hen U.S. Census Bureau Director John Thompson unexpectedly announced his resignation in May, alarm bells went off for health researchers across the country. What affect will Thomson’s departure have on the upcoming 2020 census? And what does he know that we don’t? Here’s what we know so far. Catherine Hudson Congress recently approved $1.47 billion for the DIRECTOR FOR RURAL bureau for the current fiscal year. President Trump’s HEALTH RESEARCH budget blueprint has called for $1.5 billion for the F. Marie Hall Institute Census Bureau’s work on the 2020 Census. That’s a for Rural and Community modest increase, but here’s the thing. Modest won’t cut Health it. It won’t even come close. “The budget for the census is highly cyclical,” FiveThirtyEight explains. “Every 10 years, spending soars as the bureau hires hundreds of thousands of census takers to complete the constitutionally mandated population count…. Trump’s preliminary 2018 budget would give $1.5 billion to the Census Bureau, effectively keeping spending flat in a year when, based on past 10-year cycles, it should be increasing by 60 percent or more.” The decennial census is not just about counting people for the sake of counting them. The population data collected by the Census Bureau is used to accurately apportion and determine how state and federal political districts are drawn ensuring equal representation. If certain populations or demographics are undercounted, they are essentially invisible politically. But the accuracy of the census has more than political ramifications. It can determine how federal dollars are spent. The federal government uses census data to allocate federal funding needed for social/human services, roads and infrastructure, education, and, yes, public health and research efforts. In the research world, data is needed in order to be competitive for funding, but funding is needed to collect the data. This emphasis on evidence-based programs can put rural researchers at a disadvantage. With the ever shrinking availability of federal funding to support research, it is important that accurate population data is available for rural researchers competing for grant dollars. Rural Healthy People 2020, published by the Texas A&M Health Science Center School of Rural Public Health, serves as a guide for such efforts. Some of the key areas identified by Rural Healthy People 2020 include: access to quality health services, diabetes, mental health and mental disorders, nutrition and weight status, heart disease and stroke, substance abuse, physical activity and health, older adults, cancer, maternal health , infant health, child health and educational and community-based programs. All of these priority areas require accurate population-based data, and that requires a successful U.S. Census. President Trump has the power to nominate a new census director. We can only hope that Thompson’s replacement is able to convince Congress to do the right thing and give the American people the accurate census they need and deserve.

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he NRHA is soliciting session proposals for the 2018 Annual Rural Health Conference and Rural Hospital Innovation Summit to be held May 8-11, 2018 in New Orleans, La.

NRHA’s Annual Rural Health Conference is an interactive experience designed for all rural health professionals, with seven tracks covering clinical issues, statewide public health issues, clinic management, rural communities, education, policy and learning tools for leaders. NRHA is willing to consider any new and innovative session proposals. Each year, more than 200 faculty present 48 concurrent educational sessions, 20 research papers and up to 100 research and educational posters. NRHA’s Rural Hospital Innovation Summit is dedicated to rural hospital innovation and transformation and providing premier networking and education for rural hospital leadership teams striving to innovate toward community health transformation. Any person with an interest in rural health care or rural health research is invited to submit session proposals or original research for presentation.This is an opportunity to share effective models, policies, research and information and provide your colleagues with insights and best practices addressing many of the access, quality and geographic issues confronted by rural communities. The entry deadline is August 24, 2017. Visit www.ruralhealthweb.org for submission guidelines. WINTER 2017 | RHQ   11 Summer WINTER 2017 | RHQ   11 SUMMER


Rural Research //

SURVEY OF NORTH DAKOTA DENTISTS SHINES A LIGHT ON RURAL ACCESS

A DENTAL CARE DILEMNA

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BY SHAWNDA SCHROEDER, PH.D. AND NATHAN FIX, MPH

uring 2015, the North Dakota Legislature considered the licensure of a new dental provider, a dental therapist (DT). The proposed legislation did not pass, though Senate Concurrent Resolution number 4004 called for additional study of the proposed oral health workforce solutions to include assessing the state infrastructure needed to support DT as a profession. During 2017, House Bill 1256 was proposed to license DTs in the state. In response to previous and current legislation, the Center for Rural Health at the University of North Dakota School of Medicine and Health Sciences developed a survey to assess dentists’ knowledge of proposed oral health workforce legislation, support for the proposed workforce models among dentists, and the willingness of dental providers to participate in each. Following is the general presentation of the results with particular attention to DT, as was requested in Senate Concurrent Resolution number 4004. METHODS Researchers at the Center for Rural Health developed a survey to assess dentists’ knowledge, support for, and willingness to participate in nine oral health workforce solutions identified in key oral health legislation, and by the North Dakota Dental Association: 1. Case Management - Funding and implementation of case

management, including as a reimbursable service 2. Residencies - Increasing opportunities for dental students to complete residencies in North Dakota 3. Safety-nets - Additional locations and funding for dental safety-net clinics, including mobile units 4. Medicaid - Increasing Medicaid reimbursement for dental

Dentists’ Support for Proposed Access Solutions

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Did you

know ?

That you can add nice quote here!

services 5. Seal!ND - Expanding the service area (funding) of Seal!ND, providing sealants in a school setting 6. Current DH - Utilizing dental hygienists (DH) at their expanded scope of practice (once certified), including limited restoration procedures under direct supervision of a dentist 7. Expand DH - Further expan-


89%

// URBAN DENTISTS OPPOSED TO DT IN ND

77%

// RURAL DENTISTS OPPOSED TO DT IN ND

// 187 SURVEYED 58% URBAN / 42% RURAL

sion of the scope of practice for dental hygienists (DH) including expanded restorative procedures, and general or indirect supervision 8. Expand DA - Expanding the scope of practice for dental assistants (DAs) including preventative and restorative services, and utilizing the workforce if certified 9. Dental Therapy - Develop and utilize a Commission on Dental Accreditation (CODA) certified dental mid-level provider (which may or may not borrow from emerging workforce models in MN and/ or AK) The tool was developed in partnership with a Dr. Catalanotto from the Southeast Center for Research to Reduce Disparities in Oral Health. He serves as the chair of Oral Health America’s Board of Directors and had recently developed a similar survey assessing dentists’ attitudes toward dental therapy (DT) in Florida, Georgia, and Mississippi. Researchers disseminated a paper copy of the survey with a pre-paid return envelope, and a link to an online version. The first round of surveys were sent through priority mail in December 2016 to all dentists in the State with a practice address on record with the State Board of Dental Examiners. Only those who did not initially respond received a reminder with an additional survey and pre-paid return envelope, sent through USPS standard shipping in early January 2017. Responses were anonymous. RESULTS Approximately 421 North Dakota dentists received the survey; analyses included 187 completed surveys for a response rate of 44 percent. Roughly 58 percent of respondents served predominantly urban communities while 42 percent provided care primarily to

rural residents. A large majority (77 percent) practiced general family dentistry. Dentists predominately served in either a solo (49 percent) or small group (37 percent) practice. Only 13 percent of respondents were not members of the North Dakota Dental Association. 1) KNOWLEDGE Dentists were more knowledgeable about DT than any other proposed dental care access solution. More than half of the responding dentists had no knowledge regarding case management (65 percent), and dental residencies (57 percent). North Dakota does not have a school of dentistry, nor does the State have a reciprocity agreement with any regional dental school. As a result, dentists likely have little knowledge regarding residencies for dental students. However, the North Dakota Dental Association introduced and proposed case management as a model, and yet, only 9 percent of dentists identified significant knowledge of the proposal, while 25 percent had some knowledge, and 65 percent identified no knowledge. 2) SUPPORT Dentists illustrated more support for increasing Medicaid reimbursement (98 percent supported, or would support depending on the specifics) than any other proposal. In contrast, a large majority (86 percent) did not support DT. However, DT was the only model in which there was significant variation in the level of support between rural and urban dentists. A little more than one in five rural dentists supported DT at some level (21 percent), compared to only one in ten (10 percent) of urban dentists. Results also indicated that 89 percent of dentists supported case management at some level, though 65 percent had reported having

Summer 2017 | RHQ   13


no knowledge around the given initiative. Dentists also indicated strong support for developing dental residencies for students, expanding the reach of dental safety-nets, and increasing the reach of Seal!ND. 3) PARTICIPATION Dentists were more willing to participate in proposed access solutions that did not involve changing the current workforce within their dental practices. Expanding Seal!ND and increasing Medicaid reimbursement had the highest anticipated participation among dentists, while models that proposed utilizing DHs, expanding the scopes of practice for DAs and DHs, and utilizing DTs had the lowest anticipated participation. Roughly 85 percent of dentists indicated they would not participate in DT. However, similar to dentists anticipated support, rural dentists were significantly more likely to participate in DT at some level (23 percent) than were urban dentists (11 percent). 4) IMPROVE ACCESS ISSUES Dentists were asked to indicate their level of agreement that the proposed workforce solutions would increase access to dental care for rural, American Indian, Medicaid or lowincome residents in North Dakota. Only two proposed dental care access solutions had more than 50 percent of the dentists agree or strongly agree that the models would address access issues for populations in need. •

Roughly 66 percent of dentists agreed/strongly agreed that case management would increase access. 76 percent agreed/strongly agreed that expanding reach of safety-nets would increase access. A majority of dentists disagreed/strongly disagreed that using the existing workforce at current, or further expanded scopes of practice would improve access.

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Roughly 61 percent strongly disagreed/disagreed that the current expanded scope of practice for DHs would increase access. 70 percent and 57 percent respectively strongly disagreed/ disagreed that expanding the scope of practice for DHs or DAs would improve access. A large majority (91 percent) strongly disagreed/disagreed that DT would address the access issues facing rural, American Indian, Medicaid or low-income residents in North Dakota.

CONCLUSIONS During 2015, the North Dakota legislature reviewed significant oral health legislation, including enacting legislation that changed the dental loan repayment program and creating the Advanced Practice Dental Hygienist statute. It also reviewed and defeated a DT bill in a 40-6 vote. Between 2015 and the following 2017 session, the Center for Rural Health and other organizations educated the public and oral health professionals on the access issues prevalent in North Dakota. Studies reported the need for access to care among rural residents living in the 17 counties with no practicing dentist. Data illustrated significantly high rates of decay and need for treatment among American Indian youth, and reports also highlighted the need for dental care among Medicaid enrollees with 72 percent of children enrolled in Medicaid reporting no preventive dental visit during 2015. Recognizing the continued need for oral health care access in North Dakota, the 2017 State Legislature again proposed bills related to the dental care services and access. Specifically, House Bill 1256 again identified licensing DTs in North Dakota to address access concerns for rural, Medicaid, and American Indian populations. The Bill received a “do-pass” from the House

Human Services Committee, but was later defeated in the State House by a 32-59 vote. The 2017 DT bill did not pass. However, a recent nationwide survey found that 81 percent of voters favored licensing and utilizing DTs in their states. A DT cannot practice, even if licensed by their state, if there are not dentists who support and believe in utilizing the new provider type to meet the needs of disparate populations. There has been little support for DT among dentists, and a large majority of those surveyed in North Dakota (85 percent) would not participate. However, data also illustrated a shift in thinking among rural dentists with 23 percent indicating they would participate, or would depending on the specifics. ACKNOWLEDGEMENTS Thank you to the dentists in North Dakota who responded to the survey. Thank you to Dr. Catalanotto for providing insight on the survey and mailing method. This survey was funded by the Pew Charitable Trusts, though the tool and findings are the original work of the Center for Rural Health, without influence from the foundation. The Center for Rural Health neither supports nor opposes DT legislation, but instead has a mission to connect resources and knowledge to strengthen the health of people in rural and tribal communities.

