Volume 6 Number 4
©Minnesota Office of Tourism Photo
Q U A R T E R LY
Fall-Winter 2004
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: A Personal Reflection and
Conversation with Paul Iverson
Paul Iverson was appointed to the Rural Health Advisory Committee in June 2003. He is a
pharmacist and president of Iverson Corner Drug in Bemidji, a full service community pharmacy
with four full-time pharmacists serving several small towns and a large rural population. Paul
also provides pharmacist consultation services and care to hospitals, businesses, and patients in
northern Minnesota, and serves on the faculty of the University of Minnesota College of
Pharmacy. He is past president of the Minnesota Pharmacists Association.
RHAC member Paul Iverson
I recently spent eleven days in the hospital recovering from a cerebral hemorrhage. This was
my first stay in the hospital ever and obviously has impacted my views about health care. I can
tell you that when it comes to health care, it is much better to give than receive! I was, however,
very fortunate to have good care given both in Bemidji and at St. Josephs Hospital in St. Paul.
On Saturday, November, 6th, I was enjoying a lazy Saturday morning when I suddenly developed
a severe headache. My 16- and 14-year-old sons drove me to the emergency room (their
mother was out of town) for what I feared was a cerebral bleed. A CT scan confirmed this and
the emergency room doctor told me he was going to fly me to Fargo. He also asked me what
he should tell my sons. I told him to tell them what was going on so they knew. I then had
them call their mother and a pharmacist I work with so that someone would be with them
when I flew away. They handled the stress very well, but it was a very difficult moment for all
three of us when they hugged me good-bye before I flew away. Instead of going to Fargo, I was
flown to St. Paul as the doctors there had an additional procedure they could perform if I had
an aneurysm. Fortunately, I was one of the lucky ones and my bleed was not an aneurysm, but
was a venous bleed.
The support from our families and friends was tremendous, providing my family with places to
stay, rides, and meals for over two weeks. It was a terrific reminder of why we love living in
northern Minnesota and an example of how a community can pull together to help a family in
need. How do we get this feeling of community to spread statewide?
As a patient in a hospital for the first time, I got to watch how hospital care works first hand. I
saw how important everyone’s jobs are. When I would have a good nursing assistant, the nurse
would have more time to perform assessments and charting. This allowed one of my nurses to
make a clinical observation about a concern that may have otherwise been missed. There were
other cases where the team approach helped me, such as when the social worker hooked my
wife up with the facilities pastor and when the pharmacist suggested changes to my pain
management program and improved my pain control.
What do you think are the most important issues facing rural health today?
Because of this experience and my 22 years of rural practice, I believe we have two major rural
concerns:
First, we need someone to assess the special health care needs of rural Minnesota. I had the
opportunity to have a helicopter fly me to St Paul to receive the specialized care I needed. Do
we have enough helicopters in the right places to adequately cover rural Minnesota? What
other specialty care items do we need? Where do we need them?
Karen Welle, Acting Director
Mary Ann Radigan, Editor
Cirrie Byrnes, Editorial Assistant
Second, after we assess the needs, we need to build health care teams to provide the day-to-day
care our citizens need. We will never have specialists everywhere in the state. What
innovative things can we do to improve access to their knowledge? What can we do to help
our family practice physicians, our pharmacists, mid-levels, and other health providers use the
skills they have to take care of our patients? How do we take the politics out of providing care
and let qualified professionals take care of patients? How can we best use pharmacists to get
people on the right medicine? How do we get insurance to pay for medication management so
that patients get on drugs that work and are affordable?
We live in rural Minnesota because of the quality of life, because of the people. We have all
seen friends and neighbors rally around an unfortunate neighbor. How do we get the rest of the
See “Paul Iverson”
2
(back page)
PROGRAM FOCUS
Unmet Needs and Unrealized Opportunities Rural Mental
Health and Primary Care
By Linda Norlander
Residents of rural Minnesota face significant challenges in obtaining mental health services. Accessing a psychiatrist, a
psychologist or a therapist can involve long waits and extensive travel. For many, the only option for care is through their
primary care doctors, nurse practitioners and physician assistants. As Dr. Jack Geller, a rural researcher from St. Peter,
Minnesota has said, “In rural Minnesota, primary care is not the safety net for mental health care, it is the system.”
In a series of rural health forums conducted by the Office of Rural Health and Primary Care in 2003-2004, access to
mental health services was identified as one of the top four rural health issues in Minnesota. Responding to those
concerns, the Rural Health Advisory Committee formed a workgroup to examine rural mental health and primary care.
