Volume 5 Number 3
PHOTO COURTESY OF MINNESOTA DEPARTMENT OF TRADE AND ECONOMIC DEVELOPMENT
Q U A R T E R LY
Summer 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 Rhonda
Wiering
Home:
Family:
Tyler
4 children, Matt (22), Emily (20), Joel (17), Nick (12) and husband of 23 years,
Ron, a farmer.
Hobbies: Gardening, reading, exercising, and horses
Rhonda Wiering, Rural Health
Advisory Committee Member
Rhonda Wiering is a registered nurse and is currently the patient care director for Tyler
Healthcare Center in Tyler. The Tyler Healthcare Center includes a clinic, nursing home, home
care and hospice services, and the hospital, which was recently designated as a Critical Access
Hospital. Rhonda has devoted her entire nursing career to Tyler Healthcare Center, learning
first-hand about the various departments within it. She began working at the facility in 1977
while still in college and 25 years later, is now the patient care director overseeing all of the
patient care departments within the Center.
Rhonda became involved in rural health care by virtue of where she lives and works. Living
in a rural area and being a part of rural health care, she knows the challenges rural health care
faces on a daily basis. Rhonda believes that in order for rural health organizations to survive,
they have to be willing to change. Change is something Rhonda is not afraid of, and she is
willing to take on that challenge to help move rural health care forward.
Rhonda was appointed to the Rural Health Advisory Committee (RHAC) in 1999 and serves
as a registered nurse representative. Recently, Rhonda took on the additional task of chairing
the mental health and primary care workgroup, a subgroup of RHAC, working on access to rural
mental health and primary care services. She became involved in the committee because she
was interested in learning more about health care legislation and how rural health could better
position itself to provide the best patient care. Rhonda sees her role on the committee as an
opportunity to be a voice for rural health care from her corner of the state.
What do you think are the most important issues facing rural health today?
RW: I think there are three issues facing rural health care today: access to primary health
care services, adequate reimbursement, and the shortage of health care professionals.
Estelle Brouwer, Director
Karen Welle, Assistant Director
Stefani Kloiber, Editor
•
Access to primary health care services includes both the supply of physicians and midlevel practitioners and access to services such as mental health, dental, and
pharmacies/pharmacists in rural areas.
•
Adequate reimbursement is always an issue; however, being a Critical Access Hospital
does help. Smaller facilities don’t have the volume of patients of larger facilities so the
issue of reimbursement will continue to be a challenge.
•
The shortage of other health care professionals beyond physicians and mid-level
practitioners is becoming critical for rural areas. I would add nurses, EMT’s, radiologists,
dentists, pharmacists, ophthalmologists, and lab technicians as other professions that are
or will soon be in short supply for rural areas.
What one or two changes do you think would make the most difference for rural
health?
RW: I would like to see more equity in reimbursement. Unless there is equity in
reimbursement for urban and rural, state-of-the-art rural health care will be impossible to
See “Rhonda Wiering”
2
(page 8)
PROGRAM FOCUS
Findings from the Minnesota Registered Nurse Workforce
Survey
Minnesota schools do not prepare all of the RN graduates
needed to fill positions in the state. Eighty-six percent of
the state’s RNs with an associate degree received that
degree from a Minnesota institution. The proportion of
diploma and baccalaureate prepared nurses who received
their education in Minnesota was slightly lower — 72
percent and 70 percent respectively.
By Michael Grover
Encouraged by the state’s nursing educators, health care
providers, and professional nursing organizations, the
Office of Rural Health and Primary Care (ORHPC) initiated
an effort to collect detailed nursing workforce data that
could be used by policy makers and workforce planners to
address the current shortage of RNs. In early 2002,
ORHPC sent a survey to a sample of actively licensed RNs
across practice settings in the state. Approximately 3,645
randomly selected RNs from eight regions of the state
were selected to participate in the survey. A total of 2,274
completed surveys were received for a response rate of
62.4 percent. A summary of the report, Findings from the
Minnesota Registered Nurse Workforce Survey, is
presented below.
On average, RNs working outside of Minneapolis
and St. Paul earned less. RNs earned, on average,
$26.70 per hour at their primary worksite. Those RNs
working in Minneapolis and St. Paul earned, on average,
$29.18 or about $2.50 per hour more than the state
average. RNs in Greater Minnesota earned $24.12 per
hour or about $2.50 per hour less than the state average
and almost $5.00 per hour less than RNs working in
Minneapolis and St. Paul.
