IMPACT: Health Care 2018

IMPACT of Health Care

IN KANDIYOHI COUNTY AND BEYOND | 2018

IMPACT 2018

Welcome to

TABLE of CONTENTS Health Care Overview 8 Health Systems 12 Long-term/ Home Care 18 Dental Health 28 Public Health 36 Mental Health 46 Complementary Care 56 Health Care Technology 62 Health Care Education 70 Health Care Equity 78 Rural Recruitment 82

STAFF WRITERS / PHOTOGRAPHY Anne Polta Tom Cherveny Carolyn Lange Linda Vanderwerf

Shelby Lindrud Erica Dischino Susan Lunneborg Sharon Bomstad

CONTRIBUTING WRITERS Tony Amon Mary Amon Kristin Anderson Pam Brede Lana Dirksen Pamela Ditmarson Wendy Foley Scott Hable Ashley Kjos Casie Knoshal Thomas Lange

Tara Maus Lisa McBrian Juliana Neumann Michelle Prekker Michael Schramm Leah Schueler Cindy Firkins Smith Tod Speer Ann Stehn James Zenk

PUBLISHER: Steve Ammermann EDITOR: Kelly Boldan MAGAZINE EDITOR: Sharon Bomstad

A

s a regional medical center, Kandiyohi County has stateof-the-art facilities and hundreds of medical providers who provide outstanding care. From the beginning of your life through your golden years, Kandiyohi County has

healthcare options for almost every circumstance. There are nearly 6,000 healthcare jobs in Kandiyohi County, making it the region’s top industry and that number continues to grow. Thanks to state-of-the art technology and top-notch medical providers, Kandiyohi County’s medical facilities draw from a large area of Minnesota.

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Health Care

A regional economic powerhouse, building on state legacy

Health Care

(noun): efforts made to maintain or restore physical, mental, or emotional well-being especially by trained and licensed professionals. First known use: 1940 Variants: healthcare - Merriam-Webster Dictionary

Health care maintains a place in the fabric of west central Minnesota that’s as enduring as manufacturing or agriculture.

Acute care provided by the region’s hospitals and medical clinics helps save lives and restore people to health. Long-term care and assisted living facilities meet the needs of a growing senior demographic. With 8 | IMPACT

increasing numbers of people who are aging or disabled opting to live at home in the community, home care has emerged as one of the most rapidly expanding occupations of the decade.

In all its forms, health care is one of the region’s economic powerhouses. It accounts for one in every four to five jobs, making it a critical source of employment.

Hospitals and medical practices typically occupy a key position in the economy of their community. Not only do they provide well-paying jobs but they also contribute to overall quality of life. For individuals and businesses looking to move to Granite Falls, Olivia, Litchfield or Willmar, the presence of a thriving health care infrastructure is often a key deciding factor.

Health care also is changing rapidly. Technology offers future promise for how services will be delivered and sustained, especially in a rural environment. An expanded understanding of local health has led to broad efforts to promote health in everyday life, from improved access to fresh food to trails for walking and biking.

Mental health and complementary care have become important and desired components in overall health.

At the same time, the region is confronting the twin challenges of supporting a robust infrastructure and maintaining a well-qualified workforce of nurses, dentists and other key professionals.

An increasingly diverse population has prompted a

need for health care to be more equitable to ensure west central residents all have equal opportunities to be healthy.

In towns large and small, in schools, in public health and in the private sector, west central Minnesota is building on its health care legacy to ensure the region remains a healthy place to live, work and play well into the future.

IMPACT | 9

Health Care SYSTEMS

Through years of changing landscape, quality care remains at the core The roots of the region’s health care systems started small but go deep.

One hundred years ago, health care was delivered through a patchwork of small, locally owned hospitals and doctors in independent practice, caring for patients from birth to death.

Change began in the 1930s, starting with the establishment of Rice Memorial Hospital in Willmar in 1937 and accelerating over the next two decades with a hospital building boom in towns from Benson to Litchfield to Olivia and Granite Falls.

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The expansion mode extended to mental health and long-term care.

By the 1970s, west central Minnesota was wellserved with a health care infrastructure that prided itself on being locally owned and responsive to the unique needs of the region.

The landscape today looks dramatically different.

As organizations look for ways to continue providing services and remain viable, strategic partnerships have come to the fore. Cities such as Appleton and Dawson have found ways for medical practices, hospital care

and long-term care to co-exist under one roof. Alliances have proved to be a successful tool for strengthening primary care, bringing in specialty care and reinforcing the region’s rural health care systems.

For some, the answer lies in going bigger. The benefits of joining a larger organization were a driving force in a merger that went into effect Jan. 1, 2018, between Affiliated Community Medical Centers and Rice Memorial Hospital, creating a new nonprofit subsidiary of CentraCare Health System known as Carris Health.

It’s the region’s largest home-grown health system, bringing together a total of 971 employees, 350 physicians, one 136-bed hospital and Level III trauma center, and 15 specialty locations ranging from seven hospice sites to five medical equipment retail outlets.

Carris Health points to many advantages to this new union: enhanced resources to serve patients, quality

care that remains close to home, increased access to a broader range of specialty care, improved ability to recruit and retain health care professionals, greater efficiency, and better strategic positioning to meet continuing policy changes at the state and federal level.

Some communities have taken a different path – Granite Falls, Montevideo and Olivia, for instance,

remain independent while seeking strategic partnerships and investments that allow them to preserve local control and local care.

Although the picture has altered significantly in the last few decades and changes have been gathering speed, one constant holds true: a commitment that local communities will continue to have quality care that reflects their needs and values.

IMPACT | 13

Q&A

Cindy Firkins Smith and Michael Schramm Co-chief executives, Carris Health

Q. What were some of the main factors that drove the decision to create Carris Health?

A. Carris Health was created to sustain and optimize rural health care in a time of rapid and massive change in health care delivery. ACMC Health, CentraCare Health and Rice Memorial Hospital realized that even though we faced the same challenges and frequently cared for the same patients we weren’t working together to care for them in the best way possible.

We realized that by working together we could combine our individual knowledge and expertise to reinvent rural health care to ensure we can provide the right care at the right time at the right place, for the right sustainable cost.

Q. What led to the choice of CentraCare Health as the key partner?

A. Though we researched a variety of options, CentraCare emerged as the obvious partner. Our visions and missions were very similar and, like us, they are committed to rural health and the potential to create a care approach that better fits with the future direction of health care.

Q. What do you see as the two or three most important benefits of this partnership?

A. The first, second and third most important benefit is the people who have come together as a team. We’ve been able to combine the bright and innovative ideas from three different health care entities to create new solutions to rural health care challenges. It’s true that the synergies created by a talented and dedicated team far exceed the sum of its individual parts.

We believe that when a health need arises, every one of us wants the best care possible, and we want it in our community. Our patients want these things too. We believe together, Carris Health and CentraCare, can partner to achieve this vision as a benefit for West Central and Southwest Minnesota.

Q. How have things been going during the first year of the new entity?

A. Amazingly well. People have been keen to work collaboratively and have been curious about each individual organization. We have been very deliberate about creating a mutual culture entitled “Our Best Begins with Me” that emphasizes curiosity and assuming positive intent in colleagues and it’s been very well-received.

Patients will not notice any near-term changes, but the partnership puts the hospital and clinic in a better position to work with health insurers to implement plans that feature incentives for more efficient care and preventive services.

Q. Which particular accomplishments or initiatives have you been especially proud of?

A. We are especially proud of the continued dedication of every individual in Carris Health and CentraCare to put the needs of our patients as central to every decision we make. When caught up in a whirlwind of change, it can be easy to lose the focus on our mission and the commitment to outstanding patient care has remained foremost.

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Dr. Cindy Firkins Smith, left, and Michael Schramm Q. What are some of the priorities for Carris Health over the next few years?

A. We are working to bring individual departments and service lines between the three organizations together when it makes sense to optimize care for the region. Recruiting health care professionals remains a challenge in rural medicine so we need to optimize our teamwork to take best advantage of the individuals that we have.

We will be transitioning to a single Epic electronic health record in May 2019. The Epic implementation will improve standardization for our clinicians to enable a higher quality of patient care and improve clinical efficiency. Right now, with different electronic health records, there is duplication of record keeping and potential for inaccuracies.

We will continue to work with and support other regional health care systems and providers to enable them to do their best for the patients they serve. We will continue to institute innovations in rural health care and expand telehealth, population health and maximize our quality so that people in our rural communities can be assured that their health is not compromised by geography.

We will continue our culture journey, remembering every day that doing our best for others begins with each of us.

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Fast FACTS HEALTH CARE SYSTEMS Health systems are commonly defined as the organization of people, institutions and resources to deliver health care services that meet the needs of a targeted population. Usually they include at least one hospital and one physician group.

Nationally, nearly three-fourths of hospitals and more than 40 percent of primary care physicians are part of a health system.

More than half of the health systems in the U.S. have one or two hospitals and fewer than 250 physicians.

Minnesota hospitals directly employ more than 127,000 people who collectively earn $8.6 billion in annual salaries and benefits.

Another 105,000 jobs statewide are tied to health care.

Health systems of all sizes are often a major source of employment in their community. Of the top 10 largest employers in Minnesota, five are health systems: Mayo Clinic, Allina Health System, Fairview Health Services, Healthpartners and UnitedHealth Group.

CentraCare Health System of St. Cloud is No. 16 on the list.

There are 125 24-hour emergency rooms in the state.

Minnesota ERs had more than 1.9 million patient visits in 2016.

Most Minnesota hospitals are small.

Only about a dozen are licensed for 400 or more beds. About two-thirds are licensed for 100 or fewer beds.

Source: Minnesota Hospital Association; Agency for Healthcare Research and Quality; Minnesota Department of Employment and Economic Development.

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LONG-TERM Health Care

Aging population brings greater needs; supply of caregivers shrinking We all know that our population is aging and that means we will see a growing number of people requiring long-term care, either through home health programs or care in skilled nursing and assisted living facilities.

What’s sometimes overlooked in this discussion is this: Our population of working-age people who can provide caregiver services and carry the tax burden is not growing, and in many area counties it is declining.

Many long-term care facilities are already finding it difficult to recruit the workers they need.

The declining “support ratio” of working-age citizens 18 | IMPACT

to senior citizens is just one of the challenges we are already facing in an aging society, according to Linda Giersdorf, executive director of the Minnesota River Area Agency on Aging. “Definitely think we’re up to the challenge, but it is going to take people willing to work together and compromise,’’ said Giersdorf.

She brings up two issues, broadband and economy of scale, when speaking about long-term care in rural counties: We want more people to remain independent in their own homes. It’s what most people want, and it’s the most cost-effective way to provide long-term care.

