Fall 2010 Quarterly Newsletter
CONTENTS:
Director's Column
Partner Focus
Community Focus
Special Feature
FALL
2010
Printable PDF
(PDF: 206KB/11pgs)
Email Mary Ann Radigan at
[email protected]
or call 651-201-3855 with
comments.
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newsletter to your colleagues.
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DIRECTOR'S COLUMN
GET READY FOR PAYMENT REFORM
Major reforms are in motion to better align payment for health care services
with actual health outcomes. In Minnesota, payments are now available to
certified health care homes. Further quality incentives, such as baskets of care
and provider peer grouping are on the horizon. Payment changes in the federal
health reform law will roll out nationally over the next decade. Health insurance
exchanges, accountable care organizations, value based purchasing, bundled
payments and Medicaid expansions are expected to alter the financial
landscape for every provider and facility.
Mark Schoenbaum
As Medicare, Medicaid and
insurance companies modify
how they pay for health
services, large health systems
and networks will be exploring
how to advance their positions
and best serve their patients.
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A central concept will be to
integrate systems of care both
financially and clinically in
hopes of improving health
outcomes and reducing costs.
Though some of these forces
will be outside the control of
any single organization, small
and safety net providers can
prepare themselves now for
success by focusing on some
fundamental building blocks of
payment reform.
These are:
Health care homes and care coordination. Improved
coordination is explicitly required in many of the new models.
Opportunities such as health care home designation are available in
Minnesota, and rural providers especially have deep experience in
coordinating care on behalf of their patients.
Quality reporting and improvement. Providers will be appraised
on both quality information and outcomes, with a share of their future
reimbursements based on results.
Networking and partnerships. Collaboration is integral to systemic
approaches like Accountable Care Organizations. These new entities
will be motivated to deliver comprehensive care and achieve quality
outcomes for the lowest cost possible. Size will be a critical variable in
achieving the financial reserves and patient volumes needed to be
viable, with small and community-level health care providers under
increasing pressure to join with larger entities in some fashion. Though it
may become harder to remain entirely independent, payment reforms do
not require that all independent providers either be acquired or
disappear. Safety net and rural providers have much to offer, and those
without connections to networks and care systems must begin to explore
mutually beneficial partnerships now to remain community institutions
and retain independent identities.
Heath Information Technology. Electronic health records systems
will play a key supporting role in payment reform models. Providers will
be expected to exchange clinical information when coordinating patient
care with partners and to document quality results from information
embedded in electronic records.
Cost control. Federal health reform will bring more privately insured
and Medicaid patients into the market, and payment for many of these
patients will be lower than some safety net providers receive under costbased and similar reimbursements. Cost control will also be increasingly
important as systems seek partners to produce shared savings.
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Despite many unknowns, it’s clear that payment reform will conjoin these
building blocks. Working on these fundamentals individually and together can
build a foundation for success in an uncharted future. Minnesota’s health care
safety net is successful because it knows how to be nimble, and I’m confident
it can succeed in the coming reform era.
As always, please call on us for assistance. The Office of Rural Health and
Primary Care has direct expertise in a number of these building block areas,
and we can point you to other resources as well.
Mark Schoenbaum is director of the Office of Rural Health and Primary Care and can be
reached at [email protected] or 651-201-3859.
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PARTNER FOCUS
HEALTHY MOMS—HEALTHY BABIES
by Cheryl Fogarty, P.H.N., M.P.H. Infant Mortality Consultant, Minnesota Department
of Health-Maternal and Child Health
Factors that generally decrease
the likelihood of an infant death
among White mothers —such
as being married, having a
college education and being
tobacco free—do not equally
protect infants of African
American and American Indian
mothers.
The death of an infant in the first year of life has a profound impact on families
and communities and is an indicator of the health and well-being of a
population. Averaging fewer than five infant deaths per 1,000 live births
annually, Minnesota has one of the lowest infant mortality rates in the country—
but not among all populations. Disparities greater than two-fold exist among
American Indians and African Americans. Eliminating this disparity has been
elusive.
Factors that generally decrease the likelihood of an infant death among White
mothers (e.g., being married, having a college education and being tobacco
free) do not equally protect infants of African American and American Indian
mothers. African Americans and American Indians have higher rates of infant
mortality regardless of timing of initiation of prenatal care. Even full-term and
normal birth weight infants of African American and American Indian mothers
are two to three times more likely to die in Minnesota than full-term and normal
birth weight White infants.