What do the survey results tell us?
An estimated fifteen percent of active RNs
Most RNs (70 percent) identified “to comfort and
planned to leave nursing in the next two years.
care for those in need” as one of the top three
Using the most recent employment estimate for the state’s
things that motivated them
to select a career in nursing
(see figure 1). About half
Figure 1: Reason for Choosing a Career in Nursing
chose nursing because it is a
(Top Three Reasons)
respected profession and 40
percent were influenced by a
To comfort and care for
friend or relative.
others
The RN workforce was
predominantly white, nonHispanic (98 percent). Even
though more students of color
have entered Minnesota
nursing educational programs
in the last few years, the racial
and ethnic distribution of RNs
will not reflect the larger
demographic make-up of the
state’s population for many
years if current trends
continue.
RNs typically cross
regional, state, and national
boundaries in search of
employment, either after
graduation or upon leaving
a job. Survey findings
underscore the fact that
Respected profession
Influenced by
relative/friend
Personal health care
experience
Flexible work schedule
Salary/Benefits
Limited opportunities in
other careers
First
Career advancement
Third
Second
Other
Career counseling
0%
10%
20%
30%
40%
50%
60%
70%
80%
Percent of RNs
See “Workforce Study”
(page 7)
3
ORHPC Quarterly talks with Commissioner of
Health Dianne Mandernach
Dianne Mandernach was appointed Minnesota Commissioner of Health by Governor Tim
Pawlenty on February 3, 2003. Prior to this appointment, Mandernach was the chief
executive officer at Mercy Hospital and Health Care Center in Moose Lake. She began at the
hospital as an admitting clerk in 1987, followed by stints as director of human resources and
associate administrator, before becoming the CEO. Prior to working in health care,
Mandernach spent eleven years teaching science, math, and English to junior high school
students. At the time of her appointment, she was secretary/treasurer for the Minnesota
Hospital Association Board of Directors and had served as a member of the board since
SPECIAL FEATURE
Dianne Mandernach, Commissioner
of the Minnesota Department of
Health
1997.
Commissioner Mandernach recently spoke with the ORHPC Quarterly.
What is your vision for the Minnesota Department of Health?
My vision is that MDH be at the center of an ever-expanding ring of partners. As the center,
we are the leader, the facilitator, the convener, and the resource for all who have a role in
addressing public health issues.
Having said that, the first and primary circle of partners is that of the local public health
agencies. That is where the rubber meets the road. This is where actual impact on health is
made – in communities, large and small – throughout this state. We will work to enhance
and strengthen the partnership between MDH and local public health agencies. Other circles
move out from there… hospitals, long term care facilities, educational institutions, health
plans and the list goes on.
What are your priorities for your tenure as Commissioner of Health?
There are five areas that I wish to focus on within the next year. I cannot say there is any
order to these priorities – all five are important.
The first priority is that of rural health. There are many facets to this. There is the concern
of health care costs, access, workforce shortage, and community economics. Several of these
issues are not unique to rural health, but become pronounced in rural health. We will work
with our partners to identify issues and influence the process where appropriate. Having
worked in a rural health care setting for many years, I understand the issues associated with
providing care in a rural community. Rural hospitals face ongoing challenges related to
reimbursement, workforce, and keeping up with building and equipment needs. The Critical
Access Hospital designation, created by Congress, is helping to stabilize rural hospitals. Our
state-funded grant programs are also helping. However, since rural hospitals play such an
important role in the vitality of the communities they serve, we must continue exploring how
to keep them viable.
The second priority is that of concentrating efforts around the elimination of racial and
ethnic health disparities. Minnesota is traditionally acknowledged to be one of the healthiest
states in the country… until we peel away the cover and look at our populations of color and
American Indians. It is unacceptable to say that if you are a young black male you can expect
4
September 11th gave all of us a new indication of what could
that certain medical testing will not be provided to you –
intentionally or unintentionally. It is not acceptable to know that,
as a state, we have one of the highest rates of infant mortality in
our African American community.
happen.
Could you say more on the environment of rural
hospitals today?
A third priority is that of preparedness. In the recent months,
we have been faced with a potential public health threat in SARS.
Are we prepared should there be a situation comparable to what
occurred in Toronto or China? How prepared are we for the
Positive things have happened with rural hospitals, certainly
when you look at the Critical Access Hospital Program. That has
been a wonderful program for a significant number of rural
hospitals. It’s allowed them some financial stability. It’s also
unexpected? What do we need to do to reach that level of
preparedness, knowing full well that it is impossible to totally
anticipate the “what ifs”? We need to continue the work that has
allowed them to look at some variations in staffing models.
