Volume 5 Number 4
©Minnesota Office of Tourism Photo
Q U A R T E R LY
Fall 2003
The mission of the Office of Rural Health & Primary Care is 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, policy makers and
other organizations. Together, we develop innovative approaches and tailor our tools and
resources to the diverse populations we serve.
Minnesota Rural Health Advisory Committee
Member Profile: ORHPC Talks with Dr. Darrell
Carter
Home:
Family:
Granite Falls
2 children, Dawn (31), Sheila (38), three grandchildren and wife of 26 years, Hazel,
a nurse.
Hobbies: Traveling, flying, golf, and spending time with family
Dr. Darrell Carter, Rural Health
Advisory Committee Member
Dr. Darrell Carter is a family physician with Affiliated Community Medical Center in Granite
Falls. He has been a physician in Granite Falls for 31 years, devoting his entire medical career
to Affiliated Community Medical Center and Granite Falls. In addition to being a family
physician, he is also the program director for the Comprehensive Advanced Life Support
Program (CALS) and a clinical professor in the Department of Family Medicine and Community
Health at the University of Minnesota Medical School (see “Comprehensive Advanced Life
Support: A True Life-Saver” on page 3). Dr. Carter was also named 2003 Family Physician of
the Year by the American Academy of Family Physicians and received the 2000 Minnesota
Rural Health Hero award. This list only scratches the surface of all of the projects Dr. Carter has
been involved in during his career.
Dr. Carter was raised on a farm near Ada and always knew he wanted to live and work in a
rural area. As he says, "I enjoy the rural life." In talking to Dr. Carter, it is obvious he truly
enjoys practicing in a rural area. Reflecting over his years of service, Dr. Carter added, "I can’t
think of anything I would rather do; it is a natural fit for me." He does acknowledge that rural
medicine presents its own set of challenges and demands, but feels the rewards are exponential.
Dr. Carter was appointed to the Rural Health Advisory Committee (RHAC) in 2003 and
serves as a physician representative. His involvement with CALS, the State Trauma Workgroup,
and the RHAC’s Rural Ambulance Study workgroup made applying for RHAC membership a
natural next step.
What do you think are the most important issues facing rural health today?
DC: I think there are two main issues facing rural health care today:
• Maintaining staff of rural health care providers such as physicians, midlevel practitioners,
nurses, and lab technicians, among many others, is becoming a critical issue for rural areas.
• And correlated with that is the need to maintain a staff that is trained and up to date with
the latest developments in the field of medicine. Because the medical field is changing so
rapidly, it is continually a challenge to keep abreast of those changes and to keep staff skills and
knowledge current.
Estelle Brouwer, Director
Karen Welle, Assistant Director
Stefani Kloiber, Editor
Other issues of concern are the medical-legal, and financial pressures on rural medical
facilities and providers. Rural health care providers are expected to provide the same level of
care as urban providers but with fewer resources.
What one or two changes do you think would make the most difference for rural
health?
DC: Change in both the payment and legal system have implications for helping to make a
See “Dr. Darrell Carter”
2
(back page)
PROGRAM FOCUS
Comprehensive Advanced Life Support: A True Life-Saver
By Angie Sechler and Stefani Kloiber
Imagine you are the only physician on call at a small hospital in southwestern Minnesota. At 2 a.m. you’re called to
the hospital. Each of the town’s two ambulances arrives with victims from a motor vehicle crash. One victim, a male
in his late teens, is babbling and trying to get out of neck and back restraints. A second teenager is bleeding profusely
from a large scalp laceration. A dazed toddler lies next to his young mother who is obviously pregnant and
complaining about abdominal pain. You and your team—one RN, one LPN, and four EMTs—must act quickly. Where
do you start?
Background on CALS
program is designed for members of health care teams
including physicians, nurses, physician assistants, nurse
practitioners, nurse anesthetists, paramedics, and others
who work in settings where they are exposed to lifethreatening medical emergencies but do not have the
luxury of referring to on-site specialty support.
