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RHQ

FALL 2018

Rural Health Quarterly

Redemption on the Rez Can the Winnebago Tribe Revive Their Community’s Troubled Hospital?

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


TELEHEALTH AT THE CROSSROADS MAY 23-24 NEAR Austin, TX Hyatt Regency Lost Pines Resort & Spa

REGISTER Online www.crossroadsconference.us


CONTENTS //

FALL 2018 MEDICAID EXPANSION When states (finally) embrace the ACA, rural residents tend to benefit the most.

19

ACA Navigators Short on federal funding, Obamacare enrollment navigators switch tactics.

22

The LONGEST MILE As rural counties lose obstetrics, women give birth far from home.

24

COVER STORY Redemption on the Rez Can the Winnebago Tribe of Nebraska revive their community’s troubled hospital?

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The Shiprock Chronicles

Health Education and Disaster Planning for Rural Communities 26

Morehouse School of Medicine Challenges Stereotypes about Rural Health 28

"Looking back with the perspective of a career nearing its end.... some of the best times and life lessons came about in the land of Shiprock."

Telemedicine reimbursement

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30

How to Tell the Rural Health Story

RHQ CONFERENCE CALENDAR

Community-based participatory research starts with mutual respect.

It’s time to start circling some dates as the 2019 conference calendar kicks into high gear.

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32

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Doctors give Medicare’s proposal to pay for telemedicine a poor prognosis.


DEPARTMENTS //

RURAL HEALTH QUARTERLY

Volume 2, No. 4 Fall 2018

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 - 9

// RURAL RESEARCH 10-13

Section Editors Debra Flores—Health Education Catherine Hudson—Rural Research Ronald N. Martin—Behavioral Health Cameron Onks—Public Policy Copy Editor Traci Butler Carroll Research Associate Debra Curti

// HEALTH EDUCATION 26-29

// PUBLIC POLICY 18-22

Web Developer Miguel Carrasco Contributors Phil Galewitz Barbara Mantel Melissa Oden Katja Ridderbusch Bram Sable-Smith Matt Seidholz

// HEALTH TECHNOLOGY 30-31

// CONFERENCE CALENDAR 32

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Contacts and Permissions Email RHQ at RHQ@ttuhsc.edu. For more contact information, visit www.ruralhealthquarterly.com. Rural Health Quarterly is a free publication of the F. Marie Hall Institute for Rural and Community Health at the Texas Tech University Health Sciences Center.

www.RuralHealthQuarterly.com

FALL 2018 | RHQ   3


YOU STOPPED SMOKING NOW START SCREENING

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 2018—Texas Tech University Health Sciences Center. 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.

FRANK QUIT AFTER SMOKING 22,000 PACKS OF CIGARETTES OVER 30 YEARS

Rural Health Quarterly is published four times a year and distributed without charge 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, associate dean for the School of Medicine Administration, TTUHSC Permian Basin Coleman Johnson, special assistant to the President, TTUHSC Retta Knox, RN, Hart School-Based Health Clinic, Hart, TX Susan McBride, Ph.D., RN, Program Director Graduate Informatics Program, TTUHSC Linda McMurray, executive director at TTUHSC Larry Combest Community Health and Wellness Center Will Rodriguez, senior managing director for CMHC, TTUHSC Ken Stewart, Ph.D., director of Community Development Initiatives, ASU, San Angelo, TX

Now there’s a new screening that can catch lung cancer early and could save lives. Talk to your doctor or learn more at

Dr. Julie St. John, assistant professor, TTUHSC Abilene Shari Wyatt, rural health specialist, State Office of Rural Health, Texas Department of Agriculture


RURAL

REPORTS

ALABAMA //

ARIZONA //

Rural Alabama has among the highest rates of uninsured lowincome adult citizens in the country, according to a report by Georgetown University’s Center for Children and Families and the University of North Carolina’s NC Rural Health Research Program.

$1 million in federal funding was provided to Arizona’s State Loan Repayment Program, which offers to pay educational loans for health care professionals who commit to working for two years in medically underserved areas, including rural areas facing shortages.

altoday.com | 09.25.18

ktar.com | 09.09.18

ALASKA //

ARKANSAS //

Rural Alaska Community Action Program, Inc. (RurAL CAP) was awarded a $450,000 grant to fund behavioral health services for pre-K children and their families in Alaska’s low-income rural communities. The grant expands case management and supportive services for children, including support for RurAL CAP’s Supportive Housing Division.

The percentage of low-income Arkansas adults living in small towns and rural areas who lack health insurance decreased from 45% in 2008-09 to 22% in 2015-16, says a report produced by Georgetown University and the University of North Carolina. The report credits the state's Medicaid expansion program for the improvement.

globenewswire.com | 10.10.18

talkbusiness.net | 09.25.18

RURAL HEALTH REPORTING FROM ACROSS THE NATION AND AROUND THE WORLD

CALIFORNIA // Stress and health problems plague rural, immigrant communities near the border with Mexico, according to a new study by the University of California, Riverside. Farmworkers and their families in Southern California confront a profusion of difficulties in their daily lives that create enormous amounts of stress, the researchers say. Such chronic stress is often a catalyst for physical illness and mental health problems. calhealthreport.org | 09.26.18

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Indonesia

Northern Ireland Currently, only 32% of rivers in Northern Ireland are classified as 'high' or 'good' quality, and only five of Northern Ireland's 21 lake water bodies are classified as 'good'. The main culprit is agricultural pollution, experts say. belfasttelegraph.co.uk | 09.27.17 6  RHQ | RuralHealthQuarterly.com

MEXICO

Backed by increasing demand for health care in Southeast Asia, appbased consultations are becoming more popular in the region. Though the capacity of telehealth services is limited to basic consultations, they are expected to improve health conditions in underserved areas.

Violence in Guerrero, Mexico is having a direct impact on the accessibility of medical services in rural areas, according to the medical humanitarian organization Doctors Without Borders. The organization said that many of the state’s local health care centers are staffed by a single nurse who also sleeps at the same facility.

Halodoc now has some 2 million users and a database of 20,000 doctors in the region. The consultation fee is between 25,000 to 75,000 rupiah ($1.70 to $5).

Traveling to larger population centers in the state to seek medical attention can sometimes be complicated due to turf wars between criminal gangs.

asia.nikkei.com| 09.11.18

mexiconewsdaily.com | 05.28.18


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

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

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

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

COLORADo //

Georgia //

The uninsured rate for low-income adults has dropped 29 percentage points since Colorado expanded Medicaid — the largest decrease experienced by a state, according to a new report. The state saw the uninsured rate for adults in rural areas and small towns slide from 42 percent in 2008-09 to 13 percent in 2015-16.

Funded by High Demand Career Initiative grants, the Carl Vinson Institute of Government has launched two regional partnerships in south Georgia to address the growing need for health care workers in rural communities.

denverpost.com | 09.25.18

DelAware // Delaware is taking a major step forward in a longstanding push to extend high-speed internet access to rural communities downstate.

outreach.uga.edu | 09.19.18

HAWAII //

Connecticut has passed a law that allows providers to use telemedicine to prescribe certain controlled substances. The law reverses the state’s prohibition on the prescription of controlled substances via telemedicine for the treatment of psychiatric issues and substance abuse.

The governor announced he is issuing a call for help from any service provider willing to assist in closing the gap by 2020 — an effort backed by $1.3 million in taxpayer assistance. Rural areas of the state have been largely left out of the broadband revolution due to the high cost of extending fiber optic cable and wireless services.

Hawai‘i Community College was awarded $69,333 for the school’s nursing program to help address health care labor shortages on Hawai‘i Island. Ninety percent of the school’s nursing graduates—approximately 40 students per year—go on to work in health care positions on Hawai‘i Island, addressing a critical need for care providers in rural areas.

mhealthintelligence.com | 06.27.18

delawareonline.com | 07.24.18

bigislandnow.com | 10.04.18

CHINA

HAITI

CONNECTICUT //

m

East africa Stigma remains a substantial barrier for men in accessing HIV care in rural East Africa, according to a qualitative study published in PLOS ONE. Women more readily engaged in care despite potential stigma, whereas men avoided care in response to fears around being blamed and shamed about HIV infection. The study sample consisted of 63 HIV-positive participants already enrolled in the baseline year of an HIV test-and-treat trial.

China has transformed from a poor farming nation to the world’s secondlargest economy, but the health system cannot adequately support the nation's large population. China has one general practitioner for every 6,666 people.

Health organizations have begun offering cervical cancer screenings to rural women as a way to reduce deaths from the preventable disease. WHO estimates place the number of annual deaths in Haiti from cervical cancer to be 563.

aidsmap.com | 09.14.18

nytimes.com | 09.30.18

miamiherald.com | 11.13.18 SPRING 2018 | RHQ   7


Rural Reports //

INDIANA //

Missouri //

Students and staff at Rising Sun Schools can now benefit from hightech telehealth as part of the Indiana Rural School Clinic Network’s (IRSCN) expansion to the region. Students and staff will now have the opportunity to be seen by doctors via telehealth technology without leaving the schools’ campus.

