Volume 5 Number 2
PHOTO COURTESY OF MINNESOTA DEPARTMENT OF TRADE AND ECONOMIC DEVELOPMENT
Q U A R T E R LY
Spring 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 Hospital Flexibility Program
Advisory Committee Member Profile:
ORHPC Talks with Michael Hedrix
Home:
Family:
Eden Prairie
3 children, Aaron (25), Brianna (22), Kelsie (18), and wife of 28 years, Kathy, a
preschool director.
Hobbies: Walking, running, reading, and recreational sports
Michael Hedrix, Rural Hospital
Flexibility Advisory Committee
Chair.
The Medicare Rural Hospital Flexibility
Program (Flex Program), established by
the Balanced Budget Act of 1997,
supports rural communities in
preserving access to primary and
emergency health care services. The
Flex Program accomplishes this by
focusing on five key components,
including: enhancing emergency
medical services, improving quality,
establishing Critical Access Hospitals
(CAHs), developing networks, and
promoting community development.
For more information on the Flex
Program visit the Web site at
www.health.state.mn.us/divs/chs/
rhpc/cah/index.html
Estelle Brouwer, Director
Karen Welle, Assistant Director
Stefani Kloiber, Editor
Michael Hedrix is the hospital administrator for Pine Medical Center and Nursing Home in
Sandstone and has been with the facility since 1997. Pine Medical Center, part of the St.
Mary’s/Duluth Clinic Health Care System, is a Critical Access Hospital and is one of two longterm care facilities in Pine County with 76 beds.
Michael began his career in community banking, but as the banking industry developed and
changed he decided to use his skills in the health care administration field instead. Michael says
this change has allowed him to regain what he enjoyed most about community banking working with people and developing relationships for the betterment of the local community.
Michael has over a decade of experience with rural hospitals, having worked as an administrator
for four other rural Minnesota hospitals before coming to Pine Medical Center.
Michael has been involved with the Rural Hospital Flexibility Program (Flex Program) since it
began in Minnesota in 1998. He was first introduced to the program when he was invited to
participate in the development of Minnesota’s grant application requesting funding for the Flex
Program. Michael continues to be connected to the program both as a member of the Rural
Hospital Flexibility Program Advisory Committee and now as the chair of the committee.
What do you think are the most important issues facing rural health today?
MH: In general, I think most issues in rural health today revolve around having adequate
resources, primarily capital and human resources. Resources are already scarce for rural areas,
but increasing demands from consumers and regulators ask that health care “do more with
less.” In rural areas this is an even larger challenge as they are already doing more with less.
What one or two changes do you think would make the most difference for rural
health?
MH: I think the simplification and reduction of both how we administer health care and
how we regulate it would go a long way towards making a difference for rural health. For
example, one change could be to ease regulatory requirements by reducing unnecessary or
redundant regulations. This type of change would help to lessen the work and staff time
required to ensure compliance. Another beneficial change would be to standardize
reimbursement systems. The current system requires specially trained staff for each health
system in order to produce a bill for services. A standard reimbursement system would help to
streamline the billing system and the demand for specially trained staff.
What do you think was the most important message that came out of the CAH
Quality Improvement Collaborative? (See Bigger Is Not Necessarily Better – Small
Hospitals Work Together To Improve Care In Rural Minnesota, included in this issue).
MH: Two important messages came out of the CAH Quality Improvement Collaborative.
First is the realization and understanding that rural health care doesn’t mean substandard or
poor quality health care. I think rural health care providers can and should feel good about the
quality of care they give. Secondly and perhaps more importantly for the future, we learned
that we can collectively work together to improve rural health care. I found it to be a fun and
empowering way to advance rural health care. As a rural industry there are certainly challenges
ahead, but when taken on together we have a stronger voice.
