What Creates Health In Rural
Communities?
Access, Quality, Value, Community
Ed Ehlinger, MD, MSPH
Commissioner
Minnesota Department of Health
June 28, 2011
John Wesley
was born on June 28, 1703
• He was the founder of Methodism
(name derived from the methodical
devotion to the study of religion)
• “Think and let think.”
Number 1 in milk and cheese production
Most people living in towns of <2,500 population
Harlowton, Montana
Fewest people per square mile.
Rural health care program
Highest percentage of people living
in towns of under 2,500
• Gilda Radner, one of the original cast
of SNL, was born on June 28, 1946.
• “Life is about not knowing, having to
change, taking the moment and
making the best of it, without
knowing what's going to happen
next. Delicious ambiguity."
American Rural Health Association
National Meeting
• June 15, 1981 – Madden’s Resort in Brainerd
• Keynote speech by Bill Foege
• Compared what Marco Polo experienced in his
lifetime to what each individual experienced in
the last year.
• “More change has occurred in the last 25 years
than in all of previously recorded history. And
change will never be that slow again.”
The more things change, the more they stay the same.
• “The issues of the number and distribution of
health care personnel have dominated discussions
of health services in rural communities. Efforts like
the National Health Service Corps and Area Health
Education Centers have addressed these issues.
However, with the rapidly escalating costs of
health care and the realization that these
programs haven’t been totally successful in
attracting health care personnel to rural
communities, health planners and policy makers
have been forced to reassess their approach to
rural health services.”
Ed Ehlinger – Masters Degree Thesis June 1980
Provider Knowledge of Health Care Services in a Rural Community
John Wesley
was born on June 28, 1703
• "When I was young I was
sure of everything; in a few
years, having been
mistaken a thousand times,
I was not half so sure of
most things as I was
before; at present, I am
hardly sure of anything."
National Healthcare Disparities Report
2010
• About one in five Americans lives in a
nonmetropolitan area.
• Compared with their urban counterparts,
rural residents are more likely to be
older, be poor, and be in fair or poor
health, and have chronic conditions.
Percentage of People Who Reported That Their Health was Fair or Poor by Location and Sex
(BRFSS)
14
12
11
10
10
Percent
11
11
9
9
8
12
8
Men
Women
6
4
2
0
Metro
Greater MN
Metro
2004
Greater MN
2009
Location
National Healthcare Disparities Report
2010
• Rural residents are less likely than their urban
counterparts to receive recommended
preventive services and on average report
fewer visits to health care providers.
People Under Age 65 With Any Period of Uninsurance in Past Year, by Ethnicity
Source: Medical Expenditure Panel Survey, 2001
Key: Large metropolitan = 1 million or more inhabitants; small metropolitan = < 1 million inhabitants; micropolitan = 10,000 to 50,000
inhabitants; non-core adjacent = not metropolitan or micropolitan but adjacent to metropolitan or micropolitan area.
People With a Dental Visit in Past Year by Race
Source: Medical Expenditure Panel Survey, 2001
Key: Large metropolitan = 1 million or more inhabitants; small metropolitan = < 1 million inhabitants; micropolitan = 10,000 to
50,000 inhabitants; non-core adjacent = not metropolitan or micropolitan but adjacent to metropolitan or micropolitan area.
National Healthcare Disparities Report
2010
• Although 20% of Americans live in rural areas,
only 9% of physicians in America practice in
those settings.
85 % of Total MDs
10 % of Total MDs
5% of Total MDs
National Healthcare Disparities Report,
2010
• Many rural residents depend on small rural
hospitals for their care. There are
approximately 2,000 rural hospitals
throughout the country, 1,500 of which have
50 or fewer beds.
• Most of these hospitals are critical access
hospitals that have 25 or fewer beds. Rural
hospitals face unique challenges due to their
size and case mix.
Source: MN Dept of Employment & Economic Development
National Healthcare Disparities Report,
2010
• Transportation needs are pronounced among
rural residents, who must travel longer
distances to reach health care delivery sites.
MN has been a leader in many of the
health care access and quality issues
E-health
• Avera eCare Services (session 2A)
– 24/7 telehealth access
– eEmergency, ePharmacy, eICU
• Greater MN Telehealth Broadband Initiative
(session 5E)
– Connecting over 140 hospitals, clinics, mental
health centers
MN has been a leader in many of the
health care access and quality issues
Workforce
• Community paramedics (session 3A)
• Scrubs and Scopes Club at Lake Region in Fergus
Falls (session 5A)
• MN Rural Health Hero – Therese Zink
• U of MN Rural Physician Associate Program
(RPAP)
• Glacial Ridge Glenwood Emergency Services and
Training Dept. (Rural Health Team nominee) for
training and developing volunteers
MN has been a leader in many of the
health care access and quality issues
Models of Care
• Lakewood Health System’s integrated care model
for behavioral health in primary care (session 5B)
• Mora FirstLight’s Pharmacy Dept. (Rural Health
Team Nominee) for improving medication use
• U of M Community University partnership with
Kanabec County Public Health and Perham
Memorial Home (4C) for best practices
• Stratis Health and Fairview – collaboration on
palliative care
Alexis Carrel
was born on June 28, 1873
• He was a surgeon and inventor of a
cardiac perfusion pump.