The Archdiocese of St. Louis plans to open its first health clinic in Old Mines in an effort to improve rural health care. The free clinic will offer primary care, chronic disease management, mental health care and social services for people without health insurance.

eaglecountryonline.com | 09.28.18

KENTUCKY // The Kentucky State Loan Repayment Program (KSLRP) is now accepting applications.. The KSLRP is a loan repayment assistance program that helps to recruit and retain health care providers in rural and underserved communities across the state. uknow.uky.edu | 09.06.18

MICHIGAN // Much of Michigan's over-50 population is struggling with a lack of health care, too few home and community-based services and other challenges, according to a ninemonth AARP study of the state. The study proposes that Michigan create a coordinated care network, maintain Medicaid expansion, extend broadband internet to rural areas, and implement a Family Caregiver Tax Credit. crainsdetroit.com | 10.04.18

stltoday.com | 11.12.18

New Mexico // Rural New Mexico is experiencing a shortage of nurses, and it's causing some major problems at smaller care facilities around the state. To combat this, UNM has begun training nurses already working in the field to provide a higher level of specialized care where medical facilities are continually understaffed. kob.com | 11.15.18

Minnesota // MAINE // Fish River Rural Health celebrated the grand opening this fall of its expanded Bolduc Avenue Health Center. The center houses services such as family practice medicine, osteopathic manipulation therapy, behavioral health and substance use disorder counseling, and family dental. bangordailynews.com | 11.16.18

Workers in rural areas who take care of an ailing adult or child have significantly less support at the workplace to buttress the strains of their dual roles than those in urban areas, a recent study from the University of Minnesota finds. startribune.com | 09.10.18

Mississippi //

The Youth Development Task Force of the Lycoming County Health Improvement Coalition (LCHIC) received the 2018 Rural Health Program of the Year Award.

A 181-bed Coahoma hospital, Northwest Mississippi Regional Center (Merit Health), is warning of closure. Since 2010, 87 rural hospitals across the country have closed, with most located in the South. Of that number, Mississippi had five hospital closures.

news.psu.edu | 11.10.18

mississippitoday.org | 10.17.18

MASSACHUSETTS //

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NORTH CAROLINA // Many rural counties in North Carolina lack a sufficient number of physicians for the people living there. And then there are counties that don't have any providers in a specific field. For instance, in 2017, three N.C. counties did not have a primary care provider, 17 had no general pediatrician, and 27 had no obstetrician/ gynecologist. northcarolinahealthnews.org | 12.14.18


NORTH DAKOTA //

South Carolina //

TEXAS //

Clemson University has received a funding commitment to bring highspeed broadband technology to 102 health care sites across South Carolina to improve the efficiency of rural health outreach efforts. The threeyear funding commitment amounts to $5.24 million, with the possibility of renewal at the end of the term.

Texas A&M University has been awarded a five-year, $4 million HRSA grant to help rural hospitals and health care networks throughout the country through the creation of the Center for Optimizing Rural Health. The center will actively help rural communities maintain their hospital or create other means of access to care after hospitals close.

North Dakota ranks 12th in the United States in suicide rate per 100,000 citizens, and the CDC is pointing to higher rates of suicide among rural farmers.

newsstand.clemson.edu | 08.14.18

Farmers in the the state are seeing a drop in income of about 65 percent comparative to what farmers in North Dakota were making in 2016.

According to the American Nurses Association, South Dakota’s registered nurses have the lowest annual salary of any state and the District of Columbia, ranking 51st behind Mississippi, Alabama and Iowa. Officials say factors such as the rural nature of the state and low reimbursement rates to hospitals are to blame.

thedickinsonpress.com | 11.29.18

OKLAHOMA // OSU’s Center for Health Systems Innovation is using big data to tackle rural health issues in the state. The Cerner Health Facts Database contains clinical data collected from patients across the United States. CHSI spent 18 months mining the data from the health care database and building a predictive tool that allows physicians to make an accurate diagnosis based largely on demographics, co-morbidity and data collected from lab work. newsok.com | 06.05.18

theeagle.com | 10.07.18

South Dakota // Virginia // Thousands of rural Virginians lack access to dental care. There are 89 dental care health provider shortage areas in Virginia, and about 1.2 million people live in those areas. virginiamercury.com | 09.04.18

argusleader.com | 11.23.18

West Virginia // West Virginia continues to lead the nation in adult obesity rates. 38.1 percent of adults living in the state have obesity. The impact is most serious in communities where access to healthy foods and regular physical activity is more difficult, such as lower income and rural areas.

TennesseE //

register-herald.com | 09.12.18

Wisconsin //

A critical access community provider in rural Oregon was able to reduce unnecessary emergency department visits from 17 percent to 9 percent within a six-month time span using care collaboration network technology.

Tennessee has officially posted its Medicaid waiver that would require enrollees to either seek or maintain work. Alabama, Michigan and Virginia have also posted work requirement proposals on their Medicaid websites in recent months. Tennessee's requirement will target TennCare-enrolled parents and caretakers that are not pregnant, disabled or elderly adults.

healthcareitnews.com | 08.17.18

modernhealthcare.com | 09.26.18

htrnews.com| 10.19.18

OREGON //

The Rural Wisconsin Health Cooperative found that for every two rural health jobs created, the number of other community jobs increases by one job. Access to local health care keeps health care spending, insurance premiums and taxes in the community.

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Fall 2018 | RHQ   9


Rural Research //

The Shiprock Chronicles: Adventures in Rural Epidemiology

If I were to write about all the impressions that filled my mind or of the interesting people I met or of all the strange situations I encountered around Shiprock; it easily could fill a book. In the editorial meeting for this issue of the RHQ when the topic of tribal health was discussed, my mind was flooded with Billy U. Philips, Jr. memories my time spent ATTORNEY around Gallup, F. Marie Hall Institute for Rural and Community New Mexico and Health the four corners region. One feature of those seasons of life was around Shiprock; which to me is more than a geological anomaly. It is that; a massive rock that juts up 1,500 feet above a flat plain that can be seen for miles. The geological term for that phenomenon is a monadnock, a rock that has been weathered over time so that only the hardest most resilient stone remains. A feature as enduring as the quality of my time there. As legend has it, the Navajo people on whose land the rock resides, were brought to the four corners area by a great bird. A loose translation in Navajo is something like, “Winged Rock.” As I approached the area, on Highway 64 out of Farmington, the ice in my giant cola had not fully melted into water, when I could see it on the horizon. It reminded me of a great schooner far out to sea. I had seen something akin to that once when I had come up from Van Horn on the way to Carlsbad where El Capitan rises up in the northern most reaches of the horn of Texas. I thought both memories were fitting considering that

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I was feeling like a pilgrim at that time in my life. I had just finished training as U.S. Public Health Service Fellow and particularly liked the component that prepared us to be Epidemiologic Intelligence Officers. I thought that training was near perfect for my interests and the thought of being a member of a specialized team that investigates epidemic outbreaks appealed to my sense of adventure. It was anything but ordinary work. While I was too young and full of myself to worry about things like what my Dad called needing a “good paying” job, what thoughts I had along those lines were tied up in being a member of the U.S. Public Health Service Corp. There was only one problem with that, the Nixon Administration had decommissioned it about the time the military was being downsized after Viet Nam. There were many “old salts” that were scrambling for the relatively few civilian positions that were available. So I took what I could get. As one Chief Petty Officer proclaimed, “Sonny boy, your best bet is in the middle of nowhere." He was right. I was headed for, at best, a two-year posting in Gallup. Then I would need to figure out what was next in my life. It was a place where I knew no one. It was a long way from home. And like the theme of a country and western song, my true love had dumped me; in my case not for another guy rather for graduate studies in another state. My Dad summed it up pretty well as he set me on the journey. His words went something like, “I’ve been in your position; only difference is where I was going they wanted to kill me.” He was departing for war and I was going to the land of Shiprock. He went on to remind me, “Practice being half as smart and twice as tough… and you’ll be okay in the end.” That was my state of mind when I pulled into town that hot July afternoon. In those days, the main feature of town was the Indian Health Service Hospital and some other government buildings to support the people assigned there. It was a sleepy desert town where Soviet-style architecture seemed oddly fitting since to me it felt like a kind of gulag.

