Spring 2011 Quarterly Newsletter
CONTENTS:
Director's Column
Partner Focus
Program Focus
Special Feature
Community Focus
SPRING
2011
Printable PDF
(PDF: 189KB/11pgs)
Email Mary Ann Radigan at
[email protected]
or call 651-201-3855 with
comments.
We invite you to forward this
newsletter to your colleagues.
photo
courtesy of
Lorry
Colaizy
DIRECTOR'S COLUMN
DEMANDS MOUNT ON MINNESOTA'S HEALTH CARE SAFETY NET
Mark Schoenbaum
Though Minnesota is slowly recovering from the Great Recession, the stability of
the state’s health care safety net remains fragile as demands on it rise. The
2010 census confirmed both population loss and a growing proportion of older
residents in many rural Minnesota counties, creating rising senior health needs
in communities with fewer people overall to use and support the local health
system. At the same time, uninsurance rates are up for Minnesota’s population;
for example, the rate of uninsured children in Minnesota jumped 20 percent from
2008 to 2009.
Minnesota’s health care safety net, both rural and urban, responds to these
needs. In fact, that’s why it’s there. Whether Critical Access Hospitals in rural
Minnesota, community clinics in the Twin Cities or other safety net
organizations, these providers arose when community leaders came together to
organize care for their neighbors. In rural areas, the goal was most often to
make health care available in small, sparsely populated communities. In the
http://www.health.state.mn.us/divs/orhpc/pubs/quarterly/2011/spring.html#five[5/9/2011 8:41:52 AM]
Spring 2011 Quarterly Newsletter
Twin Cities, neighborhood and community leaders formed nonprofit clinics to
serve low income and uninsured residents.
The health care safety net is first and foremost a community institution. If you
look at the boards of community clinics and rural hospitals, you’ll find community
and neighborhood leaders, patients, county commissioners, business owners
and clergy. You’ll find more volunteers making up hospital auxiliaries. You’ll find
that 75 percent of rural EMS staff are volunteers.
Community roots are a huge asset, but the fate of a community institution is
intertwined with that of its surroundings. According to the Institute of Medicine,
the strength and viability of a community’s safety net are highly dependent on
state and local support, state Medicaid policies, the structure of the local health
care market-place, and the community’s economic health.
Safety net providers have been adroit in piecing together the resources they
need. In addition to income from those with conventional insurance coverage,
they raise support from their communities and from other private sources. They
work hard to cut costs and use creative financing. However, staying financially
viable when many patients can’t afford their services is a central challenge for
health care safety net providers. State and federal support is a critical piece of
the safety net’s sustainability. For rural providers and their older populations,
Medicare reimbursement plays a central role. For urban providers, Medicaid
payments and federal operating support make continued service possible.
For both rural and urban safety net providers, state grants and related funding
can be crucial. For instance, there are 150 state-supported health professionals
serving in safety net clinics through the state’s loan forgiveness program at any
one time. Recruiting providers for safety net clinics can be a challenge, and loan
forgiveness is proven to attract physicians, pharmacists, nurse practitioners and
other professionals to the areas that need them most. Minnesota’s small rural
hospitals also receive key state funding to plan responses to community needs
like chronic disease and aging populations.
Of course the Great Recession has stressed government resources at the same
time demands on the health care safety net are growing. But as the Institute of
Medicine concluded, “infrastructure improvements and systems-building efforts
to help safety net providers strengthen their ability to survive should be
supported.” Whether we live or travel in rural areas or the urban core, a strong
safety net is in everyone’s interest, especially in times like these.
