Volume 8 Number 3
Nerstrand Woods State Park ©Minnesota Office of Tourism Photo
Q U A R T E R LY
Fall 2006
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.
Corn and competition
A farmer grew award-winning corn. Each year he entered his corn in the state fair where it
won a blue ribbon. One year a reporter asked him the secret of his success and discovered
that the farmer shared his seed corn with his neighbors. “How can you afford to share your
best seed corn with your neighbors when they are entering corn in the same competition with
you each year?” the reporter asked. “Didn’t you know?” said the farmer, “The wind picks up
pollen from the ripening corn and swirls it from field to field. If my neighbors grow inferior
corn, cross pollination will steadily degrade the quality of my corn. If I am to grow good corn,
I must help my neighbors grow good corn.”
DIRECTOR’S CORNER
Mark Schoenbaum
I recently came across this fable, in wide circulation and often attributed to James Bender. It
started me thinking about the implications of competition and collaboration in our efforts to
improve the health care safety net, both rural and urban. I’m usually among those who stress
the benefits of collaboration as the best way to overcome the challenges of limited resources,
whether financial, human or technological. Though we don’t often emphasize it, competition is
also a regular part of the outlook in health care.
Often viewed as a negative value, our organizations usually compete from very positive
motivations. We believe that the ability to serve those most in need, those without health
coverage or mobility or those with other special needs, requires us to attract a broad base of
patients and offer them as many of the services they need as we’re able. We strive to generate
revenue so we can respond to urgent priorities. With health care worker shortages, it seems
there’s often no alternative but to compete intensely for high demand positions.
But according to the farmer, if my neighbors weaken, the entire system is threatened. If the
hospital down the road or the clinic across town fails, there will be fewer to collaborate with on
projects I can’t do without partners.
So how do we balance competition and collaboration? Which approach will best help safety
net providers, as a field, respond to the next set of trends, such as public reporting, pay for
performance, and growing expectations to improve management of chronic disease? How do
community leaders best strengthen organizations?
And where do we as support organizations and policymakers focus our efforts to improve access
and quality? What emphasis should we put on helping individual organizations succeed, and
where should we require partnership as a condition of assistance?
The farmer in the fable is a winning competitor who delivers top quality results and
simultaneously helps his rivals succeed. He’s embraced the paradox that he must share his most
valuable assets to win the prize. How can we emulate the farmer and build on the tradition of
collaboration that already serves us well?
You can tell that the fable of the farmer and his amazing corn struck a chord with me, but I
don’t have any answers in this column, just questions for us to talk about as we do our work.
Let me know what you think.
Mark Schoenbaum is director of the Office of Rural Health and Primary Care. He can be
reached at [email protected] or (651) 201-3859.
The ORHPC Quarterly is using electronic distribution instead of the mail. Subscribe
at http://www.health.state.mn.us/subscribe.html or request other arrangements by
contacting Cirrie Byrnes at [email protected] or (651) 201-3844.
2
Nearly 50 delegates from Australia, Canada and the
United States met at the Mayo Clinic in Rochester, July
24-27 to share ideas on integrating rural Emergency
Medical Service (EMS) providers into rural health care
delivery systems. This international forum continues the
discussion from an historic meeting hosted in Halifax,
Nova Scotia, in the summer of 2005.
Commissioner of Health Dianne Mandernach introduced
the Rochester meeting. Others welcoming delegates
included Minnesota Rural Hospital Flexibility Advisory
Committee members Mary Hedges, director of the
Minnesota EMS Regulatory Board, and Gary Wingrove
from Gold Cross/Mayo Medical Transport. There were
updates on issues such as medical oversight,
collaboration with other health care teams, and
exploration of a graduate certificate in rural and
isolated paramedical practice.