See “Michael Hedrix”
2
(page 8)
COMMUNITY FOCUS
On the Road to a Town Near You - 2003 Community Health
Forums
By Angie Sechler
In February of this year, the Office of Rural Health and
Primary Care sought out information from Minnesotans to
learn more about the health care issues in their
communities. Thanks to the assistance of local cosponsors rural health forums were held in four
communities:
• Alexandria, sponsored by Douglas County Hospital
and Rural Health Alliance;
• St. Peter, sponsored by Region 9 Development
Commission;
• Crookston, sponsored by Riverview Hospital;
• Grand Rapids, sponsored by Arrowhead Regional
Development Commission.
Each forum included an overview of Minnesota’s
current demographic and socio-economic landscape
followed by small group discussions of the issues. All the
forums were well attended by a variety of individuals
representing hospitals, health plans, nursing homes, area
A small group discusses health care issues in
St. Peter.
agencies on aging, local public health, EMS, county
commissioners, and the Minnesota legislature.
Additionally, questionnaires asking attendees to list their
top three concerns about health care in their communities
were collected and later reviewed to determine what
issues were most prevalent.
Information from these forums will be used to help
shape the next Minnesota Rural Health Plan to be
completed by the end of this year. The Rural Health Plan
is a requirement for participation in the Medicare Rural
Hospital Flexibility (Flex) Program. The plan provides
background information on Minnesota and its health care
system, addresses access to health care in rural Minnesota,
describes Minnesota’s Medicare Rural Hospital Flexibility
Program, and outlines strategies for strengthening
Minnesota’s rural health care.
The Top Issues
Workforce shortages in all health care fields, inadequate
Medicare/Medicaid reimbursements, rising health
insurance costs,
lack of access to
mental health and
One person commented
chemical
dependency
in their questionnaire,
services, and the
“Our company had to
anticipated health
consider dropping (health
needs of a growing
care) coverage for
elderly population
were overriding
employees, and we are a
issues in all the
health care provider.
forums. Other
How ironic.”
concerns unique to
each community
came up as well. For example, cultural and language
barriers creating health disparities were major issues in
both St. Peter and Grand Rapids. In Crookston, the lack
of coordination among EMS systems, volunteer retention
and recruitment, and equipment needs were of significant
concern to many.
Top Strategies/Solutions
Discussions about health care issues often led to
suggested strategies and possible solutions. One of the
solutions most frequently mentioned was the need to
change the Medicare/Medicaid reimbursement system interstate funding equalization and equitable rural-urban
reimbursement were top priorities. Many of the small
discussion groups identified creative workforce
recruitment and retention incentives, such as increases in
loan forgiveness or making additional distance learning
See “On The Road”
(page 7)
3
PARTNERS PAGE
Bigger Is Not Necessarily Better:
Small Hospitals Work Together To Improve Care In Rural
Minnesota
By Jill Zabel and Annette Kritzler
According to the American Heart Association, heart
disease is the number one killer of Americans. One heart
condition, congestive heart failure, though a very serious
condition, can be managed through medication, diet, and
exercise. Another common condition, atrial fibrillation,
can be an early warning sign of serious heart disease.
Last year, ten of Minnesota’s smallest hospitals took on
the task of improving care for patients with these
conditions as part of an innovative pilot quality
improvement collaborative for Critical Access Hospitals
(CAHs).
The collaborative, known as the Heart Failure and
Atrial Fibrillation Collaborative for Critical Access
Hospitals, brought ten Minnesota CAHs together for a
common goal: to improve the quality of care for patients
hospitalized with heart failure and atrial fibrillation. The
long-term goal was to build the capacity of these hospitals
to improve their processes for other quality improvement
initiatives in the future. Stratis Health, the Medicarecontracted Quality Improvement Organization for
Minnesota, and the Office of Rural Health and Primary
Care jointly sponsored the collaborative, which was a
pilot project developed as a part of the Minnesota
Medicare Rural Hospital Flexibility Program.
A federally designated Critical Access Hospital or CAH
is a rural hospital licensed for 15 or fewer acute care
beds. In order to qualify for CAH status, a hospital must
make emergency medical services available twenty-four
hours a day, adhere to new certification requirements,
enter a network agreement with an acute care hospital,
and maintain an annual average length of stay of 96 or
fewer hours per patient. In return, a CAH is granted
greater staffing flexibility and receives cost-based
reimbursement for Medicare acute inpatient and
outpatient services and some Medicaid services. There
are currently 46 CAHs in Minnesota.
