Volume 7 Number 3
Lanesboro Museum, Lanesboro, Minnesota
©Minnesota Office of Tourism Photo
Q U A R T E R LY
Fall 2005
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, policymakers and
other organizations. Together, we develop innovative approaches and tailor our tools and
resources to the diverse populations we serve.
Weaving the Strands of Quality
Through Collaboration
Welcome to fall! The transition to the demands of the school year and preparations for winter can
be a good time to focus our plans and efforts. In the field of rural health, the recent Institute of
Medicine (IOM) report, “Quality Through Collaboration: The Future of Rural Health,” gives us a
very compelling framework to understand, plan and communicate about our work. In style and
substance, the IOM report gives us a comprehensive, understandable and convincing approach to
rural health quality. I’ve started using the report as an organizing concept and theme to think
about and to talk about our work in the Office and our shared goals across rural Minnesota.
This report helps us focus our energies to:
DIRECTOR’S CORNER
Mark Schoenbaum
• Adopt an integrated approach to addressing personal and population health needs at the
community level
• Establish a stronger quality improvement support structure
• Strengthen the human resources of rural communities—not only within the health care
workforce—but among all rural residents
• Provide adequate and targeted financial resources
• Use information and communications technology.
This is what all of us do in rural health. We work collaboratively for health care improvements
and connections at the community level. We strengthen human resources by building the health
care workforce and engaging rural residents in their own health and health care. We focus on
financial stability while exploring the latest in technology.
Our latest news illustrates all five of the IOM points. The Office of Rural Health and Primary
Care was named the organizational home for the state trauma system during its implementation
period. A trauma system is a logical component in an integrated system of care. It is an
opportunity for more integration with ambulance and pre-hospital care, for quality improvement
in the emergency room, and for more collaboration on discharge planning, rehab and aftercare.
It also focuses on workforce and the cross training of staff. It offers an opportunity to build on
Minnesota’s Comprehensive Advanced Life Support program (CALS) because successful
trauma outcomes require the team response already being taught to rural hospitals in the CALS
program. By its nature a trauma system is a statewide system that ties in the expertise of the
Level One and Two Trauma Centers, which made major contributions to the state’s launch of
this new effort.
In this issue, Tim Held, State Trauma System Coordinator, writes about our logical fit and the
good that will result from a statewide trauma system. After reading Tim’s article, you’ll see
“Coordination of Care: Improving Health Care in the Growing Rural Elderly Population.” The
IOM report talks about addressing quality in rural communities by looking at the people and we
recognize that the largest portion of our rural population is the elderly. Establishing a quality
improvement support structure is as applicable to the state trauma system as it is to how we
improve the health of our aging citizens.
Woven through all of the IOM points—indeed the strand that makes it all work—is
collaboration. Collaboration is a keystone of the Rural Health Advisory Committee (RHAC) and
opposite my column is an interview with RHAC chair elect, Nancy Stratman. Given all the
quality improvement work that is going on, I anticipate even greater opportunities for
collaboration among RHAC, the State Community Health Services Advisory Committee
(SCHSAC) and the State Trauma Advisory Council.
I hope you’ve noticed that the stories in this issue touch on interrelated personal and population
health efforts to improve the health of our rural communities. The subjects range across the life
span and across the health system and the themes of the IOM report pull them all together. Just
as individual wires are formed into strands and strands are woven together into cables, we can
build a stronger rural health system by collaborating for quality.
Mark Schoenbaum is Director of the Office of Rural Health and Primary Care (Office). He can
be reached at [email protected] or (651) 282-3859.
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Minnesota Rural Health Advisory Committee
Member Profile: ORHPC talks with Nancy
Stratman, the Rural Health Advisory
Committee’s chair elect
Nancy’s professional interests extend into her personal time when she can often be found reading
leadership books. She does set those books aside to ride her bike, cross country ski and kayak. In
fact she was recently seen kayaking in and out of the sea caves along Lake Superior in Bayfield,
Wisconsin. She also relishes family time with her parents, her three sisters and their families in
North Dakota or on Cotton Lake near Detroit Lakes, Minnesota.
Nancy’s husband Bruce was a long term care administrator for Good Samaritan Society; he is
currently recovering from a transplant operation after receiving a kidney from one of their
neighbors! The Stratmans worked for Good Samaritan facilities in North Dakota and Minnesota,
with their longest stay in Pipestone for 15 years, where their two children attended and
graduated from school. Their daughter Amy is a traveling labor/delivery nurse, currently on
assignment in New York City. Their son Justin is an electrical estimator in Willmar.