Looking back with the perspective of a career nearing its end after almost fifty years, some of the best times and life lessons came about in the land of Shiprock. The most important for me is simply this; not having a plan doesn’t mean that there isn’t one if you are willing to accept that opportunities may not look like that at first. Careers have trajectories and if one can think about how to fit what you know to a need then you can find a world in need of your service. There will be interesting people you meet along that way. One such person was a Navajo man named Jo. His name came from a syllable in the spoken phrase which when translated to English is the phrase, “remembering the loved ones.” Written, it would look something like, "Ayoo’ adajo’ ninigii Beedahahaniih," without the stress marks over vowels. But enough on the linguistics, as the story of Jo is much more interesting. Jo was relatively tall for a Navajo man of his age. He was lean and his skin was brown and he had classic features of his people. In that era, most Navajo people did not talk much to people like me. I don’t think they were unfriendly as much as their culture and traditions are not based so much on words as on actions. Trust is important. The communications that matters is in looks, the subtlety of which develops over time and mostly outdoors in very inhospitable conditions. I had seen Jo around the hospital and once in a neighborhood in Gallup where some patients stayed when they came for care that extended over more than a day or two. That area of town was replete with old mobile homes and traditional round houses with their doors oriented to the east and west to catch the first and last lights of the day, and a few shacks that made no sense in any culture. That area was off limits to active duty personnel. One weekend when I had had enough of doing nothing in Gallup, I decided to go out to the sacred mountain and see what I could find. I was told how to go around to the back, away from the side easily visited by tourists. I parked and started up the foothills. following along what looked like a foot-


Shiprock is a monadnock rising nearly 1,583 feet above the high-desert plain of the Navajo Nation in San Juan County, New Mexico.

path. I realized quickly that it was just where wind and, on rare occasion, rain had made a way down to the bottom. It wasn’t an easy climb, and the brush and thorns that populated the area gave refuge to all kinds of odd creatures and some rattlesnakes that seemed only wanting to be left alone. I had managed to climb to a kind of ledge that gave me a perch to survey the vista below and to provide a brief respite to catch my breath. It was shaded and I was surprised how much cooler it felt out of the blazing sun of that morning. That ledge was a great place to appreciate how bored I was when I wasn’t working and, yep, in the middle of nowhere. I sat there a good while, feeling pretty lonely. It was somewhat amazing to me that an entire nation of people could make this place home and even prosper in such a harsh environment. I could see from the stark landscape how they would be stoic and appear so remote. I could see how they might even resent having intrusions into their space and their solitude. Even still, there was something appealing about the solitude. I don’t remember why, but

after a while I was aware that I was not alone on that ledge. It was an uneasy feeling. When I climbed up to perch there I didn’t notice much, as my goal was to get to the ledge without falling. As I looked around to my left there were but a few inches before the ledge played out. As I looked to my right, I could see that, except for a small outcrop of rock, the ledge went around and appeared to be broader. Sitting there leaning against the outcrop was Jo. He was looking at me but did not say a word. Oddly, I did not think that was creepy nor did I feel threatened. It was more like two people sitting in a pew at church, both there to experience something more, united by a common purpose, but not feeling the need to talk. I nodded to him, again like in church, while we gazed out over the landscape below for several minutes. It wasn’t that I didn’t wonder what he was doing there or whether he had been there when I climbed up or what to do next. One thing was certain, I didn’t expect he would be any more likely to speak to me on that ledge than he was

in town. So I sat silently, wondering. He did finally speak. He said, “We are not alone.” That surprised me. I knew that much! “Look behind you,” he said nodding toward the rock face behind. I thought, ‘To see what – a rock face?’ but I did look. There were cracks in the rock but I could see nothing more. I looked over at Jo. He nodded again and said, “Look longer.” I did, and then I did feel creepy, as there was something in most of the cracks. Movement was what I could discern, but then, I could see tiny eyes. Jo said, “It’s na’asho’ii. We call them ‘Grandpa.'" One plopped on the ledge and I jumped a bit. I knew, ‘grandpa’ back home in Texas, but we called them horny toads. Jo smiled and I smiled. It was the first time I had seen him express any emotion. Many years later, we would recall this moment as students at the University of Oklahoma in the School of Public Health. We sat a while longer, and then just like that Jo was gone. When I was back on level ground, I began to make my way back to where I started. Soon, Jo was striding along with me. He definitely

Fall 2018 | RHQ   11


knew how to make a silent entrance and exited the same. He said only one thing as we walked that day even though we had many conversations since. “You are never alone here, but you must look longer to see.” We parted company as my path led to my car down a slight rise and he went another way. I never saw him in a car back in town; he seemed to walk everywhere. When we did meet, communication was always with a look or a nod which became so nuanced as to be our own language. One thing for sure came of that day, I began to look longer at more than just cliff faces. Real enduring relationships are built on communications and much of good communications isn’t spoken. My time in the land of Shiprock ended much sooner than I expected and very little of it was spent alone, although I probably talked less in that season of my life than ever before or since. Many people that know me would say that is a good thing, most especially Jo. He had become my friend and as it happened was a community liaison working for the hospital. Jo, knowing how I had talked so much about my esoteric training in disease outbreak investigation, revealed his concern for some of his people that had all had a similar illness that led to the hospital. I recall what he said: “We know this illness from my grandmother’s generation, but we have not known why it afflicts only some of us and only then when the creeks run with water.” This led to an adventure that could have been fatal and proved that what I knew might have saved lives even though I thought it was nearly useless in the practical world of work. The people, according to Jo, had all come from a village in the Four Corners area. All arrived with flu-like symptoms and high fevers and all but one young woman had survived and returned home. My boss, knowing my training, agreed to allow us the use of some sanitary suits, respirator mask, and related gear. A couple of our bio-lab crew members were up for a break from the monotony of daily routine and away we went. Except for meeting Jo, it was the first trip that I had made into the reservation lands. There really weren’t towns, more like little clusters of traditional houses,

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doublewides, dilapidated shacks, and camper stacks that weren’t any longer in the bed of a pickup truck. Everything other than the traditional houses were faded and worn and looked run down and old. Even a few newer houses soon faded in the desert like conditions of that region. When we arrived in the general area where most of the patients lived, Jo took over and led us from house to house. Often, we’d follow dirt roads until there was a house with people, and then we’d stop and ask questions and talk. This went on for a few days with us living out of tents and camping over the nights. We always seemed to find a way to have some fun. Jo told us that many of the people wanted to know why some got so ill, but it was clear it was more a curiosity than a worry for them. After all, they had lived with this type of thing across generations. The day that we found the house of the woman that had died we recognized it by the way it was left. Jo told us that in Navajo tradition, the front and back doors to the house had been left open, a gesture to allow the spirits to come and go. It would take time after the burial and the doors would need to be removed before the next woman to own the property could come and sweep it clean. In the Navajo custom, women own the property. It would be known that the house had passed to the next hands when new doors had been installed and the spirits would be welcome there no more. We were there at the right time as, technically, the house belonged to no one in this world yet because the doors were not new. So we began to investigate. I had brought the usual gear for that – sanitary suits, respirator masks, eye covers, gloves and the like. Once we were garbed and all air joints were taped, we had about 30 minutes to work before our body temperatures would rise above a safe level. Disrobing those garments was another process to avoid contamination, and so from start to finish it was about an hour of mostly being really hot and sweaty! Dressed like space aliens gowned in white suits, we took samples of dust, mouse feces, cobwebs, corn, and the list could go on for pages. Everything that might possibly be a causative agent was

bagged and logged and properly stored. We then set up our dousing station and washed the suits and followed all the other disrobing procedures. Even though the team was coed, we all stripped down to as little clothing as possible, while upholding personal modesty, to cool off. It was late in the day when we cruised down the road back to Gallup. We were all very grateful for air conditioning in the car, although we did not appreciate yet what an adventure we had had. It was weeks later when the news came. The analysis of our many samples had found one thing that was interesting, a viral strand; it was likely that it came from Hantavirus! I remember studying about an outbreak during the Korean War in the early 1950s. Flu-like symptoms of pulmonary disease with renal syndrome that characterized the deaths among the 3,000 troops that became ill. It was later found to be associated with a virus common in some kinds of mice. In Navajo land, it was the deer mouse that was the culprit. People were exposed when the droppings of the mice that carried the viral fragments were aerosolized, as would be common when sweeping during spring cleaning. Jo and I would later learn in an epidemiology class at OU that the virus was common in deer mice when there had been abundant rain in the Four Corners region and lots of food that led the mice to have larger liters. As if to confirm the custom of leaving the doors open where deaths had occurred, we learned that the virus survived only briefly and was killed by ultraviolet light; the light from the sun that shown through from the east in the morning and the west in the afternoon. It was a study in how such things might be learned over the course of many lives to become traditions and customs of an aged and wise people. So my dear reader, read well this issue of the RHQ. You may not know what you will learn but there will be something here for you. If nothing more you might remember this – be half as smart and twice as tough, there is a plan even if you don’t yet see it, talk less and look longer, and be grateful for the memory of the friends that remind you that you are never alone.