Mark Schoenbaum is director of the Office of Rural Health and Primary Care and can be
reached at [email protected] or 651-201-3859.
top of page
PARTNER FOCUS
MEDICAL STUDENTS MEET RURAL
by Michelle Juntunen, Communications Director, University of Minnesota Medical
School-Duluth
http://www.health.state.mn.us/divs/orhpc/pubs/quarterly/2011/spring.html#five[5/9/2011 8:41:52 AM]
Spring 2011 Quarterly Newsletter
SIM participant Erik Bostrom at
Kanabec Hospital in Mora
“You lost your insulin pump to the wood chipper?” exclaims my mentoring
physician. The patient, sporting a plaid shirt and thick boots covered in a layer
of manure that wafts up to my nose replies from behind his burly beard with,
“Don’t worry doc, I was able to fish out enough pieces to please the insurance
company.” This is how student Mackenzie Becker began her paper reflecting on her 2010
Summer Internship in Medicine experience in Alexandria. “I had the
opportunity,” Mackenzie wrote, “to put some of my newly acquired first-year
medical school skills to work. It was also my first chance being thrown into a
real clinic setting where I was asked to think about medicine like a physician
would.”
Last summer, 94 students took part in the elective Summer Internship in
Medicine. Clinical Summer Internship in Medicine experiences can last from
two to six weeks and are open to medical students from both the Twin Cities
and Duluth campuses. Most of the students travel to small rural communities in
Minnesota; although some are placed in Iowa, Wisconsin, North and South
Dakota and Michigan and one student even interned in Dutch
Harbor/Unalaska, Alaska.
Jim Root, vice president of Saint Elizabeth’s Medical Center in
Wabasha Human Resources, said the hospital welcomes students
to their facility not only for what they can give to the student but
also for what they receive in return. “Programs like SIM are a
recruitment opportunity. By providing well-rounded exposure to all
aspects of rural practice we do what we love and teach the students
and hope that we’ve made a good impression for those future
physicians looking for a practice.”
Hannah Betcher describes her Summer Internship in
Medicine (SIM) at Saint Elizabeth’s Medical Center in Wabasha.
Wabasha has an interesting health care set up. The clinic and hospital,
although physically connected, are separate organizations. The clinic is
Mayo Health Systems, while the hospital—Saint Elizabeth’s Medical
Center—is affliliated with a north central Wisconsin system. The doctors
and much of the staff work for both, and patients are often referred
between them, but all medical records and billing remain separate. Saint
Elizabeth’s includes assisted living, physical therapy, a cardiac
rehabilitation center, and dieticians. Because of all of these options,
many patients access multiple forms of care. During my two weeks with
the hospital and clinic I saw one patient in four different care settings.
Going into this internship, I anticipated shadowing doctors and getting a
chance to talk with them about their chosen fields. My experience went
much deeper. Many doctors let me conduct the patient interviews and do
my own physical exams. They instructed me in several procedures and,
through those experiences, I became more confident in all my patient
interactions. The doctors and staff spent time with me discussing my
http://www.health.state.mn.us/divs/orhpc/pubs/quarterly/2011/spring.html#five[5/9/2011 8:41:52 AM]
Spring 2011 Quarterly Newsletter
specific medical or procedural questions and making sure that I had a
good understanding of the care we were providing. Every day I felt like
my time had been spent in a worthwhile, interesting way.
Most surprising for me was discovering how much I liked primary care. I
had been warned many times to avoid the bad hours and low pay of
primary care, but I absolutely loved the variety and patient contact. In
one day I saw infants for well-baby checks and a 90-year-old patient
dealing with diminishing quality of life issues. I saw how many
procedures primary care doctors do in their daily practice.
I am definitely considering applying for Rural Physician Associate
Program (RPAP). This type of applicable, dynamic learning gave me a
chance to cement what I had learned and gear up for another year of
lectures. It also gives me a good frame of reference when deciding about
my future. I knew that I wanted to live in a small community, but I was not
sure if I wanted to practice in one. I am now more comfortable with
becoming part of a rural health care team. My time in Wabasha has
made me enthusiastic about the many possibilities available to small
town physicians.
In the spring of their first year of medical school, students who sign up for
Summer Internship in Medicine (SIM) are matched to a small community
hospital or clinic to observe rural patient care. Internships tend to be
community specific. They can include time in the emergency room, the delivery
room and surgery, as well as working with other disciplines in the hospital,
clinic and community. Internships might include clinical care, pharmacy, home
care, public health nursing, law enforcement, dentistry, chiropractic care, and
work in the laboratory, medical records and x-ray departments of the hospital.