Telehealth services help people remain in their homes in rural areas where there are only so many caregivers available. But many rural areas lack the broadband service needed for telehealth services, she said.

Giersdorf said the low population density in many rural areas also means there isn’t always the economy of scale needed by providers to offer in-home services.

There are many steps being taken to address the challenges. We are working to help people stay healthy longer. In-home and congregate dining services provides nutritious foods to older adults.

Many area agencies on aging are offering programs to educate older adults on how to better cope with chronic conditions, from diabetes to pain management.

Communities are upgrading infrastructure to serve an aging population, such as improving sidewalks to handle motorized chairs.

In some cases, we are also able to offer financial help so that homes and institutions can be upgraded

to better meet the needs of older adults with physical limitations.

We are also doing more to recruit volunteers to help older adults.

The emerging caregiver shortage is very much on the agenda. The University of Minnesota has hosted community conversations in Marshall and Crookston on what a reduction of working-age immigrants to the

region would mean.

In some areas, organizations are getting into schools and talking to young people about the benefits of working with older adults, in hopes they may consider careers or volunteer work, Giersdorf said.

It will take an “all of the above’’ strategy, along with a willingness to work together and cooperate, to meet the challenges, she said.

IMPACT | 19

Fast FACTS LONG-TERM CARE

The population of people 65 and older is projected to rise from 7,188 in 2015 to 11,375 in 2030 in Kandiyohi County. That’s an increase of 58 percent.

In Lac qui Parle County, persons 65 and older are projected to comprise 34.7 percent of the population in 2030.

In Kandiyohi, Chippewa, Lac qui Parle, Meeker, Renville, Swift and Yellow Medicine counties, more than one-quarter of the population will be age 65 and older in 2030.

The support ratio of working-age adults to those over age 65 will continue to decline.

In Kandiyohi County, the population aged 15 to 64 is expected to decline approximately 9 percent from 26,831 in 2015 to 24,536 in 2030.

One-fourth of older adults in Kandiyohi and neighboring counties are living alone, with 1,755 adults living alone counted in Kandiyohi County in 2015.

There is a sizable population of persons ages 65 and older living below the poverty line, with 6.4 percent or 438 seniors in Kandiyohi County considered to be living in poverty.

Meeker County has 11.5 percent of its senior population living below the poverty line, or 443 people.

Source: Minnesota River Area Agency on Aging IMPACT | 21

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Q&A

Pam Brede Divine Home Care

Q. Who is eligible for home care and how do you get services?

A. Everyone is eligible. They may pertain to individuals of all ages, from newborn to elderly. A quick phone call to consult is all that is needed.

Q. Who pays for home care services?

A. Home care is an affordable way to remain in the comfort of your own home — often at no charge to you. Divine Home Care accepts all forms of payment. These payment options include: • Medicare: If you are 65 and older, or disabled, and have Medicare, you may be eligible for home health services to be covered at 100 percent.

• Medicaid (Medical Assistance): Medicaid provides health care coverage to those who fall below a certain level of income set by the state. You apply for Medicaid through your local county human services office.

• Private insurance: Many private insurance plans offer coverage for home care. Eligibility requirements vary.

• County programs (Waivers) • Veterans Affairs (VA) • Private pay: If you would like to utilize Divine Home Care services rather than recovering in a facility or living outside of your own home but are not covered under any of the previous options, you may pay privately for services.

Q. Can you tell us a little about Divine Home Care, when it started and the region it serves?

A. Divine Home Care Inc. is a Medicare-certified, in-home health care agency founded in 2003 by Pam Brede and Deb Shriver. A family-run business, we have our corporate office in Willmar, as well as additional offices in Benson, Litchfield, Little Falls and Redwood Falls. These offices serve 650 clients within 26 counties in central, southern and western Minnesota. In 2013, we opened a hospice company, Divine Hospice Care.

Q. What is home care?

A. Home health care is a wide range of services for an illness or injury. It is usually less expensive, more convenient and just as effective as care you get in a hospital or skilled nursing facility. Home care provides services such as skilled nurse visits; therapy services; as well as home health aides and “supportive” care, such as bathing/dressing, housekeeping and/or transportation to name a few. Home health care is often needed when a person has had a recent inpatient stay at a hospital, rehabilitation center or skilled nursing facility.

Q. What are the range of services available through home health?

A. A full variety of services from nursing to homemaking are offered: skilled nurse visits, home health aides, personal care assistants or homemaking.

We also offer interpretive services, wound care and IV therapy, as well as occupational/physical/speech therapies, home care nursing program, respite care, and independent living services. These services are available 24 hours a day, 7 days a week.

Q. How many people are a part of the Divine Home Care team?

A. We have over 400 staff throughout the company, which includes 85 24 | IMPACT

Pam Brede nurses. Each office has an office manager and/or staffing coordinator in addition to a registered nurse branch manager and up to six additional RN case managers.

Q. How do you work with the families and loved ones of those receiving home health care services?

A. Divine Home Care understands that having staff come into your home to care for a loved one can be strange, or maybe even uncomfortable. We pride ourselves in matching the client with the right staff to ensure that there is trust and comfort in the home. We strive to make this as nonintrusive as possible.

Q. What are the questions people need to ask when considering home health care?

A. • Is the agency Medicare-certified and state licensed? (Medicare certification is the highest standard of excellence, as well as the highest regulated level of care.)

• What specific services do you provide?

• What hours do you provide services?

• Will my loved one have the same caretaker every time?

• What happens if the caretaker doesn’t show up on time or at all?

• What if my loved one doesn’t approve of the caretaker or wants a new one?

• What insurance plans do you accept?

Q. Does your doctor need to assist in getting home care services started?

A. The Divine Home Care nurses will contact your physician to get authorization to begin services based on a specialized care plan that best serves the client’s individual needs. These care plans are then reviewed every 60 days.

Q&A

Casie Knoshal Renville Health Services, administrator

Q. Renville Health Services is one of the region’s leaders in providing comprehensive, long-term care. Can you tell us a little it about what is located on the campus, including the nursing home and assisted care facilities, as well as the range of outpatient services available?

A. Renville Health Services provides skilled nursing home care, independent living, assisted living, and affordable senior housing on campus in Renville. Within Renville, we offer inpatient and outpatient therapy services (physical, occupational and speech therapy) via Aegis Therapies. In addition, we provide assisted living and memory care services in Hector.

Q. The focus on long-term care has been to allow people to live as independently as possible. Can you give us some examples of how you do that?

A. We encourage residents and tenants to continue to do all the things that they are able to do. Examples could be walking, performing range of motion, dressing, etc. However, we also have staff and services available to help care for all those from independent needs all the way to total dependent needs.

Q. The days of institutional care have given way to long-term care that is focused on providing a home-like environment.

How do you accomplish this at Renville Health Services?

A. It is our mission to help provide a true home for all residents/ tenants that reside in our buildings. First off, we strive to do this on an individualized basis. A person’s life should not need to change when they move from a community setting to an inpatient setting.

The stay might be temporary or permanent, but either way, we strive to keep the resident/tenant as comfortable as possible. We provide homelike amenities such as a warm and welcoming atmosphere and decor.

Most importantly, we strongly encourage resident choice regarding their care. Examples of this includes: multiple food choices at meal times, wake and sleep as the residents choose, resident care plan involvement and participation regarding resident goals, etc.

Q. We are facing the challenges of an aging population and a shortage of workers. Do you anticipate that the aging population in our area will lead to an increased demand for the services you provide?

A. The future has areas of uncertainty. The population is aging at an unprecedented rate and the labor force is shrinking. Renville Health Services is striving to provide aging services for the rural areas of Renville and Hector. However, it seems unclear if the industry will be able to continue to meet all the needs of aging services, especially that of always being able to remain local when needing aging services.

Q. How big is the workforce challenge, and what is Renville Health Services doing to meet the needs?

A. The challenge is here. At district and state conferences, other organizations within the industry vocalize the staffing shortages. Renville Health Services has taken on multiple avenues to help get through the

Casie Knoshal workforce challenge. Providing competitive insurance packages for employees has proven to be effective as well as providing a positive and fulfilling work environment. In addition, we started looking at specific area opportunities such as a summer internship program that is intended to educate and attract local high school/college age students to the long-term care industry. In addition, the employer-paid health insurance offered for working 30 hours a week has proven to attract a pre-retiree workforce that is not always marketed to in this region.

Q. Are you able to incorporate community participation in the care you provide, such as through volunteers and activities, and do you see benefits by doing so?

A. Yes, we have absolutely wonderful volunteers. The impact that these individuals have on the quality of life of the residents is immeasurable.

Renville and Hector have extremely supportive communities, and we are very fortunate to have the leaders and participation that we have within the communities.

Q. What would you tell young people considering career options about the benefits of serving older adults?

A. The benefits are endless. It is amazing to go to work and know that you are truly needed, and that the work you do directly impacts the lives of other people who are in need. The growth opportunity within the industry is vast while the work is extremely rewarding.

IMPACT | 25

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DENTAL Health

Challenges ahead for dentists and patients alike According to a recent survey by the Minnesota Department of Health, dentists practicing in the state are older than the median age of the general population, are concentrated in the metro area and about onefourth are expected to retire within the next five years.

Although most dental offices in rural Minnesota are solo operations, an increasing number of new dentists in the next generation want to work in large group offices.

Those factors, combined with a constant task of attracting young professionals to live and work in rural Minnesota, presents challenges for the field of dentistry and patients in west central Minnesota who need those services.

28 | IMPACT

The needs are especially acute for low-income families who use public health services, like Medicaid.

Because current government reimbursements typically don’t even cover expenses for dental visits, dentists are reluctant to see clients on public health care systems.

While many dentists donate services and volunteer for special one-day dental care visits for those who can’t afford it, that doesn’t replace access to regular dental care.

The Rice Regional Dental Clinic in Willmar, which is a collaboration between Rice Memorial Hospital and the University of Minnesota School of Dentistry, brings dental students out of the metro area to provide services to low-income families in rural communities.

The clinic also exposes dental students to life in west central Minnesota in hopes of enticing them to move here when they graduate.

There is a push to create incentives, like student loan forgiveness or subsidizing office costs, to bring new dentists to the region.

Another avenue is for local dentists to offer jobshadowing experiences to local high school students to create a source of homegrown future dentists who may return home when done with school.

Personal responsibility is another key factor in good dental care. Brushing two times a day, flossing, limiting sweets and regular dental visits can prevent oral diseases that are painful and expensive to treat.