• He won the Nobel Prize in 1912.
• He was a proponent of eugenics
and was an influence on Charles
Lindberg.
• “A few observations and much
reasoning lead to error; many
observations and a little reasoning
lead to truth.”
Life Expectancy (Years)
After 100 + years of observations
Public Health = Longer Lives
80
70
60
50
Life Expectancy at Birth,
United States, 1900 - 1996
40
30
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
of Birth
25 of the 30 years Year
of life
gained in the 20th
Century resulted from public health
accomplishments
How our healthcare money is spent
5%
Medical Care
Public Health
95%
To make a significant difference in
the health of rural communities we
need to expand our focus beyond
clinical activities.
We must focus on the entire
community and the social
determinants of health – of which
clinical care is just one (albeit an
important one).
Individual health is influenced
by the health of the community
County Health
Rankings Model
Place matters
Community matters
Health Factors
Health Outcomes
MN has begun to focus on social and
behavior determinants of health
• Ottertail County’s fall prevention program
(Rural Health Team Award winner)
• Queen of Peace Hospital, New Prague (1C) for
engaging community in health and wellness
• Statewide Health Improvement Program (2D)
in Becker, Clay, Otter Tail, and Wilkin counties
Health System Dynamics
Presented by: Jeanne F. Ayers, Minnesota Department of Health - Milstein B. Hygeia's constellation: navigating health futures in a
dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15,
2008. Available at: http://www.cdc.gov/syndemics/monograph/index.htm
Areas of Emphasis
Society's Health
Response
Healthy Public Policy & Public Work
General
protection
Targeted
protection
Primary
prevention
Medical and Public Health Policy
Secondary
prevention
Tertiary
prevention
Becoming no
longer vulnerable
Safer,
Healthier
Population
Becoming
Vulnerable
Vulnerable
Population
Becoming
Afflicted
Afflicted
without
Complications
Developing
Complications
Afflicted with
Complications
Dying from
Complications
Adverse Living
Conditions
DEMOCRATIC
SELF-GOVERNANCE
World of Transforming…
By Strengthening…
• Deprivation
• Dependency
• Violence
• Disconnection
• Environmental decay
• Stress
• Insecurity
• Etc…
• Leaders and institutions
• Foresight and precaution
• The meaning of work
• Mutual accountability
• Plurality
• Democracy
• Freedom
• Etc…
DISEASE AND RISK
MANAGEMENT
World of Providing…
• Education
• Screening
• Disease management
• Pharmaceuticals
• Clinical services
• Physical and financial access
• Etc…
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for
Disease Control and Prevention; April 15, 2008. Available at: http://www.cdc.gov/syndemics/monograph/index.htm
MDH Priorities
• Strengthen link between federal, state, and local
public health agencies.
• Integrate medicine and public health
• Bring a public health framework to health reform
• Enhance community engagement and community
ownership of health.
• Enhance health equity – eliminate health
disparities
• Build the public/political will for creating
conditions (through personal choices and public
policies) that enhance health.
John Wesley
born on June 28, 1703.
• “Do all the good you can,
By all the means you can,
In all the ways you can,
In all the places you can,
At all the times you can,
To all the people you can,
As long as ever you can.”
“Public health is what we, as a society, do
collectively to assure the conditions in
which people can be healthy.”
-Institute of Medicine (1988), Future of Public Health
Edward P. Ehlinger, MD, MSPH
Commissioner, MDH
P.O. Box 64975
St. Paul, MN 55164-0975
[email protected]
Central Role of Health in Our Society
“When health is absent, wisdom cannot reveal
itself, art cannot become manifest, strength
cannot fight, wealth becomes useless, and
intelligence cannot be applied.”
• Herophilus of Chalcedon, 335-280 BC,
• Physician to Alexander the Great
Edward P. Ehlinger, MD, MSPH
Commissioner, MDH
P.O. Box 64975
St. Paul, MN 55164-0975
[email protected]
Rural
• Of, relating to, or characteristic of the
country.
• Of or relating to people who live in the
country: rural households.
• Of or relating to farming; agricultural.
• Synonyms: bucolic, rustic, pastoral
–Often used pejoratively