Volume 7 Number 2
Rainy Lake, Voyaguers National Park
©Minnesota Office of Tourism Photo
Q U A R T E R LY
Summer 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.
Building Upon our Past—Shaping our Future
by Mark Schoenbaum
To initiate my first appearance in the Director’s Corner, please join me for a rural health and
primary care tour of a few Minnesota communities:
• In Canby, the hospital opened a dental clinic in response to the area’s urgent need.
• Floodwood community leaders partnered with Scenic Rivers Health Services in Cook to
keep the Floodwood clinic open. In Cromwell and Bricelyn, city leaders opened clinics
right inside or next door to City Hall.
Mark Schoenbaum
• Throughout south central Minnesota’s Region 9, Su Salud—a Spanish radio show on health
topics—is heard on the radio each Saturday.
• In Remer, city and township leaders formed an EMS taxing district to support their
ambulance service. Elsewhere in Cass County, leaders began planning to improve after
hours and emergency care and the long ambulance trips faced by residents and volunteers.
• In Tyler, the hospital, the local pharmacist, and the University of Minnesota Pharmacy
School collaborated to bring in a pharmacy resident. The resident explored preserving
pharmacy access and improving quality and then accepted a permanent job in Tyler.
• Northwestern Minnesota nurses, social workers and pharmacists from hospitals, nursing
homes, home health and public health agencies met with Stratis Health to collaborate on
improving discharge planning for residents.
• In Wabasha, the first class of nursing students will soon graduate from their distancelearning program taught by Minnesota West Community College instructors in
Worthington—200 miles away.
• In Minneapolis, physicians opened the Native American Community Clinic on Franklin
Avenue, and West Side Community Health Services opened La Clinica en Lake. In St. Paul,
planning is underway for a possible Pan-Asian Community Clinic.
What do these accomplishments have in common, and what do they tell us about our rural
health and primary care safety net? They all embody the values of collaboration, ingenuity and
hard work. They exemplify dedication to building vital communities, and they illustrate our
commitment to caring for our elders and providing job opportunities for our youth. These
achievements reflect our traditions, welcome newcomers and respect differences. And they
demonstrate commitment to improving health and ensuring the highest quality health services.
These values have molded ORHPC’s approach since it began in 1992, and they will continue to
steer our approach and our efforts together. They will be dependable guides in our work to
improve health care access and quality.
We’ll need this grounding to respond to the ongoing challenges of health and coverage
disparities, workforce shortages, population changes, distance to care and limited finances. It
sounds daunting, doesn’t it?
Mark Schoenbaum, Director
Mary Ann Radigan, Editor
Cirrie Byrnes, Editorial Assistant
But as we’ve seen on our tour, pioneers and innovators have shown us how progress can be
made. We all stand on the shoulders of those who came before us, and I thank my predecessors
Chari Konerza, Estelle Brouwer and Karen Welle (who has returned to her position as assistant
director) for building what I believe is one of the strongest rural health and primary care offices
in the country.
We have much to celebrate and build on, and great strengths and values to help us achieve our
vision. I am confident that we are up to the challenges that meet us every day.
Mark Schoenbaum was appointed Director of the Office of Rural Health & Primary Care
(ORHPC) in May 2005. Prior to this, he was the Office’s Director of Primary Care and
Financial Assistance Programs. Mark can be reached at [email protected]
or (651) 282-3859.
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PARTNER’S PAGE
Becoming a Rural Voice
Leadership. Passion. Knowledge. Networking. These words
describe the intangibles of what it takes to make a difference.
Recognizing that leadership is a combination of personal
attributes and a set of tools with which to show the way, the
Health Resources and Services Administration’s Office of Rural
Health Policy and the National Rural Health Association (NRHA)
developed Rural Voices in 2002. This year-long program tailors
development to potential rural health leaders and new rural
health researchers while ensuring a greater diversity of
leadership for rural communities. The intent is to help the
participants understand the changing nature of health policy and
provide them with the tools to play a leadership role in their
rural communities and act as a catalyst for change.