Each year clinic and hospital sites are contacted regarding their participation
and the number of students they can accommodate. Student placement is first
come, first served and limited to the number of available sites.
The SIM program asks participating facilities for a $500/week stipend for each
student; however, stipends are not mandatory and each site decides whether it
can provide a stipend. Students are responsible for their own meals, travel
expenses and housing, although some communities provide or help locate
housing.
Coordinated by Raymond G. Christensen, M.D., assistant dean for rural
health, and assisted by Deann Dahl from the University of Minnesota Medical
School's Duluth campus, SIM is also supported by the four regional Area
Health Education Centers. "We have really enjoyed working with our medical
students in SIM," commented Dr. Christensen. "I have the unique privilege of
reading their essays and visualizing the great experiences they receive in
Minnesota hospitals and clinics. While we do not know where they will practice
or what they will practice, we do know that all are uniquely affected by their
SIM experience." One hundred and six students have signed up for SIM this
summer and are now being matched to health care facilities. To learn more
about SIM, call Dr. Ray Christensen or Deann Dahl at 218-726-7897.
top of page
http://www.health.state.mn.us/divs/orhpc/pubs/quarterly/2011/spring.html#five[5/9/2011 8:41:52 AM]
Spring 2011 Quarterly Newsletter
PROGRAM FOCUS
FINDING WORKING CAPITAL
by Ashley Schweitzer, marketing coordinator, Nonprofits Assistance Fund
A decision to pursue a new opportunity often involves weighing the pros and
cons. Occasionally after scenario planning the right strategic and financial
decision is obvious to everyone involved. Such was the case when Rum River
Health Services assessed whether to take on full management of an existing
jointly-run program. In order to move forward, the organization needed working
capital. Jeff Larson, executive director, reached out to the Nonprofits
Assistance Fund’s Minnesota Primary Care Fund, which provided financing
and much more.
Rum River Health Services, located in Princeton, Minnesota, is a nonprofit
organization with a mission to identify and respond to community health
needs. Ten years ago, community meetings identified the need for an
outpatient facility for residents recovering from addiction. Because St. Cloud
Hospital had previously run a similar treatment program, they were a natural
partner to form Rum River Recovery Plus. Rum River Health Services
provided the location, staff and services, while the hospital managed the
insurance and government contracts, billing and other administrative tasks. By
2009, Rum River Health Services and Rum River Recovery Plus had both
grown significantly, reaching a size where they had the capacity to operate the
entire program. Around the same time, St. Cloud Hospital’s administrative
costs were increasing. After a cost-benefit analysis, it was clear that this
partnership was no longer the best structure for Rum River Health Services or
its clients. Everyone involved agreed that it was time for Rum River Health
Services to operate the program on its own.
Although making such a big decision was surprisingly easy, implementation
remained tricky. As Rum River Health Services executive director Jeff Larson
recalled, “We knew it made sense, but we didn’t know how to get from point A
to point B. There were so many unknowns.” Setting up a new billing system
and coordinating the contracts was the biggest hurdle. Rum River Health
Services had experience with billing and accounts receivable on a much
smaller scale and had never worked with insurance companies. Recognizing
that they didn’t know what they didn’t know, Rum River Health Services set out
to find short-term financing to smooth out any potential delays or cash flow
issues. All businesses, including nonprofits, need working capital to take advantage of
an opportunity. They need financing to build infrastructure and deliver services
before cash begins to flow. For Rum River Health Services, successfully
implementing this change would save costs and significantly strengthen their
financial position once the new billing system was in place. However in late
2009 the credit market was highly constricted. The banks Larson spoke to
were concerned about approving a loan due to the uncertainty of insurance
billing and the organization’s limited collateral.
http://www.health.state.mn.us/divs/orhpc/pubs/quarterly/2011/spring.html#five[5/9/2011 8:41:52 AM]
Spring 2011 Quarterly Newsletter
The Nonprofits Assistance Fund’s Minnesota Primary Care Fund is dedicated
to financing community health centers, rural clinics and hospitals and other
safety net health organizations. Its programs exist to support Minnesota
nonprofits that are unable to meet banks’ requirements. It can provide these
organizations with credit that enables them to serve their communities. The
staff is familiar with the nuances of nonprofit finance and available to provide
regular, hands-on assistance. Nonprofits Assistance Fund is able to approve
loans that traditional lenders view as too complicated or risky. Because the
current economy has impacted risk tolerance and credit standards, the fund
serves organizations that might work with a bank in a different economic
environment.