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Rural Research //

How to Tell the Rural Health Story Community-based participatory research starts with mutual respect

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hen it comes to rural health, it comes as no surprise that many challenges still abound. The negatives such as high mortality rates, lack of services and/or distance to resources, aging populations and youth flight to the cities tend to be emphasized with little agreement on how they can be improved. There is also the issue of often not being able Catherine Hudson to adequately report the rural experience due to small DIRECTOR FOR RURAL population sizes and thus the amount of suppressed data. HEALTH RESEARCH Because rural communities in this country have such a F. Marie Hall Institute for profound impact on just about every aspect of American Rural and Community lives, it is important that their stories be told in a truthful, Health valid and real way. Perhaps when telling the rural health story researchers should be more earnest in including the voices of those that live the rural reality. Community-based participatory research (CBPR) is a collaborative approach to research that involves an equitable partnership between the researchers and the population being studied. Community members and stakeholders are involved and contribute to all aspects of the research process including decision making and ownership of the results. The CBPR approach is used by academics and public health professionals to address health disparities and to influence policy change, particularly in priority populations such as racial and ethnic minorities; low-income, rural, and inner-city populations; women; and children. One of the characteristics unique to CBPR is the sharing of power and the principal of mutual respect. In other words, no one entity calls all of the shots, as can be the case in more traditional research endeavors where researchers swoop into a community, study them and leave. In CBPR, researchers recognize that the community members have a better idea of what the problems are and they possess expertise and resources that are beneficial to the process of solving those problems. This relationship does not develop overnight. Time must be taken to build trust relationships, particularly with community gatekeepers, in order to gain access to the population. This is a key step and must be approached with care. The CBPR process is intended to be mutually beneficial to all parties involved. In order for this to work, all egos must be checked at the door. The researchers and communities learn from each other and bring their knowledge, skills and assets to the table. Researchers benefit by learning things about the community, such as its history and culture, and community members learn about the process of scientific inquiry and how to go about obtaining external funding. The resulting information and findings are then shared with the community at large in ways that will be easily understood and useful. Finally, CBPR requires long-term commitment and should lead to the establishment of sustainable relationships. It should be a foundation upon which future collaborative efforts between researchers and communities can be built and continue. When attempting to tell the rural health story, researchers would do well to partner with communities and include them as narrators. Employing the communitybased participatory research method may very well lead to the realization that the answers that we seek are right there in the communities themselves.

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Grant WATCH // RURAL HEALTH AND ECONOMIC DEVELOPMENT ANALYSIS Provides funding for a single entity to increase public and stakeholder awareness of the economic impacts of rural health care sectors on rural, state and national economies. The program also intends to quantify the impact of rural health care and conduct analyses of the link between the health of the economy in a rural community and the health outcomes of the residents of those communities. Website: grants.hrsa.gov Deadline: March 27, 2019.

RESEARCH TO IMPROVE NATIVE AMERICAN HEALTH Provides grants for research designed to improve Native American health, including, conducting secondary analysis of existing data, merging various sources of data to answer critical research questions, conducting pilot and feasibility studies, and assessing and validating measures that are being developed and/or adapted for use in Native American communities. There are two funding opportunities under this program: An R21 Exploratory/Developmental Research Grant for the development of new research activities in the early and conceptual stages, and an R01 Research Project Grant that supports a discrete project. Website: grants.nih.gov Deadline: May 14, 2019.

SPRING 2018 | RHQ   13


BEHAVIORAL HEALTH //

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 and even government 14  RHQ | RuralHealthQuarterly.c officials are scrambling to find a way to halt what has been deemed a crisis.

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HE ID-

REDEMPTION on the REZ BY MATT SEIDHOLZ

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ust after midnight on July first, the Winnebago Tribal Council hoisted their tribal

flag over the lone, 13-bed hospital in Winnebago, Nebraska. That

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made it official. The hospital was under new management. Summer 2017 | RHQ   15

Fall 2018 | RHQ   15


Until that moment, the facility was called the Omaha Winnebago Hospital, and it was operated by the Indian Health Service (IHS), a federal agency charged with providing health care to the country’s 2.2 million Native Americans, including the 5,000 or so Winnebago tribal members who live in the surrounding community. But under IHS’s oversight, the hospital suffered serious problems. “It’s common knowledge that IHS failed us,” said Frank White, the Tribal Council’s Chairman. Reports from the Center for Medicare and Medicaid Services (CMS) confirm White’s judgment. In 2011, one physician slipped past the credential-review process to work in the hospital, even though his license to practice had been revoked in both New Mexico and Georgia. This, just two days after a patient died from an avoidable fentanyl overdose. In 2015, hospital nurses missed a pregnant woman’s imminent risk for pre-eclampsia and death because they had received “inadequate training or no training at all.” Later that year, CMS revoked the hospital’s Medicare certification, making it the first ever federally operated hospital to lose reimbursement from Medicare and Medicaid. And in 2017, while trying to recover certification, the hospital failed to properly sterilize a podiatry instrument, exposing up to 35 patients to potential infection from diseases like HIV and hepatitis. All this explains why the Winnebago tribe lost confidence in IHS. Today, visitors to the hospital won’t find many signs that IHS ever ran it. Some educational pamphlets still bear an IHS seal. To use the hospital’s WiFi, guests need to log onto an “ihs.gov” domain. Otherwise, the Winnebago tribe has totally rebranded the hospital, assuming control of the facility’s identity as well as its operations. They gave it a new name, the Twelve Clans Unity Hospital. Now they’ll see if they can win back the

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On July 1, 2018, the Winnebago Tribal Council hoisted their tribal flag over the Twelve Clans Unity Hospital in Winnebago, Nebraska.

Winnebago people’s trust. A STRUGGLING AGENCY In the Spiritual Room on Twelve Clans’ top floor, surrounded by colorful traditional quilts, Jim Rixner explained how Winnebago’s new management will help the hospital bounce back. Not a Winnebago tribal member himself, Rixner is the chairman of the board for the Winnebago Comprehensive Healthcare Service (WCHS),

the new entity created to oversee the community’s healthcare. “Decision-making processes in any community, it’s always best in a local level,” he said. “This new system is theoretically free of all the bureaucratic restrains [of the IHS.]” These restraints can be considerable. IHS is a sprawling organization, with 12 regional offices managing 170 service units across the country. Winnebago falls in the Great Plains region, which includes Nebraska, Iowa, and the Dakotas.


“So that means when we wanted to try something we had to run it by Aberdeen,” Rixner said, referring to the Great Plains region’s headquarters in South Dakota, “and then back to Washington. And with that many layers there’s always a reason to say no.” Often, the reason is money. Aside from managing facilities, IHS is also the primary payer for Native health care. Any tribal members who visit IHS facilities receive services without getting charged for them. “But don’t call it free,” said Mary Smith, IHS’s former director and a member of the Cherokee tribe. “This care is a treaty right that’s enshrined in the Constitution, reaffirmed by hundreds of years of treaties and legislation and Supreme Court decisions, in exchange for massive amounts of land and loss of life.” By Smith’s assessment, the Congressional budget set for IHS falls far short of what’s needed to serve the Native community. With a 2017 budget of $5.9 billion, IHS’s percapita spending is about $2,681 — or just over 25% of Medicare’s. This puts a financial squeeze on individual facilities. They’re often forced to work with old equipment, in dated facilities, and, most seriously, with inadequate staffing. “The pay scale is seriously hobbling,” Smith said. “It makes it very difficult to compete for talent.” At IHS facilities nationwide, nearly a quarter of all clinical positions are perpetually vacant. In the Great Plains region, physician vacancy rates rise as high as 36%. Danelle Smith, WCHS’s new Executive Director, sees this staffing shortfall as a major motivator for the Winnebago tribe to assume control of the hospital. All tribes have the prerogative to do so, as guaranteed by the Indian SelfDetermination and Education Assistance Act. (60% of all Native American hospitals already have.) Under the Act, tribes assume full management of their community’s health care facilities. They still, however, receive the same amount of federal dollars, which they can

spend as they see fit. In her office at Twelve Clans, Danelle explained how this helps with staffing and recruitment. “As a tribal organization,” she said, “we can recruit and bring people on board a lot quicker and we have flexibility in terms of pay scale that IHS doesn’t have.”

it free. “ThisButcaredon'tis acall treaty right

that’s enshrined in the Constitution, reaffirmed by hundreds of years of treaties and legislation and Supreme Court decisions, in exchange for massive amounts of land and loss of life.

This will be crucial for restoring the hospital’s operations. Twelve Clans’ in-patient unit has been closed since 2015, when the hospital lost CMS certification. Attracting high-quality providers — and getting their credentials cleared — has been the principal challenge in opening it up again. So far, Danelle and her team have had some success. They’ve hired two family medicine physicians, an internal medicine physician, a pediatrician, and a nurse practitioner. “All we need now is a dietician,” Danelle said. “We’ve found one, we’ve made an offer and we’re getting a start-date for them. We anticipate we’ll be ready to go with in-patient by December.” If that happens, it will put Twelve Clans on the path to earning back its CMS certification. Danelle hopes that regaining that credential would be a show of strength, what the community needs to believe in its hospital again. SIGNS OF HOPE Even without the in-patient unit, the

community’s confidence appears to be surging. Out in the hospital’s waiting room, a handful of patients sat on couches and waited for their appointments. One of them was a tribal member bringing her young daughter to the hospital’s dentist. “I think the transition team took the time and the care to hand-pick a really good staff,” she said, “I’ve gone through the clinic with my daughters and it was seamless.” A hospital facility manager, pushing a cleaning cart down the halls, said “I feel better that my tribe has taken control of this whole hospital. We can get more things done that way, without the constrictions that IHS had,” he said. A radiation technician, who was not a tribal member, said that “From my perspective, in my job, I’ve been much happier since the transition. I have a much easier time getting my departmental bills paid.” Even patients with raw memories of IHS mistreatment had positive things to say. One of them, a diabetic, recalled a dangerous episode in 2014, when a doctor accidentally gave him insulin instead of a fluid drip, sending his blood sugar down to near-fatal levels. “But I come here now and I’m treated good,” he said. “They treat me with respect.” Danelle knows that not everyone shares this sunny assessment of the tribe’s prospects. “There’s apprehension there, a lot of questions about how our tribe’s never run a hospital before, how can we expect to do a good job, none of us are medical doctors, things like that.” But she pointed out that no tribe who has assumed management of their own health care system has ever handed the keys back to IHS. “There’s a sense of pride when you know it’s ours, from a tribal perspective we all have a vested interested in the success of the organization,” Danelle said, adding, “We will succeed because we have to succeed. We have no choice."