Rural hospitals face many of the same health
emergencies as urban hospitals, with one big difference.
Rural hospitals often lack the resources that are
immediately available at urban facilities such as access to
backup staff, specialists, and diagnostic tools (for instance,
CT scanners). Added to this lack of resources is the
The CALS Course
nature of living in a rural area where distance and weather
The CALS course includes a comprehensive manual, an
can have a profound impact on the ability to transport
interactive classroom segment, and
seriously ill or injured patients to the
hands-on laboratory experience. All of
nearest hospital, let alone transferring
this is provided as an organized team
them to a larger facility. Thus, the
approach to advanced life support
survival of a patient in a rural
community depends upon the skills
"CALS makes everything training for front-line comprehensive
care providers who must confront the
and knowledge of a small team of
come together. It’s the
broadest range of medical emergencies.
"Jack-of all-trades" health care
The primary focus of the CALS training
professionals who need to be prepared
difference between
is to teach the knowledge and skills
to treat the wide diversity of lifethreatening emergencies that may
watching your 5-year old necessary to effectively treat lifethreatening emergencies before serious
present to their medical facility.
child’s ballet recital and
injury or cardiac arrest occurs.
The skills and knowledge of rural
going to see a Bolshoi
What difference has CALS made?
health care professionals were on the
minds of Drs. Darrell Carter and
ballet performance."
The first CALS course was taught in
Ernest Ruiz when they met at a
1996,
and since that time 73 courses
retreat for ambulance medical
have
been
conducted in 44
directors in the early 1990’s (see
communities
throughout
Minnesota
with more than 1500
“Rural Health Advisory Committee Member Profile:
health care providers being trained. The laboratory
ORHPC Talks with Dr. Darrell Carter” on page 2). Dr.
portion of the course has been conducted more than 230
Carter, a family physician in Granite Falls, and Dr. Ruiz,
times at the University of Minnesota and Hennepin
then chief of emergency medicine at Hennepin County
County Medical Center. While it may be too early to tell,
Medical Center, began to explore ways to provide this
the program seems to be having an impact on both the
knowledge and hands-on skill training in emergency
outcome of patients and the comfort level of providers.
medicine specifically for rural health care providers. It is
During the summer of 2003, the Office of Rural Health
from this discussion that a multi-disciplinary task force
and Primary Care conducted an onsite visit at a rural
under the umbrella of the Minnesota Academy of Family
hospital where many of the staff had completed the CALS
Physicians was formed. The purpose of the task force was
training. The purpose of the visit was to obtain
to create an advanced life support course for rural health
information on the impact of CALS training on practice
care providers.
patterns and, to the extent possible, health care outcomes.
Through this visit it became clear that CALS increases the
The outcome of the task force was the Comprehensive
comfort level of rural emergency personnel by exposing
Advanced Life Support (CALS) program. The CALS
See “A True Life-Saver”
(page 7)
3
ORHPC Quarterly talks with Assistant
Commissioner of Health Carol Woolverton
Commissioner Dianne Mandernach appointed Carol Woolverton assistant commissioner of
health in April 2003. Prior to this appointment, Ms. Woolverton was the education director
at Mercy Hospital and Health Care Center in Moose Lake. As education director, Ms.
Woolverton was responsible for assessing the health education needs of patients, residents,
and staff. She facilitated new employee orientation, regulatory training and customer service
training for all employees. In addition, she established Mercy as an accredited site for
nursing assistant and leadership and management training. She coordinated a Health
Occupations/First Responder/Nursing Assistant course offered at Mercy for the local high
school, and also served as adjunct faculty for the University of Minnesota as site coordinator
for the Rural Health School. Prior to working for Mercy Hospital, Woolverton was education
manager for Superior Memorial Hospital in Superior, Wisconsin. Woolverton is married and
has three sons.
