Spring 2011 Quarterly Newsletter

CONTENTS: Director's Column Partner Focus Program Focus Special Feature Community Focus

SPRING 2011

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Email Mary Ann Radigan at maryann.radigan@state.mn.us or call 651-201-3855 with comments. We invite you to forward this newsletter to your colleagues.
photo courtesy of Lorry Colaizy

DIRECTOR'S COLUMN

DEMANDS MOUNT ON MINNESOTA'S HEALTH CARE SAFETY NET Though Minnesota is slowly recovering from the Great Recession, the stability of the states health care safety net remains fragile as demands on it rise. The 2010 census confirmed both population loss and a growing proportion of older residents in many rural Minnesota counties, creating rising senior health needs in communities with fewer people overall to use and support the local health system. At the same time, uninsurance rates are up for Minnesotas population; for example, the rate of uninsured children in Minnesota jumped 20 percent from 2008 to 2009.
Mark Schoenbaum

Minnesotas health care safety net, both rural and urban, responds to these needs. In fact, thats why its there. Whether Critical Access Hospitals in rural Minnesota, community clinics in the Twin Cities or other safety net organizations, these providers arose when community leaders came together to organize care for their neighbors. In rural areas, the goal was most often to make health care available in small, sparsely populated communities. In the

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Twin Cities, neighborhood and community leaders formed nonprofit clinics to serve low income and uninsured residents. The health care safety net is first and foremost a community institution. If you look at the boards of community clinics and rural hospitals, youll find community and neighborhood leaders, patients, county commissioners, business owners and clergy. Youll find more volunteers making up hospital auxiliaries. Youll find that 75 percent of rural EMS staff are volunteers. Community roots are a huge asset, but the fate of a community institution is intertwined with that of its surroundings. According to the Institute of Medicine, the strength and viability of a communitys safety net are highly dependent on state and local support, state Medicaid policies, the structure of the local health care market-place, and the communitys economic health. Safety net providers have been adroit in piecing together the resources they need. In addition to income from those with conventional insurance coverage, they raise support from their communities and from other private sources. They work hard to cut costs and use creative financing. However, staying financially viable when many patients cant afford their services is a central challenge for health care safety net providers. State and federal support is a critical piece of the safety nets sustainability. For rural providers and their older populations, Medicare reimbursement plays a central role. For urban providers, Medicaid payments and federal operating support make continued service possible. For both rural and urban safety net providers, state grants and related funding can be crucial. For instance, there are 150 state-supported health professionals serving in safety net clinics through the states loan forgiveness program at any one time. Recruiting providers for safety net clinics can be a challenge, and loan forgiveness is proven to attract physicians, pharmacists, nurse practitioners and other professionals to the areas that need them most. Minnesotas small rural hospitals also receive key state funding to plan responses to community needs like chronic disease and aging populations. Of course the Great Recession has stressed government resources at the same time demands on the health care safety net are growing. But as the Institute of Medicine concluded, infrastructure improvements and systems-building efforts to help safety net providers strengthen their ability to survive should be supported. Whether we live or travel in rural areas or the urban core, a strong safety net is in everyones interest, especially in times like these.
Mark Schoenbaum is director of the Office of Rural Health and Primary Care and can be reached at mark.schoenbaum@state.mn.us or 651-201-3859.
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PARTNER FOCUS

MEDICAL STUDENTS MEET RURAL by Michelle Juntunen, Communications Director, University of Minnesota Medical School-Duluth
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SIM participant Erik Bostrom at Kanabec Hospital in Mora

You lost your insulin pump to the wood chipper? exclaims my mentoring physician. The patient, sporting a plaid shirt and thick boots covered in a layer of manure that wafts up to my nose replies from behind his burly beard with, Dont worry doc, I was able to fish out enough pieces to please the insurance company. This is how student Mackenzie Becker began her paper reflecting on her 2010 Summer Internship in Medicine experience in Alexandria. I had the opportunity, Mackenzie wrote, to put some of my newly acquired first-year medical school skills to work. It was also my first chance being thrown into a real clinic setting where I was asked to think about medicine like a physician would. Last summer, 94 students took part in the elective Summer Internship in Medicine. Clinical Summer Internship in Medicine experiences can last from two to six weeks and are open to medical students from both the Twin Cities and Duluth campuses. Most of the students travel to small rural communities in Minnesota; although some are placed in Iowa, Wisconsin, North and South Dakota and Michigan and one student even interned in Dutch Harbor/Unalaska, Alaska.