The overarching mission is to look hard at ways that
community paramedics could be integrated into the
hospital setting as well as play a role in community health
care. Wingrove said, “Rural communities are facing critical
health care worker shortages—looking at better ways that
the rural health care system can use paramedics is a smart
way to approach the shortage of health care providers and
creates a stronger, more integrated health care system. It’s
a very exciting vision, and we are definitely interested in
figuring out how Minnesota could benefit from this
approach. There is much to learn from our colleagues in
Canada, Scotland and Australia, as well as among the
states. This work brings the recommendations of the Rural
& Frontier EMS Agenda for the Future into reality in a
way that is a win-win all around.”
While the Agenda was in development in the United
States, the province of Nova Scotia and the countries of
Australia and Scotland concurrently and independently
recognized the need to expand the scope of their
respective paramedic services to meet the needs of
increasingly isolated elderly populations and overwhelmed
rural health care services. The work in Nova Scotia was of
particular interest as it was the only known working
model of Community Paramedic Practice in North
America at the time of the 2005 conference.
At the 2005 meeting, delegates discovered that rural
health issues in the four countries are remarkably similar.
It is very interesting to note that all systems that
developed “Community Paramedic/Paramedic
Practitioner” programs did so as the direct result of public
pressure for service or a sudden change in the health care
human resources dynamic of their areas. It is also
interesting to note that EMS systems were not seen as part
of the primary care continuum until most other options
were exhausted.
More information about community paramedicine and the
Rochester meeting is online at:
http://ircp.ncemsi.org/2006Agenda/tabid/398/Default.aspx.
To find out more about the Rural & Frontier EMS Agenda
for the Future, go to:
http://www.nrharural.org/groups/sub/EMS.html
PROGRAM FOCUS
Community Paramedicine: Strengthening Rural Primary Care
During 2003 and 2004, the National Rural Health
Association, the National Association of State EMS
Officials and the National Organization of State Offices of
Rural Health led a national consensus process to create the
Rural & Frontier EMS Agenda for the Future (“the
Agenda”). The first chapter of the Agenda contains a series
of recommendations for integrating EMS personnel into
rural health care systems. The Agenda project was funded
by the federal Office of Rural Health Policy.
3
COMMUNITY FOCUS
Making Lifestyle Changes to Live Better With Diabetes
by Jenny Schlagenhaft, Director of Communications/Community Relations, Saint Elizabeth’s Medical Center
When Sharon found out she had diabetes, she wasn’t
surprised, since diabetes is in her family. But she was
determined that it wouldn’t run her life. She knew she
had to make changes—big changes from her lifestyle of
smoking, snacking, drinking soda and skipping breakfast.
But rather than take baby steps, Sharon opted to make
a leap.
With the rising incidence of diabetes, one rural hospital
has reached out to the community with a holistic
approach. “It had to be all or nothing,” confessed Sharon.
“So I threw out my cigarettes, started exercising, and
changed my eating habits—all at the same time!” And
she enrolled in Saint Elizabeth’s Diabetes SelfManagement Program.
“We offer individual and group sessions, and tailor the
program to meet specific needs to help patients live better
with diabetes,” says Thompson. By combining these
elements, patients have shown measurable improvements
in blood glucose and cholesterol levels—including
increased high density lipid levels (HDL).
Diabetic Patients
220
210
200
Patients in program
190
Patients not in
program
180
Saint Elizabeth’s Medical Center in Wabasha, Minnesota,
developed a comprehensive diabetes self-management
program in 1998. They add approximately 60 new
patients per year and have seen a total of 525 patients.
Each person is taught about diabetes and how it affects
their body and basic self-care skills, such as:
• Setting goals and creating a treatment plan
• Eating for good health and controlling blood glucose
• Learning the importance of physical activity
• Monitoring blood glucose levels
• Understanding and adjusting medications
• Preventing complications
• Recognizing the relationship between stress
and diabetes
• Managing sick days.
170
160
Diagnosis chol
1 year later
Patients with diabetes and a high level of cholesterol who
participated in the program saw their overall cholesterol
level drop after one year from an average over 200 to
under 180.