IMPACT | 29

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Q&A

James Zenk Dentist, Montevideo

Q. How has dentistry evolved in the past 25 years in west central Minnesota?

A. Use of technology has been the greatest change in my past 38 years of practicing dentistry in Montevideo. We started with paper charts, chemically processing X-rays and gooey impressions. Today we have computers in every operatory, digital X-rays for immediate viewing and digital impressions and 3D printing and fabrication of our dental restorations. Dental materials have improved for longevity, ease of use and esthetics.

Tele-dentistry is in its infancy. Oral pathology, difficult cases for oral surgery, root canals, etc., can be safely transmitted through secure email with pictures taken on intraoral cameras in our office. Skype, facetime, texts – real-time communication – can happen for the patient and practitioner.

Many of the dentists in our area are aging and will be retiring in the next five years. The challenge is, who will be there to replace them?

I have watched many area dentists in several small surrounding towns not able to sell or hand over their practices to the next generation and have just closed the doors.

Q. What are the rewards of practicing dentistry in rural Minnesota?

A. The main reason I enjoy practicing dentistry in a rural farming community is the ability to build relationships and interact with my patients beyond their dental appointments. I see my patients at community functions, church, sporting activities, concerts, shopping, serving on boards and service organizations.

Q. What are the challenges for patients needing dental care in small towns, including those who qualify for public services?

A. There is a shortage of dentists willing and wanting to practice in rural Minnesota. Because of the poor reimbursement rates for dentists, a large percentage of our population on public care insurance programs can’t see a dentist.

The current reimbursement rate pays 30 cents on the dollar. It doesn’t even cover our expenses. Minnesota ranks 49 out of 50 states for the lowest Medicaid reimbursements rates for our pediatric patients. This is a barrier that has to change.

Dentists volunteer for programs like “Give Kids a Smile” and “Mission of Mercy” events, donate dental services, accept Medicaid patients and provide free education about preventive dentistry at schools and nursing homes. But volunteer programs only go so far. We need a state dental program that works for all patients.

Q. What changes will dentistry see in the next decade?

A. Most of our area dental offices are solo practices or small groups, but 50 percent of dental grads currently seek employment in large group settings.

Technology is here and it is expensive. Given the economy of scale, it’s easier for several dentists to group together to afford the latest technology that is needed provide the very best for our patients.

Dr. James Zenk Dental students graduate with an average debt of $257,000 and students are hesitant to buy a practice from a retiring dentist. Dentists need to think years ahead for their retirement and invite a new grad to associate as an employee with the option to buy as an owner over time

Q. What are proactive steps communities can take to bring a new generation of dentists to rural Minnesota?

A. Home-grow the next dentist for your town with mentorship, career days in schools and job shadowing opportunities. Identify the best and brightest young students and start a dialogue about dentistry and the profession.

Dental schools should admit more students from rural Minnesota, who are more likely to return home to work. Dental schools have started programs for rural dentistry and have invited rural dentists to talk to dental students and their spouses about practicing in a rural setting.

Some communities offer incentives like loan forgiveness, scholarships, office locations to entice dentists to practice in rural Minnesota.

Dr. James Zenk has been a dentist in Montevideo since 1981 and provides services at the Rice Regional Dental Clinic in Willmar. He has served on the West Central District Dental Society, Minnesota Dental Association and American Dental Association and was the recipient of the 2018 Minnesota Dental Association’s Guest of Honor award.

IMPACT | 31

Fast FACTS DENTAL HEALTH

The number of licensed oral health providers currently working in Minnesota: ▶ 3,377 dentists ▶ 4,698 dental hygienists ▶ 6,373 dental assistants ▶ 64 dental therapists

The overall dentist to population ratio is 1 dentist per 1,641 Minnesotans. ▶ 1 dentist per 1,601 urban residents ▶ 1 dentist per 2,153 micropolitan or large rural city residents ▶ 1 dentist per 2,272 small town or small rural city residents ▶ 1 dentist per 3,938 rural or isolated city residents

Age of dentists: ▶ The median age of Minnesota dentists is 49, compared to the median age of 41 for the Minnesota workforce. ▶ The highest percentage of dentists are 55-64. ▶ Nearly one-fourth of the state’s dentists plan to stop practicing within five years.

Adult dental visits: ▶ 74.3 percent of Minnesota adults ages 18 and older report having had at least one dental visit in the past year. ▶ 36.8 percent of Minnesota adults ages 21 and older enrolled in a Minnesota Health Care Program (Medicaid) received at least one past-year dental service.

Dental insurance: People with dental insurance are more likely to use preventive and other dental services. ▶ 26.6 percent of Minnesotans are without dental insurance. ▶ 12.1 percent of Minnesotans have forgone dental care within the past year due to cost. ▶ 2.5 percent of Minnesotans reported having problems accessing a dentist within the past year.

Children dental visits: ▶ 76 percent of Minnesota children ages 1 to 17 years have had at least one pastyear dental visit as reported by their parent or guardian. ▶ 29 percent of Minnesota children ages 1 to 20 years enrolled in a Minnesota Health Care Program (Medicaid) received at least one past-year dental service.

Source: Minnesota Department of Health 32 | IMPACT

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IMPACT | 35

PUBLIC Health

Building healthier communities today for a better tomorrow Health isn’t only an individual matter, it can impact the entire community.

A healthy community is a more productive community.

Kandiyohi County Public Health and county public health departments across the state play an important role in creating healthy communities with a vast array 36 | IMPACT

of programs and services to help individuals and families to live healthier lives.

Early family care, as well as prenatal and postpartum home visits can help mothers and young families get a good start on life, while nutritional programs like the Women, Infant and Child Food and Nutrition Service can assist in forming a healthy foundation for both

mothers and children. Public health departments also help families with issues such as breastfeeding education, mental health and even lice education.

Senior citizens can get public health assistance with finding the right home care provider to help them stay in their homes and communities longer.

Public health can also be a good resource to learn more about healthy aging.

Public health vaccination clinics, both at the public health offices as well as at workplaces, can keep thousands of people free from illness and disease.

Public health provides immunizations for children and adults, covering many of the typical vaccinations needed. Public health also has vaccination programs, along with health screenings, for immigrants and refugees. Education outreach is an important part of the vaccination process, to help spread the word about how important it is to get vaccinated, not just for oneself, but the community overall.

Public health is also concerned with making sure the community’s environment – from restaurants and lodging facilities to the air itself – is clean and healthy. In partnership with the Minnesota Department of Health, public health offices across the region license local food establishments, pools and lodging facilities. They also assists with any foodborne illness investigations.

Radon, safe drinking water and food safety are other environmental health issues public health departments are concerned about.

Another organization focused on healthy communities is the Statewide Health Improvement Partnership. Created in 2006, there are SHIP programs

throughout Minnesota. SHIP’s goal is to create healthier communities by increasing access and opportunities for active living, healthy eating and tobacco-free living.

The Kandiyohi-Renville County SHIP program has assisted with a wide variety of programs and opportunities in child care and schools, helping cities plan for more active living in their communities and offering a helping hand to get community gardens planted.

With organizations like county public health services, SHIP and others, the communities we live, work and play in can be healthy communities and help everyone live a more active and healthier life.

IMPACT | 37

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Q&A

Leah Schueler and Kristin Anderson Kandiyohi and Renville County Statewide Health Improvement Partnership coordinators Q. What is the Statewide Health Improvement Partnership?

A. SHIP is working to create healthier communities across Minnesota by expanding opportunities for active living, healthy eating and tobacco-free living.

Good health is created where we live, work, learn and play.

Schools, businesses, apartment owners/managers, farmers, community groups, senior organizations, hospitals, clinics, planning entities, Chambers of Commerce, faith communities and many more partners are creating better health together through SHIP all across Minnesota.

SHIP, at its core, is a locally driven effort. Communities choose strategies that are based on the latest science and focused on making long-term, sustainable changes in schools and child care facilities, communities, workplaces and health care settings.

Q. Why was the SHIP program started?

A. In 2008, Minnesota lawmakers recognized that controlling health care costs would require more than just changes in medical care – additional investments in prevention were needed.

With bipartisan support in the Legislature, Minnesota passed a groundbreaking health reform law. A key component of that reform was to create SHIP, which invests in preventing chronic diseases before they start.

SHIP has been instrumental in helping Minnesota keep obesity rates relatively flat and reduce commercial tobacco use and secondhand smoke exposure, factors that contribute to chronic diseases, rising health care costs, disability and death.

Q. What health issues has SHIP focused on in Kandiyohi and Renville counties?

A. Healthy food access and physical activity in our communities, schools and workplaces, and tobacco prevention and control.

Since the SHIP funding round beginning in 2014, SHIP has annually partnered with 30-plus institutions and organizations ranging from schools, to cities, to grocery stores, to fruit and vegetable farms, to counties, to child care centers, to work sites, to health care centers, to food shelves, to convenience stores, and more.

SHIP has invested in partnerships supporting healthy food access, for example providing technical assistance to and grant dollars for: the purchase of three coolers to food shelves (Kandiyohi County Food Shelf, the Link, Renville County Food Shelf); the creation and expansion of a nonprofit fruit and vegetable farm in Olivia, leveraging dollars to pay a farmer and summer workers, creating access to the public and delivering to schools, hospitals, senior care center and grocery stores; and a cooler, technical assistance (training for produce manager on how to keep vegetables fresher longer), food processing equipment for Island Market grocery store in Bird Island.

SHIP has invested in partnerships supporting active living, for example providing technical assistance to and grant dollars for biking and hiking infrastructure in the city of Willmar and Kandiyohi County; walking

Leah Schueler, left, and Kristin Anderson facilities in Raymond (purchasing a flashing pedestrian sign, allowing for safer highway crossing and supporting safe routes to schools).

SHIP has also funded four breastfeeding rooms in workplaces and at county fairgrounds; supported seven county policies aimed at reducing youth access and exposure to tobacco; and supported healthy eating and active school days in 10 local schools.

Q. Are there still challenges you are focusing on?

A. Challenges include reframing our definitions of and understandings of health. So instead of thinking of health as mostly disease and treating disease, we are contributing to refined public understanding of what creates health. That is, 90 percent of health begins where we work, live and play. Our opportunities to create and influence health begin far before the onset of illness or disease. When we see health this way – we can engage in partnership across sectors to build and influence health (in worksites, in bike lanes, in parks, in schools, in grocery stores, in food shelves, on our sidewalks, on walking paths, etc.)

Q. Why is it important there are programs like SHIP available?

A. It is important that we address pressing health concerns through prevention and creating better and more equitable conditions for health in our communities.

In addition to impacting the environment and policies, SHIPs investment in healthy communities has supported economic development. Economic development matters because without businesses, vibrancy starts to fade in our small towns.