The first ten Minnesota hospitals to achieve Critical
Access Hospital status were invited to participate in the
quality improvement collaborative. The hospitals
included were: Lake View Memorial Hospital, Two
Harbors; Pine Medical Center, Sandstone; Riverwood
Health Care Center, Aitkin; Lakewood Health Center,
Baudette; Mahnomen Health Center, Mahnomen;
4
Wheaton Community Hospital, Wheaton; Renville
County Hospital, Olivia; Tracy Municipal Hospital, Tracy;
Westbrook Health Center, Westbrook, and Zumbrota
Hospital, Zumbrota.
The Collaborative Model
The quality improvement collaborative was loosely
based on a model developed by the Institute for
Healthcare Improvement (IHI). The IHI model
successfully demonstrated that by using the collective
wisdom of collaborative participants along with an
advisory group of experts, dramatic improvements in the
quality of care could be made. The model uses
interactive learning sessions with action periods between
the sessions.
The first step
in building the
“As hard as it is to get away
collaborative
was for each
from my facility, I know
CAH to put
that one day spent in this
together a team
workshop saves me three
of people
interested in
days back on the job.”
improving the
—Collaborative participant
care provided
patients at their
facility. Each of the teams included both clinical and
administrative leadership – a physician, nurse,
pharmacist, management sponsor, and other members as
appropriate (e.g. medical records, lab, etc.). It was key
that each team include a physician willing to provide
clinical expertise and serve as a mentor, and a hospital
administrator committed to the quality improvement
effort and willing to provide the resources and support.
Following the model, the CAH teams gathered for four
learning workshops. The first workshop featured a local
cardiologist presenting on “Improving the Value of
Healthcare Provided for Patients with Atrial Fibrillation
and Heart Failure.” In addition, the agenda included
quality improvement education and data abstraction and
analysis training. Subsequent workshops built on the
quality improvement methodologies, successful
interventions, and discharge planning and working within
the community. Each workshop provided time for
sharing and networking among the participants.
Between workshops, monthly conference calls with the hospital
teams were held. As hospitals expressed a specific education need,
additional conference calls were scheduled with expert speakers
presenting. The conference calls provided time for hospitals to
share their progress and to ask for input from other participants if
they had run into a problem or concern. These check-in times
became an important milestone for the hospitals.
Each CAH team used a variety of strategies to improve the
processes of care in their hospitals. One strategy was to focus on
the patient’s experience from admission through diagnosis,
treatment, and follow-up. Another strategy was to identify
interventions to improve heart failure and atrial fibrillation care.
The interventions, also known as quality measures, were based on
current guidelines and evidence based research and generally
accepted as a standard of care.
• And, from Michael Hedrix of Pine Medical Center, “The
project was a good thing. I enjoyed seeing the progress on the
storyboards; it gave us a feeling of success.” (See Michael
Hedrix profile on page 2)
Future Collaborations
Collectively, small rural hospitals can make a difference in the
overall quality of care provided to Minnesota residents. Quality
improvement is a continuous process. This collaborative provided
a first step in improving care for heart failure and atrial fibrillation
patients. The hospitals realize that continued work needs to
happen to raise and maintain the measures. Building on the
success of this collaborative, the hospitals are using their new
knowledge to facilitate other quality improvement initiatives for
their patients.
In addition to the measurable outcomes, this collaborative also
demonstrates the success of partnerships. The collaborative has
shown that hospitals, a state agency, and a Quality Improvement
One challenge in focusing on small hospitals in a quality
Organization can work together for a common goal and achieve
improvement project of this kind is the low volume of patients,
success. The word is out on this innovative model of
making measurement more difficult. To overcome this challenge
collaboration; it has
the data from the
End-ofgained national
ten hospitals was
Quality Measure
Baseline
collaborative
attention at
aggregated and
conferences in
analyzed. The
• Increase use of left ventricular function assessment in
Washington, Florida,
data showed that
patients with heart failure
36%
43%
and Arizona as well as
from January 2001 • Increase the use of ACE Inhibitors in ideal patients with
statewide interest in
through August
left ventricular ejection fraction of less than 40%.