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Fall 2018 | RHQ   17


MEDICAID

EXPANSION

When states (finally) embrace the ACA, rural residents tend to benefit the most BY BARBARA MANTEL

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n the wake of the November mid-term election, more states will be expanding Medicaid, the government’s largest health insurance program, and rural Americans are poised to be big beneficiaries, researchers say. The federal government and states jointly fund Medicaid and states administer the program under federal guidelines. Over the past five years, 31 states and the District of Columbia expanded Medicaid under the Affordable Care Act, which was signed into law in 2010 and whose main provisions went into effect in 2013. Medicaid expansion has resulted in a dramatic reduction in the rate of uninsured low-income adults in rural and small-town America, according to a joint report released in September by Georgetown University’s Center for Children and Families and the University of North Carolina’s NC Rural Health Research Program. In the report, “Health Insurance Coverage in Small Towns and Rural America: The Role of Medicaid Expansion,” researchers focused on 46 states with significant rural populations and examined uninsured rates for lowincome citizen adults in 2008/09 and 2015/16. They found that, on average, the uninsured rate in rural areas and small towns in the first wave of 22 states that expanded Medicaid dropped

from 35 percent to 16 percent. In nonexpansion states, the uninsured rate in rural and small-town America declined from 38 percent to 32 percent. “The report shows that it is going to be impossible for a state to really make a sizable dent in the high uninsured rates in rural areas unless they expand Medicaid,” says Joan Alker, a co-author of the report and the executive director of the Center for Children and Families. Voters agreed at the polls in November. Idaho, Nebraska and Utah passed ballot measures to extend Medicaid to a greater number of low-income adults. That was a turnaround from 2016, when President Donald Trump easily carried the three states in the presidential election with a platform that included repealing the Affordable Care Act. “Expanding access to health care isn’t a blue-state value or a red-state value; it’s an American value,” said Jonathan Schleifer, executive director of The Fairness Project, a nonprofit that financed the three Medicaid ballot initiatives. Prior to the Affordable Care Act, Medicaid covered low-income children, pregnant women, disabled individuals and some poor parents and excluded all other low-income adults. The law allowed states to expand Med-

icaid to all Americans earning up to 138 percent of the federal poverty level. That amounts to $28,676 for a family of three in 2018. But in states that have not expanded Medicaid, the old rules apply and “income eligibility even for parents is pretty limited,” says Rachel Garfield, a senior researcher at the Kaiser Family Foundation, a nonprofit that analyzes health policy. “The median income limit is about 40 percent of poverty, or about $9,000 a year for a family of three in 2018,” says Garfield. Parents making more than that do not qualify. State lawmakers, often Republican, have cited the potential drain on state budgets as the biggest reason for their opposition to Medicaid expansion. The federal government has been paying the bulk of the cost of Medicaid expansion: 100 percent for 2014 through 2016, 95 percent in 2017 and 94 percent this year. The federal government’s share will continue to decline until it reaches 90 percent for 2020 and beyond. States pay the balance. Medicaid currently insures 66.7 million low-income Americans, 12 million of whom were added through Medicaid expansion, says Megan Olsen, a senior manager for policy at Avalere, a consulting firm in Washington. Once Idaho, Nebraska and Utah formalize their plans and join the 31 states that


have already expanded Medicaid, an additional 325,000 people could be enrolled in 2019, according to Avalere. Hundreds of thousands more lowincome people will be eligible when Medicaid expansion becomes effective in Maine and Virginia next year. Maine’s governor-elect, a Democrat, has promised to implement a ballot initiative that voters passed in 2017 but that the outgoing Republican governor blocked. Virginia’s legislature passed an expansion law this year and enrollment starts in January. That leaves 14 states that, to date, have no plans to expand Medicaid, although in Kansas, the incoming governor, a Democrat, supports expansion. Of those, South Dakota, Georgia, Oklahoma, Florida, Texas, Alabama, Missouri and Mississippi had the highest rate of uninsured low-income adults in rural areas and small towns in 2015/16, according to Alker and colleagues, ranging from 47 percent in South Dakota to 35 percent in Mississippi. In nearly all 14 states, the uninsured rate for low-income adults in rural areas and

20  RHQ | RuralHealthQuarterly.com

small towns was higher than the rate in metropolitan areas. There are two primary reasons for that gap, says Alker. “Rural areas tend to have higher poverty rates than metropolitan areas and in some cases higher rates of disability. And both of those things… are associated with higher rates of not having coverage,” she says. “In addition, the kinds of employment that folks in rural areas and small towns can get, oftentimes, particularly low-wage workers, tends to be in agricultural sectors and sectors that typically don’t offer health coverage with the job.” In the 22 states that expanded Medicaid coverage during the study period, the gap between uninsured rates in rural and metropolitan areas narrowed significantly or disappeared, according to the research report. The impact of Medicaid expansion on health care providers, particularly hospitals, was just as dramatic, says Alker. “There is lots of evidence to show that Medicaid expansion helped to reduce bad debt and uncompensated

care for hospitals, and this is very important for rural communities,” she says. “If you look at a map where rural hospitals have closed since the Affordable Care Act was enacted, a lot more hospitals have closed in non-expansion states.” Community health centers, whose patients are predominantly low income and disproportionately uninsured, have also benefited from Medicaid expansion, according to a study published in the June issue of the journal Health Affairs. After two years of Medicaid expansion, the centers experienced an 11 percent drop in their share of uninsured patients and a 13 percent increase in Medicaid patients. And centers in rural areas experienced increases in quality measures, such as asthma treatment and hypertension control. They also saw higher rates of mammograms and visits for treatment abuse. “Medicaid has become a key pillar for the health care system nationwide, and nowhere is that more true than in rural areas and in small towns,” says Alker.

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Fall 2018 | RHQ   21


PUBLIC POLICY //

Short On Federal Funding, Obamacare Enrollment Navigators Switch Tactics BY PHIL GALEWITZ, KAISER HEALTH NEWS

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aternity Enrollment is down sharply on the federal health insurance marketplace this fall, and the consumer assistance groups that help with sign-ups think they know why. They don’t have the staff to help as many customers as before because the Trump administration slashed funding. The federal government is spending $10 million this year on navigators who help individuals enroll in coverage. The government spent $36 million in 2017 and $63 million in 2016. “We don’t have the people to provide the enrollment assistance nor to do the outreach and marketing to let people know what’s happening,” said Jodi Ray at the University of South Florida, who has overseen Florida’s largest navigator program since 2014. Ray’s program received $1.2 million in federal funding this year, down from $5 million a year ago. Florida leads the nation in enrollment in the Affordable Care Act marketplace plans. With less money, Ray can afford to pay only 59 navigators across the state this year, down from 152 a year ago. With fewer navigators, much of the group’s counseling is done by phone instead of in person. That complicates their job, she said, because it is much easier to talk with and show marketplace customers in person when looking at dozens of health plans with different costs and benefits. Open enrollment in the Obamacare plans began Nov. 1 and will run until Dec. 15 for the 39 states covered by the federal exchange, healthcare.gov. The other exchanges — run by states — typically extend until the end of December or into January. Obamacare plans are for people

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without workplace or government coverage. Nationwide, navigator groups are scrambling to make up for the loss of federal funding to ensure they can help people make sense of their health insurance options. In South Carolina, the Palmetto Project has transformed into the state’s first nonprofit insurance agency. Several of its former federally funded navigators are now licensed insurance agents. In their new role, they get paid a commission on their sales and don’t have to follow Trump administration rules that encourage navigators to talk to customers about short-term plans with limited benefits. The agents can also help customers enroll in Medicaid, Medicare and off-exchange plans. The Community Council of Greater Dallas, which was funded last year to help with enrollment in 56 counties, has raised money from private donors to continue serving seven counties around Dallas. But it has 25 fewer navigators, so consumers seeking help must wait three days on average, compared with less than a day last year. Across Texas, 211 of 254 counties have no federally paid navigators. In Wisconsin, the organization Covering Wisconsin has raised millions of dollars from cities, counties and local United Way chapters, as well as the state Medicaid agency, to make up for the federal cuts. Even still, it will be able to provide inperson assistance in only eight counties around Milwaukee and Madison. Twenty other counties are served by telephone. The Kansas Association for the Medically Underserved is relying totally on volunteers to help consumers with in-person and telephone assistance. In the past year, the association was able to use government funding to pay about 20 navigators. Nationally, nearly 800 counties served by the federal marketplace will not have any federally funded navigators this fall — up from 127 counties in 2016, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.) Federal officials said they were not providing funds for navigators in Iowa,