One of the things that is absolutely key is that hospitals –
begun through Homeland Security to
especially rural hospitals – provide a
anticipate and prepare for public health issues
safety net. When a person needs care,
occurring from disasters of any kind – natural
where do they go? They go to the
or terroristic. This must be done in
conjunction with our local public health
partners and the entire health care system.
“Having worked in a
rural health care setting
has the Department of Human Services
As we acknowledge that, we have to
for many years, I
address the workforce issue. There is a
understand the issues
particularly in the specialized fields like
A fourth priority is that of mental health.
MDH has done work with mental health, as
hospital.
associated with providing
(DHS). I believe it is time to address this
issue from a perspective of WHAT we do
care in a rural
rather than WHO does what. This will
community.”
shortage in health care workers,
nursing — the RNs, LPNs and CNAs.
While there has been a great deal of
focus, and rightly so, on the nursing
shortage, there are additional types of
require taking a comprehensive approach in
health care positions that rural
order to meet the needs of our citizens.
communities have a tough time filling.
There are wonderful initiatives emerging throughout the state.
Pharmacists, X-ray technicians and laboratory personnel are often
We need to identify those projects, partner with those entities and
difficult for rural facilities to recruit.
together with DHS, I believe, we can make an impact.
In all fairness, there are some wonderful things happening with
The final priority is that of examining nursing home regulatory
rural hospitals and partnerships. MNSCU [Minnesota State
issues. Having been a provider of care, I know what the struggles
Colleges and Universities] and the University of Minnesota
are. It is not an easy process; any survey is difficult. It is time to
understand the workforce issue. Hospitals provide an economic
review the process, to see if we need to propose some changes
stimulus for rural areas. These are fairly good paying jobs, so you
to Washington, while enhancing the quality of care for our
want them in the community. Health care is a huge economic
seniors.
piece of what goes on in rural Minnesota.
These are the top five, for the moment. This is not an all-
One of the committees established by the Legislature as
encompassing list. Actually the list is quite long. Things such as
advisory to the Commissioner of Health is the Rural Health
chronic disease prevention, tobacco reduction, issues of maternal-
Advisory Committee (RHAC). During my time in this position, I
child health, education centered on assuming personal health
believe that by working with RHAC we can build on past
responsibility, water protection, and the list goes on. We will
successes and continue to solidify health care in our rural
begin the process and stand ready to re-prioritize as needed.
communities.
5
Rural Health and Primary Care Legislative
Wrap-Up
By Estelle Brouwer
Now that the dust from the 2003 legislative session has had a chance to settle, it’s time to
bring you up-to-date on legislative actions affecting rural health in Minnesota.
In this year of tight budgets, the good news is that rural health and primary care programs
took reductions that were roughly in-line with reductions to the rest of state government. We
still have a strong Office of Rural Health and Primary Care; we are still able to offer a range of
technical and financial assistance programs, and what’s more, we have a Commissioner of
Health who was a rural hospital administrator and thoroughly understands our issues and
programs. (See article featuring Commissioner Dianne Mandernach on p. 4.)
DIRECTOR’S CORNER
Photo caption
The bad news, of course, is that the budget cuts that did pass will inevitably reduce the
resources available to rural providers, health care facilities, and rural communities around the
state.
Here’s some of what happened in rural health and primary care legislation this year:
•
The state’s loan forgiveness programs for physicians, midlevel providers, and nurses were
combined into one streamlined program, and the funding was reduced.
•
Two rural hospital grant programs – rural hospital planning and transition grants and
isolated hospital grants – were combined into one program and the funding was
reduced.
•
Funding for the rural hospital capital improvement grant program was reduced.
•
Funding for the community clinic grant program was reduced.
•
Two nursing home grant programs initiated in 2001 – nursing home transition planning
grants and “innovations in quality” grants – were eliminated.
•
The Collaborative Rural Nurse Practitioner Program, whose purpose was to increase the
number of nurse practitioners trained and practicing in rural Minnesota, was eliminated.
Some other legislative actions of interest include:
•
Provider rates in the Medical Assistance (MA) and General Assistance Medical Care
(GAMC) programs were reduced.
•
Eligibility was tightened and co-payments and premiums were increased for
MinnesotaCare and MA.
•
The health care provider tax will be extended to services provided under MA, GAMC,
and MinnesotaCare as of 1/1/04.