Diabetic patients
48.5
48
47.5
47
Patients in program
46.5
46
Patients not in
45.5
program
“Saint Elizabeth’s Diabetes Program helps participants
gain the skills they need to improve blood glucose
control so they can live long and healthy lives,”
explains Paula Thompson, registered dietitian. Research
shows that keeping blood glucose (blood sugar) close to
normal reduces the chances of having eye, kidney and
nerve problems.
Diabetic patients
8
7.8
7.6
7.4
Diagnosis HgbA1c
7.2
7
1 year later
6.8
6.6
6.4
6.2
Patients in program
Patients not in program
Patients in the program have seen a measurable drop in
their blood sugar level.
4
45
44.5
44
43.5
Diagnosis HDL
1 year later
Patients participating in the program saw their high
density lipids increase from an average of 45 to 47.
In the United States, 20.8 million children and adults (7
percent of the population) have diabetes, a disease in
which the body does not produce or properly use insulin
to convert sugar, starches and other food into energy
needed for daily life. Another 41 million individuals are at
risk. Risk factors include obesity, inactivity, high blood
pressure or high cholesterol. Diabetes is the fifth leading
cause of death by disease in the United States. If this trend
continues, one in three Americans will develop diabetes in
their lifetime. The cause continues to be a mystery,
although both genetics and environmental factors such as
obesity and lack of exercise appear to play roles.
The individual and group sessions blend medical care,
education, exercise and support into a cohesive program.
Sharon goes on to explain, “I had so much to learn and
wanted to get it right. The classes taught me a lot about
diabetes: Topics ranged from counting carbohydrates to
monitoring blood glucose. It’s a complicated disease but
the staff made it easy to understand.”
Thompson believes that the self-management program is
successful because it is tailored to each person. This means
involving the patient and their family in:
• Individualized nursing, medical nutrition therapy and
exercise consultations
• Monthly group education sessions
• Annual assessment to determine ongoing
self-management needs
• Phone follow up and consultation to offer
ongoing support
• Communication and updates with the primary care
provider and
• Access to Saint Elizabeth’s Wellness Center.
Most insurance companies cover the costs of the entire
program, including the sessions and educational materials.
According to Saint Elizabeth’s diabetes nurse educator
Terese Hemmingsen, instruction is one ingredient of the
disease management model. Exercise is another. Since the
opening of Saint Elizabeth’s expanded Wellness Center,
patients with diabetes and other chronic diseases are
encouraged to take advantage of this resource. They
receive a thorough orientation of the equipment and
facility, a tailored fitness plan, and ongoing supervision.
Another huge benefit is the camaraderie that is formed
among the patients.
“I actually look forward to my workouts,” confides
Sharon. “It’s an atmosphere that is motivating—not
intimidating. The staff is helpful and encouraging, and the
patients who exercise alongside of me are my greatest
supporters—some are even my heroes!”
Terese Hemmingsen, RN, diabetes educator (left) and
Paula Thompson, registered dietitian (right) doing
diabetes screenings.
The Wellness Center includes cardio equipment and
strength stations and is staffed by exercise physiologists,
exercise specialists and a registered nurse. Exercise is a
part of a complete approach to bringing blood glucose
levels close to normal.
Since taking her leap, Sharon measures success in a
number of ways…“I am exercising 200 minutes a week.
I lowered my blood pressure, cholesterol and blood
glucose. I lost pounds and inches and I have more energy
and feel great!”
Bringing a Certified Diabetes Educator and an educator
with a Certificate of Training in Adult Weight
Management into the community is another element
contributing to the successful results. They offer:
• Free annual diabetes screening
• Education on diabetes and prevention
• Events for local health care providers
• Advanced diabetes education and weight
management services.
The major types of diabetes treated in Saint Elizabeth’s
program are:
• Type 1 diabetes: Results from the body’s failure to
produce insulin. An estimated 5-10 percent of
Americans diagnosed with diabetes have type 1.