SPECIAL FEATURE
Carol Woolverton, Assistant
Commissioner, Minnesota
Department of Health
As assistant commissioner of the Health Quality and Access Bureau Carol Woolverton
oversees the divisions of Facility and Provider Compliance, Community Health, Health Policy
and Systems Compliance, and Family Health. The Office of Rural Health and Primary Care is
within the Community Health Division, in the bureau Ms. Woolverton oversees.
The ORHPC Quarterly recently spoke with Ms. Woolverton about rural health care today.
What is your vision for the Minnesota Department of Health?
My vision for MDH is for it to be a central partner in connecting communities throughout
Minnesota. When I visualize the state of Minnesota I see one large and diverse community
that is a collection of many small communities. It is within this collection of small
communities where the real work takes place. One way MDH can assist with this is by being
a central partner and serving as a facilitator and resource for all communities – rural and urban
– in Minnesota. In particular, the department can assist communities in building their own
collaboratives, partnerships, and networks. MDH can also help communities by promoting
and supporting them in different capacities such as grant funding, technical assistance and
expertise, and the sharing of other resources.
Partnerships are especially important during these times of dwindling dollars. We need to
begin to look outside the box to find solutions. MDH, with all of its resources, can help bring
communities together by linking them with resources to establish collaboratives, partnerships,
or networks. Through these collaboratives, communities can search for new resources and
pool new and existing resources to find creative solutions. Working together we can try to
achieve MDH’s mission of improving, protecting and maintaining the health of all
Minnesotans.
What are your priorities for rural health as Assistant Commissioner of Health?
This is not an easy time to be part of health care and particularly rural health care. There
are so many challenges facing rural health care such as health care access, high health care
costs, workforce shortages, mental health issues, emergency preparedness, and health
disparities, to name a few. These are the same challenges that urban areas face, but the issues
are amplified in a rural community. Resources to rural communities are decreasing while
they are being asked to do more and more. How do we meet these challenges?
4
One of my priorities in meeting these challenges is to facilitate,
promote, and support the collaborations that are imperative to
rural communities. Having worked in rural communities
throughout my career, I have found they are also uniquely
talented at collaborating and creating partners because of their
limited resources. I have also found they are very resourceful at
finding innovative solutions.
Another key priority is to maximize the relationship between
the Rural Health Advisory Committee (RHAC) and MDH. Both
Commissioner Mandernach and I feel very strongly about being a
physical presence on the RHAC. The committee is an important
link to the issues confronting rural communities and rural health
care and what MDH, as partner, can do to help find solutions.
program is a major positive for rural communities from an
economic standpoint. The economy of many of our rural
communities is based on the health care industry; they are often
times the largest employer. Remaining financially stable is often a
challenge for them and this program is one positive step towards
allowing that capability.
However, even the Critical Access Hospitals have workforce
issues to contend with. The workforce is getting older and there
are fewer graduates coming from the health care professions
programs creating a large gap in the health care workforce.
Adding to that is the availability of specialty health professions in
rural areas. It is becoming increasingly difficult to find nurses and
physicians to work in a rural area and nearly impossible to find
radiology and laboratory
technicians.
A third priority is directed
at enhancing the rural health
The recruitment and
care workforce by
retention of health care
supporting programs that
professions will be even more
create incentives for
"Having worked in rural
important as we move into
students and graduates to
communities
throughout
my
the future. Programs like the
work in rural areas. Loan
Rural Health School and the
forgiveness programs are one
career,
I
have
found
they
are
loan forgiveness programs I
way for students to
mentioned previously have
experience the rural life
uniquely talented at collaborating
helped. But more needs to
while also reducing their
be done to place students in
school debt. Another
and creating partners because
rural communities where
program, the Rural Health
of their limited resources.
they can experience their
School, is a great example of
profession from a rural
academia and health care
I have also found they are very
perspective and have the
collaborating to help address
opportunity to see the
rural health care workforce
resourceful at finding
uniqueness, richness, and
issues. After this year, the
strengths of the collaborations
Rural Health School will
innovative solutions."
and partnerships that are
become a part of
foundations in a rural
Minnesota’s new Area
community.