IMPACT | 39

Q&A

Ann Stehn Kandiyohi County Public Health director

Q. What is the mission of Kandiyohi County Public Health?

A. Kandiyohi County Public Health leads efforts to prevent illness, disease and injury; promote healthy and safe neighborhoods; and protect and enhance the well-being of those who live, work, learn and play in our communities.

Q. Why is it important for public health to exist?

A. When people think about health, they often think about health care and hospitals and clinics. Public health works at the community level to improve health. Safe water, immunizations, tobacco prevention, active living, food safety, access to healthy food, and disease prevention and control are all examples of public health activities. Public health focuses on improving and protecting community health and well-being, with an emphasis on prevention.

Q. Public health departments run several programs for families and young children. Why? A. Much of public health practice is prevention-oriented and based on scientific research. Our prenatal, postpartum and early family home visiting programs are designed to improve the health of mothers and their families, reduce injury and illness, improve readiness for school, increase financial stability/independence and improve parenting and family interactions. We invest in these programs because research has shown their effectiveness in achieving outcomes that improve health and wellbeing. Many public health prevention programs have been shown to have a return on investment for every dollar spent, ranging from $3 to $5 depending on the program.

Q. How does public health assist the senior population?

A. Public health nurses work with our human services staff in the area of home and community-based services. Our staff provide assessment and assistance in locating the resources necessary for people to live independently in the community for as long as possible while still meeting their health and safety needs. Public health also provides general information and referral for a wide variety of services and supports in our community for healthy aging.

Q. Kandiyohi County has a significant immigrant and refugee population. Are there programs and services to assist them?

A. Public health serves people in the process of immigrating, becoming a citizen, or that have refugee status with a variety of services. Most of the services surround immunizations, health screenings, and required refugee health exams (for those new to our country). This work is a part of the essential public health function of disease prevention and control.

They may also be participating in other programs for which they qualify such as Women, Infants and Children and family home visiting.

Q. What else do public health staff do that people might be surprised by and why does it fall underneath the public health umbrella?

A. Many people don’t realize that we have registered sanitarians as a part of our staff and a delegation agreement with the Minnesota Department 40 | IMPACT

Ann Stehn

of Health to license food establishments, pools and lodging facilities. This service is important to our community. We emphasize a preventative, educational approach with our license holders and can be responsive to any business changes or concerns that are reported. We also assist the Minnesota Department of Health with foodborne illness investigations.

Q. How important is it for people to live in a healthy environment and how do public health offices assist with that?

A. Maintaining a healthy environment is critical for our quality of life and years of healthy life. Healthy and safe air, water, soil, and food are central to our well-being. Our built environment, such as roads, parks and community infrastructure, also have an impact on health. Kandiyohi County Public health works on a wide variety of environmental health issues such as lead, radon, safe drinking water, food safety, healthy living, and public health nuisances that may exist in the community.

Q. What successes has Kandiyohi County Public Health had?

A. Kandiyohi County has a strong public health history. We provide a variety of quality services such as WIC and family home visiting as well as work at the individual and community level to support healthy behaviors and community change. We have been successful in decreasing tobacco use and exposure to secondhand smoke, maintaining high immunization rates, planning for public health emergencies, and responding to infectious disease in our community.

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Fast FACTS KANDIYOHI COUNTY PUBLIC HEALTH

Kandiyohi County Public Health activity in 2016:

▶ 139 prenatal visits to 45 clients and 206 visits to postpartum clients. ▶ On average 1,656 participants used the Women, Infants and Children Food and Nutrition Service per month. ▶ Public Health immunized 516 people with 1,163 doses of vaccine. ▶ 1,059 doses of seasonal flu vaccinations were administered at 26 worksite clinics.

The Kandiyohi-Renville Community Health Board licensed 292 food, pool and lodging establishments in 2016, while completing 411 inspections.

The prescription drug takeback program, started in 2011, has collected nearly 11,000 pounds of unwanted prescription and over-the-counter drugs.

Kandiyohi County spent approximately $53.17 per person on Public Health expenditures in 2016.

SHIP distributed $37,733 to 32 partners and leveraged $2,564,500 in additional funding in the communities in 2016.

The Kandiyohi and Renville County Statewide Health Improvement Program purchased refrigeration for the Willmar Area Food Shelf, established the Willmar Bikes bicycle and pedestrian education and advocacy group and received a bike fleet from the Minnesota Department of Transportation for school use.

Source: Kandiyohi County Health and Human Services 2016 Public Health annual report

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MENTAL Health

Stigma, availability of services hinder treatment options One in every five Minnesotans will have some sort of mental health condition each year, that’s according to the Minnesota Department of Human Services.

That is an estimated 1.1 million people annually.

The conditions and causes of those mental health issues vary greatly. Mental health conditions can be anything from depression and post-traumatic stress disorder to bipolar disorder and schizophrenia. Mental health illnesses can also be caused by drug abuse.

While some people may be predisposed to mental 46 | IMPACT

health conditions because of genetics, environment and family history, mental health illnesses can also be caused by biological, psychological and environmental factors.

Young and old can be impacted by mental health conditions.

The National Institute of Mental Health said more than half of chronic mental health conditions begin by the age of 14, with three-quarters starting by age 24.

On the other end of the aging spectrum, the National

Council on Aging reports one in four older adults will suffer from a mental health illness. By 2030 this number could be close to 15 million people.

One area where mental health is of growing concern is in the nation’s jails. The National Alliance on Mental Illness reports that 15 percent of men and 30 percent of women in jail have a serious mental health condition.

That is nearly 2 million people nationwide. It is an issue that has not escaped rural areas in greater Minnesota.

Most mental health conditions can be treated with therapy, medication or a combination of both.

Unfortunately, due to the lack of services and a stigma against admitting a person has a mental health illness, many people go without treatment. This can be especially difficult for law enforcement officers, who often find themselves having people convicted to a jail sentence when they may need mental health services and treatment instead of incarceration.

Organizations like Woodland Centers in Willmar is one of a dwindling number of places people can find the services and treatment they need in greater

Minnesota. The rural regions of the state have been impacted by the closings over the years of regional treatment centers and state hospitals.

Woodland Centers offers a wide range of services and treatments including outpatient and inpatient services, residential detoxification, mobile crisis services and therapy for children, adults, families and groups.

While the stigma surrounding mental health is improving, there is still much to be done.

Loved ones of those suffering from a mental health condition can help, by offering their support, educating themselves and sharing the important message that

the illness is treatable.

Ashley Kjos, CEO of Woodland Centers, said that as long as people are still wary of sharing their suffering, there is work to be done. “Once a person with depression, anxiety or schizophrenia can talk openly about his or her symptoms without fear of judgement, rejection or negative consequences, as is the case with other health conditions (heart disease, diabetes, cancer), then we as a society will know that we have reached a significant reduction in the stigma surrounding mental health,�

Kjos said.

IMPACT | 47

Q&A

Ashley Kjos Woodland Centers, CEO

Q. What is mental health and what kind of illnesses or disorders can be considered under that description?

A. Mental health diagnoses are conditions that affect one’s emotional, psychological, and social well-being. It affects how we think, feel and act. It also helps determine how we handle stress, relate to others and make choices.

Examples are schizophrenia, depression, anxiety, intellectual disabilities and disorders due to drug abuse. Most of these disorders can be successfully treated with medication and/or therapy.

Q. What can cause someone to suffer from a mental health illness?

A. Many factors contribute to mental health including biological, psychological and environmental factors. Biological factors include one’s genetics, brain chemistry and brain injuries. Psychological factors that contribute to mental illness include witnessing or experiencing trauma or abuse, loss and grief, neglect, and lack of ability to relate to others in a healthy way. Finally, environmental factors also contribute to mental illness. These factors include various life stressors such as divorce, death of a loved one and family history of substance abuse or mental health problems.

Q. Is there one disorder over others that Woodland Centers sees the most of?

A. Depression continues to be the leading mental health disorder treated at Woodland Centers. In 2017 Woodland Centers served 5,367 individuals of which 36 percent were experiencing depression.

The next leading mental health condition is an adjustment disorder (19 percent of all clients seen in 2017) followed by anxiety disorders (16 percent of all clients seen in 2017).

Q. Is the stigma surrounding mental health getting better?

A. The stigma surrounding mental health continues to be a challenge but it has improved. We are seeing more people receive services than ever before.

It is becoming common knowledge that we cannot address a person’s health without addressing mental health – the body and mind are connected and need to be addressed as one, not separately.

Stigma still exists and prevents many from getting the help they desperately need.

Once a person with a mental health condition can openly talk about his or her symptoms without fear of judgment, rejection or negative consequences, as is the case with other health conditions, then we as a society will know that we have reached a significant reduction in the stigma surrounding mental health.

Q. What can friends and family do to help if a loved one is suffering from a mental health problem?

A. The support of friends and family when managing a mental health problem is vital to recovery. An individual’s support system can be the influencing factor that assists someone in initiating and progressing through treatment.

Friends and family members can assist by reaching out and letting the person know they are available to help, even if that just means listening.

Sharing the message that mental illness is common and very treatable is vital.

48 | IMPACT

Dr. Ashley Kjos Everyone is touched by mental illness, either personally or through a friend or family member. Mental health knows no limits based on age, gender, race, ethnicity, socioeconomic status, etc.

Q. Should mental health be considered a public health issue?

A. Mental health is a public health issue. Health care providers, legislators and government officials need to recognize the importance of providing highquality prevention and treatment of mental health conditions in order to assist individuals in getting back on track in their lives and assist our culture in being overall healthy which will equate to an improved economy.

It is also vital that mental health providers receive adequate payment for services provided. Insurance companies and government officials need to ensure that the billing rates provided to mental health providers are sustainable and are equivalent to other health care rates provided to physical health providers.

Q. What do you think the future of mental health treatment looks like?

A. The future of mental health treatment will focus on integrating primary care and mental health care so that individuals are able to access all the services needed for whole health.

We are facing a shortage of mental health professionals including psychiatrists and licensed counselors in our country which has limited our ability to serve individuals as needed. As the stigma diminishes and more people seek out needed treatment, more young people will be needed to enter into this field which will mean that assistance with student loans, better pay for individuals working in this field, and improved working conditions need to be achieved to draw people into this line of work.

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Q&A

Scott Hable Renville County Sheriff

Q. How big of a challenge is mental health in inmates at the jail?

A. Mental illnesses among inmates in our jails is not a new issue.

However, as we begin to recognize various mental illnesses and understand more about them, we face increased challenges in providing appropriate treatment and care of the inmates.

For various reasons, more and more people are being diagnosed with mental illnesses, many of which are being medicated.

Statistically, inmates in a jail are more likely to be on a psychotropic medication than others in our society (non-incarcerated).