Montana or New Hampshire because no organizations applied in those states. Nearly 12 million people across the country — including nearly 9 million on the federal exchange — enrolled in Obamacare plans for 2018. At the halfway point in the six-week enrollment period, 2.4 million people chose a plan for the 2019 coverage year on healthcare.gov, the federal health insurance exchange, according to data released Wednesday by the federal Centers for Medicare & Medicaid Services. That compares with nearly 2.8 million consumers who selected their coverage through the exchange during the first 25 days last year. Among states with the largest enrollment drops: Pennsylvania (down 25 percent from last year), Missouri (down 25 percent) and Ohio (down 20 percent). The annual enrollment tally is being closely followed in part because 2019 marks the first year since the marketplace plans began in 2014 that Americans won’t be fined for failing to have coverage. But consumer experts think the lack of navigator funding could end up having a bigger impact on enrollment. Caroline Gómez-Tom, navigator program manager of Covering Wisconsin, said the end of the so-called individual mandate penalty has been a “nonissue” among people seeking coverage. “Some folks mention it, but at the end of the day they still walk away with health coverage,” she said. “The ability to have coverage at affordable prices outweighs the penalty being gone because people still see health care insurance as important to have.” Katrina McGivern, director of policy and public affairs for the Kansas Association for the Medically Underserved, said people in rural areas of the state will have the most difficulty getting help as a result of funding cuts. After five years of experience, she said, she is hopeful that people are figuring out how to do it on their own. Still, she added, there are always “people who need assistance to get through it.”

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hen Sarah Scantling went into labor last summer, she had to drive 30 miles and across state lines. Three years earlier, the only maternity ward where she lives in Pemiscot County, Missouri closed down. Scantling had to choose between a handful of other hospitals in the region between 20 and 70 miles away. She chose to give birth in the hospital in Dyersburg, Tennessee. It’s not uncommon for pregnant women in rural America to have to travel to give birth; the percent of rural counties without hospital obstetrics has increased in recent years to 54 percent, up from 45 percent in 2004. Still, 30 miles is a long way to be from your family if something goes wrong, as it did with Abilene. “I knew something was wrong when she didn’t cry. And then they just rushed her away,” Scantling recalls. Abilene was born with a hole in her heart. It was unexpected. The hole hadn’t shown up on any ultrasound. She was taken even farther from home on a medical flight to a hospital in Memphis, 130 miles away. “I didn't get to hold her for two days. I got to say goodbye to her and that’s it,” Scantling says. ‘WE FELT IT WAS COMING’

THE LONGEST MILE As rural counties lose obstetrics, women give birth far from home BY BRAM SABLE-SMITH / SIDE EFFECTS PUBLIC MEDIA

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Pemiscot County tried to rebuild its maternity program before it shut down three years ago. Pemiscot is rural — and the poorest county in Missouri — but the county-owned hospital has weathered many ups and downs. It recruited family practice doctor Erica Scheffer and her husband, an OBGYN, to modernize the obstetrics unit. “We were making improvements. We were getting new equipment, new nurses, sending the nurses for more training,” Scheffer remembers. “And then probably two years into it, things started going south.” The hospital lost more than $3 million in 2013. To stay alive, the hospital started to cut some of the more costly programs. Obstetrics was the first to go.


“We all felt it was coming,” Scheffer says. Pemiscot is part of a trend in obstetrics unit closures. According to research published in Health Affairs, 179 rural hospitals closed their obstetrics units between 2004 and 2014. Katy Kozhimannil, director of research at the University of Minnesota’s Rural Health Research Center, which conducted the study, says there are many reasons rural delivery units become too costly to keep around. Medicaid, for example, pays hospitals much less for child delivery than private insurance does. And Medicaid pays for more than half of all rural births — compared to about 40 percent in urban parts of the United States. Plus, just like their populations, birth rates in rural counties are dropping. “And as numbers fall, it becomes harder and harder to maintain the staffing and the skills that are needed to be ready for a birth at any time,” Kozhimannil says. “And the way those communities respond differs pretty dramatically.” 32 WEEKS Dr. Sheffer was Sarah Scantling’s doctor during her first pregnancy. After Scantling’s son was born, Scheffer became his pediatrician while also helping Scantling through postpartum depression. Now, Scheffer still sees pregnant women at Pemiscot County Hospital, but only for 32 weeks. After that, she refers them to a different doctor at a different hospital to finish their prenatal care and to deliver. That is, if they can make it. “Sometimes they don’t have a way to get to the new doctor and just show up when it's time to deliver. And sometimes, that’s by ambulance because that’s the only way they have to get there,” Scheffer says of her patients. The hospitals in the area have a name for that: “drop-in deliveries.” Sometimes Scheffer’s patients don’t make it to their new hospital at all. She says at least three babies have been delivered in the emergency room at Pemiscot County Hospital since the obstetrics unit closed.

TOP: Sarah Scantling's daughter, Abilene, was born in Dyrseburg, Tennessee, 30 miles from their home in Pemiscot County, Missouri. BOTTOM: Dr. Erica Scheffer still sees pregnant patients in Pemiscot County until 32 weeks, when she refers them to a different doctor at a different hospital to deliver. BRAM SABLE-SMITH / KBIA/SIDE EFFECTS PUBLIC MEDIA

Sarah Scantling was fortunate to have someone who could drive her to her appointments. She was also fortunate both Tennessee hospitals that delivered and cared for Abilene accept Missouri's Medicaid for payments. Now, Scantling can bring her baby girl to see Dr. Scheffer, like the rest of the family. “Sometimes I come up here and just ask them to listen to [Abilene’s] heart,” Scantling says. “And they say, ‘Honey, she’s just sleeping.’”

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It’s a relief, she says, to be back with the doctor who knows her family so well. This story was produced by Side Effects Public Media, a news collaborative covering public health. Bram SableSmith reported 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. This story is part three in a series on rural hospitals.

Fall 2018 | RHQ   25


HEALTH EDUCATION //

Health Education and Disaster Planning for Rural Communities BY MELISSA ODEN

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ealth Education is an incredibly flexible profession. It has an innate ability to deeply influence many different arenas that affect the human experience, thus creating long-lasting, positive impacts in our communities and on the people who live in them. Being a Certified Health Education Specialist (CHES), in particular, has opened many doors for me to work with groups of people who I never would have guessed I would be working with in geographical areas I never dreamed I would be working in. The good people of rural Van Zandt County, Texas, fall into this category. On April 29, 2017, seven tornadoes ripped through Van Zandt County in Northeast Texas, leaving in its wake nine million dollars in private property

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damage, and four fatalities. Two of the seven tornadoes were found to have caused the most damage, and were rated an EF-3 and EF-4, respectively. The areas that were affected the most were immediately to the East and immediately to the West of the city of Canton, Texas. In the hours and days that followed this disaster, many people came together in interdisciplinary teams to perform search and rescue, to provide emergency medical care, food and shelter, and to address aftercare needs (social, emotional, spiritual) that always accompany events such as this. Once the initial crisis has passed, there are many other long-term needs to be addressed, and this is where Public Health in general and health education specifically can play a pivotal role in assisting communities recover from disastrous events, and, in fact, did. Through a series of fortuitous events following the Van Zandt County disaster, Russell Hopkins and I were connected through a mutual colleague. Russell had just assumed the mammoth task of being Van Zandt County’s Long Term Recovery Group (LTRG)

Chair, and juggling that new role with his ongoing responsibilities as the Director of the Northeast Texas Public Health District (NET Health). NET Health has provided Public Health Emergency Preparedness (PHEP) and Disease Surveillance services to the residents of Van Zandt County since 2002. In the last three years, the County has had four declared disasters. Severe weather has visited the area with alarming frequency. This started the PHEP department at NET Health on a mission to address the issue of Community Recovery as this has been a core capability that never seemed to offer easy solutions when creating annual work plans. On Mother’s Day 2015, an EF3 tornado struck the unincorporated areas of Van Zandt County and moved into the town of Van. The tornado killed two people and hospitalized 48 with many more people less severely injured. The immediate response after the tornado worked reasonably well with plenty of opportunities for improvement identified in After Action Reports provided through the work of the county’s Long Term Recovery