In this photo of the 2004-2005 Class of Rural Voices,
Angie is first in the second row from the bottom
The Office of Rural Health & Primary Care’s Angie Sechler, a research analyst, was selected as one of 14 emerging rural
health leaders for the 2004-2005 class. Participants attend three meetings during the year, two in conjunction with national
conferences. Each Rural Voices meeting focuses on educating participants in rural health policy by asking accomplished
leaders to share their knowledge of the public policy process. Conference calls provide additional interaction with rural
health leaders and a final group presentation builds and reinforces the skills and knowledge acquired during the year.
The "rural voices" come from across the United States, each working in different capacities of the rural health care
system. Their first face-to-face gathering was two fall days in Washington, D.C. where participants heard from one another
and from several prominent policy leaders. Former Centers for Medicaid and Medicare Services (CMS) official, Thomas
Hoyer, who has 31 years of experience with Medicare and Medicaid, gave participants the straight story on Washington
influence. Bill Finerfrock, Director of the National Association of Rural Health Clinics; and Hilda Heady, President of the
National Rural Health Association (NRHA) shared the personal and professional experiences that led them to become
passionate advocates for rural health. As Angie describes it, "I came away from this first meeting with a much better
understanding of rural health and the great work of rural health leaders."
Conference calls also connected the "rural voices." One involved a discussion with Tim Size, who served on the Institute
of Medicine’s (IOM) Committee on The Future of Rural Health Care. He provided a firsthand account of how the
committee took on the task of finding ways to ensure rural America benefited from the national efforts to improve the
quality of the health care delivery system. The committee’s work resulted in the new IOM report, Quality Through
Collaboration: The Future of Rural Health. Participants learned about each of the strategies for advancing the quality of
rural health care and the exciting opportunities in store for the rural health field. They were especially encouraged to
learn of the report’s recommendation for integrating population health strategies into personal health services. Rural
communities, given their smaller size and collaborative nature, could lead the rest of the country toward integrating
personal and population health needs. In the words of Mr. Size, this was "revolutionary!"
The second Rural Voices meeting again occurred in Washington, D.C.—this time in March 2005 in conjunction with the
National Rural Health Association’s Rural Health Policy Institute. The policy conference gave participants the chance to
really observe and learn the art of advocacy. There were small group discussions on universal access and statewide health
resources, constituency group meetings around special interests, panel discussions on new developments in Medicaid and
Medicare policy and the economic viability of rural America, speeches by rural health advocates and a keynote by Health
and Human Services Secretary Michael Leavitt. The entire conference prepared attendees to carry a unified rural health
message to national leaders. The "rural voices" met with Chandra Branham, Senior Legislative Analyst with CMS; Mary
Wakefield, Director of the Center for Rural Health-University of North Dakota; and Rachel Gonzalez Hanson, Chief
Executive Officer of Community Health Development, Inc. to learn key aspects that drive policy and the best ways of
working with chief decision makers.
The "rural voices" assembled a panel of experts at the National Rural Health Conference in New Orleans in May to
present examples of innovative workforce shortage solutions. This panel discussion and a separate luncheon were the final
gatherings of the 2004-05 Rural Voices class. If Angie’s comments are an indication of success in developing one new
rural health leader, the program is worthwhile and important. "I hope to put into practice everything I learned from the
personal stories and words of advice of rural health advocates and leaders and by staying involved in NRHA. Every
moment of Rural Voices has been a valuable learning experience. I encourage anyone interested and committed to
advancing the rural health cause to consider applying to the Rural Voices program."
To obtain more information about the Rural Voices program, contact Angie at [email protected]
or (651) 282-6329 or visit the Web site at http://ruralhealth.hrsa.gov/policy/ruralvoices.htm.
3
SPECIAL FEATURE
Health Care Directives: What all Rural Residents Should Know
By Linda Norlander, R.N., M.S
There has been much in the news and our own
conversations lately about what can happen when
someone is no longer able to speak for themselves.
Without a written directive, what begins as a personal and
family tragedy can erupt into a public dispute.
Every adult in this country, young or old, should have a
written health care directive. This is particularly important
for rural residents because families are often separated by
great distances and crisis health care is often delivered
outside the community.
What is a health care directive?
A health care directive (formerly known in Minnesota as a
"living will") is a written document that can guide health
care decisions if you are unable to make or communicate
decisions for yourself. In a health care directive you may
do one or both of the following:
• State your wishes and preferences about the kind of
care you want and/or
• Name a person or persons to make decisions for you.