• Type 2 diabetes: Results from insulin resistance
combined with relative insulin deficiency. Most
Americans who are diagnosed with diabetes have
type 2.
• Gestational diabetes: Affects about 4 percent of all
pregnant women—about 135,000 cases in the United
States each year.
For more information on this program, contact Paula
Thompson or Terese Hemmingsen, (651) 565-5568.
Working out in the Wellness Center
5
PARTNER FOCUS
Career Ladder for Education and Advancement in Nursing
by Karen Skraba, Itasca Community College, educational grant coordinator
Hibbing Community College, Itasca Community College
and Rainy River Community College created a seamless
avenue from Certified Nursing Assistant to Licensed
Practical Nurse to Registered Nurse (Associate Degree)
when they received a 2003 federal Health Resources and
Services Administration grant to develop a Career Ladder
for Education and Advancement in Nursing (CLEAN).
This seamless approach to education and career growth
included developing a distance learning or online
component within existing programs to increase rural
enrollment. The colleges believed that if rural nursing
professionals had access to education, it would be possible
to create a sustainable rural workforce. This workforce is
particularly critical in the large and sparsely populated
rural areas.
were delivered via interactive television (ITV) at Itasca and
Rainy River Community Colleges. Course assignments and
proctored testing were available online. In the spring of
2005, 18 students graduated.
In the spring of 2005, a second cohort of 31 LPN to RN
students was accepted at Hibbing Community College.
This cohort also received a basic orientation. Their
transition class was taught online and all three fall
semester classes started as online courses. However, about
halfway through fall semester, a change in faculty required
a major course to be offered via ITV. This change was
extremely difficult for the students and faculty even
though the other two classes for fall semester remained
online. One of the spring semester courses was affected
and was offered via ITV. Eighteen students graduated in
the spring of 2006.
Itasca Community College enrolled the third cohort of
students in the Practical Nursing Program in the fall of
2005. These students received all theory course work
online. On-campus students have clinical experience two
days a week; however, to make travel and living
arrangements more convenient, the clinical experiences
for the online students occurred every other week for
four days. Six of the 10 students graduated in the spring
of 2006.
Elements of success
The colleges had four objectives when they applied for
the grant:
• Development of Rural Nursing Theory
• Development of the Distance Learning
Model/Online Components
As a result of the grant, 36 new registered nurses (RN)
and eight licensed practical nurses (LPN) graduated,
although at the time of this article, not all have completed
their board exams. One student summarized the feelings
of most by saying, “I’m glad that I could stay in my own
community to complete my degree.”
Program organization
Nursing courses were delivered via distance learning to
three cohorts of students.
In the spring of 2004, 31 LPNs from the International
Falls and Grand Rapids areas were accepted into the RN
program at Hibbing Community College. Prior to starting
classes, the students were invited to the school for an
orientation to the campus, the nursing program, the
theory of rural nursing and online coursework. During the
summer session students took an LPN to RN transition
class online. Students were enrolled in three nursing
classes in the fall semester and two in the spring semester.
This first cohort took only one of their classes each
semester as an online class. In the other classes, lectures
6
• Development of a Preceptor Model for Clinical
Experiences and
• Enrollment and Retention of Students.
Development of Rural Nursing Theory
A consultant familiar with rural nursing theory was hired
to evaluate the nursing programs for rural nursing content.
After reviewing the programs, the consultant worked with
faculty members of each program to incorporate the
principles of rural nursing theory into the curriculums.
Manuals were developed; and faculty, students and
preceptors received training in the concepts of rural
nursing theory. This includes the definition of health,
distance and access to resources, the symptom-actiontimeline process in seeking care for illness and injury, and
choice of residence and health care providers and the
implications all of these have on a rural practice.
“I didn’t think I would be able to
further my education because of
time, distance and the costs. Even
though there have been rough
coordinator, in collaboration with directors from the
nursing programs and clinical facilities, developed a
preceptor model. This is a one-on-one experience with a
clinical nurse, for a portion of the clinical experiences.