Q. What steps does the Sheriff’s Office follow if there is an inmate or a member of the public going through a mental health crisis?

A. Our unwavering priority is the safety of the public. Once any public safety concern is addressed, our focus then becomes getting the mentally ill subject to an appropriate place where help is available. In the jail, that might mean that an inmate is segregated from the general jail population and seen by our jail’s psychologist.

If in the public, that might mean having the subject seen at a hospital for an examination and evaluation. In both cases, help is available in varying forms, including therapy, medications, etc.

Q. In your opinion is the state doing enough to help law enforcement and jails meet the mental health needs of inmates?

A. No. The “system” we have in place today with regard to mentally ill inmates in jail is broken and grossly inadequate.

When a crime is committed, the suspect is oftentimes both chemically dependent and mentally ill. Using today’s “system,” that person is brought to jail and, in many jails, “warehoused” in a cell to wait for a court date.

Once convicted, they serve a jail sentence.

If that offender is chemically dependent, he or she can receive chemical dependency treatment only after being released from jail. Then, if that offender is also mentally ill, he or she can receive treatment for mental illness only after their jail stay and chemical dependency treatment, or vice versa.

Unfortunately, many of those people end up back in jail before receiving the appropriate treatments and, thus, the process restarts. We have virtual silos in place for chemical dependency, mental illness and criminality. With the current, broken modality, offenders must complete their time in jail or treatment in one silo before moving to the next.

Q. What should be done to fix the system?

A. Create a system where these virtual silos are taken down. If offenders are incarcerated, then the system needs to allow both chemical dependency treatment and treatment for mental health issues right in the jail, which can occur simultaneously. Today, the Renville County Jail provides chemical dependency treatment right in the jail but, although we can identify various mental illnesses, we have no mechanism or funding for effectively treating many of those mental illnesses.

Sheriff Scott Hable Q. Why is mental health something law enforcement can no longer ignore?

A. Unfortunately, because of factors like the closing of regional treatment centers across Minnesota, when there is no place to adequately treat people with acute mental health issues, they oftentimes end up in jail. The “system” (referred to above) then begins its very broken cycle.

The “system” in place today puts much of the burden and cost of housing or otherwise caring for the mentally ill on county jails. Given the proper funding from the state, significant advancements could be made in taking down the virtual silos that exist in our current model.

Q. Being a sheriff’s deputy can be a very difficult job, both physically and emotionally. How does the Sheriff’s Office assist with employees who need counseling or other mental health help?

A. Renville County offers all of its employees access to mental health professionals for any issues or concerns, whether work-related or not, through its Employee Assistance Program.

Like many other emergency services agencies (police, fire, EMS), the Renville County Sheriff’s Office has access to and occasionally uses a Critical Incident Stress Debriefing as a tool to cope with difficult calls.

Additionally, our employees also have access to the above-mentioned Employee Assistance Program.

IMPACT | 51

Fast FACTS MENTAL HEALTH

1 in 5 Minnesotans face mental illness each year.

1 in 25 people have a serious mental illness like bipolar disorder or schizophrenia.

1 in 10 young people have experienced a period of major depression

Source: Minnesota Department of Human Services

One half of all chronic mental health illness begins by the age of 14, threequarters by age 24.

About 24 percent of state prisoners have a history of mental health conditions.

90 percent of those who die by suicide had an underlying mental illness.

Source: National Institute of Mental Health

2 million people with mental illness are booked into jails each year.

15 percent of men and 30 percent of women booked in jails have a serious mental health condition.

Nearly one in four police officers have thoughts of suicide at one point in their life.

The suicide rate for police officers is four times higher than for firefighters.

More police officers die by suicide than in the line of duty. There were 140 law enforcement suicides in 2017.

Law enforcement reports a higher rates of depression, posttraumatic stress disorder, burnout and other anxiety-related mental health conditions.

Source: National Alliance on Mental Illness

In 2016 Minnesota had a total of 194 mental health beds in state hospitals available. That comes out to 3.5 beds for every 100,000 people.

In 2010 Minnesota had 206 mental health beds in state hospitals, 3.9 beds per 100,000 population.

Source: Treatment Advocacy Center 54 | IMPACT

COMPLEMENTARY Health

Care

Growing trend mixes alternative and mainstream care

Most people are familiar with mainstream western medicine.

You get sick or injured and you go to the doctor for prescription medications, surgery, stitches or chemotherapy – to name just a few of the many science-based and research-proven practices used in medicine today.

But before there were well-equipped clinics and hospitals and trained medical professionals, people 56 | IMPACT

relied on homegrown remedies, plant-based beverages or poultices, midwives, diet, exercise, massage, meditation and earnest prayers to a higher spirit to cure illnesses and to preserve good health.

Some of those early cures and practices were steeped in the traditions of cultures from around the world and plants and herbs that grew where people lived were used to treat ailments.

While sharing the same goal of healing – and

sometimes sharing the same plant-based substances used to treat illness – “alternative” medicine and modern medicine are often at odds with each other.

The relationship gets especially complicated when “alternative” care is chosen instead of mainstream medicine.

But there appears to be a growing trend now to use some types of alternative care together with mainstream medicine in a practice called “complementary” care or “integrative” care.

According to findings from the National Center for Complementary and Integrative Health and the National Center for Health Statistics, which is part of the Centers for Disease Control and Prevention, a 2007 National Health Interview Survey shows that

about 38 percent of adults and 12 percent of children in the United States use some form of complementary and alternative medicine, such as natural products and deep breathing.

Mainstream medical facilities, including the Willmar Regional Cancer Center, are incorporating some

complementary care practices to provide comfort to patients and to supplement their mainstream medical treatments.

It may be a trend that will continue to grow as medical professionals and patients explore the marriage of old and new medical practices.

IMPACT | 57

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Q&A

Lisa McBrian and Juliana Neumann Complementary Care

Q. What is “complementary” therapy and what are the most common types of therapies?

A. Complementary therapy, also referred to as “integrative therapy,” are therapies that are not part of mainstream medicine but are used in combination with current medical practices.

Some examples of complementary therapies include acupuncture, aromatherapy, massage, meditation, music therapy and pet therapy. These therapies are not meant to take the place of modern medicine but instead are used to complement medical care.

Q. What are some of the potential benefits of complementary therapies?

A. Complementary medicine has been shown to provide many benefits including: lessen pain, relieve nausea, improve fatigue, decrease anxiety and depression, and improve sleep.

Q. What are the types of complementary therapies provided at the Willmar Regional Cancer Center?

A. At the Willmar Regional Cancer Center, we provide pet therapy and aromatherapy. The pet therapy is done weekly in conjunction with Rice Hospice using the volunteers and therapy dogs that have completed the Rice Hospice Pet Therapy training.

Aromatherapy is done using patches containing a controlled amount of 100 percent pure essential oils.

These patches are applied to the upper chest either on clothing or skin. The aromatherapy is inhaled via normal breathing. Because we know not all people embrace the concept of aromatherapy, we chose to use the patch method of delivery so other patients would not be affected.

Q. How is aromatherapy used at the Willmar Regional Cancer Center and what has been the response from patients?

A. Patients undergoing cancer treatments are often tired of taking pills and undergoing procedures. Aromatherapy is introduced to these patients to assist with alleviating symptoms or side effects they have without having to take a pill or undergo a procedure.

The most common symptoms we use aromatherapy for are nausea, pain, anxiety and insomnia. Because many patients are not familiar with the concept of aromatherapy and what it is used for, they are sometimes reluctant. With an explanation of what it is and how it works, most patients are open to trying it when it is offered, and many are pleasantly surprised with the result. The aromatherapy chosen is based on each individual patient’s needs. A quick assessment with a registered nurse is completed and then the appropriate aromatherapy is selected. A reassessment of symptoms is then done, to ensure the right aromatherapy treatment has been chosen.

Q. How is pet therapy used by the Willmar Regional Cancer Center and what has been the response from patients?

A. One day a week volunteers with their therapy dogs visit the main lobby and chemotherapy areas giving patients the opportunity to interact with

Lisa McBrian, left, and Juliana Neumann the dogs. Patients are allowed to pet the dogs if they want to. Sometimes just the presence of a dog is all that is needed. Cancer patients are often very stressed and anxious if they are waiting for scan results or anticipating starting a new treatment, and when the dogs arrive, you can see the patients relax as they engage with the dogs. The therapy is optional and volunteers are very aware and have learned to sense if a patient seems interested in engaging with the dogs.

Q. What has been the response from the rest of the regional medical community regarding the use and benefits of complementary therapies?

A. In the past, complementary medicine was something patients tried on their own and were often reluctant to talk to their primary care providers about. Today that is changing. More and more providers are seeing the positive effects complementary therapy can have when used in conjunction with traditional medicine. The biggest barrier for patients to using complementary therapies is cost. Most insurance companies don’t cover these therapies so they are an out of pocket cost to patients.

Q. What is the future for complementary therapies?

A. The hope is, as research shows more and more how beneficial complementary therapies are, insurance companies will begin covering these services so they are accessible to more patients. The belief is that if people were able to use therapies such as these more, the overall cost of health care would be less because less medications and procedures would be needed.

Lisa McBrian and Juliana Neumann are Registered Nurses and Care Coordinators at the Willmar Regional Cancer Center. Affiliated with the Virginia Piper Cancer Institute, the center is located in the Rice Memorial Hospital building.

IMPACT | 59

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Opportunities in the following positions: • Physicians (Various Specialties) • Staff Nurse • Advanced Practice Registered Nurse • Licensed Practical Nurse • Nursing Assistant • Housekeeping Aids (Veterans Only)

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60 | IMPACT

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Located sixty-five miles northwest of the twin cities of Minneapolis and St. Paul, the City of St. Cloud and adjoining communities have a population of more than 100,000 people. The area is one of the fastest growing areas in Minnesota, and serves as the regional center for education and medicine.

Enjoy a superb quality of life here— nearly 100 area parks; sparkling lakes; the Mississippi River; friendly, safe cities and neighborhoods; hundreds of restaurants and shops; a vibrant and thriving medical community; a wide variety of recreational, cultural and educational opportunities; a refreshing four-season climate; a reasonable cost of living; and a robust regional economy!

Fast FACTS COMPLEMENTARY CARE Complementary and integrative medicine is used together with conventional medicine.

Alternative medicine is used in place of conventional medicine.