The Minnesota Department of
Health studied deaths of
Minnesota’s American Indian
babies that occurred in 20052006. Some of the women
interviewed reported poor
care, poor communication or
insensitive remarks at the time
of their baby’s death. The
case review team determined
that institutional racism in the
health care system was a high
priority issue and formed a
work group to address it. The
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project report is online (PDF:
826KB/100pgs).
Maintaining awareness that American Indians and African Americans are more
at risk of an infant death is a first important step for providers and facilities to
take along with focused patient education using cultural common sense and
respect.
Six Steps to a Healthy Mom and Baby
So where do we start when it seems overwhelming to address all the causes?
These six steps focus our efforts:
1. Preconception and inter-conception care. Pregnancy outcomes are
best for women who enter pregnancy with optimum health status from
comprehensive primary health care throughout their reproductive years.
2. Early and regular prenatal care. Referrals to local public health
agencies are helpful in identifying and assisting with conditions such as
depression, stress, substance use, poor nutrition, intimate partner violence, lack
of resources and social isolation.
One of Minnesota’s potential barriers to prenatal care was recently lifted with
legislation eliminating the mandate for providers to report women’s use of
marijuana and alcohol during pregnancy. This amendment leaves the approach
to take to the provider’s judgment. Information on substance abuse in pregnancy
is on the March of Dimes site and the Minnesota Organization on Fetal Alcohol
Syndrome site.
3. Healthy weight and nutrition. Strategies to
prevent overweight and obesity in children and adults
begin during fetal development in pregnancy by
moderating a mother’s weight gain, and continue in
infancy by supporting exclusive breastfeeding for at least
six months. To refer pregnant women with low incomes to
Minnesota’s Women, Infants and Children Nutrition
Program (WIC) for nutrition services, call 800-942-4030.
4. Being smoke free during pregnancy results in fewer miscarriages,
stillbirths, preterm and low birth weight births, and lowers an infant’s risk of
dying of Sudden Infant Death Syndrome (SIDS) threefold. Tobacco use impacts
thousands of pregnancies in Minnesota each year, more in greater Minnesota
than in the metro. Pregnancy is often a great motivator for women to quit
smoking. Health care providers can provide the needed support and counseling
by using the 5 As and referral to our state’s Quit Plan program.
5. Breastfeeding is vital for maternal and infant health and reduces health
care costs.
6. Safe infant sleep. The leading cause of death for American Indian infants
is a combination of Sudden Infant Death Syndrome (SIDS) and other sleeprelated asphyxia/suffocation deaths due to unsafe sleep environments. It is the
third leading cause of death for White, Hispanic and African American infants.
Minnesota’s Safe and Asleep campaign and parent education materials are
most helpful when presented and modeled for parents of newborns at the
hospital.
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A Word About Cesarean Sections
Although Cesarean sections save lives of both mothers and babies, they also
increase the risks of complications and set women up for Cesarean sections in
future pregnancies. In Minnesota about 27 percent of deliveries are by
Cesarean section. The March of Dimes has an initiative to decrease Cesarean
sections and late preterm births by hospitals establishing a protocol for no
elective inductions before 39 weeks. It is often a failed induction that stresses
both mother and fetus and leads to an emergency Cesarean section. These
babies have morbidity and mortality rates significantly higher than full term
babies.
Looking Ahead
Even though Minnesota’s infant mortality rate is one of the better state rates, it
is important to remember that more than 400 deaths occur every year. The
multiple and complex causes of infant deaths require all of our efforts, strategies
and innovations. Most important is the ongoing collaboration and communication
we have with primary care providers and our local public health and tribal health
partners. Our newborn intensive care units and neonatologists are among the
world’s best and save babies’ lives every day. Our goal, however, is to prevent
both high risk births and the needless deaths of healthy infants through ongoing
health promotion and education across the life span.
Tools
Text4baby* is a free mobile information service
designed to help young pregnant and parenting women
care for their health and give their babies the best
possible start. Women who sign up for the service by
texting BABY to 511411 (or BEBE for Spanish) receive
free text messages each week, timed to their due date
or baby’s date of birth. The Minnesota Department of
Health is an outreach partner of this national program.
Stratis Health’s Culture Care Connection website has valuable resources and
advice for health care organizations to assess and address institutional racism.
The Centers for Disease Control and Prevention (CDC) identified breastfeeding
as an important intervention to prevent childhood obesity, July 2007 (PDF:
1MB/8pgs).