•
The health care capital expenditure reporting threshold was increased from $500,000 to
$1 million.
•
Funding for community-based services for seniors was reduced. This includes
Alternative Care, home-delivered meals and dining programs.
•
Pharmacists were granted authority to administer flu and pneumonia vaccines.
•
The state’s poison information center received continuing funding.
If you have questions about these or other 2003 legislative actions, feel free to give me a call
or drop me an e-mail.
Postscript: As I write this in late July, the Medicare Prescription Drug bill is in conference on
the Hill in Washington. Both the Senate and House bills include a number of helpful
provisions for rural providers. Stay tuned…
6
Estelle Brouwer is director of the Office of Rural Health and Primary Care. She
can be reached at (651) 282-6348/[email protected]
Workforce Study
(continued from page 3)
licensed RN workforce (54,920), this finding translates into an
estimate of approximately 8,000 RNs who plan to leave the
profession in the next two years. Why are nurses leaving the
profession? Almost 90 percent of RNs chose “work
dissatisfaction” as one of their top three reasons (see figure 2).
Summary and Conclusion
Job Satisfaction
RNs viewed themselves as highly skilled workers and almost all
RNs who provided direct patient care agreed that the work they
do is important (98 percent). Yet, one out of every four RNs
indicated that they would not encourage others to pursue a career
in nursing.
While RNs generally felt that their personal level of pay was
satisfactory (66 percent), the majority felt that they and their
nursing colleagues remain underpaid for the work they do. When
asked if they felt that they were appropriately compensated for
the work expected of them, the findings reveal an equal split —
46 percent equally agreed and disagreed.
With regard to patient care, most RNs (75 percent) felt that
they had sufficient input into the program of care for each patient.
Yet, only 46 percent of RNs felt they had sufficient time for direct
patient care. Eight of every ten RNs also felt that there is too
much clerical and “paperwork” required in their job. Many RNs
felt that barriers exist that hinder their ability to move beyond
providing adequate care to providing superior care for patients.
Almost seven out of every ten RNs agreed with the following
statement: “I could deliver much better care if I had more time
with each patient.” That statement is further affirmed by a
similar percentage (68 percent) of RNs who agreed with the
statement that they could deliver a better care plan if they didn’t
have so much to do all the time.
Survey findings strongly suggest that efforts to increase nursing
educational capacity could be ineffective if an overwhelming
number of nurses leave the profession; an estimated 15 percent of
RNs planned to leave the profession in the next two years.
Increasing the supply of RNs in the long-term is needed but
should be done with careful consideration for the ebb and flow of
RN workforce within the state. Therefore, policymakers may
want to consider additional financial incentives, such as
scholarships and loan forgiveness, which help to target nursing
graduates to areas with the greatest need.
Survey findings underscore the fact that the stability of the RN
workforce in Minnesota is critical to the current and future
delivery of quality patient care. The fact that a large majority of
RNs surveyed identified the desire “to comfort and care for
others” as the main reason they entered the profession must be
kept at the center of any further efforts to recruit and retain nurses.
The report, Findings from the Minnesota Registered Nurse
Workforce Survey, the survey instrument, and survey data are
available to download from the Office of Rural Health and
Primary Care Web site at www.health.state.mn.us/divs/
chs/workdata.htm
Michael Grover recently left the position of workforce
analyst for the Office of Rural Health and Primary Care.
For more information on the Health Workforce Analysis
Program, contact Karen Welle at (651) 2826336/[email protected]
Figure 2: Reason for Leaving the Nursing Profession
100%
(Top Three Reasons)
Percent of Active RNs Who Plan to Leave Nursing
90%
80%
First
Second
70%
Third
60%
50%
40%
30%
20%
10%
0%
Work
dissatisfaction
Retirement
Personal/Family
issue
Pursue nonhealth career
Unable to
provide safe care
Reason
Pursue other
health career
Other
Return to school Illness/Disability
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
Rhonda Wiering
(continued from page 2)
maintain. We rely on equitable reimbursement for technology, capital funds for new
equipment, and updated facilities.
Another change that would help make a difference is to provide adequate physician
reimbursement. As physician reimbursement continues to decline for Medicare and Medicaid,
we will have increasing problems keeping them in rural communities where that is the major
portion of their practice. Again, addressing this issue is critical to maintaining primary health
care in rural communities.
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]
This information will be made
available in alternative format –
large print, Braille, or audio tape
– upon request.
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