77%
100%
Minnesota.
2002, 266 patients
• Improve patient education for patients discharged with
were treated for
heart failure (all elements needed to be present)
3%
17%
Stratis Health is
heart failure and
using the new
• Increase the number of atrial fibrillation patients discharged
470 patients were
knowledge gained
on Warfarin or who have a plan for Warfarin after discharge 77%
85%
treated for atrial
from this collaborative
fibrillation. Results • Increase the number of patients that have a plan for
to launch another
a follow-up visit after discharge.
39%
68%
of the data show
collaborative with 22
that the
additional Critical Access Hospitals. This second collaborative,
collaborative was a success. An improvement from baseline to
which started in March 2003, will again focus on heart failure and
end-of-collaborative monitoring was found for all the quality
will add inpatient adult immunizations as a new focus. Once
measures. The table above demonstrates the results of the
again, the Office of Rural Health and Primary Care will provide
collaborative.
support for the participating hospitals.
What did the participants say about the collaborative?
Jill Zabel is the Flex Program coordinator for the Office of
Rural Health and Primary Care. She can be reached at
• “As hard as it is to get away from my facility, I know that one
(651) 282-6304/[email protected]
day spent in this workshop saves me three days back on the
job.”
Annette Kritzler is a project manager for Stratis Health.
• “It’s nice to know we are not alone – we face similar
She can be reached at (952) 853-8590 /
problems. I thought it was just us.”
[email protected]
The Results of the Collaborative
• “We found better responses on patient satisfaction surveys
after nursing staff implemented the revised patient education.”
5
Welcome to new staff member
Linda Norlander
By Estelle Brouwer
It’s spring, which means it’s time for new
beginnings, especially in lovely but frigid
Minnesota. I’d like to take this opportunity to
introduce you to someone who represents a
new beginning in the Office of Rural Health
and Primary Care — Linda Norlander, one of
the newest members of our staff.
DIRECTOR’S CORNER
Photo caption
Linda joined us in December as supervisor
of the Rural Health Program Development
unit. What that means in practice is that
Linda Norlander
Linda works hand-in-glove with the state
Rural Health Advisory Committee to carry out
the research and analysis they need in order to do the important work of advising the
Commissioner of Health on rural health issues. It also means she supervises a small but hardworking group of research and administrative staff, serves as a member of our office’s
management team and, as the only nurse on our staff, brings the valuable perspective of a
licensed health care provider to many of our internal discussions.
Linda is well known in the world of end-of-life care, both here in Minnesota and across the
nation. Before coming to our office, she served as director of the Minnesota Partnership to
Improve End of Life Care, and earlier, as supervisor of a Medicare certified hospice program.
In addition to her role as a health care provider and manager, however, Linda has another
passion – writing. She’s been a writer for most of her life, but only recently started writing
nonfiction. And for that she’s already won two awards:
• For her book Choices at the End of Life: Finding Out What Your Parents Want Before It’s
Too Late, she won the 2003 Caregiver Friendly Award from Today’s Caregiver magazine.
• For her book To Comfort Always: A Nurse’s Guide to End of Life Care, she received an
award of merit from the International Society of Technical Communicators.
Over the next several months, Linda will be spending a good deal of her time working with
the Rural Health Advisory Committee to discover and highlight ways to improve access to
mental health services in rural Minnesota. I encourage you to start to get to know Linda by
giving her a call or dropping her an e-mail. While you’re at it, let her know your thoughts
about how we can improve access to rural mental health services. Linda can be reached at
651-282-6317 or [email protected].
Estelle Brouwer is director of the Office of Rural Health and Primary Care. She
can be reached at (651)282-6348 or [email protected]
6
On The Road
(continued from page 3)
opportunities available. Other ideas centered on community
development-involvement strategies, coordinated health service
delivery, and the need to increase the numbers of mental health
and chemical dependency practitioners.