Jim Root, vice president of Saint Elizabeths Medical Center in Wabasha Human Resources, said the hospital welcomes students to their facility not only for what they can give to the student but also for what they receive in return. Programs like SIM are a recruitment opportunity. By providing well-rounded exposure to all aspects of rural practice we do what we love and teach the students and hope that weve made a good impression for those future physicians looking for a practice. Hannah Betcher describes her Summer Internship in Medicine (SIM) at Saint Elizabeths Medical Center in Wabasha. Wabasha has an interesting health care set up. The clinic and hospital, although physically connected, are separate organizations. The clinic is Mayo Health Systems, while the hospitalSaint Elizabeths Medical Centeris affliliated with a north central Wisconsin system. The doctors and much of the staff work for both, and patients are often referred between them, but all medical records and billing remain separate. Saint Elizabeths includes assisted living, physical therapy, a cardiac rehabilitation center, and dieticians. Because of all of these options, many patients access multiple forms of care. During my two weeks with the hospital and clinic I saw one patient in four different care settings. Going into this internship, I anticipated shadowing doctors and getting a chance to talk with them about their chosen fields. My experience went much deeper. Many doctors let me conduct the patient interviews and do my own physical exams. They instructed me in several procedures and, through those experiences, I became more confident in all my patient interactions. The doctors and staff spent time with me discussing my

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specific medical or procedural questions and making sure that I had a good understanding of the care we were providing. Every day I felt like my time had been spent in a worthwhile, interesting way. Most surprising for me was discovering how much I liked primary care. I had been warned many times to avoid the bad hours and low pay of primary care, but I absolutely loved the variety and patient contact. In one day I saw infants for well-baby checks and a 90-year-old patient dealing with diminishing quality of life issues. I saw how many procedures primary care doctors do in their daily practice. I am definitely considering applying for Rural Physician Associate Program (RPAP). This type of applicable, dynamic learning gave me a chance to cement what I had learned and gear up for another year of lectures. It also gives me a good frame of reference when deciding about my future. I knew that I wanted to live in a small community, but I was not sure if I wanted to practice in one. I am now more comfortable with becoming part of a rural health care team. My time in Wabasha has made me enthusiastic about the many possibilities available to small town physicians.

In the spring of their first year of medical school, students who sign up for Summer Internship in Medicine (SIM) are matched to a small community hospital or clinic to observe rural patient care. Internships tend to be community specific. They can include time in the emergency room, the delivery room and surgery, as well as working with other disciplines in the hospital, clinic and community. Internships might include clinical care, pharmacy, home care, public health nursing, law enforcement, dentistry, chiropractic care, and work in the laboratory, medical records and x-ray departments of the hospital. Each year clinic and hospital sites are contacted regarding their participation and the number of students they can accommodate. Student placement is first come, first served and limited to the number of available sites. The SIM program asks participating facilities for a $500/week stipend for each student; however, stipends are not mandatory and each site decides whether it can provide a stipend. Students are responsible for their own meals, travel expenses and housing, although some communities provide or help locate housing. Coordinated by Raymond G. Christensen, M.D., assistant dean for rural health, and assisted by Deann Dahl from the University of Minnesota Medical School's Duluth campus, SIM is also supported by the four regional Area Health Education Centers. "We have really enjoyed working with our medical students in SIM," commented Dr. Christensen. "I have the unique privilege of reading their essays and visualizing the great experiences they receive in Minnesota hospitals and clinics. While we do not know where they will practice or what they will practice, we do know that all are uniquely affected by their SIM experience." One hundred and six students have signed up for SIM this summer and are now being matched to health care facilities. To learn more about SIM, call Dr. Ray Christensen or Deann Dahl at 218-726-7897.
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PROGRAM FOCUS