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This article is adapted from a data brief courtesy of the Center for Rural Health at the University of North Dakota School of Medicine & Health Sciences. The original brief, “Dentists’ Knowledge, Support, and Participation in Proposed Dental Care Access Solutions: Results of the North Dakota Survey of Practicing Dentists (April 2017),” is complementary information to a series of fact sheets regarding Oral Health in North Dakota. Visit the CRH webpage for more: ruralhealth.und.edu/what-we-do/ oral-health.


Rural Health Research Gateway The Rural Health Research Gateway is an online library of research and expertise. It’s free to use, searchable, and provides access to the work of all ten federally-funded Rural Health Research Centers and Policy Analysis Initiatives. The Rural Health Research Center (RHRC) is the only Federal program that is dedicated entirely to producing policy-relevant research on health care in rural areas. The Federal Office of Rural Health Policy funds seven RHRCs and three rural health policy analysis initiatives. The Centers study critical issues facing rural communities in their quest to secure adequate, affordable, high-quality health services for their residents.

This online resource of research connects you to: • Research and Policy Centers • Research Projects • Experts • E-mail Alerts • Fact Sheets • Policy Briefs • Reports • Communication Toolkit

How can we help? • info@ruralhealthresearch.org • www.facebook.com/RHRGateway • twitter.com/rhrgateway

ruralhealthresearch.org This project was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under grant # U1JRH26218. The information, conclusions, and opinions expressed in this toolkit are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.


Public Policy //

COMMUNITY HEALTH CENTERS & A PRIMARY CARE WORKFORCE: A RURAL SAFETY NET BY JANELLE ALI-DINAR, PH.D.

ENDORSEMENTS In addition to 19 congressional co-sponsors, the following organizations have publicly endorsed the Community Health Center and Primary Care Workforce Expansion Act: • • • • • • • • • • • • • • • • • • •

National Association of Community Health Centers National Association of Social Workers National Healthy Start Association API Morehouse School of Medicine Association of Clinicians for the Underserved NAACP Public Citizen National Center for Lesbian Rights National Minority Quality Forum Remote Area Medical Prescription Justice Racial and Ethnic Health Disparities Coalition Los Angeles LGBT Center Lana’i Community Health Center African American Health Alliance Bi-State Primary Care Association Waimanalo Health Center STEM4Us

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ural health care faces a number of unique challenges that often get lost in the din of the health care reform debate, and these challenges are only compounded by the vulnerability of Medicaid and the ongoing insurance exchange crises under the Patient Protection and Affordable Care Act (PPACA). That said, U.S. Sen. Bernie Sanders (I-Vt.) and U.S. Rep. Jim Clyburn (DS.C.) have introduced a bill to address some of these challenges. It’s called the Community Health Center and Primary Care Workforce Expansion Act. Initially created by a mandated funding stream that was part of the PPACA, the Community Health Center Fund provides financial resources for Federally Qualified Health Centers (FQHCs) and the National Health Service Corps (NHSC). Additionally, it created the Teaching Health Center Graduate Medical Education program (THCGME). The PPACA appropriated funds for these three programs for the 2011 through 2015 fiscal years. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended funding for 2016-2017, but the funding expires Sept. 30, 2017 – and its absence will create a domino effect of health care devastation for rural providers. Additionally, the PPACA included a three-year Nurse Practitioner Residency Training demonstration for FQHCs and Nurse Managed Health Centers (NMHCs) that expired in 2015. EXPANSION ACT: POSSIBLE HOPE FOR RURAL HEALTH The FHQC model currently serves nearly 25 million people across the nation, representing a group of important safety net providers in rural America, where about a third of all residents live in underserved areas. The FQHC model provides enhanced reimbursement from Medicare and Medicaid, as well as other benefits, via a sliding fee scale and comprehensive services (either on-site or by arrangement with another provider), including preventive health, dental, mental health and substance abuse, transportation necessary for adequate patient care, access to hospitals and specialty care and an ongoing quality assurance program. ROBUST FUND ALLOCATION FOR AN INCREASED NUMBER OF PATIENTS The bill Senator Sanders and Congressman Clyburn introduced would achieve a win-win for urban and rural access to care via the goal of doubling the number of patients served by community health centers/FQHCs, as well as doubling the NHSC budget. This would allow such entities to train more nurse practitioners while adequately funding teaching health centers, all of which are much-needed steps in addressing the primary health care workforce crisis. Today there is a predicted shortage of 30,000 primary care physicians and nearly a million nurses over the coming 15 years, nationwide. Additionally, the Community Health Center and Primary Care Workforce Expansion Act would dramatically expand (and make permanent after 10 years) these four programs and provide robust funding for physical capacity and infrastructure building of community health centers to meet the needs of a growing


and medically underserved population. LEGISLATION NEEDS AND INCREASED FUNDING The proposed bill would provide the following: •

$5.1 billion in FQHC in 2018, rising to a 2027 total of $12.5 billion, allowing capacity building for CHCs/ FQHCs to meet the needs of twice as many people by 2028.

Increased funding for the NHSC, with its budget projected to rise from $850 million in 2018 to $1.5 billion in 2028. This is especially important since 59 million Americans live in designated primary care shortage areas, 47 million live in dental health care shortage areas, and 97 million live in mental and behavioral healthcare designated shortage areas.

An increase in funding of THCGME, from $176 million in 2018 to $260 million in 2027. This is critical since teaching health centers are located in 27 states, and 75 percent are FQHCs. Additionally, studies find that, unfortunately, nearly four in 10 THC graduates (compared with 2 percent of traditional medical residents) become primary care providers in nonprofit, community health centers in underserved communities.

The authorization and appropriation of over $18 billion for capital projects to invest in the infrastructure and expand the physical capacity of the over 1,400 FQHCs in the United States.

Increased funding for nurse practitioner residency training programs, going from $35 million in 2018 to $80 million by 2027. This is much needed since such programs are in desperate need, from scope of practice to training, recruitment, succession planning and expansion into community-based settings.

A mechanism for a sustained increase of funding for every year after 2027, taking into account the expansive needs of the aforementioned programs so that they never face budget threats in the future.

GET ON BOARD For those who have FQHC questions, please reach out to the Subcommittee on Primary Health and Retirement Security staff at 202-224-5480. If your FQHC would like to be added to the list of support organizations, contact Britt Weinstock (britt weinstock@help.senate.gov), staff director of the HELP Committee.

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Rural America is at an impasse. On top of the aforementioned additional disparities of care, federal health care reform must protect access to care, including enhanced reimbursements for rural providers. This article first appeared on www.racmonitor.com on June 28, 2017. Permission to published granted by RACmonitor.

POLICY BRIEFS // JULY 10, 2017 - The Centers for Medicare & Medicaid Services (CMS) announced 141 individual market qualified health plan issuers have submitted initial applications to offer coverage using the Federally-facilitated Exchange eligibility and enrollment platform in 2018. At the initial filing deadline last year, 227 issuers submitted an application compared to 141 this year, a 38 percent drop in filings. “This is further proof that the Affordable Care Act is failing,” said CMS Administrator Seema Verma. “Insurers continue to flee the Exchanges, causing Americans to lose their choice for health insurance or lose their coverage all together. These numbers are clear: the status quo is not working.”

JULY 11, 2017 - Alaska requested, and has been granted, a State Innovation Waiver under Section 1332 of the PPACA that allows the state to implement the ARP for the next five plan years. The ARP is a state-operated program which covers claims in the individual market for people with high cost conditions in order to help stabilize premiums for healthier participants. Alaska projects that the ARP will reduce premiums by 20 percent in 2018, and more consumers may have coverage. JULY 19, 2017 - The Health Resources and Services Administration (HRSA) is recognizing ten states for outstanding quality performance of their Critical Access Hospitals (CAHs) in achieving the highest reporting rates and levels of improvement over the past year. The 10 top-performing states – Wisconsin, Maine, Utah, Minnesota, Illinois and Pennsylvania (tied), Michigan, Nebraska, Indiana and Massachusetts – built on their previous successes by investing Federal Office of Rural Health Policy (FORHP) funds into quality improvement projects and developing technical assistance resources that improve high-quality care in their communities.

Summer 2017 | RHQ   17


Public Policy //

From left: RAM founder Stan Brock; A RAMUSA road crew rolls into Tennessee; A RAM dental clinic operates out of a school gym in Chattanooga,

RAM

Remote Area Medical provides free health care, but a patchwork of state laws limits its reach

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BY DAVA STEWART

here is an organization that has not been affected by any of the national health care debate or federal legislation in the last few years. Remote Area Medical (RAM) clinics have provided health care services to people who live in areas where such services are not available, or if they are available, are inaccessible. RAM provides dental care, vision care and medical care to patients, for free, no questions asked, and has been doing so since 1985. RAM was founded by Stan Brock, who has led a full, colorful life that

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sounds like a movie script. He has worked as a cowboy, was a host on Mutual of Omaha’s Wild Kingdom and has dedicated years to the philanthropic endeavor that is RAM. Brock was injured as a young man while living in Guyana. When he was hurt, he was in a remote part of the country. It was a 26-day journey to the nearest doctor, and there was doubt as to whether or not he would survive. The experience inspired him to get his pilot’s license and begin flying medical personnel to similarly remote places to provide care.

Although originally RAM provided services in places such as Guyana, the organization soon found there was a great need in the United States. Today 90 percent of the work RAM does is in the US, though they still operate clinics in Guyana and provide disaster relief throughout the world. Even in the early days of holding US clinics, RAM faced a problem. The state of Tennessee, at that time, did not allow medical volunteers from out of state to provide care to residents. Brock himself led the movement to change the law, and in 1997, Tennessee passed legislation recognizing medical licenses from other states for volunteers to provide free medical care to the indigent population. Today, 38 states still do not allow volunteers to provide medical care if they are not licensed within the state where the care will be provided. For example, if a physician from Ohio agrees to volunteer with RAM, and wants to attend a clinic being held in Texas, unless the physician goes through the process to become licensed in Texas, it is illegal to provide care there. Although there are some federal standards for medical education, each state operates a medical board which oversees licensure, and the requirements are wildly different stateto-state. The Affordable Care Act (ACA) has not impacted RAM clinics, because the majority of people who attend the clinics are coming for dental and vision care, and the ACA largely does not address those needs. Brock says that none of the recent legislation in the national spotlight is likely to affect the people


who come to RAM clinics. However, the state laws related to medical licensure represent a significant barrier to providing free services to a segment of the population that has few, if any, other options for care.