A June 2008 CDC report describes what hospitals can do to support
breastfeeding.
Minnesota’s WIC website on breastfeeding and Peer Support
Birthing hospitals in Minnesota can attain the World Health Organization’s BabyFriendly designation.
Minnesota Department of Health Infant Mortality Reduction Initiative
Disparities in Infant Mortality Report, January 2009 (PDF: 4MB/66pages)
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The Academy's goal is to
continue to see more than 90
percent of the graduates move
on to post-secondary education
and ensure that at least half are
embarking on training in a caring
profession.
COMMUNITY FOCUS
TWIN CITY HIGH SCHOOL STUDENTS TRAIN FOR HEALTH
CARE JOBS
In 2005, the Augsburg Fairview Academy began preparing Twin Cities high
school students for careers in health care. The charter public school in
Minneapolis helps students from disenfranchised communities explore health
careers and other caring vocations, receive training and certification, and go
on to college. Students gain work experience in professional settings, earn
early college credits while still in high school, and 90 percent of graduates go
on to college. The idea for the school arose from its cosponsors: Augsburg
College was committed to creating accessibility for traditionally underserved
urban students and Fairview Health Service’s goal was to give more youth a
first-hand view of vocations in health care.
The Academy opened in September 2005 and held its first year’s classes in
Saint Paul. It shared a building with Great River School and served an
enrolling class of 42. In the 2006-2007 academic year, the Academy relocated
to Minneapolis and enrollment has grown each year. Enrollment for 2010-2011
is approximately 120 students.
College approach to high school
Augsburg Fairview Academy offers classes Monday through Thursday with
intensive academic support after school and on Fridays. There are also flexible
afternoon/evening classes offering assisted online learning for students
interested in self-directed study. One licensed teacher to 15 students and
computers for all the students further encourages academic success.
In the teen (and family) friendly atmosphere, Academy students are treated
like adults to encourage motivation and self-discipline. The students are given
trust and independence—such as an unlimited bus pass—with the expectation
that they will conduct themselves as responsible and self-directed learners.
The College Fast Track program offers an accelerated curriculum that makes
it possible for incoming ninth grade students to complete all required credits in
state-mandated subjects by the end of their junior year. Students can also
take subsidized paraprofessional and preprofessional courses at local
community colleges and post-secondary training programs. These students
graduate with college credits and health care certification as nursing
assistants, practical nurses, home health aids, dental assistants or
electroneurodiagnostic technicians.
Post-secondary enrollment options (PSEO) are available in 12th grade.
Through PSEO, students earn simultaneous high school and college credits. A
student who begins PSEO as a junior could earn an Associate’s degree by
high school graduation.
In addition to College Fast Track as a path to earning early college credit, the
Academy offers students the opportunity to study Advanced Placement
courses through the Self-Directed Learning Program of assisted, online
courses.
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Once students graduate, two years of college are available tuition free through
the Power of You program at Metropolitan State University, Minneapolis
Community & Technical College and St. Paul College. This initiative is
intended to significantly increase the post-secondary participation rates of
Minneapolis and St Paul high school graduates, particularly students of color.
To guide and support students making plans for college and a future career,
each year students must enroll in a course focused on college and career
readiness. Students explore career choices and college options. They learn
the “ins and outs” of applying to college and preparing financial aid
applications. And perhaps the strongest motivator, they learn from college
students and health professionals what to expect when they leave high school.
Future plans
The school’s focus remains on an effective college prep program for students
having difficulty with high school studies. The need for academic support
among Academy students is so great that the school has decided to increase
its resources for direct support in this area by adding a full-time lead teacher.
To address the unmet demand to help students deal with social and emotional
problems that threaten to overwhelm them, the Academy is also adding an
individual with long experience in social work to serve half time in student and
family support and half time as the school’s college and career coordinator.
Along with a strengthened faculty and staff, the Academy is bolstering
collaborations with post-secondary institutions and a growing list of health care
providers. The Academy has set a goal of ensuring that every student will
show one and a half years of academic growth in reading, writing and math
each year, and every student will have multiple opportunities for personal
contact with local health care providers each year. In addition, the Academy
will continue to see more than 90 percent of the graduates moving on to postsecondary education and ensure that at least half are embarking on training in
a caring profession.
More information is on the Augsburg Fairview Academy website.