FINDING WORKING CAPITAL by Ashley Schweitzer, marketing coordinator, Nonprofits Assistance Fund A decision to pursue a new opportunity often involves weighing the pros and cons. Occasionally after scenario planning the right strategic and financial decision is obvious to everyone involved. Such was the case when Rum River Health Services assessed whether to take on full management of an existing jointly-run program. In order to move forward, the organization needed working capital. Jeff Larson, executive director, reached out to the Nonprofits Assistance Funds Minnesota Primary Care Fund, which provided financing and much more. Rum River Health Services, located in Princeton, Minnesota, is a nonprofit organization with a mission to identify and respond to community health needs. Ten years ago, community meetings identified the need for an outpatient facility for residents recovering from addiction. Because St. Cloud Hospital had previously run a similar treatment program, they were a natural partner to form Rum River Recovery Plus. Rum River Health Services provided the location, staff and services, while the hospital managed the insurance and government contracts, billing and other administrative tasks. By 2009, Rum River Health Services and Rum River Recovery Plus had both grown significantly, reaching a size where they had the capacity to operate the entire program. Around the same time, St. Cloud Hospitals administrative costs were increasing. After a cost-benefit analysis, it was clear that this partnership was no longer the best structure for Rum River Health Services or its clients. Everyone involved agreed that it was time for Rum River Health Services to operate the program on its own. Although making such a big decision was surprisingly easy, implementation remained tricky. As Rum River Health Services executive director Jeff Larson recalled, We knew it made sense, but we didnt know how to get from point A to point B. There were so many unknowns. Setting up a new billing system and coordinating the contracts was the biggest hurdle. Rum River Health Services had experience with billing and accounts receivable on a much smaller scale and had never worked with insurance companies. Recognizing that they didnt know what they didnt know, Rum River Health Services set out to find short-term financing to smooth out any potential delays or cash flow issues. All businesses, including nonprofits, need working capital to take advantage of an opportunity. They need financing to build infrastructure and deliver services before cash begins to flow. For Rum River Health Services, successfully implementing this change would save costs and significantly strengthen their financial position once the new billing system was in place. However in late 2009 the credit market was highly constricted. The banks Larson spoke to were concerned about approving a loan due to the uncertainty of insurance billing and the organizations limited collateral.

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The Nonprofits Assistance Funds Minnesota Primary Care Fund is dedicated to financing community health centers, rural clinics and hospitals and other safety net health organizations. Its programs exist to support Minnesota nonprofits that are unable to meet banks requirements. It can provide these organizations with credit that enables them to serve their communities. The staff is familiar with the nuances of nonprofit finance and available to provide regular, hands-on assistance. Nonprofits Assistance Fund is able to approve loans that traditional lenders view as too complicated or risky. Because the current economy has impacted risk tolerance and credit standards, the fund serves organizations that might work with a bank in a different economic environment. Already familiar with Nonprofits Assistance Fund from financial management trainings, Larson found templates on the website that helped him form a business plan and project the cash flow and explored options for financing with Nonprofit Assistance Fund loan officer Michael Anderson. Michael was so helpful, he made it seem possible. We talked through everything. Anderson was impressed that Rum River Health Services leadership recognized the challenges of installing a new billing system and the uncertainty of when they would begin receiving funds from the contracts: It is very hard to predict how long it could take. Obtaining additional working capital to smooth out this transition was a smart management decision. Jeff acknowledged and planned for the unexpected. Larson describes the process of applying for a loan with Nonprofits Assistance Fund as simple and easy, We walked through everything over the phone. Michael helped us consider different scenarios and offered useful suggestions. And he provided hopefrom the beginning he approached the project as viable. In Nonprofits Assistance Fund, Rum River Health Services found a partner that provided resources, strategic guidance, capital, and realistic optimism. Although Rum River Health Services encountered a series of setbacks implementing the billing system, having cash in the bank helped. We had planned for uncertainty. Even without money coming in, we all knew it was ok. But there is absolutely no way we could have done this without Nonprofits Assistance Fund and the Minnesota Primary Care Fund. If your organization needs working capital or facilities financing, Nonprofits Assistance Fund can help. The Minnesota Primary Care Fund provides loans and lines of credit to nonprofit health organizations in Minnesota. The fund is supported by the Robert Wood Johnson Foundation and partners with the Minnesota Department of Healths Office of Rural Health and Primary Care to meet the needs of nonprofit health care providers. Contact the Minnesota Primary Care Fund at 612-278-7180 or www.nonprofitsassistancefund.org to learn more.
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SPECIAL FEATURE