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here are several reasons state medical boards may consider more leniency when it comes to licensure. In the aftermath of Hurricane Katrina, it became clear that states needed to have exceptions for emergency situations. The authors of a 2014 article, “Liability Reforms Needed to Provide Timely Care to Disaster Victims,” published in the Bulletin of the American College of Surgeons, describe some of the difficulties that volunteers faced in trying to help victims of the disaster. They say that more than 33,000 volunteer health professionals either responded to requests for assistance or arrived to help. “However, legal issues, such as licensing and credentialing, civil liability, and reparations for harm to volunteers, delayed or prevented these volunteers from providing care,” say Naveen Sangji, MD, and the co-authors of the article. Many states have since enacted good samaritan laws or other legislation relevant to disasters or emergency situations. Attorney Denise Bloch of Sandberg Phoenix & von Gontard in St. Louis, Missouri, says that emergency situations and the services that RAM provides through their clinics are different issues. When there are emergencies such as Katrina, or the tornadoes in Joplin, Missouri in 2011, volunteers must be mobilized and nearly all states have some sort of legal provision for those situations. “Then you have the other issue,” she says, “and that is when the population is so rural, so poor and so underserved. That’s a totally different circumstance, and that’s where not all states are allowing volunteers, and there’s no other access—that’s the key—there’s no other access to care, no matter how you look at it.” Telemedicine is another area that is bringing the need for more streamlined licensing procedures to the forefront. The promise of telemedicine—that patients

can get care even if the clinician is not physically accessible—is less exciting when state lines effectively represent walls that limit access to care. Yet, although telemedicine may help bring care to those who otherwise don’t have access, it does not address the same issues that RAM does. In order to benefit from telemedicine, patients still need some sort of health insurance coverage or to pay out of pocket, and physicians are providing the service as part of their regular practice with the expectation of remuneration. Patients at RAM clinics do not pay, and all care providers are volunteers. The medical board in the state of North Carolina has streamlined the process of expedited licensure for applicants who have maintained a clean license in another jurisdiction and wish to become licensed in North Carolina. However, volunteers still must be licensed within the state. Jean Fisher Brinkley, the communications director for the North Carolina Medical Board says it comes down to a thorny ethical question: “Is potentially poor care better than no care?” She adds that there have been cases where the North Carolina board declined licenses when other jurisdictions had granted them. The regulatory body exists, after all, to make sure that all licensees meet quality standards. Brinkley says that all patients, regardless of their economic status, should not have to worry about whether or not the person providing health care services is qualified to do so. “The board understands the need and demand for issuing licenses more quickly, but a critical point is that the board is only willing to streamline the process hand-in-hand with ensuring our standards of quality are met,” she says. West Virginia recently passed legislation allowing physicians licensed in other states to volunteer to provide care to the indigent population. In 2016, during devastating floods in the state, RAM provided disaster relief. Now, the organization will be able to more easily hold clinics there. Vicki Gregg, the clinic manager at RAM, says, “Dealing with a closed state or a state that won’t allow out-of-state

providers, we are limited to trying to recruit from within and cannot call on the groups who are our staple providers.” In addition to the complications posed by state medical board licensing regulations, RAM organizers must also address the regulations imposed by dental boards, nursing boards, and optometry boards, because professionals from all of the those fields volunteer at the clinics. Because 85% of the attendees at the clinics are there for dental care, recruiting dental care professionals is particularly important. Disaster situations do not often require dentists or hygienists, and dental care cannot be delivered via telemedicine, so the forces that are driving change in medical licensure are not also shaping the course of dental licensure. Gregg says that the community hosts she works with tell her it is often difficult to recruit volunteers among local dentists because the perception seems to be that the clinics take business from them. However, given the level of poverty and lack of dental insurance among many RAM patients, that seems unlikely. Legislation such as that passed in West Virginia offers one solution.

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ecently, the United States Public Health Service (USPHS) signed a memorandum of understanding (MOU) with RAM. Although the commissioned corps officers are able to work in any state, the MOU will not change where clinics are held, or how RAM and the community that hosts it works with recruit volunteers. The MOU formalizes the relationship, allowing the USPHS to more widely advertise opportunities to volunteer with RAM within its ranks. RAM benefits from the additional volunteers. Regardless of the outcome of the ubiquitous national debate about health care and health insurance, no pending outcome is likely to address the dental needs of the people who attend RAM clinics. Whether the barriers to providing that care are overcome through changes to state law, cooperation among the various entities involved or through some other mechanism, many more people who have few other choices could receive care they desperately need.

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Summer 2017 | RHQ   19


Public Policy //

GROW OR DIE

To survive, rural hospitals need to attract more patients. But the demographics don’t add up.

BY BRAM SABLE-SMITH

$

1.25 million. That’s the size of the bill that could have shuttered the only public hospital in rural Pemiscot County, Missouri in August 2013. $750,000 for payroll. $500,000 for a bond payment. $1.25 million total. One August day in 2013, the hospital’s CEO Kerry Noble had to face facts: The money just wasn’t there. It took an emergency bailout from a local bank to keep their doors open. For now. For the nearly 700 rural hospitals in the United States on the brink of financial collapse, relatively small amounts of money can be the difference between life and death. There are variables that can strengthen their chances of survival: Did their state

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expand Medicaid? Does their patient mix include some higher-paying private insurance? Are they able to recruit doctors? But health policy researchers say the problem for rural hospitals is deeper than all these issues. Rural America’s dwindling populations make it nearly impossible to keep these community institutions afloat. “It’s a very narrow edge on which a lot of these rural hospitals are living,” says Andrew Coburn, director of the Maine Rural Research Center. “Because we’re talking about very small numbers. The loss of 10 to 20 percent of their patient load is more significant than it would be in New York City, because it represents a much higher portion of their total revenue.” Pemiscot County’s hospital is the only public hospital in a county with a population of about 18,000. The next nearest ERs are between 20 and 50 miles away, depending which direction you drive—and two of the four nearest hospitals are in different states. Those distances can be a matter of life or death for someone who has a heart attack or serious injury. The post office in Caruthersville, Missouri, the government seat of Pemiscot County, the poorest in Missouri. In this county that was once dominated by agriculture and

manufacturing, the median income here is $29,600. The county is still the number six producer of soybeans in the state, and number four producer of both cotton and rice. But far fewer employees are needed to yield those crops than 50 years ago. In fact, health care has increasingly become the main industry in the area. Pemiscot Hospital is the county’s largest employer. But the hospital’s business model, like many rural hospitals’, is precarious. For one thing, the hospital absorbs between $7 million and $9 million in bad debt every year—that’s the care they provide to people who can’t afford to pay for it. Medicaid expansion offered by the federal government under the Affordable Care Act would have helped reduce that burden, but the Missouri legislature turned that option down. What’s more, the hospital’s CEO Kerry Noble would later learn they’d missed out on millions of dollars due to an accounting error on a state Medicaid survey. Suddenly a hospital with annual revenues around $50 million couldn’t afford to spend $1.25 million in one month. A SLOW DECLINE Earl Bullington’s wood-paneled office is in downtown Caruthersville, the government seat of Pemiscot County,


just a stone’s throw from the Mississippi River. He’s an advisor for Focus Bank, which rescued the Pemiscot County hospital in 2013. Aside from a few years away for college, Bullington has spent all 83 years of his life here in Pemiscot County, his life span roughly aligned with the hospital’s. He was a teenager when the hospital was built and he watched it go up. Later when he was married, his wife gave birth to their three kids in the hospital’s maternity ward. “Not every county could have a hospital, but we did and it was a good one,” Bullington says. But Bullington also saw the arrival of an invention that inadvertently doomed the hospital: the mechanical cotton picker. “A farmer by the name of Looney Holland had the first picker that arrived on our farm,” Bullington says. “I think that changed Pemiscot County more than any one thing.” That was in 1951—the same year the county’s hospital was completed. Suddenly, one machine could do the job of 40 people. Since then the county’s population has dropped from 50,000 to 18,000. That’s 30,000 fewer people who might’ve used the county hospital. Coburn of the Maine Rural Research Center says population decline, and thereby a loss of potential patients, is a lot more significant for hospitals in rural areas than a proportional loss in urban areas. “It represents a much higher portion of their total revenue,” he notes. Two loans from Focus Bank have helped the Pemiscot County hospital avoid financial collapse. Coburn says low population also makes it harder for rural hospitals to pay off the money they borrow to keep their facilities up to date, because to pay that debt down the hospital either has to become more efficient or grow its revenues. Both of those are hard to do in a small, rural community where the population—and therefore the patient base—is shrinking and the hospital’s services are already slim.

Earl Bullington, advisor for Focus Bank, which rescued the struggling Pemiscot County hospital in 2013. The pictures on his wall depict the farmland in Pemiscot County, Missouri. BRAM SABLE-SMITH / SIDE EFFECTS PUBLIC MEDIA

“Hospitals have to grow their way out of this problem,” Coburn says, “and that’s very hard to do in a community where you only have so many people to serve.” Many of those communities, in places such Georgia and Maine, have responded with new tax levies and bond initiatives. One hospital in Polk County, Tennessee even created a GoFundMe page—though they raised just $5,534 of their $100,000 goal. Pemiscot County turned to Focus Bank. GETTING CREATIVE Back in 2013, Pemiscot CEO Noble was looking for a solution. “I began to get creative,” Noble recalls. He called up Focus Bank to ask for an emergency loan of $1.5 million. “And we got it,” Noble says. The emergency loan was enough money to make payroll, make the bond payment and to keep the hospital going through March 2014. Then, Noble went back to the bank to get a five-year loan worth $3.9 million to buy out the hospital’s old debt. “We knew what would happen to this community if that hospital closed,” Earl Bullington says. “You lose

your hospital, that’s kind of like losing your right arm. It’s the difference between driving five miles or 50 miles to the hospital,” he adds. Now the hospital has to work to keep itself open. They’ve found new revenue streams, such as a prescription drug program for low-income patients, and made difficult decisions to cut costly services like obstetrics and outsource others such as an ambulance service—decisions that mirror trends at rural hospitals across the country. The loan from Focus Bank bought the hospital a little more time to evolve. But no matter what it does, it has to face the reality that rural America’s population isn’t going to get any larger. “There’s a need for coordinated policy response,” says Coburn. “I don’t see that happening across the country yet, but I think it’s going to.”