Group (LTRG). Unfortunately, this group disbanded after the final financial distribution was made. After the April 2017 tornadoes, however, the primary concern became making LTRGs a permanent feature in the county. Lacking any previous experience, the LTRG began reaching out to the former members of the Van 2015 LTRG, Texas Department of Emergency Management (TDEM) and the City of Rowlett for ideas and lessons learned from other LTRGs that had been formed in the aftermath of other disasters in Texas. Russell was at this point in the process when we were introduced. I was the Project Manager for a grant that was being administered through the American Planning Association – Texas Chapter (APA-TX) (via the CDC) called Planners4Health, a three-year initiative whose goal was to bring planners and public health professionals back together in a symbiotic working relationship to make communities healthier. APA-TX was looking for a project on which to spend this newly awarded grant money, and Russell was looking for help. It was the perfect match. In July 2017, the Planners4Health Team took a field trip to Canton to survey the damage and talk with members of the LTRG to determine the best way to help them. It was evident from the very beginning of this process that my Health Education skills and competencies were going to be put to the test. I had never worked in Disaster Recovery or in a rural community before and, truth be told, thought I had no idea what I was doing or how I was going to lead my team to success. I convinced myself to lean into the skills in my Health Education Tool Box, and off my team and I went to create an intervention for the folks in Van Zandt County. The main deliverable of the grant was hosting a Round Table Event in Canton in October of 2017. The goal of that event was to bring together Emergency Management Professionals to disseminate the Tool Kit that the Planners4Health Team had created (which was the second deliverable of the grant). Unfortunately, the Tool Kit was not ready in time to disseminate

at the Round Table Event. However, that turned out to be a positive turn of events in this case, because the team was able to glean some important information from the attendees at the Round Table Event that helped in the final version of the Tool Kit. We are in the process of moving into the second phase of this project, which will focus on implementing these Round Table Events in five different Health Service Regions in rural communities across the state of Texas. The third phase will be a research project focusing on building and measuring resiliency in rural communities to not only help them post-disaster, but leveraging and strengthening the Social Determinants of Health in each community to create better overall health outcomes regardless of whether they experience a

disaster or not. Health educators are uniquely positioned to address issues in disaster planning by viewing this type of education as an expansion of the prevention model. By taking this view, health educators can take a deeper dive into the social determinants of health that need to be addressed in rural communities to assist those communities in becoming more resilient. To that end, we recommend that health educators familiarize themselves with the National Incident Management System (NIMS) and the Incident Command System (ICS). The self-study courses ICS 100 and 200 cover both NIMS and ICS. ICS 700 and 800 are for those professionals with an interest in health and medical disciplines. Courses are available for free at fema.gov. A free training account is required.

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Fall 2018 | RHQ   27


HEALTH EDUCATION //

Morehouse School of Medicine Challenges Stereotypes about Rural Health BY KATJA RIDDERBUSCH

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ee Whitton is somewhat unique among his peers at Morehouse School of Medicine. A white male raised in a small town near Chattanooga, Tennessee — and a third-year medical student at the Atlanta school, which has a predominantly black and female student body coming mainly from urban areas. Tall, with a casual demeanor and a silvery faux hawk hairstyle, 27-year old Whitton doesn’t mind standing out. “My class has about 100 students, and I’m definitely a minority,” he says with a smile. At the time of our interview, he’s at the halfway point of his two-week rural rotation, which is a requirement during family medicine clerkship at Morehouse. He works in the office of Dr. Steven Wilson, a primary care physician, just outside of the central Georgia town of Warner Robins. It’s eerily quiet here during the lunch hour on a sunny fall day. Not a single car is parked in front of the nondescript strip mall unit, and the sidewalk is deserted. Yet there are about 70 patients on this day’s schedule. Whitton admits that he didn’t expect such a heavy patient load. In his first week, he says he’s seen about 100 patients, “and I’ll probably double that number by the end of my time here.” Another thing he didn’t expect was the variety of patients and their wide range of diseases, from bone disorders to seizures. “Honestly, I expected some monotony in rural health,” he says. “Mostly high blood pressure and

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diabetes and colds, just doing the same thing over and over.” Challenging some of the stereotypes about rural health is part of the rotation’s plan, says Dr. Dolapo Babalola, a professor of family medicine and director of student education and rural health at Morehouse. Another goal is to help students “get a feel for what it really means to be a physician on the front lines of primary care, to apply more of their clinical skills instead of relying too much on labs and technology,” adds Babalola, who is from Nigeria and a Morehouse graduate. “We want the students to get hands-on experience with the patients,” she continues. Take their medical history, do a physical exam, present the case to the doctor. The hope is that more students will consider a career in primary care in rural areas. That’s where the physician shortage in the U.S. has the most daunting impact, according to a study by the Association of American Medical Colleges. The report predicts a shortage of up to 120,000 physicians by 2030. Rural and underserved areas in the South could be especially hard hit, the study suggests. Morehouse School of Medicine was founded in 1975 as part of

Morehouse College, a historically black and all-male liberal arts college. The medical school became independent in 1981, and is now co-educational with currently 541 students on a 13-acre campus in downtown Atlanta. Rural health has been part of the Morehouse curriculum for the past 25 years, but most of its graduates tend to gravitate toward underserved urban areas. “Out of 160 medical schools in the United States, only 30 to 35 have dedicated rural tracks,” says Mark Deutchman, a professor at the University of Colorado’s School of Medicine, who studies rural programs in U.S. medical schools. While Morehouse is not among those schools, Deutchman says it is off to “a very good start,” with classroom and clinical components fostering rural care. “But in order to make the rural education sustainable they would need to do longer clinical experience,” he adds, giving students the chance to really get embedded in a rural clinical environment. Some medicals schools in the Midwest, like the University of Minnesota-Duluth, send students to rural areas for up to six months. Compared to most urban medical schools, however, Deutchman

Dr. Steven Wilson and Lee Whitton, a third-year medical student at the Morehouse School of Medicine.


says that Morehouse ranks above the fold in terms of its rural commitment. The school has increased its outreach efforts, especially through pipeline programs targeting high schools and colleges in rural areas. In addition, Morehouse has fostered an alliance with the Area Health Education Centers (AHEC) in Georgia, a network of programs designed to distribute medical students and doctors to underserved areas. Through AHEC and its network of alumni, Morehouse partners with rural physicians willing to take on medical students for their rotations. In 2009, rural primary care, including a clinical rotation, became a required course for third-year students, Babalola says. Fourth year students can elect to go back to a rural area. Morehouse recently introduced a mobile health clinic—a van with three exam rooms that was originally designed for clinical research. It brings free care to rural Georgia patients struggling with transportation. Student volunteers run the clinic, under the supervision of local physicians. Most Morehouse graduates still prefer an urban practice, but Babalola says she’s seen more newly minted doctors willing to set up shop in the countryside. One of them is Dr. Joy Baker. After finishing her residency in OB-GYN in 2012 she worked at a hospital in Columbus, Georgia. Two years later, she moved to Thomaston, a small middle Georgia town where she now works out of Upson Regional Medical Center, a 115-bed hospital. She’s one of only two OB-GYNs in a rural patch that spans eight counties and 2,700 square miles. And she’s the only one who actually lives where she works. “So when there’s an emergency, I’m it,” she says. Baker, 38, grew up in metro Atlanta. Yet she enjoys the smalltown atmosphere, her neighbors, her patients, and her quaint ranch house

that has a bright pink front door and a sunroom filled with the aroma of cinnamon candles. She always thought she’d be a trauma surgeon in a large urban hospital. But two events during medical school prompted her to change course. The first happened in her rural health rotation, which she did near Rome in northwest Georgia. She vividly remembers: “There was this patient, an older gentleman. The doctor came into the room and immediately asked him, without an exam or conversation, ‘What’s up? You don’t seem to feel well.'” The physician sent the patient to the hospital, where he was diagnosed with a heart condition. “And I thought that was amazing, knowing your patient so well, practicing medicine on such a personal

blank canvas that I could create on.” And so she did. She introduced telemedicine for patients with high-risk pregnancies, after she pushed the hospital to apply for a grant. Every Wednesday she holds a high-risk clinic in her office, where she takes ultrasound images and transmits them to a perinatologist in Atlanta, a doctor who specializes in high-risk pregnancies. High-risk patients used to have to travel 50 or more miles to see a specialist, and many people in the area don’t have the resources to do that, she says. Baker also launched weekly prenatal care groups to educate women about proper nutrition and fitness during pregnancy, labor and delivery, and newborn care and breastfeeding. “I saw these groups during my residency at Morehouse,

Out of 160 medical schools in the United “States, only 30 to 35 have dedicated rural tracks.

level,” she says. “There’s no chance you could ever do that if you work in an inner city emergency room.” In her final year of medical school, Baker worked in an Atlanta hospital trauma unit. A man with a gunshot wound was wheeled in—his kidney beyond repair, she recalls. When she watched the surgeon toss the shattered organ across the operating table, she thought, “that’s not for me. That’s not what I want to do for the rest of my life.” She decided to give OB-GYN a try. “There’s still a lot of adrenaline,” she says, but it also allows her to practice what she calls “happy medicine.” When she first signed her contract in Thomaston, she says she was a little scared, “because there were no other permanent OB-GYNs here.” But she also saw it as “a wide open space without much structure, like a

and I knew right away that this is what I wanted to implement in my practice.” Baker says she may move back to the city some day. “But right now, I’m feeling very comfortable here.” In Warner Robins, the lunch break is over, and patients start pouring into Dr. Wilson’s office. Lee Whitton, the Morehouse medical student on rotation, has to go back to work. If he had to pick a specialty right now, he says he would probably choose general surgery. But after the experience here, family medicine in a rural setting might be another option “I enjoy the variety. I enjoy the patient load. And I like small towns,” he says. Briefly hesitating, he adds, “Yeah, I could see myself working as a country doctor.” After all, he’s used to standing out.