Nancy Stratman
PROFILE
Nancy Stratman is the administrator of Rice Care Center, Rice Memorial Hospital’s skilled nursing
facility in Willmar, Minnesota. Prior to becoming a nursing home administrator, Nancy built 20
years of experience at various Good Samaritan locations—in laundry facilities, business and
accounting offices and as a nursing assistant. In between she earned her undergraduate degree in
business administration from Minot State University and her master’s in management from
Southwest Minnesota State University. Nancy is a member of Rice’s Leadership Development
Team, which dovetails with her passion for bringing a team together to ensure that life is pleasant
for residents. She is a frequent speaker for the organization and to other long term care facilities
on leadership topics, including creating a respectful workplace.
Nancy, what do you think are the most important issues facing rural health today?
NS: The availability of care and services! Both in my professional life and as the child of parents
who are aging in a rural North Dakota community, I am concerned about the availability of
health care providers to meet the needs of elderly who choose to stay in their rural communities.
It is very difficult and frustrating to find dental care, consistent primary care providers and
services. Rural communities are challenged to attract health care professionals—people who are
willing to live and make their careers in the small towns dotted throughout the state. Rural
health care providers and schools need to provide rural experiences and exposure for students.
Along with this we need community welcoming committees, which include businesses and
organizations pointing out the advantages of living the rural life.
What one or two changes do you think would make the most difference for rural health?
NS: I see the need for support groups and respite care being huge—especially for those with
chronic conditions. Support groups provide valuable information for people with chronic
conditions and their family caregivers. With knowledge comes the power to adapt and make the
changes necessary to continue quality of life, even though life may be different. Respite, shortterm, temporary care for people with disabilities gives the regular caregiver some time off. This
allows the caregiver to take a vacation or even just to get away for a few hours to relieve the
stress of providing care. Getting away can help prevent abuse and neglect by offering the gift of
time and support. Often in long term care we see family members who are exhausted from the
demands of giving 24-hour home care to residents prior to admission. Family caregivers need to
realize that their health is also very important and that there are many options of supportive
services at varying levels.
The Rural Health Advisory Committee advises the Commissioner of the Minnesota Department of
Health and other state agencies on rural issues; provides a systematic and cohesive approach
toward rural health issues; and encourages cooperation among rural communities and providers.
Regular meetings are held at Snelling Office Park in St. Paul, Minnesota and are open to the
public. Dates, times and directions are online at http://www.health.state.mn.us/divs/chs/rhac.htm
or contact Tamie Rogers at [email protected] or (651) 282-3856.
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PROGRAM FOCUS
Minnesota’s Statewide Trauma System Implementation Begins
by Tim Held
What is a trauma system?
The 2005 Minnesota Legislature authorized the
Commissioner of Health to implement a statewide trauma
care system. Trauma care advocates in Minnesota have
long worked to get this system—so effective at saving
lives—up and running.
A trauma system is an organized, multidisciplinary
response to caring for severely injured people. It spans the
continuum-of-care—from prevention, through EMS triage,
treatment and transportation to hospital emergency and
surgery care, and rehabilitation. Best practice standards
and guidelines direct each stage of trauma care to ensure
that injured people are promptly transported and treated at
facilities appropriate to the severity of injury. A state
agency typically oversees a state trauma system and its
four primary components:
Impact of trauma in Minnesota
A simple review of the trauma (injury) related data
collected by the Minnesota Departments of Health and
Public Safety reveals that unnecessary death and disability
continues year after year, placing a huge burden on
families and communities.
• Trauma is the leading cause of death for Minnesotans
ages 1 to 44. Overall, trauma is the third leading
cause of death for all Minnesotans.
• In the 1990s, nearly 21,000 Minnesotans died
from trauma.
• On average, more than 2,300 Minnesotans die from
trauma each year.
• Motor vehicle crashes are the leading cause of trauma
deaths in Minnesota—655 in 2003.
• In 2003, 69 percent of the fatal motor vehicle crashes
were in rural areas.
• In 2003, the economic cost of motor vehicle fatalities
in Minnesota was more than $7 million.
• More than 4,000 Minnesotans are hospitalized each
year for central nervous system injuries, including
spinal cord and traumatic brain injuries.