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This story was produced by Side Effects Public Media, a news collaborative covering public health. Bram Sable-Smith is reporting this series during a yearlong Reporting Fellowship on Health Care Performance sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.

Summer 2017 | RHQ   21


Making a Healthy Difference for Rural Texans

SERVING THE TEXAS RURAL HEALTH COMMUNITY The obstacles faced by health care providers and patients in rural areas are vastly different than those in urban areas. The Texas Rural Health Association (TRHA) is a nonprofit organization whose primary goal is to improve the health of rural Texans. Since 1984, individuals and organizations of TRHA have been dedicated to providing leadership on rural health care issues through advocacy, communication, and education.

THE TRHA MISSION  Promote rural health as a distinct concern in Texas.  Serve as a strong and unifying voice for concerned citizens,

community leaders, public officials, and health care providers and organizations working to improve rural health in Texas.  Advocate for rural health and promote an enhanced status

and improved health system for rural Texans.  Provide a forum for exchange and distribution of

information and ideas related to improvement of rural health.  Encourage the development of appropriate health resources

to all rural areas of Texas.

WWW.TRHA.ORG | 512-368-9860 | PO BOX 201363 AUSTIN, TX 78720


TECH FOR VETS //

Health Technology //

TEXAS TELEHEALTH SENATE BILL DROPS CONTROVERSIAL IN-PERSON EVALUATION REQUIREMENT

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he Department of Veterans Affairs has launched a new online tool that will help veterans compare various treatment options for post-traumatic stress disorder (PTSD).

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arlier this summer, Texas Gov. Greg Abbott signed a bill into law, changing the face of telemedicine in the state. With Governor Abbott’s signature on Senate Bill 1107, physicians can now utilize telemedicine services with patients they haven’t met in person. This represses an earlier requirement that physicianpatient relationships had to be established with an Travis Hanson in-person visit first. Executive Director, Texas cleared a big hurdle with this change, as Innovative Healthcare this was the last major U.S. market blocking the Transformation growth of video doctor consultations. Texas was the F. Marie Hall Institute last state to uphold this requirement. Now that it’s for Rural and Community abolished, direct-to-consumer telemedicine compaHealth nies can expand their services across the nation. “To date Texas has lagged behind the rest of the country in establishing a supportive regulatory environment for the expansion of telemedicine, a proven delivery model for increasing access to care—especially for rural Texas—and providing a less costly alternative to visiting emergency rooms for non-emergency conditions,” said Jamie Dudensing, CEO of Texas Association of Health Plans. “We’re one step closer to removing barriers to this important technology.” The passage in the Texas House is the latest legislative momentum for telehealth, which offers access to physicians and patients via smartphone, tablet or computer. Employers and private insurers are already embracing the trend as a way to make health care more convenient and avoid costly and unnecessary trips to the emergency room or a more expensive physician’s office. “Unlike other companies who see telehealth as an app or a phone service, we have always maintained that telehealth should extend the relationship between patients and the health care brands they trust,” American Well CEO Dr. Roy Schoenberg said. This is good news for companies like Teladoc, Doctor on Demand, American Well and MDLive. Teladoc is especially cheering. The telehealth provider has been entwined in a six-year legal battle with the Texas Medical Board regarding the scope of telemedicine in the Lone Star State. “Teladoc undertook the responsibility to preserve access to telemedicine in Texas more than six years ago, and we are gratified to have been the telehealth company invited to collaborate with the Texas legislature and others in the state to accomplish this laudable goal,” Teladoc CEO Jason Gorevic said in a statement. “Our commitment to the state and its citizens has never wavered, and we now look forward to reactivating our industry-leading video capabilities and ending our legal dispute in the state of Texas.” The new law is also a win for residents of Texas, where access to healthcare—especially in rural areas—continues to be a challenge. Texas ranks 46th out of the 50 states in terms of primary care physicians per capita, as there are only 71.4 PCPs per every 100,000 people. Additionally, 35 of Texas’ 254 counties don’t have a family physician.

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www.ptsd.va.gov/apps/Decisionaid The PTSD Treatment Decision Aid is a free, interactive online tool that helps educate patients about effective treatment options for PTSD and encourages them to participate actively in decisions about their care. “The health and well-being of the courageous men and women who have served their country in uniform is the VA’s highest priority,” said VA Secretary David J. Shulkin, M.D. “The PTSD Treatment Decision Aid is an important step in putting veterans in control of their health care. By helping to bridge understanding and communication between veterans and providers about the most effective treatment options available, we are ensuring veterans receive the treatments that best promote their healing and recovery.” The tool includes information about evidence-based PTSD treatments, such as talk therapy and prescription medication options. It also includes useful information designed for people who have served in the military. Users can watch videos of providers explaining different treatment options and what to expect with those treatments, and hear from veterans who have benefited from them. According to VA findings, eight of every 100 people will experience PTSD at some point in their lifetimes, and almost 620,000 of the veterans treated by VA have Summer 2017 | RHQ   23 a diagnosis of PTSD.

Summer 2017 | RHQ   23


Health Technology //

PROJECT ECHO

‘Changing the World, Fast!’

That’s Project ECHO’s slogan and its mission. The ECHO model is expanding—across diseases and specialties, across different types of delivery and payment systems and, increasingly, across the planet. BY SANJEEV ARORA, M.D., ET AL.

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Summer 2017 | RHQ   25


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or almost three years, Type 1 diabetes controlled Kaycee May’s life. May, who lives in Portales, a town of about 12,000 in eastern New Mexico, received her diagnosis when she was 17. Her condition was so serious that her doctors feared she would fall into a diabetic coma. They sent her to a hospital more than 100 miles away in Lubbock, Texas, where she stayed for a week. Afterward, she travelled to Lubbock every month to see the specialist who managed her care—a two-hour drive each way for a 30-minute appointment. These days, May controls her diabetes, instead of the other way around. Through a program called Endo ECHO, she now gets excellent care for her diabetes right in Portales, where she lives and works. “Before Endo ECHO, I felt like I had a gigantic burden,” says May, who, in addition to being a wife and mother, works at a daycare center and goes to college. Now, she says, her life is much more manageable. May’s situation is typical for millions of Americans who live in rural and remote communities where specialist doctors are few and far between. People who have common but complex health conditions may have to travel hundreds of miles and wait weeks or months to get the care they need. That often means taking a day off from school or work, paying for gas or a bus ticket—or going without care until the condition becomes much more serious and more difficult and costly to treat. It’s no wonder we are seeing increasing health gaps between Americans living in rural areas and those in urban areas. A report from the U.S. Centers for Disease Control and Prevention found that, compared to urban dwellers, people in rural communities have higher death rates and suffer more preventable deaths from heart disease, stroke, cancer, injury, and chronic respiratory disease. Endo ECHO, the program that turned Kaycee May’s life around, is part of Project ECHO (Extension for Community Healthcare Outcomes), which helps people in rural and remote communities across the United States get high-quality health care for more than 50 common complex medical conditions, including rheumatoid arthritis, chronic pain, heart disease, HIV, hepatitis C, and opioid addiction. Project ECHO educates and supports community providers—including not only primary care physicians but also nurses, nurse practitioners, physician assistants, counselors, social workers and community health workers—so that they can provide specialized care and services for their patients, in their communities.

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ere’s how it works: Primary care providers who join Project ECHO choose a common, complex health problem, such as HIV or chronic pain, in which they want to specialize. These providers enroll in ECHO free of charge, usually with one or more colleagues, at a community health center or federally qualified health center. Through basic videoconferencing technology, they participate in weekly teleECHO clinic

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sessions, sort of like virtual grand rounds, led by a team of specialists located hundreds—or even thousands—of miles away. The specialist team includes people from all the professions needed to treat the condition at hand. For example, the Endo ECHO team at the University of New Mexico Health Sciences Center (UNMHSC) in Albuquerque that supports May’s primary care provider in Portales has an adult endocrinologist, a pediatric endocrinologist, a nephrologist, a pharmacist, a psychiatrist, a nurse manager, a community health worker and a social worker. This way, community providers seeking specialty knowledge gain access to a range of perspectives and expertise together, in real time. The teleECHO sessions involve primary care providers at multiple sites. For example, every Wednesday at noon, teams of primary care providers from nine community health centers across New Mexico connect to the Endo ECHO clinic session. During the two-hour sessions, providers take turns presenting de-identified patient cases and working with specialists to determine treatment. The specialists listen, ask questions, and offer their advice. They are also available to primary care providers for guidance on cases outside the clinic sessions. Although these specialists never see the patients whose cases they’re discussing, they provide expert advice to the trained clinicians who know the patients best, in this way helping to ensure that these patients receive excellent, comprehensive care in their own communities. Through Project ECHO, community health providers acquire the knowledge, skills, and support they need to provide high-quality care to patients who otherwise might not be able to get it. They can do more for more patients. By maintaining treatment in local communities, that care is more efficient and more patient-centered. And by sharing their expertise and working with multidisciplinary teams to support primary care providers in rural and underserved areas, specialists help more patients get the care they need to live healthier lives. Their knowledge and expertise reach exponentially more patients than when they see patients one on one.

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roject ECHO started in New Mexico, where 32 of 33 counties are fully or partly in federally designated health professional shortage areas. Originally, we sought a way to bring life-saving treatment to the more than 28,000 New Mexicans infected with hepatitis C. In 2004, fewer than 5 percent of those patients had been treated. The liver disease clinic at UNMHSC was one of only two such clinics in the state at the time where patients with hepatitis C could get treatment—and it had an eight-month waiting list. Knowing that thousands of patients were suffering and even dying from a curable disease because they couldn’t access treatment was unacceptable to us. Accordingly, Project ECHO at UNMHSC was launched and developed a partnership with the state health department, the Indian Health Service, the state prisons (which housed 2,300 infected and untreated


Thanks to Endo ECHO, Kaycee May is able to manage her diabetes while remaining with her family in rural Portales, New Mexico.