HOW CLINICS CAN CHANGE THE WORLD

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Alcohol use and abuse is pervasive. Prenatal care that includes thorough and regular screening and prevention of prenatal alcohol useas a standard of care for all clinics, medical providers, health departments and health insurance companiesis a starting point for change. Primary care clinics have an opportunity to take the lead on preventing fetal alcohol syndrome and its devastating and widespread consequences. Lydia Caros, D.O., executive director of the Native American Community Clinic in Minneapolis, sees the impact of brain damage due to prenatal alcohol exposure. She believes that of all the systems providing services to families and children affected by alcohol use, primary care clinics are in the best position to make a real difference. Says Dr. Caros, Women struggling with alcohol use will continue to use during pregnancy until we change our clinic systems to address this issue. Fetal alcohol syndrome: a preventable disability Prenatal alcohol exposure results in developmental delays and neurobehavioral deficits that are irreversible. Yet it is entirely preventable. Alcohol screeningas a regular part of prenatal health care that includes education about the dangers of alcohol use during pregnancyis the first step to help women who struggle with alcohol abuse from exposing their babies to its devastating and long-term impact. If youre not looking for it, you wont find it The Native American Community Clinic found that up to 70 percent of pregnant women visiting the clinic were drinking prior to the first prenatal visit. The clinic responded by: Screening every pregnant woman with questions that address how much and how often the patient drinks alcohol (not yes or no) at every prenatal visit. Asking about alcohol use patterns prior to the pregnancy; this is the pattern that the mother will revert to if she comes under stress. Identifying her stressors, including depression, post-traumatic stress disorder, domestic violence, lack of support from spouse or family. Providing resources and support for those stressors to help prevent her from turning to alcohol use in a crisis. Providing support and referral for treatment of chemical use if indicated. The clinic found that only 1-2 percent of the patients used alcohol again during their pregnancy. Prior to the screening, they could assume that about 85 out of the 120 babies born annually at the clinic were exposed to prenatal alcohol. Over 10 years, 850 babies benefited from this approach in one small clinic in one city, proving that clinics can make a difference!

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According to Dr. Caros, most women they see who are using alcohol are not chemically dependent. With education and general support, most are able to stop using during pregnancy. For those with dependency problems, these simple efforts can help women stop using. Every small support a woman hears from her provider can have an impact. If a mother is unable to stop using during the first pregnancy, but the provider continues the message, she may be ready for change in her next pregnancy. This is particularly important because damage is cumulative. With each subsequent pregnancy exposed to alcohol, there is potential for more damage to fetal brain development. How much is too much? There is no known safe amount. If the provider gives the message that one drink will be fine, it opens the door for a woman struggling with use to cause significant damage. Identifying exposed children Dr. Caros recommends that clinics seeing children should always ask about prenatal alcohol exposure as part of the general history/data base in a way that gives women permission to tell what they drink. Ask a mother, Did you drink during pregnancy? If she says no, ask: How about the first few months when you didnt even know you were pregnant? If she says yes, ask: "Was that on a daily basis?" When she tells you how often, ask how much and be specific, e.g., Was that four drinks (or a 12-pack) at a time? Follow-up for children exposed to alcohol use in pregnancy is critical. Children with a history of exposure should be monitored carefully for developmental and behavioral issues. An ideal time for an assessment is 3 to 5 years of age (before entering kindergarten). A childs specific needs and strengths will be clear before they enter the school system, and they will be more likely to receive needed help. How clinics make the change If the questions are asked respectfully and consistently, patients understand and appreciate that the provider thinks the issue is important enough that it needs to be addressed. Hearing this message from the provider has a significant impact. That message also gets around in the community through friends and relatives. What can be more important than protecting the brains of the next generations? A free toolkit with all the screening tools, education materials and counseling messages very busy clinics can use to incorporate necessary screening is available from Renee Gust, senior health promotion specialist for Hennepin County Human Services and Public Health, at renee.gust@co.hennepin.mn.us.