• For every death, more than 13 people are hospitalized
for trauma-related injuries.
What is particularly notable is the predominance of
trauma’s impact on the young. If Minnesota were to
measure its deaths using years of potential life lost—the
number of years between early death from injury and an
“average” age of death at 70—trauma would be the
leading cause of death for all Minnesotans.
Reflecting on this, former U.S. Surgeon General, C.
Everett Koop said,
“If some infectious disease came along that affected
children in the proportion that injuries do, there would
be huge public outcry and we would be told to spare no
expense to find a cure and to be quick about it.”
Why a trauma system?
The time between a severe injury and receiving definitive
surgical care is the “golden hour.” Survival diminishes
with time and a trauma system that quickly provides
definitive care enhances survival chances.
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• Trauma center designation
• A trauma registry, which supports system performance
monitoring and provides feedback for improvement
• Emergency Medical Services (EMS) triage and
transport guidelines
• Interfacility (hospital to hospital) transfer guidelines.
A state trauma system also provides a foundation for
disaster preparedness and response. As part of its day-today activities, it coordinates and monitors the movement
and care of severely injured people and adjusts to
fluctuations in surge capacity and diversions due to
availability of resources.
Benefits of a trauma system
Forty-one states have trauma systems, though the
comprehensiveness and maturity of these systems vary,
largely due to inadequate or unstable funding. In states
with mature systems, the benefits are remarkable:
• Decrease in motor vehicle crash deaths of 9 percent
• Increase of 15 to 20 percent in survival rates of
seriously injured patients
• Increase in productive working years
• Increase in statewide disaster preparedness.
Expanding Minnesota’s trauma care
Prior to the passage of this year’s trauma legislation,
Minnesota was one of nine states without a formal
statewide trauma system. This does not infer, however,
that there is not excellent trauma care available in much
of the state. There is. For many years, a few Minnesota
hospitals voluntarily maintained verification through the
American College of Surgeons as either Level I or II
Trauma Centers creating pockets of trauma care and
prevention excellence. But many citizens are isolated from
trauma care resources.
The state trauma system will expand specific trauma care
interventions and resources (e.g., training and education,
transportation, treatment/transfer guidelines, internal
performance improvement programs and equipment) to
those hospitals that wish to participate, and network these
resources so no part of the state lacks access to time-critical,
coordinated trauma care.
Hospital participation is voluntary. There are four separate
levels of formal trauma designations that hospitals may
pursue, based on their resources and capabilities. Every
hospital with an emergency room/department meeting the
criteria is encouraged to participate. Specific designation
criteria is on the Minnesota Comprehensive Statewide
Trauma Systems Plan site at:
www.health.state.mn.us/traumasystem.
department. The Trauma Program is already working across
MDH. The MDH Injury and Violence Prevention Unit will
provide technical support for and epidemiologic analysis of
the Web-based trauma registry. The Trauma Program is
coordinating an effort to link its registry to the MDH Office
of Emergency Preparedness’ Web-based Hospital Resource
Tracking System so hospitals submit trauma resource and
registry data to one MDH site. More important, the trauma
registry must link with the electronic EMS data, so crossagency coordination with the EMS Regulatory Board
(EMSRB) will be accomplished. Because EMS is regulated
outside of MDH, the EMSRB has statutory oversight for the
relevant EMS portions of the trauma legislation. Seamless
coordination between these agencies is imperative.
Immediate priorities
There are three priorities before the Trauma Program can
begin operating:
1. Establishing a State Trauma Advisory Council
The State Trauma Advisory Council (STAC) is defined in
statute as a 15-member council to advise the
Commissioner of Health on issues related to the trauma
system. The Office of the Secretary of State will
administer the open appointment process. Appointment
applications opened in mid-September, appointments will
be made by mid-October, and STAC’s first meeting will be
mid-November to early December.
2. Establishing a trauma registry
Trauma Program implementation
For implementation, the Trauma Program was placed under
the Minnesota Department of Health’s (MDH), Office of
Rural Health and Primary Care (ORHPC), because of its
compatible program delivery responsibilities. The Trauma
Program and the ORHPC share similar goals and clients.