Summer 2017 | RHQ   27


inmates), and community clinicians who were willing to treat hepatitis C in rural areas. An evaluation of Project ECHO published in the New England Journal of Medicine in 2011 found that the outcomes of hepatitis C patients treated by primary care providers trained through Project ECHO were equal to those of patients treated by university specialists. And many more people were getting treatment for hepatitis C as a result of Project ECHO—thousands more. Since then, Project ECHO has expanded far beyond New Mexico’s borders, serving residents of rural and remote communities across the United States and in Africa, Asia, Europe, and Central and South America. The model has demonstrated remarkable flexibility—it works across geographic regions, across cultures, and across payment systems. In health care, it is being used to spread best practices for problems as diverse as autism, cancer, bone health, mental illness, and reproductive health. Other systems, including education and law enforcement, are exploring the ECHO model as well. Currently, ECHO is significantly expanding its effort to combat America’s opioid addicSanjeev Arora, M.D., is director tion crisis. This evolved of Project ECHO. out of work to address New Mexico’s terrible and longstanding problems with opioids. For example, Española, a town in the northcentral part of the state with fewer than 11,000 residents, has consistently ranked among the top U.S. cities for percapita rates of opioid overdose deaths. Until just a few years ago, treatment for opioid addiction was virtually non-existent in Española. Today, hundreds of patients are in treatment. Lives are being saved – and changed. “There’s more hope in the community,” says Leslie Hayes, M.D., a primary care physician at Española’s El Centro Family Health Clinic. Hayes is one of three physicians in Española certified to prescribe buprenorphine for opioid addiction. All three were trained to prescribe buprenorphine through Project ECHO; Hayes was the first. She typically carries the maximum allowable caseload for buprenorphine treatment—100 patients, many of whom are pregnant women. Now, Hayes not only provides opioid addiction treatment—through Project ECHO, she has become an expert, serving as a mentor to physicians around the Southwest who are trying to provide care for pregnant women under-

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going buprenorphine treatment. In her own practice, she ensures that women get proper prenatal care and monitors their progress after birth. Some of these women now have toddlers who are healthy and doing well. Last year, the White House presented Leslie Hayes with an award in recognition of her work as a Champion of Change in her community. Now the effort that began in New Mexico is taken to a national level, through work with the U.S. Health Resources Services Administration (HRSA) and in partnership with the University of Washington, the Billings (Mont.) Clinic, Huther Doyle and the Western New York Collaborative, and the Boston Medical Center. Together, we are training primary care providers at more than 110 federally funded health centers to treat substance use disorders, including opioid addiction with buprenorphine. In addition, through federal funding provided under the 21st Century Cures Act, 20 states are using the ECHO model to combat opioid addiction. Opioid ECHO, as the new HRSA program is called, aims to dramatically increase treatment capacity for substance use disorders in underserved communities where the need for treatment may be great but the availability of effective care is limited. Essentially, we are trying to create many more Leslie Hayes’s across the country. Mental and behavioral health is another area where we are working hard to increase treatment capacity in rural communities. It’s estimated that up to 80 percent of mental health disorders go undiagnosed and therefore untreated. This is a huge problem in rural America, where, again, there simply aren’t enough specialist providers to meet the need. In many rural communities, the nurse practitioners and other non-physician clinicians who provide the bulk of primary care are also the ones practitioners’ patients turn to when they have mental and behavioral health problems. Typically, however, these clinicians lack the training, support, and confidence to provide high-quality care for these disorders. For three years, Project ECHO has tested a new model that provides additional training and practice experience in mental and behavioral health treatment to family nurse practitioners working in community health centers. These family nurse practitioners partner with community health workers who have also received specialized training and practice experience. Together, they form a primary behavioral health care team based in the community, in a setting that patients already know and trust.

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s stories like Kaycee May’s and Leslies Hayes’s show, Project ECHO has the potential to change the dynamic of health care across rural America. Rural communities have critical assets that frequently are overlooked: the dedicated primary care physicians, nurses, nurse practitioners, physician assistants, community health workers, counselors and social workers who are the backbone of rural health care. By engaging these front-line


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roject ECHO (Extension for Community Health Outcomes) occupies a unique position on the spectrum of emerging telehealth models that are becoming increasingly important to improving health in rural communities. Most telehealth models and programs create one-to-one connections between doctors and patients to support direct care or between doctors and doctors to support consults. Project ECHO creates many-to-many connections for the purposes of freely sharing best-practice medical knowledge and exponentially expanding access to high-quality, specialized care. Sanjeev Arora, M.D., the liver disease specialist at the University of New Mexico Health Science Center who conceived Project ECHO, often describes the model Dale C. Alverson, M.D. as a “force multiplier.” By engaging local providers on the front lines of care in continuous learning networks with teams of specialist mentors located hundreds Professor Emeritus Medical Director, or even thousands of miles away, Project ECHO builds new capacity for care at the Center for Telehealth, University community level. Essentially, it is a platform for enabling multiple physicians in of New Mexico multiple sites to treat patients whose problems previously fell outside their skill set. Past president of the American As a result, many more patients can get the health care they need, when they need Telemedicine Association it, in or near the communities where they live. This is obviously very important in rural areas that have severe provider shortages. Instead of bringing in new providers, Project ECHO brings in new knowledge and skills for existing providers to use for the benefit of their communities. Project ECHO is not a cure-all for our health care system; nor does it replace the need for specialists. But it encourages a more collaborative kind of care between specialists and primary care providers that is a win-win for everyone. The ECHO model is now being used to treat a wide range of complex chronic diseases and has been replicated across the United States and around the world. Today, Project ECHO operates more than 120 hubs for more than 60 diseases and conditions in 23 countries. ECHO’s mission is to democratize medical knowledge and get bestpractice care to underserved people all over the world, with a goal of touching the lives of 1 billion people by 2025. As telehealth continues to evolve, Project ECHO will play an important role in helping to improve health and quality of life in rural communities in the United States and around the world

providers in a learning network where they receive ongoing mentorship and support, the ECHO model builds permanent local capacity to provide specialized care. In addition, providers who participate in Project ECHO experience increased professional satisfaction and reduced feelings of professional isolation. This is critical in rural communities, where provider burnout and stress are high. We want providers to feel satisfied with and supported in their work, and we want them to continue practicing in rural communities. Project ECHO can help. The future is promising. Currently, Project ECHO has teleECHO clinics in 30-plus states and more than 130 centers of excellence, usually universities or academic medical centers, that we call “hubs.” Although the model has spread quickly, we believe that pace will pick up even more. In December 2016, following unanimous approval by Congress, the ECHO Act was signed into law. The ECHO Act directs the U.S. Department of Health and Human Services and HRSA to study the ECHO model and its ability to improve patient care and provider education, and to report those findings to Congress, along with recommendations for reducing barriers to use and supporting opportunities

for further adoption of the model. Congressional leaders on both sides of the political aisle expressed deep optimism to help patients in rural areas get the care they need, when they need it. Project ECHO’s roots are in rural America. And although we have set a goal to touch 1 billion lives worldwide by the year 2025, we envision that millions of those lives will be in small towns, tribal villages, and remote communities across the United States.

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The following writers contributed to this story: Sanjeev Arora, Karla Thornton, Miriam Komaromy, Bruce Struminger, Joanna Katzman, Matt Bouchonville, Mike Lewicki and Jennifer Snead. Project ECHO has received funding from a number of sources, including support from The Leona M. and Harry B. Helmsley Charitable Trust, the GE Foundation and the Robert Wood Johnson Foundation.

Summer 2017 | RHQ   29


Behavioral Health //

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PEACE OF MIND

East Texas clinicians, educators and clergy are joining forces to bring mental health care to the masses. BY COSHANDRA DILLARD

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or the last three years, hundreds of people have flocked to a church in Tyler, Texas during the fall for the annual Peace of Mind Tyler Mental Health Conference. At each event, mental health advocates, clinicians, educators, clergy and those who have lost a loved one to suicide share their expertise or their own experiences about mental health. In its inaugural year, Kay Warren of Saddleback Church—founded by her husband Rick—stood at the podium and painfully detailed her son’s suicide the year prior. In the months before and after her visit to Tyler, she had been speaking candidly to the public about how mental illness rocked her family. Much of the feedback following the first conference in Tyler was a mix of elation and surprise. Local interest in learning about mental health and how to effectively address issues within the church was overwhelming. The running anecdote in East Texas has been that it’s the buckle of the Bible Belt. There appears to be a church on every corner. Strangers are casually greeted with, “What church do you attend?” Faith is a central part of life in these parts. But according to mental health advocates, historically, there seemed to be missed opportunities when it came to the church addressing mental illness and its effects on families. It’s even more profound in rural areas, since more than half of rural residents—60 percent— live in a mental health professional shortage area, according to the American Psychological Association. People often turn to their faith to address mental health issues, which is why advocates knew East Texas would be a good place to begin a conversation at the Peace of Mind conference. Matthew Stanford, Ph.D., chief executive officer at The Hope and Healing Institute and adjunct professor in the Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine and the Department of Psychology at the University of Houston, has researched how churches deal with mental health, finding that


church leaders tend to be unprepared to handle congregants’ mental health issues. His research suggests that the way churches dealt with mental illness isolated its congregants, sometimes leaving them questioning their faith. It doesn’t help that they already have limited or no access to mental health services. Other studies have shown that few churches have adequate plans to assist families living with mental illness. For example, a Lifeway Research survey showed that the “response of people in church to individuals’ mental illness caused 18 percent to break ties with a church and 5 percent to fail to find a church to attend.” According to the same survey, “22 percent of pastors agree that they are reluctant to get involved with those with acute mental illness because previous experiences strained time and resources.” But something is changing. In recent years, the effort to spread awareness about mental health and treatment has manifested in the forms of tool kits for religious leaders, conferences and collaborations between mental health professionals, clergy and advocates. In addition, more people are coming out of the dark instead of dealing with shame and stigma. Today, churches and organizations such as The Meadows Mental Health Policy Institute are acknowledging both faith and science in the search for adequate treatment. They host events and provide tools for organizations in larger cities that serve as a hub for rural communities, such as Beaumont and Amarillo. “There are more opportunities for discussion of mental health in places like churches, synagogues and mosques,” says Phil Ritter, chief operating officer at The Meadows Mental Health Policy Institute. The change may be just a small part of broader societal changes across the country. “My perception is there is a general shift in our culture that isn’t specific

to church or rural areas. It’s across the board,” explains Andy Keller, president and chief executive officer at The Meadows. That shift, he said, moved faster as national headlines surrounding mass shootings often brought mental illness to the forefront. “Sandy Hook was an event that changed the tone,” he says. Keller also attributes leaders such as Warren who’ve made it easier for people to be vocal about their experiences. “When we have a church leader like that that’s well known talking about it, it makes a big difference,” he says.