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Health Technology //

Doctors Give Medicare’s Proposal To Pay For Telemedicine Poor Prognosis BY PHIL GALEWITZ, KAISER HEALTH NEWS

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he Trump administration wants Medicare for the first time to embrace telemedicine across the country by paying doctors $14 for a five-minute “check-in” phone call with their patients. But many physicians say the proposed reimbursement will cover a service they already do for free. And the Medicare reimbursement — intended to motivate doctors to communicate with patients outside the office — could have a chilling effect on patients because they would be required to pay a 20 percent cost-sharing charge. Medicare said the call would be used to help patients determine whether they need to come in for an appointment. But doctors and consultants said the virtual sessions could cover a broad array of services, including monitoring patients starting a new medicine or those trying to manage chronic illnesses, such as diabetes. The Medicare Payment Advisory Commission, which provides guidance to Congress, panned the proposal last month, saying it could lead to excess spending without benefiting patients. “Direct-to-consumer telehealth services … appear to expand access, but at a potentially significant cost and without evidence of improved quality,” the commission’s chairman, Dr. Francis Crosson, said in a letter to the Centers for Medicare & Medicaid Services (CMS). “Due to their greater convenience, these services are at risk of misuse by patients

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or provider.” Congress has shied away from expanding the use of telemedicine in Medicare — even as it has become commonplace among private insurers — because of concerns about higher spending. Budget hawks worry that rather than replace comparatively expensive in-person visits, extra telemedicine billings would add to them. Lack of coverage — except in rare circumstances — means fewer than 1 percent of the 50 million Medicare beneficiaries use telemedicine services each year. Federal law forbids Medicare from paying for telemedicine services that replace in-person office visits, except in certain rural areas. That’s why CMS called the new benefit a check-in using “virtual” or “communications technology,” said Jacob Harper, who specializes in health issues at the law firm Morgan, Lewis & Bockius. In addition to the check-in call, CMS has proposed starting to pay physicians to review photos that patients text or email to them to evaluate skin and eye problems, as well as and other conditions. It also has proposed paying physicians an unspecified fee for consulting electronically or by phone with other doctors. “Innovative technology that enables remote services can expand access to care and create more opportunities for patients to access personalized care management as well as connect with their physicians quickly,” said CMS Administrator Seema Verma when announcing the proposal. CMS said it hopes to enact the changes in 2019. Officials will announce their final rule after evaluating public comments on the plan. Verma and other CMS officials say they believe the change would end up saving Medicare money by reducing unnecessary office visits and catching health problems early, before they become more costly to treat.


But in its detailed proposal, CMS acknowledges the telehealth service will increase Medicare costs. CMS said the telehealth will result in “fewer than 1 million visits in the first year but will eventually result in more than 19 million visits per year, ultimately increasing payments under the [Medicare physician pay schedule] by about 0.2 percent,” or eventually about $180 million per year. Because the change must be budget-neutral, CMS is paying for this by decreasing some other Medicare physician payments. CMS doesn’t expect rapid adoption of the telehealth service, partly because doctors can get paid from $35 to $150 for an in-person visit. “Because of the low payment rate relative to that for an office visit, we are assuming that usage of these services will be relatively low,” CMS said in its proposal. The virtual check-in can be conducted by physicians or nurse practitioners or physician assistants working with a doctor. Only patients who have established relationships with a doctor would be eligible for the service. Doctors also would not be allowed to bill for the check-in service if it stems directly from an in-person visit or is followed by an appointment with the doctor, according to the CMS proposal. Dr. Michael Munger, a family physician in Overland Park, Kan., and president of the American Academy of Family Physicians, said many doctors routinely check on patients by phone. Still, he applauded the effort to increase physician pay. “Anytime you can tie payment to what many of us are already doing is good,” he said. Mercy, a large hospital system in St. Louis, has been offering telehealth services even without reimbursement because it helps patients access care and lowers costs in

the long run, said Dr. J. Gavin Helton, president of clinical integration at Mercy Virtual. “We are already on this path, and this will help to continue to grow our programs and make them financially sustainable,” he said. Still, Helton said the “check-in” fee from Medicare won’t be enough to motivate providers to start telehealth services. He said the new reimbursement signals that Medicare wants to pay for services to keep patients well rather than just treat them while they are sick. Other physicians were more skeptical, particularly while Medicare has also proposed reducing some fees for inperson office visits. In a letter to CMS, Dr. Amy Messier, a family medicine doctor in Wilmington, N.C., raised concerns about the effect this could have on patients’ expenses. “I worry about implementation of this from the patient perspective now that we are charging patients for this previously free service and they have to pay their portion of the charge,” she said. “Patients will be less likely to engage their physician outside of the office visit and more likely to seek care face-toface at more expense, when perhaps that visit could have been avoided with a phone call which they will no longer make because it comes with a charge,” she said. Dr. Todd Czartoski, chief executive of telehealth at Providence St. Joseph Health in Renton, Wash., predicts most doctors won’t use the proposed telehealth service. “It’s still easier for a doctor to go room to room with patients lined up,” he said. “It’s a step in the right direction, but I don’t think it will open the floodgates for virtual care.”

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RHQ CONFERENCE CALENDAR C

heck out our list of rural health conferences, and let us know if you’re hosting one so we can help spread the word. Email us the details at RHQ@ttuhsc.edu. AHA Rural Healthcare Leadership Conference February 3 - 6, 2019 Arizona Grand Resort and Spa 8000 S. Arizona Grand Parkway Pheonix, AZ www.aha.org Rural Health Policy Institute February 5 - 7, 2019 Omni Shoreham Hotel 2500 Calvert Street NW Washington D.C. www.ruralhealthweb.org West Virginia Rural Health Workforce Day February 8, 2019 West Virgina State Capital 1900 Kanawha Blvd East Charleston, WV wvrha.org Maine Hospital Association Small or Rural Hospital Conference February 13-15, 2019 Sunday River, 27 Grand Circle Newry, Maine www.themha.org Florida Rural Health Association Educational Summit March 4-5, 2019 UNF University Center 12000 Alumni Drive Jacksonville, FL floridaruralhealth.org Colorado Rural Health and Hospitals Conference March 6-8, 2019 Denver Marriott West 1717 Denver West Marriott Blvd. Golden, CO cha.com National Association of Rural Health Clinics 2019 Spring Institute March 25-27, 2019 Hyatt Regency Riverwalk 123 Losoya Street San Antonio, TX narhc.org

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Northwest Regional Rural Health Conference March 25-27, 2019 Hilton Seattle Airport and Conference Center 17620 International Blvd Seattle, WA cm.wsu.edu Pennsylvania Public and Community Health Conference April 2, 2019 Eden Resort and Suites 222 Eden Road Lancaster, PA ppha.wildapricot.org

nebraskaruralhealth.org Michigan Rural Health Conference April 25-26, 2019 Soaring Eagle Casino and Resort 6800 Soaring Eagle Blvd. Mount Pleasant, MI www.mcrh.msu.edu Alabama Rural Health Conference April 25-26, 2019 Montgomery Marriot Prattville Hotel 2500 Legends Circle Prattville, AL www.mcrh.msu.edu

Colorado Rural Health Center Forum April 3-5, 2019 Renaissance Denver Stapleton Hotel 3801 Quebec Street Denver, CO coruralhealth.org

Mississippi Rural Health Clinic Conference May 3, 2019 Jackson Hilton 1001 County Line Rd. Jackson, MS www.mcrh.msu.edu

Institute for Rural Health Research Conference April 10-11, 2019 Bryant Conference Center 240 Paul W Bryant Drive Tuscaloosa, AL cchs.ua.edu

Rural Hospital Innovation Summit May 7-10, 2019 Atlanta Marriot Marquis 265 Peachtree Center Ave NE Atlanta, GA www.ruralhealthweb.org

Nebraska Rural Health Conference April 24-25, 2019 Younes Conference Center 416 W Talmadge Rd. Kearney, NE

NRHA Rural Health Conference May 7-10, 2019 Atlanta Marriot Marquis 265 Peachtree Center Ave NE Atlanta, GA www.ruralhealthweb.org


Learn telemedicine clinical presenting procedures, technology, and business!

Frontiers in Telemedicine Certificate Course This program focuses on competency-based learning and is designed for licensed healthcare professionals, including mental health professionals, nurses, nurse practitioners, physician assistants, residents, and medical doctors who desire to learn about telemedicine.

Online Learning and Resources

Live Lectures and Equipment Demonstration

Hands on Practice with Patients and Equipment

At the end of this course, the student should be able to demonstrate:  basic knowledge of Telemedicine/Telehealth and define those who could benefit from this technology  knowledge of the Originating/Distant site, as well as the clinician/staff roles at each one  ability to operate certain telemedicine technologies  knowledge of the procedures for a telemedicine encounter  utilization of knowledge required to present and manage the patient through telemedicine  application of communication skills in patient and medical team communication

http://frontiersintelemedicine.org/


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Rural Health Quarterly 2.4 – Fall 2018  

Redemption on the Rez: Can the Winnebago Tribe Revive Their Community’s Troubled Hospital? • The Shiprock Chronicles: Adventures in Rural Ep...

Rural Health Quarterly 2.4 – Fall 2018  

Redemption on the Rez: Can the Winnebago Tribe Revive Their Community’s Troubled Hospital? • The Shiprock Chronicles: Adventures in Rural Ep...

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