CAM is a term used to refer to complementary and alternative medicine

Most popular CAM therapies include ▶ Non-vitamin, non-mineral natural products are used by nearly 18 percent of individuals using CAM ▶ Deep-breathing exercises: nearly 11 percent ▶ Yoga, tai chi or qi gong: 10.1 percent

Most popular CAM therapies continued ▶ Chiropractic or osteopathic manipulation: 8.4 percent ▶ Meditation: 8 percent ▶ Massage: 6.9 percent ▶ Special diets: 3 percent ▶ Homeopathy: 2.2 percent ▶ Progressive relaxation: 2.1 percent ▶ Guided imagery: 1.7 percent

Who uses CAM? ▶ About 38 percent of adults in the United States use CAM ▶ About 12 percent of children use some form of CAM

Findings from the National Center for Complementary and Integrative Health and the National Center for Health Statistics (part of the Centers for Disease Control and Prevention) taken from a 2007 National Health Interview Survey.

IMPACT | 61

Health Care TECHNOLOGY Technological advances in health care improve patient care

Technological advancements large and small have been a consistent part of the practice of medicine all the way back to its beginning.

Some things have remained much the same for years, like the trusty stethoscope, while others have seen frequent advances, said Dr. Kenneth Flowe, head of emergency medicine at Rice Hospital in Willmar.

Through the years, advances in surgery, cancer treatment and radiation therapy have aided physicians in improving outcomes and recovery time for their patients.

62 | IMPACT

The interaction with technology begins for patients when they enter most any medical facility. An electronic medical records system is used to register them when they check in.

A physician most likely consults electronic medical records, not the manila folder filled with a stack of reports on paper.

Technology has advanced in ways that have improved patient outcomes and increased efficiency. They have also made physicians’ lives easier in some ways.

Medical testing can be done more accurately, and

results come back faster.

Advancements have brought better surgical techniques, like laparoscopy and now the Da Vinci Xi robotic surgical system. The new UroNav uses an MRI to help pinpoint prostate biopsies.

Many types of imaging can be used to help in diagnosis and treatment, from X-ray to ultrasound to CT scans to MRIs to PET (positron emission tomography) scans. The imaging can be used to help target surgery or radiation therapy. Advancements over time have reduced the amount of patients’ radiation exposure.

The Da Vinci robot helps patients and doctors, Flowe said. The robot is more flexible than a laparoscope, so a surgeon has a better 3D view of any scarring or adhesions in a person’s abdomen, for example. Incisions are smaller, so patients heal faster, too.

And doctors’ backs get a break, so it could extend a surgeon’s career.

Rather than bend over an operating table, surgeons sit at a console in the operating room and manipulate the instruments held by the robot.

New technology can be costly, but in the long run it can improve lives and even save money, Flowe said.

The challenge for each facility is to work to find better ways to practice and still remain financially viable, he added.

IMPACT | 63

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Q&A

Thomas Lange Rice Memorial Hospital, surgeon

Q. How have advances in technology changed your practice over time?

A. One thing that has helped me is electronic medical records.

That has helped me because I can get a patient’s information so much easier. We used to have a different paper chart for the patient, and one in the clinic, and every place that they went to.

Now a lot of surrounding clinics are on Epic (software system), so I can get a lot of that information a lot easier. I think that gives better patient care. It’s much easier for my job. I think it makes for more accurate care, too.

The other one that has really helped me is being able to see digitized MRIs, ultrasound, etc. All of that I can pull up on my laptop from an outside hospital, if they’re in our network. I get a call from hospital, “I’ve got a patient here, can you look at the CAT scan?” I can look at all the images and talk to them on the phone at the same time.

Q. What would you call the most important technological advancement in recent years?

A. Genetic testing has been a big deal. It’s helped identify patients that might be higher risk for certain types of health issues, breast cancer, colon cancer. It can change how often they are screened.

It helps a woman making a decision on what type of surgery she wants for breast cancer, if she’s positive for one of the breast cancer genes. It helps with treatment afterwards, sometimes they can identify which breast cancers will respond to certain treatments better. I think it’s going to change lots of things in the future.

Q. What type of additional training have you sought to use new equipment that has become available?

A. I really enjoy working with the (Da Vinci Xi surgical system) robot. It helps me do laparoscopy but better – better visualization, more range of motion to it, easier to suture. It’s easier to do my job, and I think I can do a better job on some of the surgeries with it. Da Vinci has training on models, then animal training, cadaver training. I’ve watched a lot of surgeries at other places. There’s a good online education for that through American College of Surgeons, the colorectal society and DaVinci themselves. The Da Vinci device itself has a software simulator on it. So you can do a lot of practicing on the device. It’s just a computer program, and it’s really good for practicing suturing and using different controls. You really have done a lot of them before you work on patients. You are controlling the whole thing. The robot doesn’t do anything on its own; it’s all under our control. I am literally 5 or 10 feet from the patient.

Q. What are some ways that technology has improved health care and patient outcomes over time?

A. With the robot, recovery time is supposed be less. There are varying things with that. It seems like people get out of the hospital a lot quicker.

Used to be standard that after an open colon surgery, people would be in the hospital five days. Most of the time if I do a colon resection with the robot, it’s two or three days before they get out of the hospital. With smaller incisions, people seem to recover quicker from it.

Dr. Thomas Lange, general surgeon, shows a video of a MRI, magnetic resonance imaging, machine to Willmar Senior High students.

Q. How do you and your facility evaluate new equipment when deciding whether to use it?

A. A lot of times, we go to different conferences. I go to the Mayo Clinic conference every year for general surgery. These are experts from all over the world they bring in, so you can see what they’ve been using. Then you read papers on it and go watch a case. It’s a leap of faith to see if it makes sense to do it.

When we got the robot here, there were physicians who were against this because this is not the way to do it. It’s expensive, and there’s no benefit to the patients. The same thing was argued about laparoscopy. What’s the standard of care now for taking out a gallbladder – it’s laparoscopy.

I give credit to the hospital. They were the ones that encouraged us to do it. I didn’t think about doing it, because I thought it was too expensive.

Pretty much all the OB-GYNs and general surgeons that come out now are trained on a robot. If you don’t have that and you’re trying to recruit someone out of residency, good luck. You’re not going to have success with that.

Dr. Thomas Lange, a surgeon, has practiced at Rice Memorial Hospital for 17 years.

IMPACT | 65

Q&A

Tod W. Speer Willmar Regional Cancer Center, radiation oncologist and medical director

Q. How have advances in technology changed your practice over time?

A. Broadly speaking, the major advances in radiation oncology have resulted in more effective and safer treatments. These milestones have come to fruition as a result of improved imaging of tumors and the more accurate delivery of radiation treatments.

Q. What would you call the most important technological advancement in recent years?

A. Although there have been many technological advancements in the field of radiation oncology, two major technologies have been amalgamated to make a major paradigm shift to improve outcomes and to further limit toxicity. The first major technology is image guidance (IG). IG is the utilization of imaging technology to locate the tumor or cancerous tissue prior to initiation of the radiation. Typical IG platforms consist of using ultrasound, X-rays, CT imaging or MRI. The most common form is CT imaging, which is also utilized at Willmar Regional Cancer Center. This allows the radiation treatment machine, called a linear accelerator, to deliver the radiation to the target with millimeter accuracy. The second major technology is intensity modulated radiation therapy (IMRT). IMRT represents a treatment process that shapes and pushes the radiation into irregular configurations. Subsequently, this increases the dose to the tumor and limits dose to normal tissue.

Q. What type of additional training have you sought to use new equipment that has become available?

A. The main training for these technologies consists of a focus on radiographic anatomy. As the radiation delivery becomes more accurate, so must the ability of the radiation oncologist to identify the correct target. Training seminars are available independently or available at national meetings. In my case, I previously trained resident physicians at the University of Wisconsin, Department of Human Oncology, in these techniques.

Q. What are some ways that technology has improved health care and patient outcomes over time?

A. These technologies have been instrumental in improving health care in radiation oncology. For example, many trials have shown that IMRT has increased control of disease and decreased toxicity at multiple cancer sites. A “spin-off� technology from IG and IMRT is stereotactic body radiotherapy. This technology allows the radiation oncologist to deliver a large amount of focused radiation to solitary tumors in the lung or body, not amenable to surgery. It is 85-90 percent effective. Another technology, Accuboost, allows radiation to be delivered in breast cancer 66 | IMPACT

Dr. Tod W. Speer therapy in a safer fashion, significantly reducing radiation to the lung and heart. Willmar Regional Cancer Center will be the first radiation center in Minnesota to make this technology available.

Q. How do you and your facility evaluate new equipment when deciding whether to use it?

A. The evaluation of new technologies is initiated by me as the medical director. The initial assessment analyzes the clinical benefit to our patients. We look at improved quality of care, including survival and lessening of toxicity. If this appears promising, we then assess our patient population to make sure a reasonable number of patients will be treated with and benefit from the new technology. If the potential benefit seems reasonable, the data will be presented to the Hospital Board for final approval.

Dr. Tod W. Speer, radiation oncologist and medical director at Willmar Regional Cancer Center, has practiced medicine 26 years and has been at the cancer center four years.

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Fast FACTS TECHNOLOGY IN HEALTH CARE

Up-and-coming technology advancements expected in 2018: Next generation vaccine platforms: Enables faster development and more delivery methods New targeted breast cancer therapies: Experts expect to increase survival rate and reduce chemotherapy for many patients

Further reduction of LDL (bad) cholesterol: The lower the better Further emergence of telehealth: Extends health care to patient’s home

Scalp cooling for reducing chemotherapy hair loss: A new cooling system was approved in 2017.

Enhanced recovery after surgery: New protocols to speed recovery to avoid complications and readmissions.

Hybrid closed-loop insulin delivery system: Called the world’s first artificial pancreas.

Centralized monitoring of hospital patients: Studies of this approach suggest better survival rate after cardiac arrest.

Neuromodulation to treat obstructive sleep apnea: An implant to stimulate breathing

Gene therapy for inherited retinal diseases: inserts healthy genes for use by retina

Source: Cleveland Clinic

Doctors’ growing use of technology ▶ 45 percent – U.S. doctors who routinely access clinical data from outside their offices

▶ 65 percent – Doctors who do e-prescribing ▶ 78 percent – Doctors who enter patient notes into electronic medical records

Source: King University website, Bristol, Tennessee IMPACT | 69

Willmar Senior High students look at the vision tower that is attached to the Da Vinci Xi surgical system at Rice Memorial Hospital.

Health Care EDUCATION

Abundance of health care education offered across the region West central Minnesota offers many avenues of education in health care fields. In fact, many people working in health care in the area received some or all of their training at area colleges anc clinics.

Area community colleges offer numerous technical and associate degrees in health care fields. They train nurses, emergency medical technicians, certified nursing assistants, pharmacy technologists, medical coding specialists, phlebotomists, dental assistants and many other health care workers.