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hen local advocates felt there wasn’t enough awareness about mental illness in East Texas, the Peace of Mind conference was born. It is a program of the Samaritan Counseling Center, a local interfaith organization that provides counseling for East Texans. In the organization’s office in downtown Tyler, they take a holistic approach to addressing mental health needs: working with the whole person—mind, body and spirit. They collaborate with faith communities—offering training and resources to area clergy. They’ve been responsive. “There is a foundation of healing that can happen when we work well with our faith communities,” says Rebecca Lincoln, clinical director at Samaritan Counseling Center. Seeing the need in underserved rural areas, the organization opened counseling locations in four rural communities: Lindale, Jacksonville, Kilgore, and Henderson. Rick Ivey, senior pastor at First United Methodist Church Lindale, said pastors are realizing that mental illness isn’t a condition that can be prayed away only. For four years, Ivey has led a 1,000-member church in rural East Texas which averages an attendance of about 350 at each service. “The growing trend is to look at it more as a medical condition rather than something that is wrong with them,” Ivey says. “Prayer has to be a significant

part of helping people who are struggling with mental illness. It’s something that should be in addition to.” He, too, notices that stigma has been reduced. “I think it is because of larger exposure to media, television, public service announcements and advertisings for medications. It’s become a little more understandable. There is more openness to it. It’s no longer secretive. It’s not the stigma it once was.” His church provides space for meetings and a place for resources for clients of the Samaritan Counseling Center. Advocates are also calling for more awareness and are urging legislators to allot more funding for mental health programs, particularly for rural areas. It’s just part of the work that The Meadows Mental Health Policy Institute does. Texas has increased funding for services in the last legislative session, but the state continues to lag in mental health spending compared to other states. So, community leaders continue to speak up. “Leaders in the faith community are becoming involved in public policy and advocacy to support the mental health system,” Ritter says. “Tyler is a good example of that.” The fact that we’re talking about the issue more in our society is very important and it creates a call to action for the policy leaders in our communities and in our state.”

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hile there is progress, it is slow. Nonetheless, Keller gives credit to churches for their dedication to healing. “Communities of all faiths are critical to helping us heal,” he says. “It’s not that people don’t want to be helpful. They don’t know how to be helpful. Churches have a huge untapped role to play that they already play for other diseases.” He added, “Some churches have moved forward and others have not, but we’re still encouraged to see the progress, although it’s still early.” Lincoln echoes the sentiment. “It’s something we have to stick with,” she says. “It takes time.”

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Behavioural // Section Title Health //

SEARCH+ RESCUE

Inside Montana’s Suicide Mortality Review BY CINDY UKEN

TH HID

In the frontier state of Montana, where kids are taught from a young age to “cowboy up,” suicide has a stranglehold on its people. Residents, many of whom live in isolation, are killing themselves at a rate faster than almost any other place in the nation. Mental health, public health government n the frontier state of Montana, where kidsand are even taught from a 32  RHQ | RuralHealthQuarterly.c officials aretoscrambling find a way halt what has young age “cowboy up,to ” suicide has atostranglehold on been its people. Residents, many of whom live in isolation, are killing themselves deemed a crisis.

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at a rate faster than almost any other place in the nation. Mental health professionals and government officials are scrambling to find a way to halt what has been deemed a crisis.

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HE ID-

com

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Summer 2017 | RHQ   33


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or nearly four decades, Montana has ranked in the top five states for having the highest rate of suicide, often placing at No. 1. In Big Sky Country, residents young and old alike kill themselves at nearly twice the national average. Between 2005 and 2014, the crude rate of suicide in Montana was 22.33 per 100,000 people; the national rate during that period was 12.22 per 100,000. In raw numbers, 2,199 Montana residents died by suicide for an average of 220 people per year during this time period. The Montana Suicide Mortality Review Team was created in 2013 by House Bill 583 and signed into law by Gov. Steve Bullock after mental health officials characterized the suicide rate as a “public health crisis.” The team started examining death certificates and talking to coroners, looking for answers behind the troubling phenomenon. After examining the 555 suicides that occurred in Montana between Jan. 1, 2014 and March 1, 2016, the team concluded that access to lethal means (firearms), alcohol, a sense of being a burden, social isolation, altitude, undiagnosed and untreated mental illness, lack of resiliency and coping skills, and a societal stigma against depression all contribute to the long-term, cultural issue of suicide in Montana. The report further stunned an already shocked state: •

In Montana, between 2005 and 2014, suicide was the number two cause of death for children ages 10-14, adolescents ages 15-24, and adults ages 25-44, behind only unintentional injuries (CDC, 2016) In 2015, 29.3 percent of high school students in Montana reported they felt so sad or hopeless almost every day for two weeks or more that they stopped doing some of their usual activities (Montana Youth Risk Behavior Survey, 2015). For 2014 and 2015, the highest rate of suicide in Montana is among American Indians (35.5 per 100,000) followed by Caucasians (28.1 per 100,000).

“What is a realistic investment in saving lives?” asked Matt Kuntz, executive director of NAMI Montana. “We have been trying to solve the problem for decades in the dark.” With the help of a $303,000 grant from the Montana Research and Economic Development Initiative, comprised of committed facilitators and the Montana State University Center for Mental Health Research and Recovery, a new youth suicide prevention intervention program has been introduced to about 1,400 seventh- and ninth-grade students in eight Montana schools. “Montana may have just taken the lead in bringing the best suicide prevention program in the world to the state,” said Kuntz, who once was on the brink of hanging himself. No one knows if this is the solution and no one has the answers, Kuntz added. But, he said, you have the “burden” to bring the best existing evidence available to the state, and he believes this might be it. “How to do this right is something we’re learning as we go,” Kuntz said in a telephone interview with Rural Health Quarterly.

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“The critical thing is to be guided by the evidence but with the realization that at the same time kids are dying without effective suicide prevention training.”

THE YAM PROGRAM The research-based program, which has been found to reduce suicide attempts and suicidal thoughts by more than 50 percent, is called YAM, or Youth Aware of Mental Health. The five-hour program is spread over five weeks. Using trained facilitators, YAM includes interactive talks, as well as three hours of role-playing and mental health referral resources for youth. The program is designed to teach both mental health awareness and risk factors that are associated with suicide, as well as a set of skills for dealing with adverse life events, according to Matt Byerly, M.D., director of the MSU Center for Mental Health Research and Recovery. It is one aspect of a multifaceted approach to reducing deaths by suicide in Montana and has the endorsement of the Montana Suicide Mortality Review Team. There is a myriad of prevention programs all aimed at reducing suicide, but Byerly said this is the right one for Montana. “It has the best evidence for reducing suicide attempts and suicidal thoughts in adolescents,” he said. An important component of YAM is that it is directly delivered to each youth, rather than to “gatekeepers,” or those people who frequently interact with youth, such as teachers, school staff and community leaders, Byerly said. Montana and Texas are the first states in the nation where YAM is delivered. In addition to delivering the program to students, researchers will conduct an initial study to determine YAM’s feasibility and acceptability by youth, their parents, schools and communities in the U.S., Byerly said. A third component of the effort is to adapt YAM so that it is culturally appropriate for high school students, American Indian students and youth of military service families in Montana. “Not only do we want to pilot YAM to determine its effectiveness, but we want to see if it is a good fit for Montana,” said Karl Rosston, suicide prevention coordinator for the Montana Department of Health and Human Services. “There’s not many programs that have been tested first in Montana. This gives us an opportunity to see it from the start.” The pilot study was completed in the spring. Follow-up assessments were completed in early June and data entry is under way, Byerly said. There are currently no results. However, Byerly said, “Informal feedback has suggested that the intervention is well accepted by students and schools.” Montana’s staggering suicide rate has long been under the watchful eye of Democratic Gov. Steve Bullock. He has argued that the state has a responsibility to do all it can to protect individuals from suicide and ensure that every young person “knows their value” at school, home and in their communities. “The YAM program takes on this responsibility head-on and is especially important to not only reducing the risk of suicide, but helping young people develop the underlying emotional health resilience they need to navigate stressful situations in life,” Bullock said. YAM was developed in Sweden, and more than 11,000 ninth

YAM is an evidence-based mental health promotion program for 14 - 16 year olds. To learn more about the program or sign up for the newsletter, visit www.y-a-m.org.

grade students in 10 European countries participated in the initial study. Results of the study showed that YAM was the only intervention of three that was superior to the control group, reducing suicide attempts and suicidal thoughts by more than 50 percent compared to the control group. The findings were published in the journal “Lancet” in 2015. One of the authors of those finding was David Brent, M.D., a psychiatrist in Pittsburgh, Pa. affiliated with UPMC-University of Pittsburgh Medical Center. “No one program could address all the issues,” Brent told Rural Health Quarterly. “YAM is a good choice because it is one of the few programs that has been rigorously evaluated and cuts the rate of suicidal ideation and attempts in half. It cannot be the whole solution, but I believe the folks in Montana have been strategic and that this is one of several initiatives.” Four master trainers of YAM visited Bozeman in April to provide a week-long training for YAM facilitators, which was the first training of its kind in the U.S. Twelve Montanans and three Texans completed the training. Carl C. Bell, M.D., is a staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago and is a member of the Rosalyn Carter Mental Health Task Force. He described the YAM program as a “good start.” Bell said he has seen various research projects on suicide prevention move forward, but they are all poorly designed and usually focus on preventing suicide behavior. But, he maintains, that does not mean such interventions are actually preventing suicide. Bell told Rural Health Quarterly that after familiarizing himself with YAM he is “not impressed.” Kuntz and Byerly disagree. “How long would it take something else coming down the pipeline to demonstrate this level of effectiveness,” Kuntz asked. “Is there anything else on the horizon that looks like it could be nearly this effective in reducing depression and suicidal ideation through a population intervention in high school youth? A key component of YAM is that the program is delivered by a group of people with expertise working with youth regarding mental health issues,” Byerly said. He emphasized that many of the facilitators are people who have advanced education in mental health fields, as well as teachers and community health professionals. “Suicide is a huge problem in Montana—one of the biggest problems Montana faces,” Byerly said. “We’re fortunate to have this opportunity to be the earliest involved with a very promising intervention. Ultimately, we’ll be participating in evaluating the true impact of the intervention.”