Already familiar with Nonprofits Assistance Fund from financial management
trainings, Larson found templates on the website that helped him form a
business plan and project the cash flow and explored options for financing
with Nonprofit Assistance Fund loan officer Michael Anderson. “Michael was so
helpful, he made it seem possible. We talked through everything.” Anderson
was impressed that Rum River Health Services’ leadership recognized the
challenges of installing a new billing system and the uncertainty of when they
would begin receiving funds from the contracts: “It is very hard to predict how
long it could take. Obtaining additional working capital to smooth out this
transition was a smart management decision. Jeff acknowledged and planned
for the unexpected.” Larson describes the process of applying for a loan with Nonprofits Assistance
Fund as simple and easy, “We walked through everything over the phone.
Michael helped us consider different scenarios and offered useful suggestions.
And he provided hope—from the beginning he approached the project as
viable.” In Nonprofits Assistance Fund, Rum River Health Services found a
partner that provided resources, strategic guidance, capital, and realistic
optimism. Although Rum River Health Services encountered a series of
setbacks implementing the billing system, having cash in the bank helped. “We
had planned for uncertainty. Even without money coming in, we all knew it was
ok. But there is absolutely no way we could have done this without Nonprofits
Assistance Fund and the Minnesota Primary Care Fund.” If your organization needs working capital or facilities financing, Nonprofits
Assistance Fund can help. The Minnesota Primary Care Fund provides loans
and lines of credit to nonprofit health organizations in Minnesota. The fund is
supported by the Robert Wood Johnson Foundation and partners with the
Minnesota Department of Health’s Office of Rural Health and Primary Care to
meet the needs of nonprofit health care providers. Contact the Minnesota
Primary Care Fund at 612-278-7180 or www.nonprofitsassistancefund.org to
learn more.
top of page
SPECIAL FEATURE
HOW CLINICS CAN CHANGE THE WORLD
http://www.health.state.mn.us/divs/orhpc/pubs/quarterly/2011/spring.html#five[5/9/2011 8:41:52 AM]
Spring 2011 Quarterly Newsletter
Alcohol use and abuse is pervasive. Prenatal care that includes thorough and
regular screening and prevention of prenatal alcohol use—as a standard of
care for all clinics, medical providers, health departments and health insurance
companies—is a starting point for change. Primary care clinics have an
opportunity to take the lead on preventing fetal alcohol syndrome and its
devastating and widespread consequences.
Lydia Caros, D.O., executive director of the Native American Community Clinic
in Minneapolis, sees the impact of brain damage due to prenatal alcohol
exposure. She believes that of all the systems providing services to families
and children affected by alcohol use, primary care clinics are in the best
position to make a real difference. Says Dr. Caros, “Women struggling with
alcohol use will continue to use during pregnancy until we change our clinic
systems to address this issue.”
Fetal alcohol syndrome: a preventable disability
Prenatal alcohol exposure results in developmental delays and
neurobehavioral deficits that are irreversible. Yet it is entirely preventable.
Alcohol screening—as a regular part of prenatal health care that includes
education about the dangers of alcohol use during pregnancy—is the first step
to help women who struggle with alcohol abuse from exposing their babies to
its devastating and long-term impact.
If you’re not looking for it, you won’t find it
The Native American Community Clinic found that up to 70 percent of
pregnant women visiting the clinic were drinking prior to the first prenatal visit.
The clinic responded by:
Screening every pregnant woman with questions that address
how much and how often the patient drinks alcohol (not yes or no) at
every prenatal visit.