The only way to ensure that your wishes are respected is
to discuss them with your family, name a health care
agent who can make decisions for you and complete a
written directive.
Why do I need to talk about this with my family?
When a health care discussion does not occur, people are
vulnerable to treatments and care they might not want,
and families are forced into making difficult decisions—
often in a crisis—without knowing what a loved one
would want. Completing a health care directive is the
opportunity to talk in depth about the care you wish and
the reasons behind those wishes.
A middle-aged daughter said, when she faced a difficult
decision regarding risky surgery for her mother following a
severe stroke, "I’m glad we sat down and had a serious
talk last year because I knew this wasn’t the way she’d
want to live out the rest of her days."
How do I start?
Start by making sure that the right people are at the
table. This discussion needs to happen among those who
might be involved in health care decisions. The most
common decision makers include spouses, children,
siblings and parents.
If you find yourself at a loss for how to begin the
conversation, consider the following questions:
• What would I hope for if I was considered terminally
ill? People often hope to receive care at home, to
have time to put their affairs in order, for a chance to
say good-bye.
• What kind of medical treatments would I want if I
4
could no longer speak for myself? Thoughts on this
might range from "Don’t put me on a ventilator" to
"Make sure I’m not in pain."
Think about your reactions to the death of others. For
example, after Terri Schiavo died, a middle-aged woman
said, "I believe in the sanctity of life and if I were in the
same situation, I don’t think I would want anyone to
remove my feeding tube." On the other hand, a father of
two responded to the situation by saying, "I would never,
never want to be kept alive that way. I don’t believe my
life would have value and I would be placing an incredible
burden on my family."
What should my health care directive say?
Health care directives give you an opportunity to write
down what you want for care. It is a legal document
meant to ensure that your wishes will be honored.
Directives can include general statements about your
values and beliefs and specific statements about care
wishes. For example, a 70-year-old mother and
grandmother wrote:
If the situation should arise in which there is no
reasonable expectation of my recovery from a physical or
mental disability, I request that I be allowed to die and
not be kept alive by artificial means. I do not fear death
itself as much as the indignities of deterioration,
dependence and hopeless pain.
The directive can also speak to specific treatment
decisions and specific care wishes. Common areas to
discuss include:
• Thoughts on pain relief and comfort measures.
One person might say, "Give me everything you’ve
got. I don’t want to be in pain." Another might say,
"I’d rather have less pain medication, if necessary
to be alert."
• Wishes regarding feeding tubes or artificial hydration
(IVs). An 87-year-old great grandfather said, "I don’t
want any of those tubes to keep me alive. When it’s
my time to go, it’s my time to go."
• Life support such as cardiopulmonary resuscitation
(CPR) or artificial ventilation. One young mother said
about CPR, "At this point in my life, resuscitate me!"
• End of life care. Many nursing home residents request
no further hospitalization. Others request hospice care
or care at home.
Who should be the health care agent(s)?
The agent can legally make health care decisions when
you can no longer speak for yourself. The agent:
• Knows your care wishes and goals. Never name an
agent who does not know what you want.
• Advocates for the desired care. As one health care
agent noted when her father was hospitalized, "Even
though the people who were caring for Dad had the
best of intentions, the system can be very complicated.
It took me three days of bothering the nursing staff
before a ‘Do Not Resuscitate’ order was written. I had
to be persistent."
• Is available to make decisions if necessary. Often
decisions need to be made quickly. If your agent travels
or is difficult to reach, consider naming a second agent.
Where do I find a health care directive form?
Information on health care directives is on the
Minnesota Department of Health Web site at
www.health.state.mn.us/divs/fpc/profinfo/advdir.htm.
Linda Norlander R.N., M.S. is a planning supervisor
for the Minnesota Department of Health - Office of
Rural Health & 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.
Five Tips on Health Care Directives
1. This is more than a piece of paper! The way to ensure
that your wishes are respected is to complete a
directive, name an agent and DISCUSS YOUR VALUES,
WISHES AND HOPES WITH YOUR FAMILY!
2. Your health care agent is key. Name someone you can
trust, who will be available to make decisions and who
knows what you want.
3. People need to know where to find your directives. Do
not lock it up in a safety deposit box.
4. You need to have your signature witnessed by two
people or notarized to make it legal. You do not need
a lawyer to fill out a directive.