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Intermediate Level Training in MI, PN and Chronic Disease Management


Health Education //

A HEALTH PROFESSIONAL PIPELINE

Education and outreach programs attempt to address America’s rural provider shortage

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ealth professional shortages have been and continue to be a concern throughout the United States, but the rural communities are faring worse than others. Health professionals include primary care practitioners, dental and mental health providers. As noted in the Debra Flores map below, for some states, the shortDIRECTOR, ages are noted throughout the state to WEST TEXAS AHEC include urban and rural areas, but for F. Marie Hall Institute the majority of the states the greatest for Rural and Community shortages are in rural areas. Health The primary care provider shortage is more dramatic (6,799), compared to dental (5,592) and mental health (4,724). According to the Rural Health Information Hub, health professional shortage areas may be designated according to geographic region, population-specific or facility-based. The geographic designation as implied is based on a demarcated geographic area. Some designations, occasionally in urban areas, and shortage areas are selected based on a subset of the population, usually with

incomes 200 percent below federal poverty level. Some health care facilities considered safety net such as Federally Qualified Health Centers and Federally Qualified Center Look-Alikes, Indian Health Services and some Rural Health Clinics automatically receive the shortage designation. So what is being done about this health professional shortage crisis? Area Health Education Centers Program supports community-based interprofessional clinical training, continuing education, and outreach activities in order to improve the distribution, diversity, quality, and supply of the primary care health professions workforce serving in rural and underserved health care delivery sites. Area Health Education Centers (AHEC) are located throughout the United States, and AHECs have been around for over fifty years. In 2016, there were 52 centers throughout the United States, with at least one in each state. Introduction to health careers for AHEC programs typically begins at the high school level for students. The goal is to matriculate students interested in health careers into a career pipeline. Activities facilitated by different AHECs include introducing students to the different health related career opportunities through education/presentations and participation in youth health service corps. Additionally, high school stu-

Health Professional Shortage Areas (HRSA Data Warehouse)

Summer 2017 | RHQ   37


dents are introduced to different health careers through field trips that include tours of medical facilities, simulation centers and summer camp. Students are kept engaged at the undergraduate level by providing internships and memberships in collegiate service corps. Exposure to the different career opportunities through mentorships and volunteerism are integral in the process of remaining in the pipeline because these activities are used to strengthen medical applications. AHECs are required to maintain a database that includes the number of students reached each year by the services provided and although these numbers are impactful, the difference is evident in the individual student stories. One such story, shared below, is written by Christian Castro:

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s I prepare to begin the next chapter in my life I can’t help but think back on how I got to this point. Walking onto the Texas Tech campus my freshman year I felt just like every other student in their 1st year: anxious, nervous, excited and even a little proud. You see I come from a traditional Hispanic family whose seeds come from individuals who immigrated to the United States at an early age with little education in order work and support people other than themselves. My Christian Castro grandparents were not fortunate enough to have completed their education, apart from one grandfather who completed his high school education. Instead my grandparents left their homes in Mexico to come to the United States to work, and at as early as 14 years old some of them were even the primary source of income for their families back in Mexico. Education was a luxury that they could not afford, but working at multiple jobs they were able to make a better life for themselves and their children. Because of their sacrifices they could provide the opportunities that were never offered to them through proper education for their children and so forth. So, to have even been standing on a campus of a university as prestigious as Texas Tech University was a testament to not only my determination and will to succeed, but the support and hard work of my entire family. Despite being proud of this milestone in my life, I would be lying if I said I wasn’t also terrified as an incoming freshman. Sure, I had the support of a wonderful family, but I was 300 plus miles away from home. I was on my own, and whatever was going to happen from here on in was going to be solely my responsibility. I knew I wanted to be a doctor, but no one in my family or group of friends had ever done this, so I had no one to guide me. Probably the scariest thing I remember feeling was starting my freshman year not knowing anything about how to go about becoming a doctor. However, I was not going to let this stop me, so I began searching for organizations and opportunities that would help guide me along my path, and luckily for me I came across the Double T Health Service Corps.

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The DTHSC (Double T Health Service Corp) was one of my guiding lights in pursuit of getting into medical school. I was introduced to students interested in the same field as me, partnerships with entities such as West Texas AHEC research opportunities, volunteer opportunities, and leadership opportunities. I would go on to climb the ranks of the organization until I reached the highest position of President in my last year, and along the way I was able to found many high school outreach programs and mentoring programs for students that were interested in pursuing careers in health professions. In a way I founded these programs with the idea that I could be a guiding light for students coming from similar backgrounds as myself and providing at least some guidelines for how to go about completing and continuing your education into a health profession. My journey was not without hardships and failures, it was not without times when I felt like giving up, but I never did. Four long, hard years of biology, chemistry, organic chemistry, virology, immunology, etc., but I never quit. I never gave up. I like to think that I never gave up because I learned from my parents and from my grandparents that no matter how tough something is or how hard a class may be, if you set your mind to it nothing is impossible. The countless sleepless nights, the long hours of studying before tests, and the many microwavable noodles over four years culminated into one of the greatest achievements in my life, acquisition of my Bachelors of Science in Biology from Texas Tech University. As proud as this accomplishment makes me, it was a phone call I made in December that I will remember most about my last year at Texas Tech. The phone call was to my father and mother, and I told them for the first time that I would be attending Paul L. Foster School of Medicine in 2017. This moment of joy and tears after all the sacrifices made by my family, the hard work of my parents, and the support of organizations such as the DTHSC and West Texas AHEC was by far the most proud and accomplished I had ever felt in my life. Now, as I prepare to continue my education as a medical student I will always remember the people that helped me get where I am today because without them I would not be here. I know the road ahead will be difficult, but with the support of those around me and the ideals I was raised with I know I can accomplish anything. My name is Christian Michael Castro, and I am proud to say that I am a part of the Paul L. Foster School of Medicine Class of 2021.

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his is but one among hundreds of success stories shared among AHECs nationally. Stories like Christian Castro’s are the reason AHEC programs and youth health service corps such as the Double T Health Service Corp are instrumental in the recruitment of physicians and other health care professionals into the career pipeline. These personal stories are the ones that speak to the effectiveness of the program provided through AHECs throughout the country.

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www.eagletelemedicine.com


Health Education //

COMMUNITY HEALTH WORKERS FACE A CHANGING LANDSCAPE Why some CHW advocates think certification is a mistake BY BARBARA MANTEL

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arly in the afternoon on a temperate June day, Rodrigo Gallego drove along the mildly undulating roads of the Black Dirt Region of Orange County, New York, where, he estimated, more than 500 migrants from Puebla, Mexico work the fields of the surrounding onion farms. Originally from Columbia and fluent in Spanish, Gallego, 53, is a community health worker at the nearby HRHCare Alamo Health Center. He spends Monday through Friday steering the clinic’s van through the entrance of one farm after another, stopping to speak with the workers who wave him down. Gallego connects them to health care, taking them to the Alamo clinic and regional specialists, translating and keeping in regular touch. Their primary complaints are vision problems, fingernail fungus, skin rashes and back pain, he said. Most speak no English, and many have no way of getting around. “Some people say to me, ‘Oh, you’re just a driver.’ But I say I am a person who listens to what these workers need,” said

Rodrigo Gallego is a Community Health Worker in Orange County, New York.

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More than 500 migrants from Puebla, Mexico work on onion farms in New York’s Black Dirt Region.

Gallego, remembering his own struggles as a newly arrived immigrant in 1986. Last year over the course of three days, he helped a migrant farmworker with a lump in her breast make an appointment at the clinic, accompanied her to see a surgeon at the Catskill Regional Medical Center and helped her apply for the hospital’s charity care. Gallego pulled up to a house trailer where a worker on his lunch break was standing by the door. Gallego had taken the man to the Alamo clinic a few weeks earlier. Now he needed Gallego’s help with the resulting laboratory bill for blood work. The amount seemed too high, and Gallego took the paperwork and said he would investigate. “My job is not limited to health,” said Gallego, who has held his position with HRHCare Community Health, a nonprofit system of Federally Qualified Health Centers serving the Hudson Valley and Long Island, for 15 years. “Sometimes they need help sorting through bills. Sometimes they need clothes. Sometimes they need food.”

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ommunity health workers have been around for decades, helping underserved communities address the negative effects of so-called social determinants of health, such as language barriers, unstable housing, substandard education, environmental perils and

limited access to transportation and to healthy foods. “These are special people who relate to the population that they serve,” said Ann Kauffman Nolon, president and chief executive officer of HRHCare Community Health, which has employed community health workers since its first health center opened in Peekskill, New York in 1975. And they are in increasing demand, in part because the federal government began awarding grants under the 2010 Affordable Care Act to hire them. In 2016, there were roughly 52,000 community health workers in the United States, up from about 38,000 four years earlier, a 37 percent increase, according to the U.S. Department of Labor. Experts in the field say those absolute numbers don’t capture the tens of thousands who volunteer or are in temporary positions that are funded by grants as well as thousands of others who do the same work under an array of titles. But as demand for their services rise, many community health workers are finding that the nature of their job is changing. Public health departments, schools, community-based social service organizations, religious organizations and Federally Qualified Health Centers are the traditional users of community health workers. Now as hospitals and health plans face steady government pressure


to lower costs and improve health outcomes, they too are turning to community health workers to help them reach those goals. In fact, the number of community health workers employed by hospitals climbed by 74 percent between 2012 and 2016, according to government figures. The prospect of working for large health care institutions makes some community health workers uneasy. They worry that they’ll be turned into nursing assistants and be asked to take blood pressures or be told to sit at a desk all day helping patients fill out forms rather than visiting people at home and in their neighborhoods. To protect their mission, gain professional respect and promote more reliable pay, community health workers in some states are urging their legislatures to adopt a certification program. But certification is controversial. Opponents say it’s unnecessary and harmful because the requirements can bar effective people from the field.

cost savings far exceeded the cost to run the program, according to a 2011 journal article. “And the satisfaction coming from the members who were working with the community health workers was really high,” said Karen Warren, Molina’s vice-president of clinical operations and healthcare services. After the pilot, Molina expanded the program and began hiring community health workers directly. It sent them and some of their supervisors to the University of New Mexico for training. But it was a bumpy transition.

olina Healthcare operates health plans in California, Florida, Illinois, Michigan, New Mexico, New York, Ohio, South Carolina, Texas, Utah, Washington, Wisconsin and Puerto Rico. The company contracts with local health departments to administer government programs, such as Medicaid and the Children’s Health Insurance Program, and with the federal government to administer Medicare. It employs about 300 community health workers across ten different plans. Molina hired its first community health workers in 2012, after a successful pilot study in New Mexico. In that study, hundreds of plan members with poorly controlled chronic diseases who were high users of hospital resources were assigned community health workers to help coordinate their care. The workers were trained and employed by the University of New Mexico. These plan members experienced significantly larger reductions in hospital admissions and prescriptions compared to similar members who received no such outreach. The resulting

“In the first few months of launching the program, some of the supervisors, especially the nursing staff, didn’t know how to work with the community health workers,” said Warren. The supervisors kept them in the office, instructing them to try and conduct health risk assessments of plan members by phone. Warren said Molina administrators quickly saw the problem and retrained some supervisors, reassigned others and enforced the notion that community health workers “may come into the office to drop off some information or to come to a meeting, but they are based in the community,” ideally engaging with members in their homes. In some Molina health plans, community health workers have advanced to be supervisors. But problems remain at other health plans and hospital systems, say experts. For example, some are turning their community health workers into medical or nursing assistants. “Advocates in the field see this as a canary-in-the-coal mine kind of situation,” said Carl Rush of the Project on

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“My job is not limited to health. Sometimes they need help sorting through bills. Sometimes they need clothes. Sometimes they need food.”