Asking about alcohol use patterns prior to the pregnancy;
this is the pattern that the mother will revert to if she comes under
stress.
Identifying her stressors, including depression, post-traumatic
stress disorder, domestic violence, lack of support from spouse or
family.
Providing resources and support for those stressors to help
prevent her from turning to alcohol use in a crisis.
Providing support and referral for treatment of chemical use if
indicated.
The clinic found that only 1-2 percent of the patients used alcohol again during
their pregnancy. Prior to the screening, they could assume that about 85 out
of the 120 babies born annually at the clinic were exposed to prenatal alcohol.
Over 10 years, 850 babies benefited from this approach in one small clinic in
one city, proving that clinics can make a difference!
http://www.health.state.mn.us/divs/orhpc/pubs/quarterly/2011/spring.html#five[5/9/2011 8:41:52 AM]
Spring 2011 Quarterly Newsletter
According to Dr. Caros, most women they see who are using alcohol are not
chemically dependent. With education and general support, most are able to
stop using during pregnancy. For those with dependency problems, these
simple efforts can help women stop using. Every small support a woman hears
from her provider can have an impact. If a mother is unable to stop using
during the first pregnancy, but the provider continues the message, she may
be ready for change in her next pregnancy. This is particularly important
because damage is cumulative. With each subsequent pregnancy
exposed to alcohol, there is potential for more damage to fetal
brain development.
How much is too much? There
is no known safe amount. If the
provider gives the message that
one drink will be “fine,” it opens
the door for a woman struggling
with use to cause significant
damage.
Identifying exposed children
Dr. Caros recommends that clinics seeing children should always ask about
prenatal alcohol exposure as part of the general history/data base in a way
that gives women permission to tell what they drink.
Ask a mother, “Did you drink during pregnancy?” If she says no, ask: “How about the first few months when you didn’t
even know you were pregnant?”
If she says yes, ask: "Was that on a daily basis?"
When she tells you how often, ask how much and be specific, e.g.,
“Was that four drinks (or a 12-pack) at a time?”
Follow-up for children exposed to alcohol use in pregnancy is critical. Children
with a history of exposure should be monitored carefully for developmental
and behavioral issues. An ideal time for an assessment is 3 to 5 years of age
(before entering kindergarten). A child’s specific needs and strengths will be
clear before they enter the school system, and they will be more likely to
receive needed help.
How clinics make the change
If the questions are asked respectfully and consistently, patients understand
and appreciate that the provider thinks the issue is important enough that it
needs to be addressed. Hearing this message from the provider has a
significant impact. That message also gets around in the community through
friends and relatives. What can be more important than protecting the brains
of the next generations?
A free toolkit with all the screening tools, education materials and counseling
messages very busy clinics can use to incorporate necessary screening is
available from Renee Gust, senior health promotion specialist for Hennepin
County Human Services and Public Health, at
[email protected].
http://www.health.state.mn.us/divs/orhpc/pubs/quarterly/2011/spring.html#five[5/9/2011 8:41:52 AM]
Spring 2011 Quarterly Newsletter
For more information, contact Dr. Lydia Caros at [email protected].
top of page
COMMUNITY FOCUS
HEALTH CARE HOMES: GROWING AROUND MINNESOTA
“Patient involvement leads to increased confidence and reduced anxiety.
Patients and their families feel more in control,” explains Connie Blackwell,
director of North Metro Pediatrics, an urban health care home.
"I feel better than I have in a really long time," said Mary Falk, a patient at
Lakewood Health System, a rural health care home.
Health care homes offer a significant redesign of care in Minnesota. Known
nationally as “medical homes,” health care homes focus on primary care and
develop a team of providers, patients and families to coordinate health and—
ultimately—contain or decrease health care costs.
Rural and Urban Safety Net Clinics Getting on Board
Minnesota developed a practical process so rural and urban practices of
varying sizes can become certified as health care homes, receive new
payments for care coordination and see benefits to the practice, its patients
and the health care system. Today Minnesota has 91 certified health care
homes and shortly that number will increase to 133.