5. Revisit your directive periodically, especially if your
health or family situation changes.
Join us in Duluth for the 2005 Minnesota Rural health Conference where we will focus
on maintaining and improving health care services in greater Minnesota.
Information for the July 18-19 conference in Duluth, Minnesota is online at
http://www.health.state.mn.us/divs/chs/orhconf.html or contact Sally Buck at Rural Health
Resources Center [email protected] or (800) 997-6685, ext. 225
5
PROGRAM FOCUS
Differences in health exist between rural and
metro residents “Health and Well-being of
Rural Minnesotans” a tool for providers and
public health professionals
A new Minnesota report shows that geography may be a factor in our health and well-being. In
comparing rural and urban residents, the Health and Well-being of Rural Minnesotans: A
Minnesota Rural Health Status Report found some areas of greater health risk for rural
residents. Men in Greater Minnesota are more likely to smoke than urban residents. More rural
residents are overweight and less likely to participate in physical activity. Greater Minnesota
residents are also less likely to wear seatbelts. Other areas, such as diabetes prevalence, show
Greater Minnesotans are similar to Metro residents.
"This report shows us that rural areas, with their distinctly different demographics and social
and economic characteristics, present a unique set of health care challenges," explains Linda
Norlander, of the Minnesota Department of Health’s Office of Rural Health & Primary Care.
"While the report doesn’t explain why differences in health status between urban and rural
residents exist, it does provide us with a starting point for discussion."
The Health and Well-being of Rural Minnesotans report includes behavioral risks, disease and
injury prevalence, birth outcomes and causes of death, such as:
• Men living in Greater Minnesota are more likely to smoke compared to men living in
the Metro area, 26.5 and 22.2 percent respectively. There is very little difference in the
smoking percentages among females living in Greater Minnesota and the Metro area
(19.5 to 19.3 percent).
• Forty-six percent of rural residents age 65 and older report lost six or more of their
permanent teeth because of decay or gum disease, compared to only 32.3 percent of
urban elderly.
• Middle and high school students living in Greater Minnesota are more physically active.
Slightly more than 31 percent of sixth, ninth and 12th graders combined said they play
sports on a school team six or more hours a week compared to just 24 percent of Metro
area school students.
• More than half of the firearm-related injuries in Greater Minnesota are self inflicted
(52.9 percent), while firearm injuries in the Metro area are more frequently due to
homicide or assault (55.1 percent).
• Teen birth rates in Greater Minnesota were lower compared to Metro area from
1998-2002. (13.4 vs. 17.2 per 1000 female 15-17-years-olds).
The Health and Well-being of Rural Minnesotans report produced by the Office of Rural Health
& Primary Care and the Center for Health Statistics in the Minnesota Department of Health
supports efforts that already are underway at the community, state and federal level to address
urban-rural disparities in health care access and health status. These include development of a
statewide trauma system, public health education, community innovations in health care and
emergency medical services, and financial assistance for rural health care providers and
communities.
The Office of Rural Health & Primary Care plans to share the report with local public health
agencies and health care providers across the state to continue to focus on ways to reduce or
eliminate differences rural-urban health status. The report is online at
http://www.health.state.mn.us/divs/chs/healthwellbeing.pdf.
6
Minnesota Rural Health Advisory Committee
Member Profile:
ORHPC talks with Rick Failing
Rick Failing is the administrator of
Kittson Memorial Healthcare
Center in Hallock, Minnesota.
Just one fact about Rick Failing explains how unwavering he is to a commitment. Rick was in
Reserve Officers’ Training Corps (ROTC) at the Madison campus of the University of Wisconsin
at a time when students were told not to wear their uniforms outside of the classroom. Yet Rick
stayed with ROTC and, after graduating in Agricultural Economics, he entered the U.S. Air
Force as an officer and worked for two years in the F16 fighter plane development office at
Wright-Patterson Air Force Base. Rick earned his master’s on the weekends at Central Michigan
University and served for two years in the Medical Service Corps. He resigned his commission
as a captain and began his civilian health care career in Linton, North Dakota before becoming
MeritCare’s onsite administrator of Perham Memorial Hospital and Homes, a 36-bed hospital
and 102-bed nursing home.