Health Education Center
(AHEC) program, which emphasizes community based training of
On a final note, I would like to say how impressed I am by the
health care professionals through community/academic
work performed here at MDH. Being new to the department and
partnerships.
to state government, I was immediately struck by the breadth and
depth of this department. I had worked previously with the
These are just a few of my priorities for rural health. I have
department in other capacities; I had a good concept of the scope
many more priorities than I can list here.
of work the Health Department performs. Now as an assistant
Could you say more about the future of rural health?
commissioner, I am even more awed by the diversity of the work
performed at MDH on a daily basis. There are a lot of great
While times are definitely tough for rural hospitals and for rural
things happening at MDH; I am proud to be a part of it. It has
health overall, there are many positive programs to build on. One
and will continue to be an exciting journey.
such program is the Critical Access Hospital program. This
5
DIRECTOR’S CORNER
Minnesota Rural Health Stars Represent the Rural Health
Spectrum – From Prevention to Emergency Care
By Estelle Brouwer and Stefani Kloiber
In Minnesota, we have many stars when it comes to
providing high quality, patient-friendly rural health care.
Every year since 1999, a few of those stars have received
special recognition as recipients of Minnesota’s rural
health awards. This year’s awardees – Rural Health Hero
Darrell Smith of the Cook County Ambulance Service
and the Madelia Hospital’s "Fight the Fat" Team – are
truly outstanding representatives of Minnesota’s rural
health community. What is more, these two awardees
represent opposite and equally important ends of the
health care spectrum – prevention and emergency care.
The diverse contributions of these awardees serve as a
reminder that every part of the rural health system is
critical to maintaining a healthy population and healthy
communities.
Darrell Smith, Cook County Ambulance Service
For more than 29 years, Smith has been an Emergency
Medical Technician for the Cook County Ambulance
Service, beginning as a volunteer and now serving as the
director of the ambulance service. Smith has been a
leader in providing instruction and mentoring to
countless EMTs throughout the Cook County area. He
was instrumental in obtaining a grant to implement a
pilot EMT training program for high school students to
encourage young people to become involved in the first
responder programs in the area. For 20 years he has been
a CPR instructor and is also an EMT/FR instructor at
Hibbing Community College.
His daughter, Lisa Bolen, who is also an EMT,
nominated Smith for the award. Bolen says her dad is
her hero "because his compassion and calm, caring
attitude as well as his knowledge of lifesaving medical
skills, helps our patients and families feel comfortable and
well taken care of in a time of crisis."
Madelia Hospital "Fight the Fat" Program
In the spring of 2003, Madelia Community Hospital
challenged the residents of Madelia to "lose a ton" of
weight through a 10-week "Fight the Fat" program.
Nearly 250 people and one dog participated in the
program, which included an enrollment fee of ten dollars,
weekly meetings with individual weigh-ins, health
screening services, and speakers on nutrition, physical
fitness and motivation. The program emphasized a team
approach with teams selecting such names as the Fat
Losers, Jelly Bellies, Chubby Checkers, Plump
Parishioners, and the Dixie Chunks. Madelia met their
goal of losing a ton after just eight weeks of the program,
with a total loss of 2,115 pounds.
“Fight the Fat” team members receive their Rural
Health Team Award.
The impetus for "Fight the Fat" came from Deb Grote,
a patient billing coordinator at Madelia Community
Hospital. After indulging in a Thanksgiving Day dinner
and lying on the couch to rest, she watched a television
program about the residents of Dyersville, Iowa, who
together shed hundreds of pounds. Feeling inspired by
the successes of this small town, Deb gathered her
friends and spoke with her colleagues at Madelia
Community Hospital about starting a similar program for
Madelia.
Congratulations, one and all!
Rural Health Hero Darrell Smith and daughter Lisa
Bolen.
6
Estelle Brouwer is director of the Office of Rural
Health and Primary Care. She can be reached at
(651) 282-6348/[email protected]
A True Life-Saver
(continued from page 3)
them to procedures rarely encountered on the job and that CALS
has improved the speed and efficiency of transferring critical
patients to higher levels of care.