Connie Blackwell, N.P., director of North Metro Pediatrics, says that as a nurse
practitioner-run, pediatric primary care clinic, North Metro’s focus was already
on teaching preventative care. Even before becoming certified as a health care
home, North Metro providers involved the family by giving them choices,
explaining their options and asking for their feedback. “Families are really
pleased because we take the time to follow through with their care,” says
Blackwell. Teaching a teenager with asthma how to use his inhaler and how to
recognize when he needs to talk to his mom or the school nurse involves the
patient in his own care. And that allows for more ownership, which yields better
outcomes.
“What is different about being a certified health care home is reimbursement,”
explains Blackwell. “We can now get reimbursed for some of the work we do
to coordinate and collaborate with families and outside resources, which is
especially important for children with complex and unique health care needs. If
patients have insurance they qualify for the health care home. If they do not
have insurance, they may not qualify; however, we treat all of our patients the
same whether we get reimbursement or not. We like to be able to coordinate
care for our patients because it benefits families.”
Lakewood Health System (LHS) was one of the first in the state to develop and
implement a state accredited health care home. Patients are now realizing the
benefits. Mary Falk, a Lakewood patient, describes the health care home as
http://www.health.state.mn.us/divs/orhpc/pubs/quarterly/2011/spring.html#five[5/9/2011 8:41:52 AM]
Spring 2011 Quarterly Newsletter
patient-and family-centered. “I feel better than I have in a really long time. I
don’t worry about my health like I used to because I know that at any time I
can call LHS and get the answers I need—from someone who personally
knows me and my health.”
With a laundry list of complicated medical problems and medications, Falk was
often told that hospice or the nursing home were her only choices. Her primary
care physician, Christine Albrecht, M.D., reports, “There’s no doubt that since
enrolling in our health care home, Mary is happier, healthier and living with an
excellent quality of life—at home. She is the perfect example of the kind of
patient who, when given appropriate care and access to that care, is more
likely to remain healthy, out of the hospital, and living as independently as
possible.”
With over 600 patients enrolled in Lakewood’s health care home, the
organization has seen reduced rehospitalizations for its high-risk patient
population and has received positive feedback from patients and family.
Health care homes contributing to state goals
In the innovative team approach of a health care home, the providers, families
and patients work in partnership to improve the health and quality of life for
individuals, especially those with chronic and complex conditions. Health care
homes develop proactive approaches through care plans, with patients and
families at the center. Increased care coordination between providers and
community resources results in even more continuity of care.
Minnesota’s Vision for a Better State of Health has a triple aim:
The health of the population
The patient experience of care and
The affordability of health care by decreasing the per capita cost.
Health care homes are an important component of that vision of improvement.
More health care home information is online at
http://www.health.state.mn.us/healthreform/homes/index.html.
top of page
VIEW ONLINE ALL PREVIOUS ISSUES OF THE OFFICE OF RURAL HEALTH AND PRIMARY CARE
PUBLICATIONS.
Minnesota Office of Rural Health and
Primary Care
P. O. Box 64882
St. Paul, Minnesota 55164-0882
Phone 651-201-3838
Toll free in Minnesota 800-366-5424
http://www.health.state.mn.us/divs/orhpc/pubs/quarterly/2011/spring.html#five[5/9/2011 8:41:52 AM]
Spring 2011 Quarterly Newsletter
Fax: 651-201-3830
TDD: 651-201-5797
www.health.state.mn.us/divs/orhpc
REGISTER NOW: THE MINNESOTA RURAL HEALTH
CONFERENCE IS JUNE 27-28 IN DULUTH
MISSION: To promote access to quality health care for rural and
underserved urban Minnesotans. From our unique position within state
government, we work as partners with communities, providers,
policymakers and other organizations. Together, we develop innovative
approaches and tailor our tools and resources to the diverse
populations we serve
http://www.health.state.mn.us/divs/orhpc/pubs/quarterly/2011/spring.html#five[5/9/2011 8:41:52 AM]