When the entrepreneurial bug bit, Rick and a partner began a Medicare Cost Report support
business in Oregon and Washington. It was so successful that it cost too much time away from
his very young family so Rick joined Blue Cross/Blue Shield of North Dakota as its Provider
Relations Manager.
Rick’s wife grew up on her family’s farm 15 miles from Hallock, Minnesota. Rick’s hometown
in Wisconsin is about the size of Hallock so they both knew exactly what type of place they
wanted to raise their three children. In 1993, the position as administrator of Kittson Memorial
Healthcare Center in Hallock seemed made for the Failing family. Rick explains, "It was in our
children’s best interest and it was an opportunity for me to get back into what I’m comfortable
doing—administration, which in rural health care is often looking for a solution that may not
be obvious."
Rick and his wife, Marla, have three children in high school. When Rick isn’t serving as
president of his church and on regional and state health care committees, or fundraising in the
community, he putters in his strawberry beds and raspberry patch. But his real love is
supporting his sons’ and his daughter’s sports activities. Maybe, just maybe when the nest is
empty in three years, Rick will pull out those books that are stacking up; take up woodworking;
fish some more…maybe…
Rick, what do you think are the most important issues facing rural health today?
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
www.health.state.mn.us/divs/chs/
rhac.htm or contact Tamie Rogers at
[email protected] or
(651) 282-3856.
RF: My definition of true rural is a community that is 3,000 people or less. The most important
issue is maintaining primary heath care services in these smaller, less populated rural areas. We
have to look at two major problems—a weak economy and the lack of providers. Kittson
County and areas in southwestern Minnesota are losing population and the median age is
growing so it becomes a struggle to keep the doors all over town open. The remedy is creating
and sustaining vibrant communities through economic opportunity. Economic opportunity will
attract young people and their presence will sustain the community and support primary rural
health care services.
In a rural area, finding medical providers is a constant challenge; this includes the resources to
deal with mental health issues, which cross all age groups. The stressors that concern parents—
tight incomes, employment, divorce—also affect their school-age children. Rural areas also have
large elderly populations trying to cope with depression, loss, grief and separation from their
nuclear family.
More and more providers are raised with the bright lights of the city—or at least access to
McDonald’s. Explaining how good life is in Andy’s Mayberry isn’t easy. I’ve lived in rural and
urban areas and I appreciate that people know me, I can drive to work in a few minutes and
when I want to go fishing, I can easily get there. Up until a few years ago we still had a home
milk delivery service, and when Mike knew we weren’t home he’d walk in and put the milk in
our refrigerator. For me there is a real appeal in that. But it’s a problem when a small town
doesn’t have opportunities for the spouse who is a chemist or an engineer. So we are trying to
grow our own local nurses, lab technicians, physician assistants and physicians.
See “Rick Failing”
(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.
Rick Failing
(continued from page 7)
What one or two changes do you think would make the most difference for
rural health?
RF: State and federal governments need to look at rural health issues from an economic
standpoint. With $5 million to $10 million in development funds, local governments could
attract nonretail employment that would have a major impact on a community. This would
create a positive ripple up and down main street and into the classrooms. The health care
facility might be the largest employer but without a strong employment base, the area’s
economic pyramid begins to fall down.
Further promotion of telehealth would also make a difference. Telemental health is being well
received and in some cases it is as effective, if not more so, to provide this type of local
counseling rather than require an hour’s drive. With telepharmacy, a pharmacy technician
working with a remote pharmacist can keep a local pharmacy open. With telehealth, an
emergency room physician can be made available to on call rural mid-level practitioners,
because we cannot expect our local doctors to continue to be on call the way they are today.
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.
Finally, we need legislators to be consistent and take a long range view. With the Critical
Access Hospital (CAH) designation came a higher level of reimbursement (cost based) from
Medicare to help ensure that care continues to be available in rural areas. Minnesota has
more than 140 hospitals, 66 of them are Critical Access Hospitals. This program has been a
huge success story for Minnesota, and nearly all of Minnesota’s qualifying rural hospitals have
been either designated as a CAH or plan to by the end of 2005. But when there is dialogue in
Washington, D.C. that calls this and other policies into question, it is difficult to plan because
we don’t know what our future revenue stream will be. After working hard to make sure that
our small hospitals and clinics are reimbursed fairly, Minnesota cannot afford to step
backwards. Access to quality rural health care depends upon creating a level field.
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