Over the past year, the workgroup, made up of people from across the state representing health care professionals,
consumers, providers and educators, has:
• Met bimonthly to identify the major barriers to access, discuss promising practices and issue recommendations for
improvement
• Reviewed national and state-level research and literature to determine the current landscape
• Conducted a survey of rural primary care providers to capture a snapshot of the issues and needs within the primary
care clinic system
• Conducted a survey of Critical Access Hospital emergency rooms to gain a better understanding of how mental health
emergencies are handled by the state’s smallest hospitals
• Interviewed providers and educators to learn more about innovative programming currently underway to address rural
mental health issues
Key Findings
National research related to the role of primary care in providing mental health services reveals that primary care is often
the most used system for delivering care. Studies have shown that:
Of patients who seek care for mental disorders, 50% of that care is provided by primary care physicians.
Sixty-seven percent of all psychopharmacologic drugs are prescribed by primary care practitioners.
Ninety-two percent of all elderly patients received mental health care from primary care providers.
According to the Mental Health Association of Minnesota, 950,000 Minnesotans have mental health problems of some
kind and over 170,000 have diagnosable “serious” mental illness in any given year. While studies have shown that the
prevalence of mental health distress in rural communities is no greater than in urban and suburban areas, evidence does
exist that services are often limited or non-existent.
A workgroup survey of Minnesota rural primary care clinic physicians, nurse practitioners, and physician assistants
conducted in summer 2004 provided a snapshot of the mental health care and issues addressed at the clinic level.
Similar to national studies, the survey revealed that approximately 10% of patient visits were primarily for mental health
issues. Additionally, 60% of the respondents identified that they were seeing an increase in the number of patients with
mental health problems. Substance abuse, including alcohol, methamphetamine and other drugs was the most frequently
mentioned issue of concern.
Challenges in providing care included the amount of waiting time for mental health services. Estimates ranged from
several days to several months for an appointment with a mental health specialist. As one provider wrote, “Waiting two
to three months for these consults is insufficient, unacceptable care. This is my greatest challenge.”
Travel distance to obtain professional mental health services was also noted as a significant problem. A physician in
northern Minnesota said, “Too often help is a car ride away without a tank of gas.” The survey found that the average
distance to services was over forty miles.
See “Unmet Needs and Unrealized Opportunities”
(page 5)
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PARTNER PAGE
Minnesota 2004 Rural Health Awards Focus on Volunteers
By Karen Welter
Each year, the Office of Rural Health and Primary Care has
the privilege of helping recognize those who have made a
difference in rural health in Minnesota. The 2004 award
selection process mirrored past years in the level of
dedication of those nominated; there are always more
worthy candidates than available awards. This year’s
awardees, Marie Comstock and the Senior Helping Hands
Program Peer Volunteers, represented the best of a strong
field of candidates. The awards were presented at the
Minnesota Rural Health Conference, entitled “Rural
Minnesota: On the Road to Better Mental Health,” held
October 26 in St. Cloud. Awardees were selected for their
compassion, efficiency, coordination, innovation,
collaboration, unselfishness, quality, and leadership in rural
health care.
them, “Marie Comstock is a lady with futuristic ideals
who has made generous sacrifices to better the health of
the people of the Roseau Community and its surrounding
area. Marie has been a key component in providing
quality health care to Roseau County for over five
decades!”
The Senior Helping Hands Program Peer Volunteers
received the Rural Health Team Award for their dedication
and commitment to the residents of central Minnesota.
They have made invaluable contributions by assisting
troubled seniors to recover and re-enter the community
through their empathy, leadership, and mentoring. More
importantly, they serve as examples of healthy recovered
Marie Comstock of Roseau received the Rural Health Hero
Award for her dedication and commitment to the residents
of Roseau County. For half a century, Comstock has been
an integral player in providing quality health care to
Roseau County. Beginning in the early 1950’s, Comstock
believed that her community of Roseau and its
surrounding areas needed a new hospital. Hence, she was
instrumental in organizing the Roseau Area Hospital
Volunteers from the Senior Helping Hands Program
receive their Rural Health Team Award.
persons for others to emulate. Their efforts truly are
making a difference in the quality of life for seniors
struggling with chemical dependency and mental health
issues. Award recipients include 50 peer volunteers
dedicated to fourteen counties of central Minnesota,
which include the Board on Aging regions of 7W, 7E and
Region 5. Lu and Clyde McNally accepted the award for
the entire peer volunteers’ team.
Rural Health Hero, Marie Comstock, with colleagues
from Roseau Area Hospital and Homes.
District formed in 1958. Comstock canvassed support for
the organization from her township, adjacent townships,
and the city of Roseau. As a charter member of the board
of directors, she has been actively involved in every
directorial level of the hospital district over the past 50
years. Comstock’s perspective and outlook involving
quality health care has been and continues to be visionary,
persistent, energetic, and dedicated.