70 | IMPACT

Ridgewater College is one of a group of community colleges around the state participating in a comprehensive nursing program, Minnesota Alliance for Nursing Education. It allows students to study to be a nursing assistant and stay with the school to graduate as a registered nurse with a bachelor’s degree.

Ridgewater’s program is in the top 5 in the state.

The program allows students to earn the earlier certifications and work in their field as they progress to higher degrees.

There’s a nursing care shortage at all levels.

“Really, there’s a need for everyone,” said Lynn Johnson, director of nursing at Ridgewater.

Alongside schools, clinics and hospitals in the area participate in many aspects of medical education.

Hospitals and clinics often work with students from area schools. High school students are hosted for educational tours. Students do their clinical training in hospitals, emergency rooms and clinics.

Medical students interested in practicing in rural areas work with doctors in the area to learn more about the life of a rural physician.

The University of Minnesota sends medical students to spend a couple days with practicing physicians before they start medical school.

The University of Minnesota Duluth, which has a

sharper focus on rural medicine, sends students to spend five separate weeks over an 18-month period shadowing physicians. During that time, they live with the doctors and do everything with them, including family activities.

The Rural Physician Associate Program brings medical students to rural communities for nine months.

The length of time allows them to see the continuum of care over a longer period, said Dr. Mary Amon of the Family Practice Medical Center in Willmar.

Several physicians in the area participated in Rural Physician Associate Program as students and now work with students in their practices.

IMPACT | 71

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Q&A

Pamela Ditmarson

Pamela Ditmarson, Tara Maus, Michele J Prekker, RNs

Q. What attracted you to the field of nursing?

A. Ditmarson: Experiences with caring for family members with comorbidities.

Prekker: I was attracted to nursing because of the flexibility of the career and the opportunity to pursue an area of passion and interest.

My own passion is end of life/palliative care and education. I feel as if I had a calling to nursing and all the experiences in my life were stepping stones. Nursing chose me, I think!

Q. Why did you decide to attend Ridgewater College’s nursing program?

A. Ditmarson: It allows for several areas of clinical experiences, affordability and a great educational opportunity.

Maus: The staff at Ridgewater really care. The nursing instructors want their students to succeed. It was known how hard they worked to make our education experience the best possible.

Prekker: I knew from researching it that it was a great program. I liked that the classes were smaller and there was more educator/student interaction opportunity. It was also local, which was a big plus because I was a non-traditional student caring for a family and a farm in addition to taking classes.

Q. How did you use Ridgewater’s programs on your path to becoming a registered nurse?

A. Ditmarson: I was able to step through each program which allowed me to build on knowledge and hands-on skill.

Maus: I chose Ridgewater’s MANE curriculum to obtain my associate degree which allowed me to become licensed as an RN. As a RN I was able to work as a pediatric home health nurse while continuing my education for my bachelor’s degree. My bachelor’s degree has opened many career doors, including my dream job as an obstetrics/pediatrics nurse. In the future, I plan to obtain a master’s degree. The Ridgewater MANE program was practical and convenient for me.

Prekker: The opportunity to experience several areas of nursing through my clinical rotations and the very close, supportive relationship I developed with my instructors helped me find my niche and solidify my goals. My positive experiences at Ridgewater reawakened in me a confidence in my ability as a student and encouraged me to continue furthering my education.

Q. What types of health care jobs did you hold while a student, and what type of work do you do now?

A. Ditmarson: As a student I was a caregiver for a local company part time and worked as a certified nursing assistant at a local long-term care facility.

Currently, I am the ACMC New London-Spicer RN and clinical site manager.

I enjoy a variety of caring for patients and managing the clinic.

Prekker: While a student, I worked as a nursing assistant. After receiving my licensed practical nursing degree, I worked in that capacity while working toward my RN. I think the experience of working in those areas while being a student has made me a more well-rounded nurse and ingrained in me respect for all areas of health care work. My current role is as the clinical services performance improvement supervisor for Carris Health/Rice Hospice. I am

Tara Maus

Michelle J Prekker working on my master’s degree in nursing education.

Q. Did you have difficulty finding jobs in your field?

A. Prekker: There was no difficulty finding a job. Shortly after graduation I was hired by Rice Hospice and I have been here ever since. Nursing is a field that is only going to be growing and there is room for all areas of interest. It is a great career!

Ditmarson: Not at all. I found a job in the home health care field within one week after passing my (National Council Licensure Examination-Registered Nurse) NCLEX-RN exam.

Three former students in the Ridgewater College Minnesota Alliance for Nursing Education program participated in answering a series of questions about the program. Pamela Ditmarson, registered nurse: earned bachelor’s degree, now nursing & site manager and the medical home care coordinator at New London-Spicer ACMC/Carris Health clinic.

Tara Maus, registered nurse: a bachelor’s degree graduate from the first cohort of MANE, advancing to work on a master’s degree. Michele J Prekker, registered nurse: graduated with associate degree in nursing at Ridgewater, went on to earn a bachelor’s degree, now in a master’s program. Will be doing clinicals for her program at Ridgewater.

IMPACT | 73

Q&A

Tony and Mary Amon Family Practice Medical Center, physicians

Q. What types of educational work do you and other area physicians do with medical students?

A. We work with the Rural Physician Associate Program. Students in their third year of medical school come here for nine months.

The goal of the program really is to put people back in rural areas.

The only years we haven’t had an RPAP student are the years the University didn’t assign one to us.

The University of Minnesota Minneapolis has a program where the first-years come out for a couple days before they even start, spend some time shadowing.

Duluth’s first- and second-years come out and spend a whole week with us, five weeks in the first 18 months. They live with us, do everything our family does. If it’s fun, they have fun with us. If it’s work, they work with us.

Residents from St. Cloud come for a rural rotation. We’ve assisted multiple nurse practitioners and physician assistants in their family medicine rotations.

Q. How does the RPAP program benefit students?

A. This is what they imagined, seeing patients.

The goal is to have a longitudinal experience. If they see somebody the first month here that’s a newly diagnosed pregnancy, they would follow the pregnancy, see the delivery and the baby.

They get to see the progression of the treatment.

An advantage is you’re the only student. When there’s something going on, you have a front row seat. And everybody wants the student.

Q. What do you teach students that they may not learn in medical school?

A. They’re getting the basic science. Here, they’re learning communication skills, some life skills like how do you do this job which can take 40 to 100 hours of your week, have a family, have a dog. Work-life balance.

We’re teaching them a wide breadth of medicine in a community setting.

In the Cities, if you see someone in a clinic, you’re not going to run into them outside of the clinic.

One thing students get out of being here, relationships are deeper between the patient and the physician.

Q. What do the students learn about practicing in a rural area?

A. It’s not 8-to-4 medicine.

One thing they’re a little surprised at when they’re here – you just saw that kid in the clinic yesterday, and now you’re here cheering and he’s on your son’s hockey team. You’re talking to his parent, and you delivered him. They’re kind of in awe, a little bit, over that long-term relationship.

That’s not the model they have while in training in the Cities. The model Wilmar gives them is great. It models a lot of collaboration between the physicians. It’s totally exciting to have a student around. Another physician 74 | IMPACT

Drs. Tony and Mary Amon will call and say I have a great case for your RPAP student to see.

They see more of the social aspect of illness. Here they’re seeing people living with whatever their diagnosis might be. I think sometimes they’re surprised that we do the same things they do at the university. They’re seeing some of the same types equipment they see in the bigger hospitals.

It’s just not to the scale, instead of four robots we have one.

We’re trying to break the stereotype that we don’t do good medicine. We have the same electronic records, up-to-date medical information, same standard of care.

Q. Why do you do this work?

A. The thing about physicians, doctor means to teach, so we love to teach.

The students are excited and love to learn. It helps you see things differently; it reminds you why you did this. A great outcome would be as a recruitment tool, but it’s really because it’s fun. We don’t get paid.

It is hard, because teaching takes time. It adds hours to your day. You do try to spread it out, because it’s a little intrusive with patients. Most of our patients understand what our mission is. They are willing to accept the student. If a patient doesn’t want a student, people do speak up.

The patients are just as important to the education process of our future physicians.

Drs. Mary and Tony Amon of Family Practice Medical Center of Willmar participate in the Rural Physician Associate Program, which brings third-year University of Minnesota medical students to rural areas.

Both participated in the program as students.

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IMPACT | 75

Fast FACTS HEALTH CARE EDUCATION Health care occupations listed in top 30 job openings in Minnesota: 2. Personal care aides, 6,640 openings, 9.8 percent job vacancy rate 4. Nursing assistants, 2,918 openings, 9.4 percent job vacancy rate 7. Registered nurses, 2,480 openings, 4 percent vacancy rate

A shortage of nurses and other health care workers is a national problem.

Minnesota also suffers.

10. Pharmacy technicians, 1,770 openings, 23 percent job vacancy rate 11. Licensed practical and licensed vocational nurses, 1,571 openings, 2 percent job vacancy Rate: 16. Home health aides, 1,126 openings, 4.5 percent job vacancy rate

Source: Minnesota State Careerwise, Top 30 Minnesota Job Vacancies, fall 2017 https://careerwise.minnstate.edu/jobs/topvacancies.html

Practical nursing placement rates: The program admits 20 students on each campus (Hutchinson and Willmar) each year.

2016 – 100 percent 2015 – 100 percent 2014 – 100 percent

Ridgewater College’s placement rates for its nursing students are an apparent indication of the need for nursing care. (Numbers from 2017 are not final)

According to Ridgewater, some graduates choose to go on to earn a bachelor’s degree and are not licensed completing an associate degree. The majority of students are licensed after their associate degree and work as nurses while pursuing their bachelor’s degree.

Associate degree registered nursing placement rates: This program admits 26 students per campus per semester each year.

2016 – 95 percent 2015 – 98.2 percent 2014 – 100 percent

Source: Lynn Johnston, Director of Nursing, Ridgewater College 76 | IMPACT

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IMPACT | 77

Health Care EQUITY

Local, regional initiatives aim to reduce health disparities Minnesota usually ranks as one of the healthiest states in the nation. But a closer look makes it clear that this isn’t the whole story.

Overall health and health outcomes vary significantly among Minnesotans depending on race, ethnicity, preferred language, income level and geography. Infant mortality is higher, for example, within the AfricanAmerican community. Tobacco use is more prevalent in low-income households, and rural communities across the board struggle more than their urban counterparts with issues such as poverty, aging, access to health care services, access to fresh food and opportunities for healthy exercise.

78 | IMPACT

Collectively, these health disparities are costly both in dollars and in reduced human potential. And as west central Minnesota becomes increasingly diverse, there’s growing urgency to work toward health equity – that is, providing individuals and individual communities with what they need to achieve and sustain optimal health.