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For more information, contact Dr. Lydia Caros at lcaros@nacc-healthcare.org.

COMMUNITY FOCUS

HEALTH CARE HOMES: GROWING AROUND MINNESOTA

Patient involvement leads to increased confidence and reduced anxiety. Patients and their families feel more in control, explains Connie Blackwell, director of North Metro Pediatrics, an urban health care home. "I feel better than I have in a really long time," said Mary Falk, a patient at Lakewood Health System, a rural health care home. Health care homes offer a significant redesign of care in Minnesota. Known nationally as medical homes, health care homes focus on primary care and develop a team of providers, patients and families to coordinate health and ultimatelycontain or decrease health care costs. Rural and Urban Safety Net Clinics Getting on Board Minnesota developed a practical process so rural and urban practices of varying sizes can become certified as health care homes, receive new payments for care coordination and see benefits to the practice, its patients and the health care system. Today Minnesota has 91 certified health care homes and shortly that number will increase to 133. Connie Blackwell, N.P., director of North Metro Pediatrics, says that as a nurse practitioner-run, pediatric primary care clinic, North Metros focus was already on teaching preventative care. Even before becoming certified as a health care home, North Metro providers involved the family by giving them choices, explaining their options and asking for their feedback. Families are really pleased because we take the time to follow through with their care, says Blackwell. Teaching a teenager with asthma how to use his inhaler and how to recognize when he needs to talk to his mom or the school nurse involves the patient in his own care. And that allows for more ownership, which yields better outcomes. What is different about being a certified health care home is reimbursement, explains Blackwell. We can now get reimbursed for some of the work we do to coordinate and collaborate with families and outside resources, which is especially important for children with complex and unique health care needs. If patients have insurance they qualify for the health care home. If they do not have insurance, they may not qualify; however, we treat all of our patients the same whether we get reimbursement or not. We like to be able to coordinate care for our patients because it benefits families. Lakewood Health System (LHS) was one of the first in the state to develop and implement a state accredited health care home. Patients are now realizing the benefits. Mary Falk, a Lakewood patient, describes the health care home as

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patient-and family-centered. I feel better than I have in a really long time. I dont worry about my health like I used to because I know that at any time I can call LHS and get the answers I needfrom someone who personally knows me and my health. With a laundry list of complicated medical problems and medications, Falk was often told that hospice or the nursing home were her only choices. Her primary care physician, Christine Albrecht, M.D., reports, Theres no doubt that since enrolling in our health care home, Mary is happier, healthier and living with an excellent quality of lifeat home. She is the perfect example of the kind of patient who, when given appropriate care and access to that care, is more likely to remain healthy, out of the hospital, and living as independently as possible. With over 600 patients enrolled in Lakewoods health care home, the organization has seen reduced rehospitalizations for its high-risk patient population and has received positive feedback from patients and family. Health care homes contributing to state goals In the innovative team approach of a health care home, the providers, families and patients work in partnership to improve the health and quality of life for individuals, especially those with chronic and complex conditions. Health care homes develop proactive approaches through care plans, with patients and families at the center. Increased care coordination between providers and community resources results in even more continuity of care. Minnesotas Vision for a Better State of Health has a triple aim: The health of the population The patient experience of care and The affordability of health care by decreasing the per capita cost. Health care homes are an important component of that vision of improvement. More health care home information is online at http://www.health.state.mn.us/healthreform/homes/index.html.
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VIEW ONLINE ALL PREVIOUS ISSUES OF THE OFFICE OF RURAL HEALTH AND PRIMARY CARE PUBLICATIONS.

Minnesota Office of Rural Health and Primary Care P. O. Box 64882 St. Paul, Minnesota 55164-0882 Phone 651-201-3838 Toll free in Minnesota 800-366-5424

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Fax: 651-201-3830 TDD: 651-201-5797 www.health.state.mn.us/divs/orhpc

REGISTER NOW: THE MINNESOTA RURAL HEALTH CONFERENCE IS JUNE 27-28 IN DULUTH

MISSION: 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

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