The Roseau Area Hospital and Homes, Inc., nominated
Comstock for the Rural Health Hero Award. According to
4
The Senior Helping Hands Program, a community
outreach program working with older adults experiencing
chemical dependency and mental health problems,
nominated the peer volunteers for the Rural Health Team
Award. According to them, “the peer volunteers are
compassionate and unselfish in working with the older
adults they assist…Senior Helping Hands volunteers are
mentors or leaders for the clients in treatment. This is
significant to troubled older adults who many times donít
fit in with younger recovering individuals.”
Karen Welter administers the health professional loan
forgiveness program for the Office of Rural Health and
Primary Care. Karen can be reached at (651) 282-6302
or [email protected]
Unmet Needs and Unrealized Opportunities
(continued from page 3)
A survey of Critical Access Hospital (CAH) emergency rooms also conducted in summer 2004 provided another snapshot
of safety-net services in rural Minnesota. Respondents identified that about 10% of their emergency room visits are related
to mental health. Over the past two to three years, 36% said that mental health emergency room visits have increased.
One respondent noted, “We are seeing more severe behavioral or mental health patients.” Another wrote, “We are
seeing more chronic medical problem patients [and} there is always an underlying mental health issue that seems to be
forgotten or never addressed.”
The most common types of emergency issues identified in the survey included:
• Substance and alcohol abuse
• Depression and anxiety
• Suicide (attempted or considered)
• Dementia
Both the primary care survey and the CAH survey identified a high interest among doctors and nurses caring for these
patients to learn more about mental health and how to treat it.
Promising Practices
The workgroup identified a number of promising practices that could result in improved access to care and improved
quality of care and concluded that collaboration is a key component of most of these practices. The Shared Care
Psychiatry program in Detroit Lakes is an example of a successful collaboration between the Dakota Medical Center,
MeritCare Clinics, Becker County Human Services, Lakeland Mental Health Center, and St. Mary’s Regional Hospital.
Even though some of the providers involved are actually competitors, they are all working together to assure that
psychiatric services are available to their patients in the clinic setting. This model of care has reduced waiting time for
psychiatric services from weeks and months to less than a week for an evaluation.
Recommendations
Recommendations from the workgroup will be finalized in the winter of 2005 and sent to the Commissioner of Health. A
full report will be available and posted on the ORHPC website in March of 2005. The report will include
recommendations in these areas:
• At the community and provider level illustrated by examples of existing innovative practices
• For health systems including hospitals, clinics and payer systems
• For educators of health professional students and for continuing education for practicing professionals
• For state-level policy-makers
Conclusion
While rural Minnesota faces daunting issues in assuring access to mental health services through the primary care system,
the workgroup has stressed that this is also a time of great opportunity.
In order to meet the current needs, we can no longer do business as usual. We must screen, identify
and treat in primary care clinics. To do this, collaboration is required and rural providers must be
trained and supported. In addition, funding streams must be redesigned to reimburse and support
collaborative models of care (Mental Health and Primary Care Workgroup minutes, February 2004).
Linda Norlander supervises rural health program development activities in the Office of Rural Health and Primary Care.
She can be reached at (651) 282-6317 or [email protected]
5
Estelle Brouwer recently accepted a fellowship from George Washington (GW)
University in Washington, DC, to study international development. She and
her family plan to move to Washington in the near future, and Estelle will
enroll in GW’s Elliott School of International Affairs in January. Estelle
resigned as director of the Office of Rural Health and Primary Care effective
December 1, 2004. The Quarterly invited her to write this final column before
her departure.
DIRECTOR’S CORNER
My Long Minnesota Goodbye
By Estelle Brouwer
Just a few weeks ago, my husband Gary and I were searching for rental housing in
Washington, DC. We’d followed up on some leads and were beginning to feel that peculiar
combination of fatigue and sticker-shock that is familiar to anyone who has looked for a
house in the DC area. We were about to call it a day when my cell phone rang.
“Hello – did you call about renting a house in North Arlington?”
We then had the standard conversation – rental amounts, lease agreements, the basic stats
on the house. After a few minutes, we reached the critical point in the conversation.
“Do you have any pets?”
“Well, yes, a three-year-old lab and a couple of cats.”
A long pause. My heart sank, as it had many times before at this particular point in
conversations like this.
“You’d have to cover the floors – I just had them re-done. And I’d really need a two-month
security deposit rather than just one.”
“Oh, we’d be happy to put down an extra deposit. We expect that.”