Prior to implementation in a clinical facility, the preceptors
received training in rural nursing theory, nursing program
and course objectives, and preceptors’ roles and
responsibilities. The first cohort of RN students worked
with the preceptors for a total of 24 hours. Students and
preceptors felt this was such a valuable experience that it
was increased to 32 hours for the second cohort. The
Practical Nursing Program used the preceptor model for
the integrated practicum portion of their clinical
experience. Students’ clinical experiences were in their
home community when these were available.
The preceptors facilitated deeper learning and took
advantage of teachable moments as the students used
what they were learning in the classroom. One preceptor
said, “It was exciting to provide quality clinical
experiences close to home and for students to see and
experience real world nursing.” All students who were
able to have the precepted learning experience reported a
profound impact on their nursing education.
While the preceptor model of providing clinical nursing
experience helps students apply what they are learning
in the classroom, it requires commitment and support
from the academic institution and the community partner
to be successful.
spots along the way, I am thankful
Enrollment and Retention of Students
that I earned my RN degree and
The educational coordinator developed a recruitment plan
with campus recruitment staff. A major focus was to
improved life for my family!”
—Student Comment
Development of the Distance Learning
Model/Online Components
An expert in developing and sustaining successful virtual
learning communities advised the nursing directors,
faculty and grant staff on best practices. This included
providing quality online instruction and developing a
community among online learners. The campus
orientation is critical to helping online learners identify
with the campus. To build this identity, the program
organizers found that it was important to have events that
involved all students. A technical support faculty member
was also available for assistance in developing, testing and
implementing online coursework.
Development of a Preceptor Model for
Clinical Experiences
All students in a nursing program require a significant
number of clinical experiences. The educational
include five students in each cohort from economically
disadvantaged populations within the region. The
educational coordinator attended high school career and
college fairs and community events. Individuals completed
cards for the nursing program they were most interested
in, allowing the campus recruiter to track the student, as
well as supply initial program information.
Students were introduced to the mentors during
orientation and this proved to be an important retention
tool. The program directors of the Practical Nursing
7
To learn more about the
Office of Rural Health &
Primary Care programs, visit
our Web site:
www.health.state.mn.us/divs/ch
s/orh_home.htm.
CLEAN (continued from page 7)
Programs and the educational coordinator were all mentors, making more than one mentor
available to most students.
Tutoring was available to all students at the main campuses and the second cohort of RN
students had graduates of the program as their tutors at the off-campus sites.
The Practical Nursing Program directors, serving as mentors, also helped with scheduling of
clinical events. As one faculty member commented, “It was really nice to have the mentors
assist with setting up clinical sites. They ensured that the sites met and often exceeded the
requirements. Very helpful!”
What worked
“Support for this project was low key but was always there—every day.” Faculty comment
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.
Collaboration among college administrators, nursing program directors, faculty and community
partners was key to the success of the grant. While not everyone was engaged to the same
degree, everyone worked together toward a common goal.
It was important to plan involvement from the start by bringing all parties to the table to
develop common ground and clarify roles. When a variety of partners, academic and
community institutions are involved the various missions and visions must have a common link
and value to everyone.
The program directors, grant coordinator and a contracted evaluator examined the process
continuously. Regular meetings of the directors identified and addressed issues as they occurred,
and special meetings with students and faculty were held as the need arose.
Future plans
The faculty and students felt CLEAN was successful enough to continue. Hibbing and Itasca
will continue to offer the nursing programs via distance and online options.
Hibbing Community College will offer the second year of the RN program via the distance
learning model of ITV. Contact Barbara Bozicevich at (218) 262-6743 or
[email protected] for more information.
Itasca Community College (ICC) continues to offer the LPN program online. ICC accepted 10
students into the program for the 2006-2007 school year. This year clinical experiences will be
offered once a month for four to five days. For more information, contact Candace Perry at
(218) 327-4464 or [email protected], or Sue Aldrich at (218) 327-4457 or
[email protected].
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