CHW Policy & Practice at the University of Texas Institute for Health Policy. “To community health workers, by and large, their work is a calling, a way to serve their community, and they don’t really want to be doing needle sticks and stuff like that.” Others complain that supervisors are “limiting them and isolating them to one role,” said Sergio Matos, the cofounder and executive director of the Community Health Worker Network of New York City, which conducts research and advocates for and trains community health workers across the state. For example, some are being told that their job is solely to bring in patients and that others, such as social workers, will then do the health education and goal setting, he said. “If you function that way, then you’re just providing disconnected, fragmented, dysfunctional services instead of a connected, strategized and resourced effort to create change in people,” said Matos. In addition, Matos is concerned that people may view community health workers employed directly by hospitals and health plans with suspicion, as an authority figure much like a physician. “People may think, ‘Hey, you’re just here to make sure I take my medication’” and not to help with other challenges that can impact health, such as employment or housing, he said. In an attempt to deal with the dilemma, some health care providers in the state avoid directly hiring community health workers and instead contract with community-based organizations, and New York has become a laboratory for such experimentation, said Matos. So have other states, said Rush. For example, health care providers in San Antonio will contract with the Martinez Street Women’s Center, a community-based neighborhood organization that employs community health workers, and “they’ll say, ‘We’ll give you the money. These are the results we want, and you figure out how to make it work based on your knowledge of the community,’ ” said Rush.

Summer 2017 | RHQ   41


The same occurs at CREA Results, a grassroots organization in Denver, Colorado with more than 25 community health workers. CREA tells Medicaid health plans that want its help with enrollment outreach and new member education that any such campaign will not carry the health plan’s brand and must create benefits for the community beyond helping the plan meet its numbers, according to Rush. Hospitals and health plans should contract with community-based organizations as a matter of equity, said Maria Lemus, executive director of Visión y Compromiso, a Californiabased organization that advocates, trains and supports community health workers and promotores. (Promotores “share the same language, culture, ethnicity, status and experiences of their communities,” according to the group’s website, as do many but not all community health workers.) Many promotores and community health workers are volunteers, and it’s not fair to have hospital- or plan-employed workers making $35,000 a year while others do the same type of work for free, said Lemus. “Health care organizations should be supporting community organizations so that they can pay promotores,” she said. But that kind of cooperation is not always easy to arrange. “There are some areas in California, especially in rural areas, that don’t have community-based organizations that can take on that capacity,” said Lemus. So Visión y Compromiso is training community leaders as promotores and helping community organizations build their infrastructure so they can engage with medical providers.

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s community health workers are increasingly seen as a critical part of health care, employers will expect that the people they hire will have a some kind of core training, a set of key competencies and a scope of practice, said Geoff Wilkinson, a clinical associate professor at Boston University School of Social Work. “And all that drives an expectation

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of credentialing,” he said. Wilkinson has been instrumental in developing Massachusetts’ certification program, which is expected to take effect in the fall and is supported by the majority of the state’s community health workers, who were deeply involved in the process. In 2002, Texas became the first state to adopt a certification program for community health workers, and Ohio soon followed. More recently, Florida, New Mexico, Oregon and Rhode Island have embraced certification, which varies from state to state but usually includes an application, references and some combination of work experience and training in core competencies, such as effective communication, client assessment and advocacy. Many other states are considering it. But critics say state certification creates too many hurdles. “It would eliminate a lot of community promotores from participating. It would set up criteria that may or may not be relevant,” said Lemus. In Texas, for example, at least 21 of the 39 training programs listed on the Department of Health’s website are in English only. Florida’s certification program requires an exam. Ohio training programs must include coursework in anatomy and physiology, and applicants must have a high school degree. Most states require application fees. And all require criminal background checks. “Nothing’s broken. Why do we need to impose certification?” asked Matos. “There’s an incredible body of knowledge out there and evidence around the effectiveness and value of community health workers, in all kinds of settings, and that’s all been done without certification.” Several states have tried to minimize barriers. For example, the certification application in Texas has no fee, and, in recognition that many undocumented immigrants are doing this work, the state does not ask for social security numbers. Texas also exempts experienced community health workers from the training requirement in perpetuity, while Mas-

sachusetts will do so for the program’s first several years. Wilkinson said Massachusetts has tried hard to learn from other state’s mistakes. It’s certification program will not require a high school diploma. And it will allow applicants to look back 10 years to fulfill the work experience requirement. That’s because accruing experience can take a community health worker a long time; most are funded by grants that eventually end, leading to periods of no or parttime employment. In addition, Massachusetts’ certification board will look at each applicant’s criminal background check case by case to ensure that qualified non-violent offenders are not eliminated. A non-violent drug offender, for instance, may be uniquely qualified to work with people struggling with addiction. But Jamie Berberena, a New Bedford, Massachusetts community health worker who is in favor of certification, is concerned that, despite the precautions, some good people may nevertheless be excluded. “I know that the board will review case by case, but a community health worker with a criminal background might not want to revisit their past and so may opt out of certification,” said Berberena, who works for the local health department and trains community health workers to act as intermediaries between clinicians and the community. In all states, certification is voluntary, which means employers can continue to hire community health workers who choose not to or are unable to become certified. (In Texas, the law says all CHWs must be certified, but the state does not enforce this provision.) But Matos said these programs are voluntary in name only because “the health care industry loves their certifications and titles and status and accreditations and boards” and will gravitate to community health workers who are certified. “If there are folks who are certified, we certainly look at that. We appreciate any extra schooling or education that they have,” said Warren of Molina


Healthcare. At the same time, “a fantastic set of work experiences” would be looked at in a similar way as certification, she said and added that Molina hires community health workers without certification in states that offer it. Ultimately, community health workers who favor certification are hoping it will lead to better and more stable pay. But there is no evidence to date from the states with certification to support that notion. Grants remain the main source of funding. Wilkinson blamed fee-for-service. Until a few years ago, Medicaid would not reimburse for community health workers because they are not licensed clinical providers. A 2014 Medicaid rule change allowed for payment for nonclinical services, but few states and few providers have taken advantage of it. As the health care system moves away from fee-for-service to alternative payment schemes that force providers to assume more risk for the health of their covered populations, the value of community health workers will become increasingly evident, said Wilkinson. Pay should improve and come out of providers’ global budgets, he said, and some providers will want certification to help justify that. New York is not considering statewide certification at this time, according to a health department spokesperson, but Gallego wishes it were, in case he ever had to move and apply for a new job, he said. “For some people, it doesn’t matter that you have been doing this work for 15 years to build trust and help people if you don’t have a paper saying you are a community health worker,” said Gallego. As the lunch break ended and workers headed to the fields, Gallego turned his van, which he calls the “confessionary,” back to the clinic. The farmworkers in the area, who are mostly single men, “know that whatever they tell me, I won’t tell anybody else, just the doctor if they give me permission,” said Gallego. “Everything said here is private. Nobody has to know.”

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RHQ CONFERENCE CALENDAR

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

Rural and Community Health Documentation and Coding Boot Camp Sept 6-7, 2017 Gainesville, FL nosorh.org

NHRA Critical Access Hospital Conference Sept 27-29, 2017 Kansas City, MO www.ruralhealthweb.org

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

Maryland Rural Health Conference Oct 5-6, 2017 McHenry, MD www.mdruralhealth.org

Hawai’i Health Workforce Summit Sept 9, 2017 Honolulu, HI hawaiistateruralhealth.org New York State Association for Rural Health Conference Sept 14-15, 2017 New Paltz, NY www.nysarh.or

South Carolina 21st Annual Rural Health Conference Oct 10-12, 2017 Greenville, SC scorh.net West Virginia Rural Health Conference Oct 10-13, 2017 Canaan Valley, WV wvrha.org

CHCA Conference Sept 20-22, 2017 Little Rock, AR chc-ar.org

National Association of Rural Health Clinics Fall Institute Oct 17- Oct 19, 2017 Indianapolis, IN narhc.org

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

Oregon Rural Health Conference Oct 18-20, 2017 Sunriver, OR www.ohsu.edu

Summer 2017 | RHQ   43 Summer 2017 | RHQ   43


THE LAST WORD Remembering the Extraordinary Life and Legacy of F. Marie Hall BY BILLY U. PHILIPS, JR.

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lorence Marie Hall, our friend and our founder, died recently after a long but courageous and sometimes lonely battle from the ravages of modern medicine which can prolong life but not necessarily the quality of it. I remember a luncheon with her a couple of Christmas seasons ago when, in the midst of what had been light-hearted recollections of our younger days, she paused and asked me one of those questions that each of us should consider. It went something like this: “What will you say if you have the last word on my life?” I wish you could see her face as I did that day. She had those steel blue eyes fixed upon me, and I was hooked with no way to dodge an answer. I said three things to her. “Marie, I may be the one left here after you move on into

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eternity, but I am neither qualified nor will I have the last word on your life. There is only one who has that word and I believe you know him; all that you have done privately and in public to help others make that even more so than I might imagine. I will leave that part of my answer right there.” She smiled and said, “That’s not what I mean. Give me an answer.” Then I said, “Marie, there will be no last word on your life because you have started something that cannot be stopped. You have helped others and some of them will help others and so on.” She said, “That’s the premise of a popular new book.” I agreed and said, “It is the truth of it that makes us wonder about it enough to write and muse about it.” We sat there and thought about it. If silence is an issue with you, then conversations with Marie probably wouldn’t be your cup of tea. After a time, she said, “We can see those our lives touch and we can imagine that we have made a difference.” Patti Patterson, a friend of ours had that kind of conversation with Marie. When she received the Rural Health Trailblazer Award at the 2017 Crossroads Conference, she said it this way: “It’s like throwing a rock in a pond, the rock makes its splash but then the ripples fan out until they meet the shore and then they bounce back and they raise the amplitude of each successive wave even higher.” That’s a pretty good last word. Marie pressed me once more that day. “What will you say?” I said then what I feel now. “I’ll say, I once had a friend who changed me because she believed in me. That will be my last word.” She smiled and changed the subject and we ended with a nice lunch and went back to life. Not very long ago, as I stood over her grave site, three things happened that reminded me of her question. I spoke to her pastor, a fine Anglican Rector; he said things that made me even surer that the One who has the last word would be pleased to receive Marie. I knew and he knew and many knew that she was safe and sound and no doubt in awesome wonder at how she mattered. Then at a point in the graveside ceremony, nursing and allied health students from Howard College filed by her casket, each one placing a daisy on top – bright, vibrant, colorful flowers. Each alone was pretty but in the end together those flowers arranged one-by-one made a bouquet more beautiful than all the rest there. Just as those students would do and all those touched by them would do in turn. I looked around at the people standing there that morning and through the tears that well up in my eyes, even now as I write this, I realized that because our friend believed in us, we are her ripples. Like she did for us; we must believe in each other and raise each other higher. So, my dearest Marie, there is no last word on your life – just ripples.

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Profile for Rural Health Quarterly (RHQ)

Rural Health Quarterly 1.3 - Summer 2017  

Project Echo • Save Our Census: Funding Cuts Pose Threat to Rural Research •  Expansion Act Aims to Enhance Reimbursements • Grow or Die: A...

Rural Health Quarterly 1.3 - Summer 2017  

Project Echo • Save Our Census: Funding Cuts Pose Threat to Rural Research •  Expansion Act Aims to Enhance Reimbursements • Grow or Die: A...