We chatted a while longer and found we have a lot in common, including a passion for
international work. She’s a health officer for the U.S. Agency for International
Development, about to go on assignment in Guinea, West Africa.
“Where do you work?” she asked.
“The Minnesota Department of Health.”
“Oh my goodness. I can hardly believe it! My dad and my brother and sister-in-law all live
in Minnesota. If you’re from Minnesota, I’m not worried about your dog. I can just tell
you’ll be a wonderful renter. You can forget about the extra security deposit.”
Being from Minnesota has meant a lot to me over the years, but this may be the first time
it’s actually saved me a bundle of cash. We Minnesotans are known for being responsible,
considerate, sensible people. These are all stereotypes of course, but I’ll admit it – I’m
proud of our positive reputation and you can count on me doing my best to affirm it,
wherever my journey takes me. Because after all, Minnesota is and always will be my
home.
6
See “Director’s Corner”
(page 7)
Director’s Corner
(continued from page 6)
What’s Next for the Office of Rural Health and Primary Care
And now it’s time for my long Minnesota goodbye. For you, the rural health community of Minnesota, I have many
warm feelings and a great deal of respect. I also have confidence that the Office of Rural Health and Primary Care will
continue to provide the kind of principled leadership, targeted assistance, and useful information that is needed to keep
rural health strong in Minnesota.
Karen Welle, assistant director of the Office for nearly seven years, will serve as interim director until a permanent director
is chosen. If you don’t know Karen, feel free to give her a call or send her an e-mail to say hi. Karen is a good person, a
gifted manager, and a knowledgeable rural health professional. The office is in great hands with Karen.
Before I left the Office, Karen and I, along with Mark Schoenbaum and Linda Norlander, the other two members of our
leadership team, agreed on a set of short-term goals for the Office, to ensure that it stays focused and productive during
these weeks or months of transition. Here are the goals:
• Continue to nurture and support the Office’s many partnerships. Without our partners, we cannot achieve our mission
of promoting access to quality health care for rural and underserved urban Minnesotans.
• Continue to support and build the quality and capacity of Minnesota’s rural health system through the Rural Hospital
Flexibility Program.
• Ensure that the ORHPC’s grant and technical assistance programs continue to be administered in a fair, effective and
customer-friendly manner, in order to ensure continued support and development of a strong Minnesota rural health
system.
• Continue to provide high quality, thoughtful, information-based support for the work of the state Rural Health Advisory
Committee.
• Continue and build ORHPC’s capacity in the areas of health workforce support and health workforce data analysis.
Some of these short-term goals will of course continue on into the future in the form of long-term goals. However, the
four of us agree that it is important, in these times of budget and human resource constraints, to be explicit about where
the Office’s energy will be focused in the short run.
In the short run and the long run, I wish you the very best. This is a state full of incredible people doing amazing things,
and I am blessed to have worked with you for all these years. Be well, keep in touch, and godspeed.
Estelle Brouwer was director of the Office of Rural Health and Primary Care from 1997 through November 2004.
Estelle can be reached at ebrouwer @Comcast.net
Karen Welle, interim director, can be reached at [email protected] or 651-282-6336.
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
Paul Iverson
(continued from page 2)
state to view rural Minnesotans as a part of their family? How do we help the rest of the
state understand that in addition to providing them with lakes to fish, deer to hunt, and trails
to hike and bike, we need to provide them with access to quality health care, so that if they
are “up north” and have a cerebral hemorrhage, they can receive the care they need to
survive. How do we get them to share in the costs of providing those services throughout the
state?
What one or two changes do you think would make the most difference for rural
health?
I believe keeping health care local whenever possible is critically important. Having as many
local providers as possible improves professional collegiality. It also decreases travel time and
inconvenience for patients - especially seniors - and keeps our communities healthier, both
physically and financially.
I also believe a good Medicare prescription drug and medication management coverage would
do a great deal to increase access to drug therapy by seniors. We often see seniors skipping
doses to save costs on medicine, thus raising costs to Medicare for the treatment of drug
therapy misadventures due to failure of the improperly taken medication. Having coverage
include a pharmacist providing medication management services would maximize the benefit
to our seniors and help control costs.
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.
Another thing we have seen with a few of our younger families is the inability to change jobs
once their child is diagnosed with a chronic disease. They are unable to go out on their own,
as they cannot afford the transition from one insurance to another. One way to drastically
change how we view our health care would be to eliminate the business deduction for
insurance and replace it with a personal deduction. This would mean we would all become
better purchasers of insurance by buying our own and having deductibles that would match
each family’s needs. It would get rid of “group rate” and encourage insurance companies to
pool bigger groups together, making insurance rates more consistent and affordable.
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