What’s next for CALS?
The program has received numerous accolades and recently
reached beyond Minnesota borders and across international
waters. In September, the University of Minnesota Medical
School hosted CALS training for the United States Department of
State, Foreign Service Medical Providers. Approximately 120
physicians, nurse practitioners, and physician assistants assigned
to U.S. embassies around the world participated in a weeklong
series of emergency medical training courses, part of which
included CALS training, as well as training in tropical medicine,
bioterrorism and disaster preparedness.
Some providers’ thoughts about CALS
To sum up, here are a few comments from CALS trained health
care professionals – in their own words:
"CALS has definitely improved our speed and efficiency. CALS
allows us to be much more comfortable with trauma cases and
to anticipate the patient’s needs, and be better prepared for
them." – Nurse
"Before CALS, I wouldn’t have thought about equipment
needed in my clinic. No alternative to CALS exists that teaches
a rural clinic physician about equipment." – Physician
"CALS makes everything come together. It’s the difference
between watching your 5-year-old child’s ballet recital and
going to see a Bolshoi ballet performance." – Physician
Photo courtesy of the CALS Program
Interest in the CALS course has grown tremendously over the
years; demand for the course is nearly surpassing the capacity to
provide it. At present, the course has been offered only in
Minnesota. There is, however, interest in expanding the program
nationally. The course was largely developed as a grassroots effort
with help mostly from volunteers; according to CALS staff, the
expansion of the program will require more resources in terms of
funding and staff.
CALS has received funding that has aided in the addition of
more programs for health care providers in Minnesota. Funding
provided by the Office of Rural Health and Primary Care is
assisting Critical Access Hospitals to obtain CALS training for their
emergency department staff. In addition, a grant from the
Minnesota Emergency Medical Services Regulatory Board helps to
defray tuition costs.
Students practice during a CALS training.
To learn more about the CALS program, visit their Web site at http://www.mafp.org/cals.asp
Angie Sechler is a health services/workforce research analyst for the Office of Rural Health and Primary Care. She can
be reached at (651) 282-6329/angie.sechler.state.mn.us
Stefani Kloiber is the editor of this publication, and can be reached at (651) 282-6338/[email protected]
Thank you to Dr. Darrell Carter, Kari Lappe, and Minnesota Medicine for their contributions to this article.
7
To learn more about the
Office of Rural Health & Primary
Care programs, visit our Web site:
www.health.state.mn.us/divs/chs/
orh_home.htm
Dr. Darrell Carter
(continued from page 2)
difference in rural health care. First and foremost is equal reimbursement for equal work. For
example, the average income for nurses in rural areas is less than their urban counterparts.
This discrepancy in payment creates competition between rural and urban health care
facilities, making it difficult to maintain a health care staff in rural areas.
The high cost of malpractice insurance is also having a negative impact on rural health care.
Many providers are not willing to assume the challenges of rural medical practice due to their
concerns over malpractice. Reducing the threats associated with malpractice would help rural
health care.
Finally, providing training for people to work in rural areas is very important. Health care
that is provided in a rural area is different from that provided in an urban area. Rural health
care providers need to be trained to handle the wide range of conditions that they encounter
and need to treat on their own without the luxury of having all the latest in equipment or
specialists readily at hand.
This information will be made
available in alternative format –
large print, Braille, or audio tape
– upon request.
Printed on recycled paper with a
minimum of 20% post-consumer waste.
The Rural Health Advisory Committee advises the Commissioner of Health and other state
agencies on rural health issues, provides a systematic and cohesive approach toward rural
health issues, and encourages cooperation among rural communities and among providers.
Meetings are regularly held at the Snelling Office Park at the corner of Energy Park Drive and
Snelling Avenue in St. Paul and are open to the public. For dates, times, and directions, visit
the Web site at www.health.state.mn.us/divs/chs/rhac/meetings.htm or contact Tamie
Rogers at 651-282-3856/[email protected]
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