Alexandria
The first community forum site was the Douglas County
Hospital in Alexandria. Twenty-seven attendees of this forum
were most concerned with the shortage of workforce affecting all
health care fields, limited access to mental health and chemical
dependency services, inadequate reimbursements, and the
growing health care needs of the elderly. When asked “what do
you think will improve health care in your community?” one
respondent wrote, “I would say we really need more psychiatrists,
psychologists, and geriatric physicians who specialize in the
elderly population and particularly those with mental health
issues.”
St. Peter
St. Peter’s new community center was the second forum
location. A local co-sponsor, Region 9 Development Commission,
presented the audience with the recent results of a 2002 Regional
Health Behavior survey designed to monitor health status, identify
health problems, and establish health promotion priorities in 27
counties of south central and southwestern Minnesota. The
survey served as a great example of local communities working
together to improve health status throughout south central and
southwestern Minnesota. “Allowing communities to maintain
autonomy to problem solve and find solutions with assistance
from agencies such as ORHPC, Region 9 and regional health
agencies [will help improve health care]” said one audience
member. The greatest health care concerns among St. Peter
attendees were workforce shortages, rising insurance costs, poor
health behaviors, and the quality of care and cultural/language
barriers for immigrants who have relocated to the area.
Crookston
Despite the day’s sub-zero temperatures, a warm, welcoming
crowd turned out for the third forum held at the Crookston
campus of the University of Minnesota. Again, the greatest
concerns expressed were workforce shortages, inadequate
reimbursements, and rising health insurance costs. Other issues
topping their list were the lack of coordination between health
care providers and communities, the recruitment and retention of
EMS volunteers, and the impact of state budget cuts to mental
and elderly health programs. A respondent to the questionnaire
speculated about the logic of recent state budget proposals, “At a
time when offering ‘services in place’ to seniors in the most
independent setting, usually their home, is the method of choice,
state funding is being cut to programs [i.e. Meals on Wheels] that
support that model.”
Grand Rapids
The final forum was held in the community of Grand Rapids at
their area library. Unlike the previous forums, the highest-ranking
issue concerning the Grand Rapids attendees was the lack and
cost of health insurance. As one person commented in their
questionnaire, “Our company had to consider dropping [health
care] coverage for employees, and we are a health care provider.
How ironic.” Other issues of concern emerged in the following
order: workforce shortages, growing health care needs of the
elderly population, the need for more mental health and chemical
dependency services, and cultural/language barriers to health
care.
Next Steps
The forums were a valuable opportunity to gather community
Angie Sechler takes notes during a small group discussion of
health care issues in Grand Rapids.
input to feed into a new Minnesota Rural Health Plan. The Office
of Rural Health and Primary Care intends to continue seeking
rural community involvement and has already begun planning for
the next series of community forums. Look for us coming to a
town near you.
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/
[email protected]
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
Michael Hedrix
(continued from page 2)
In addition, I think the collaborative demonstrated that there can be an advantage to being a
rural hospital - one is that our interests are more likely to be focused on patient care, and not
drained by competition. Another advantage is that as a group we can support and help each
other to improve and ensure quality health care. Because we all face some of the same
challenges, this support is helpful in facing future challenges.
What changes would you like to see come from the CAH Quality Improvement
Collaborative?
MH: It is my hope that this type of collaboration be applied to improve the processes for
quality improvement initiatives in other health care areas. It was and continues to be a great
method to help us achieve our best practices.
On a final note, a special thank you should go to Stratis Health for their facilitation of this
collaborative. They worked hard to create a supportive and secure environment that was very
collegial and focused on patients and improving care.
This information will be made
available in alternative format –
large print, Braille, or audio tape
– upon request.
The Rural Hospital Flexibility Program Advisory Committee provides program planning,
development, and implementation consulting, issue identification, problem solving, and
evaluation development for the Minnesota Rural Hospital Flexibility Program. Meetings are
held three to four times a year 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/rhpc/cah/index.html or contact
Cindy LaMere at 651-282-3833/[email protected]
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