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SPECIAL FEATURE
TELEMENTAL HEALTH: CAN IT WORK FOR RURAL MINNESOTA?
Real time video exchange for
consultation and care is
available in a growing number
of rural community health
centers, primary care clinics,
hospitals and emergency
departments.
Five years ago the Rural Health Advisory Committee (RHAC) studied and
reported on Mental Health and Primary Care in Rural Minnesota. The
committee examined national health care trends, surveyed rural primary care
clinic providers on mental/behavioral health issues, examined Critical Access
Hospital mental/behavioral health emergency room visits, and highlighted
examples of promising practices for provider education and care delivery.
The committee found that:
Rural primary care providers were seeing an increase in
mental/behavioral health patients in their clinics. Primary care providers
initiated most mental health diagnoses and were often the prescribers of
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necessary medications for mental health conditions.
The shortage of rural mental health providers resulted in long waits for
appointments and long distance travel to obtain care.
The cost of mental health care and the complexity of payment systems
were barriers for patients seeking care.
Stigma about mental/behavioral health problems was a barrier to care,
especially in rural areas.
Rural primary care practitioners were interested in more education on
managing mental/behavioral health.
Acknowledging that rural mental health access depends not only upon a strong
primary care foundation, but also requires a variety of innovative models of
delivery, the Rural Health Advisory Committee decided to take a deeper look at
another important tool—telemedicine. Telemental Health in Rural Minnesota is a
report that follows months of study and discussion, and proposes some
solutions for strengthening telemental health services in Minnesota
Telemental Health
The findings of five years ago remain true today. Primary care remains the de
facto access point for the majority of rural patients with psychiatric disorders. To
obtain screening, diagnosis and treatment, rural residents must often wait
weeks and even months for an appointment with a mental health professional
and travel great distances to receive services. Costs to health care systems are
great when people in mental health crises end up in emergency rooms.
Telemental health is an important tool for accessing mental health services in
rural Minnesota. Real time video exchange between remote sites for
consultation and care is available in a growing number of rural community
health centers, primary care clinics, hospitals and emergency departments.
Telemental health is an important tool to enable consultations between rural
mental health and primary care providers and connect these providers to
education and training opportunities. As access to and understanding of the
technology increases, telemental health services could reach patients in more
settings such as nursing homes, schools, prisons and individual households.
Benefits
Benefits of telemental health in rural Minnesota include:
Increased access. All mental health procedures that are delivered in
person can be delivered remotely via telemental health, giving patients
access to providers outside of their geographic area.
Better outcomes. Earlier intervention and easier access helps
patients engage in their care and, ultimately, improves mental health
outcomes and saves health care costs.
Cost-effective. More than 85 percent of patients seen via telemedicine
remain in their communities, enhancing the financial viability of the local
community hospital or clinic. Costs are reduced overall for patients,
providers and health systems.
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Enhanced coordination of care. Research shows that patients
most often discuss their mental health concerns first with their primary
care physician. Telemedicine promotes the integration of primary care
and mental health by providing easy access to psychiatric consultations
for family physicians. It creates opportunities to engage mental health
providers on the patient care team.
Barriers
Barriers to telehealth are common across many settings; however, certain
barriers are somewhat unique to telemental health, including:
Information and Training. Minnesota lacks a central resource for
telemental health information and training. Each facility or organization
embarking on the provision of telemental health services must locate its
own resources and information, causing a great duplication of effort.
Reimbursement. A lack of uniform, consistent and equitable
reimbursement for telemental health services creates a significant barrier
to providing the service.
Infrastructure and Technical Support. Telemental health cannot
happen without Internet connectivity and equipment. There is inconsistent
broadband coverage throughout Minnesota. Technical start-up costs
associated with telemental health can be cost prohibitive, especially for
small, independent facilities and providers.
Workforce. There remains a shortage of mental health providers in
rural Minnesota. The number of psychiatrists and nurse practitioners
certified in adult or child psychiatry has decreased. A limited number of
psychologists and licensed clinical social workers are practicing in rural
areas.
Recommendations
Detailed recommendations are in the complete report (PDF: 61 pages /879KB).
A few highlights include a telemental health resource hub for health care
professionals; a committee to address statewide payment, administration and
regulatory barriers in the context of federal regulations; funding for telemental
health equipment; and loan forgiveness for telemental health providers.
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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
Fax: 651-201-3830
TDD: 651-201-5797
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www.health.state.mn.us/divs/orhpc
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
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