Both take a voluntary, collaborative approach to their work
with customers, and both take a systems approach that
focuses on the benefits of integrating health care delivery at
the community, regional and state levels. Both have
experience and understand hospitals, especially small rural
hospitals, which will be an early focus. Both work with the
state’s EMS system, another critical component of a trauma
system. The Trauma Program will be designating hospitals as
trauma centers; ORHPC has similar experiences, designating
70 Critical Access Hospitals. Finally, both have been heavily
involved in supporting the efforts of the statewide
bioterrorism hospital preparedness program. Funding is
appropriated by the legislature from an increase in hospital
licensure fees.
Creating a secure, Web-based state trauma registry, which
is accessible, is an integral component of the system.
Stand-alone registries would be prohibitively expensive
for smaller, low-volume hospitals.
3. Establishing a trauma hospital designation process
A formal trauma hospital designation process is the most
visible component of the system, involving both STAC
and the registry.
Promising future
Through the direction and support of key legislative leaders,
hospital leaders, physician and nurse leaders, EMS industry
leaders, and the numerous related professional associations
and programs, Minnesota is well prepared to implement this
much anticipated statewide trauma system. Improved lifesaving, injury-reducing trauma care for Minnesotans has
never been more promising.
For more information, contact Tim Held, State Trauma
System Coordinator, at [email protected] or
(651) 296-8290 or visit www.health.state.mn.us/traumasystem.
A permanent MDH home for the Trauma Program will be
determined later, once the system is implemented and there
is time to evaluate how its evolving mission fits within the
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PARTNER PAGE
Coordination of Care: Improving Health Care
in the Growing Rural Elderly Population
by Linda Norlander
Minnesota is aging—approximately 12 percent of Minnesotans
are 65 or over. In 25 years, that number will rise to 23
percent. Meanwhile, 40 percent of the aging population is
already living in rural Minnesota. People over 65 are more
likely to have health related problems and more likely to need
services that result in moves among homes, hospitals and
nursing homes.
Preparing for Growing Elderly Population
Improved coordination of services can result in improved
outcomes for patients.
Stratis Health, Minnesota’s Medicare Quality Improvement Organization, in collaboration with
the Office of Rural Health and Primary Care, recently presented a series of workshops in rural
Minnesota on improving coordination of care across settings and improving the quality of care
within health care settings. At sessions held in conjunction with the Stratis Workshops, the
Office of Rural Health and Primary Care held forums with the participants to talk about current
challenges in caring for the elderly and ideas for preparing for the future.
Coordination of Care
Coordination of care means making sure that everyone involved in caring for a patient,
including family and health care providers, have the right information at the right time to
provide the best services possible. This is particularly important when a patient is moving into a
new setting, such as from a hospital to a nursing home.
One workshop participant described her personal experience regarding poorly coordinated
services:
“My elderly mother was discharged from the hospital recently
with a prescription for a medication that needed to be injected
daily. No one set up home care services for her, no one assessed
her ability to do the injections herself and no one considered that
her small town pharmacy might not have the drug. Fortunately,
I’m a nurse and I was able to figure it all out. But what about
those patients who don’t happen to have a nurse in the family
when something like this happens? Those are the patients who
end up in the emergency room or back in the hospital.”
The workshops addressed a number of ways to ensure good
coordination of care including:
• A discussion of the elements of discharge planning
• An introduction to the concept of case management and
• An introduction to the concept of health literacy.
Discharge Planning
In the first of the two-part series on care coordination, participants were
challenged to look at the resources and systems in their own communities
to come up with ways to better communicate across settings.
Good discharge planning is key to ensuring that patients and providers get
the right information. It starts with an understanding of how care is
provided in each setting. That is why participants from all types of facilities
were invited to be a part of the workshop.
6
A team from Winona responded to the challenge of improving discharge
coordination between settings by designing a community-wide discharge
form. The team, made up of hospital, nursing home and home
care participants, created the form to provide consistent
information on patients. The form includes both check box items
and ample space for physicians and other health professionals to
include pertinent information about care.
Case Management
In case management, one person—usually a nurse—coordinates
the care services for a patient both within a health care setting
such as a hospital and also between settings. The case manager
acts as an advocate and advisor, helping the patient progress
through the health care and benefits system. Case managers do not
make diagnoses or treatment decisions, nor do they make
judgments about benefit eligibility. Case managers work to ensure
that the best clinical practices are used by assessing the best ways
to use the limited financial resources of the health care system and
maintaining continuity throughout the recovery process.