The public conversation surrounding health equity has led to numerous initiatives, some local in scale and others regional.

Communities, entities and health organizations have launched projects designed to fill various needs.

They’re tackling issues such as improved access to

diabetes prevention, ease of transportation to medical appointments, increased availability of fresh food and more support for families isolated by age or caregiving responsibilities.

One key effort underway is Healthy Together Willmar, a $2 million, multi-year effort supported by Blue Cross and Blue Shield of Minnesota to develop community-led initiatives that reduce barriers and promote health equity. It’s hoped that projects created in Willmar can be applied or replicated in communities across the state.

One of the goals of Healthy Together Willmar is to support existing work, with a focus on improving health among populations that face the greatest inequities.

The initiative also has established a Community Table, a diverse group of residents exploring innovative ways to promote health equity. Down the road, a Responsive Care Table will be established as well to look at how local health care can become more accessible and culturally responsive to all segments of the community.

For the past few years, Minnesota Community Measurement has been collecting data from medical

clinics statewide to track performance on key measures and analyzing not only clinical quality but disparities as well.

The first report, issued in 2015, found numerous gaps for issues such as blood pressure control, childhood immunization and optimal diabetes care. Lowerincome patients often fared worse on these measures.

There also were racial, ethnic and even geographic disparities.

The most recent report, released in 2018 and containing data collected in 2017, documented

progress but continued to note that inequities persist across geography, race and ethnicity.

The hope is that by tracking and measuring health inequities, clinics can use the information to make improvements at the local level.

“Our mission is to accelerate the improvement of health by publicly reporting health care information,” Minnesota Community Measurement wrote in its annual report. “Our vision is to drive change that improves health, patient experience, cost and equity of care for everyone in our community.”

IMPACT | 79

Fast FACTS HEALTH EQUITY

Across multiple measures and geographic regions, white and Asian-American populations in Minnesota generally have better health outcome rates.

American Indian, AfricanAmerican and Hispanic patients generally have the lowest rates.

Residents of rural Minnesota face health inequities regardless of race, ethnicity, language or country of origin. They are statistically less likely to receive recommended preventive screenings and more likely to defer other types of health care because of cost or transportation challenges.

As of 2010, 16 percent of the population in Kandiyohi County was over the age of 65, compared to 13 percent in Minnesota overall. The county is projected to have one in four residents of retirement age by 2030.

9 percent of Kandiyohi County residents are low-income and do not live near a grocery store, compared to 6 percent of Minnesotans statewide.

Eight percent have to travel more than 20 miles to get groceries.

Racial and ethnic disparities account for an estimated $60 billion in excess health care costs in Minnesota each year.

Nearly one in three Kandiyohi County residents under the age of 5 are children of color, while only 2 percent of county residents 65 and older are persons of color.

57 percent of Kandiyohi County residents have opportunities for physical activity, compared to 84 percent of Minnesotans statewide.

13 percent of Kandiyohi County residents live below the poverty line, slightly more than the statewide rate of 12 percent. Among Kandiyohi County children under the age of 6, one in every five lives in poverty.

Sources: Minnesota Community Measurement; Healthy Together Willmar 80 | IMPACT

Q&A

Wendy Foley Blue Cross and Blue Shield Minnesota, senior health improvement project manager

Q. What is health equity, and how is it different from equality?

A. Equality means that everyone gets the same thing, while equity means that everyone gets what they need. One example is – equality would be everyone getting a pair of shoes, but they happen to be a women’s shoe that is a size seven. That would be very useful to those who had that shoe size, but not for anyone else.

When it comes to health, different people have different needs. Using equity as the benchmark ensures that people have access to the resources needed to live their healthiest lives. Simply stated, equality sounds fair; equity is fair.

Q. Why should health equity matter to the community?

A. Advancing health equity results in lives saved, money saved, more productivity and a stronger community overall – because when people are healthy, the community is healthy.

Many of our fellow community members in Willmar face significant barriers to health, ranging from receiving culturally appropriate care, experiencing isolation and a lack of community connection, and having access to things they need to be healthy. At Blue Cross, we believe that all people, regardless of race, income, ZIP code or other factors, should have opportunities to live the healthiest lives possible.

Q. Tell us a little bit about the role of Healthy Together Willmar in reducing disparities.

A. The mission of the Healthy Together Willmar initiative is to create a future where all members of the Willmar community have access to the resources and opportunities needed to achieve their best possible health.

Willmar is a great place to live, while it is also home to some significant disparities, ranging from a lack of access to healthy options to community members experiencing feelings of isolation and loneliness. It’s situations like these that Healthy Together Willmar is working to change.

Q. What are one or two accomplishments that Healthy Together Willmar is especially proud of?

A. It’s been wonderful to see folks come together from all different backgrounds and lived experiences. Our community is vibrant and diverse, and we’ve been very proud of the part we’ve played to create spaces for people to come together across their differences and learn more about each other.

I’m also proud to be part of an organization that champions health equity and knows the importance and value of community-led solutions.

Wendy Foley Blue Cross has been intentionally innovative with the Healthy Together Willmar initiative by having the community largely drive the work from idea to implementation.

The successes we are seeing in the community reflect that commitment, such as supporting new leaders from traditionally underrepresented communities through the establishment of the Community Table.

Q. What are some of the next steps for this initiative?

A. Throughout this year the Healthy Together Willmar initiative has provided funding to 14 groups in the community who proposed specific plans to improve the health of the community. These projects range from intergenerational relationship building to supporting English/Somali conversations and classes, and they are great examples of people coming together to affect change and improve community health.

We’re excited to launch a second round of this type of funding later this year, to further the impact of the Healthy Together Willmar initiative.

We’re also excited about the work of the newly formed diabetes coalition, which is a new group of Willmar stakeholders working to evolve our community and health system for healthy lifestyles, diabetes prevention and diabetes treatment.

IMPACT | 81

Rural Health Care RECRUITMENT Doctors a challenge to find; more rural training opportunities needed

There’s a shortage of rural physicians, and the challenge will be with us for some years to come.

In part, it’s a supply and demand issue. There’s a shortage of primary care physicians coming into practice, said Lorry Massa, president and CEO of the Minnesota Hospital Association and former CEO at Rice Memorial Hospital in Willmar.

The other challenge is that more new physicians are joining urban health centers rather than rural ones. It’s easier to recruit into a larger medical group, most of which are in urban areas, Massa explained.

He also points out that many doctors train in urban areas. They marry people who they meet in these urban areas. And, many appreciate the broader range of cultural activities, sports and 82 | IMPACT

other activities urban areas offer. Urban areas also can offer a broader range of employment opportunities for their spouses.

One possible solution is to give more medical students an opportunity to experience rural practice, and the rural lifestyle. The Minnesota Hospital Association believes one of the bottlenecks in recruiting more physicians for rural health centers is the need for more rural residency training programs.

Dr. Raymond Christensen, M.D., associate director of the Rural Physician Associate Program with the University of Minnesota Medical School, also cited a need for “rural training tracks” in the state. He’d also like to see the Duluth medical program grow into a four-year, rural focused program.

Lorry Massa

Dr. Raymond Christensen

Massa said the Minnesota Hospital Association also supports loan forgiveness as an incentive to get young doctors into rural areas.

Rural health centers are using a number of strategies to cope with the physician shortage.

Advanced practice nurses and physician’s assistants are handling a larger share of the workload.

Some rural hospitals staff their emergency departments with mid-level practitioners, as long as a physician is available to back them up.

Telemedicine is still in its early stages, but it too is helping hospitals cope with the shortage, according

to Massa. Many hospitals have also relied on the J1 Visa program to bring in foreign-trained physicians, but changes in the immigration situation are adversely affecting the supply.

Rural health care centers are also starting farther upstream in recruiting young people interested in medical careers.

While the challenges are big, both Massa and Christensen expressed optimism. Christensen noted that rural physicians have many reasons for loving and maintaining their rural practice.

There are many with rural upbringings who will

continue to choose rural areas for their practice, he explained.

And when it comes to physicians, this is one area where rural areas often lead urban areas in compensation.

Many rural facilities offer higher compensation to primary providers, sometimes as part of bidding wars with others, said Massa.

And, of course, rural health centers are well-aware of what’s at stake and devoting their energy to finding solutions. “You don’t have a health system if you don’t have a physician,’’ Massa said.

IMPACT | 83

Q&A

Lana Dirksen Chippewa County-Montevideo Hospital and Clinics, M.D.

Q. Can you tell us a little bit about yourself and family, and where you grew up?

A. I grew up on a family farm near Clara City and was very active in farming, FFA and 4-H. I enjoy being active with my kids and their athletic events, cheering on the Montevideo Thunderhawks and jogging. My parents and many relatives live in the area, so I’m often able to see family and enjoy time at our family lake cabin.

My husband stays home with our children. His support allows me to focus on my career and keep up with the demands of a busy practice. I was appointed to serve on the Chippewa CountyMontevideo Hospital Board.

Q. What led you to pursue a career in family medicine?

A. As a teenager I had cancer and went to the University of Minnesota for treatments. The experience opened my eyes to many of the health crises people can go through. I recognized I wanted to help prevent disease when possible and help people through their medical journeys. Family medicine allowed me the most opportunity to fulfill this.

Q. What led you to return to a rural setting to practice medicine?

A. The University of Minnesota provided robust training. I participated in the Summer Internship in Medicine and Rural Physician Associate Program in Montevideo, Willmar and Paynesville.

I was impressed by how well physicians knew patients and how that improved medical care and satisfaction for both the patient and physician. It made the decision to move back to our hometown area easy for my high school sweetheart and me. The community warmly welcomed our family and continues being very supportive.

Q. What do you see as the rewards of practicing in a rural setting?

A. Seeing people in many settings – as co-workers, patients, neighbors and around town – makes it easy to build relationships.

I especially enjoy celebrating with families at the birth of a new baby. Providing obstetric care, and all medical care, takes a team.

Our team members know their roles and also know each other, making for a great team. Our team can respond quickly and makes it safer to live in the rural areas.

Q. What points would you make to a young medical student deciding whether to pursue a rural practice?

A. I think many times new physicians are afraid to consider practicing in rural areas due to concerns with lack of support or resources. I haven’t found this to be an issue. People here are very supportive: We’re providing modern health care and collaborating all the time. My patients are really hard-working individuals who are very appreciative of medical care. It’s a joy to share in this kind of community.

84 | IMPACT

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Nurse practitioners and physician assistants are carrying more of the load, providing services in place of physicians in a number of areas, including emergency departments.

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When it comes to compensation, this is one area where rural beats urban.

Rural health centers often offer higher compensation than do urban centers for primary physicians.

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