Karen Zander, a nurse and expert in case management, presented a
case example at the workshops. She showed a video of “Mrs.
Peterson” who had a mild stroke. Through the course of
hospitalization and rehabilitation, the patient suffered multiple
complications that ultimately resulted in her death and $140,000
in cost for care. Zander challenged participants to review the case,
look at best clinical practices for stroke treatment, assess the best
setting for the patient and come up with a different outcome.
Participants were able to formulate plans for Mrs. Peterson using
evidence-based clinical guidelines for stroke management that
prevented complications. Additionally, they used more costeffective settings for rehabilitation such as skilled nursing facilities
and home care. In reworking the care Mrs. Peterson experienced a
good outcome and they were able to reduce costs to between
$10,000 and $20,000.
Health Literacy
A growing body of research
documents that patients
often don’t understand the
information they receive
from their health care
providers. Low literacy
levels contribute to the
problem. One study found
that 26 percent of the
participants could not understand the information on an
appointment slip. Forty-two percent could not comprehend
directions for taking a medication on an empty stomach and 60
percent did not understand the standard informed consent that all
patients sign for treatment.
In presenting to the workshops, Nancy Wolf, R.N., quality
improvement manager from Stratis Health, reported that health
literacy is a significant problem due to the heavy reliance on the
written word for patient instruction in an increasingly complex
health care system. Additionally, an aging and a more culturally
diverse population have more challenges in understanding health
related information. She presented strategies to improve
communication that include:
• Slowing down
• Taking time to listen to patients’ concerns
• Using plain, non-medical language and
• Focusing on key messages.
“Speak to the patient in understandable terms. For example,
instead of using the word ‘hypertension,’ use ‘high blood
pressure,’” offered Wolf.
Providers can further help by incorporating “Ask me 3,”
encouraging their patients to understand the answers to three
simple but essential questions in every health care interaction:
1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?
More information is online at http://www.askme3.org.
Current Challenges in Caring for the Elderly
Participants discussed their current challenges to finding services
for the elderly in their community. Several common themes
developed. These included lack of transportation, lack of services
such as homemaking, nursing, meals-on-wheels and home health
care, and a need for more centralized information on services.
For many, transportation was the key issue. A participant from
central Minnesota noted, “If someone has trouble getting to the
doctor, they simply don’t go until it’s too late.” A recent national
study on rural access to transportation reflects the concern
expressed by the forum participants. The study found that licensed
drivers living in rural areas made twice the number of chronic care
and regular care visits in a year than unlicensed rural residents.
Workshop participants also shared the resources they used for
obtaining services, including hospital social workers and social
services through the county, county public health and local senior
services. A number of respondents also reported using the Internet
to find information and resources.
A participant from southern Minnesota commented, “One thing
we could use right now is a central source for information—like a
one stop call center.”
Envisioning our own futures
Workshop participants were
asked to envision their own
retirement and think about
what they would want in their
community to ensure a healthy
aging experience. Again,
availability of transportation
was one of the most frequently
listed wishes. One participant
commented, “I want either
reliable, easily available transportation, or services and shopping
within walking distance.”
Many commented on the need for a variety of housing options
including affordable assisted living. As a participant in the
Duluth workshop said, “I’d like to have a nice log cabin where I
can live independently, but also have it attached in some way to
other services.”
See “Coordination of Care”
(back page)
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.
Coordination of Care
(continued from page 7)
Another observed, “We need housing that includes a mix from single family homes to
townhomes to assisted living.”
Others discussed the importance of not only service
availability, but quality of life issues. As a southern
Minnesota participant observed, “I want to live in a
community where I can feel like I have something
to contribute.”
Mark Schoenbaum, Director
Mary Ann Radigan, Editor
Cirrie Byrnes, Editorial Assistant
This information will be made
available in alternative format –
large print, Braille, or audio tape
– upon request.
Whether future wishes involved transportation,
housing, medical services, or quality of life, the
need to support independent living was a common
thread. “We want to have nursing home services in
our community, but no one wants to live there if
they can avoid it,” one participant observed.
Linda Norlander R.N., M.S. is a planning supervisor for the Minnesota Department of
Health-Office of Rural Health and Primary Care. She is the co-author of “Choices at the End
of Life, Finding Out What Your Parents Want Before It’s Too Late” and “To Comfort Always,
A Nurse’s Guide to End of Life Care.” Contact her at [email protected] or
(651) 282-6317.
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