QUARTERLY. Spring 2003 Volume 5 Number 2

Transcription

1 Spring 2003 Volume 5 Number 2 QUARTERLY PHOTO COURTESY OF MINNESOTA DEPARTMENT OF TRADE AND ECONOMIC DEVELOPMENT The mission of the Office of Rural Health & Primary Care is to promote access to quality health care for rural and underserved urban Minnesotans. From our unique position within state government, we work as partners with communities, providers, policy makers and other organizations. Together, we develop innovative approaches and tailor our tools and resources to the diverse populations we serve.

2 Minnesota Rural Hospital Flexibility Program Advisory Committee Member Profile: ORHPC Talks with Michael Hedrix Home: Family: Hobbies: Eden Prairie 3 children, Aaron (25), Brianna (22), Kelsie (18), and wife of 28 years, Kathy, a preschool director. Walking, running, reading, and recreational sports Michael Hedrix, Rural Hospital Flexibility Advisory Committee Chair. The Medicare Rural Hospital Flexibility Program (Flex Program), established by the Balanced Budget Act of 1997, supports rural communities in preserving access to primary and emergency health care services. The Flex Program accomplishes this by focusing on five key components, including: enhancing emergency medical services, improving quality, establishing Critical Access Hospitals (CAHs), developing networks, and promoting community development. For more information on the Flex Program visit the Web site at rhpc/cah/index.html Estelle Brouwer, Director Karen Welle, Assistant Director Stefani Kloiber, Editor 2 Michael Hedrix is the hospital administrator for Pine Medical Center and Nursing Home in Sandstone and has been with the facility since Pine Medical Center, part of the St. Mary s/duluth Clinic Health Care System, is a Critical Access Hospital and is one of two longterm care facilities in Pine County with 76 beds. Michael began his career in community banking, but as the banking industry developed and changed he decided to use his skills in the health care administration field instead. Michael says this change has allowed him to regain what he enjoyed most about community banking - working with people and developing relationships for the betterment of the local community. Michael has over a decade of experience with rural hospitals, having worked as an administrator for four other rural Minnesota hospitals before coming to Pine Medical Center. Michael has been involved with the Rural Hospital Flexibility Program (Flex Program) since it began in Minnesota in He was first introduced to the program when he was invited to participate in the development of Minnesota s grant application requesting funding for the Flex Program. Michael continues to be connected to the program both as a member of the Rural Hospital Flexibility Program Advisory Committee and now as the chair of the committee. What do you think are the most important issues facing rural health today? MH: In general, I think most issues in rural health today revolve around having adequate resources, primarily capital and human resources. Resources are already scarce for rural areas, but increasing demands from consumers and regulators ask that health care do more with less. In rural areas this is an even larger challenge as they are already doing more with less. What one or two changes do you think would make the most difference for rural health? MH: I think the simplification and reduction of both how we administer health care and how we regulate it would go a long way towards making a difference for rural health. For example, one change could be to ease regulatory requirements by reducing unnecessary or redundant regulations. This type of change would help to lessen the work and staff time required to ensure compliance. Another beneficial change would be to standardize reimbursement systems. The current system requires specially trained staff for each health system in order to produce a bill for services. A standard reimbursement system would help to streamline the billing system and the demand for specially trained staff. What do you think was the most important message that came out of the CAH Quality Improvement Collaborative? (See Bigger Is Not Necessarily Better Small Hospitals Work Together To Improve Care In Rural Minnesota, included in this issue). MH: Two important messages came out of the CAH Quality Improvement Collaborative. First is the realization and understanding that rural health care doesn t mean substandard or poor quality health care. I think rural health care providers can and should feel good about the quality of care they give. Secondly and perhaps more importantly for the future, we learned that we can collectively work together to improve rural health care. I found it to be a fun and empowering way to advance rural health care. As a rural industry there are certainly challenges ahead, but when taken on together we have a stronger voice. See Michael Hedrix (page 8)

3 COMMUNITY FOCUS On the Road to a Town Near You Community Health Forums By Angie Sechler In February of this year, the Office of Rural Health and Primary Care sought out information from Minnesotans to learn more about the health care issues in their communities. Thanks to the assistance of local cosponsors rural health forums were held in four communities: Alexandria, sponsored by Douglas County Hospital and Rural Health Alliance; St. Peter, sponsored by Region 9 Development Commission; Crookston, sponsored by Riverview Hospital; Grand Rapids, sponsored by Arrowhead Regional Development Commission. Each forum included an overview of Minnesota s current demographic and socio-economic landscape followed by small group discussions of the issues. All the forums were well attended by a variety of individuals representing hospitals, health plans, nursing homes, area A small group discusses health care issues in St. Peter. agencies on aging, local public health, EMS, county commissioners, and the Minnesota legislature. Additionally, questionnaires asking attendees to list their top three concerns about health care in their communities were collected and later reviewed to determine what issues were most prevalent. Information from these forums will be used to help shape the next Minnesota Rural Health Plan to be completed by the end of this year. The Rural Health Plan is a requirement for participation in the Medicare Rural Hospital Flexibility (Flex) Program. The plan provides background information on Minnesota and its health care system, addresses access to health care in rural Minnesota, describes Minnesota s Medicare Rural Hospital Flexibility Program, and outlines strategies for strengthening Minnesota s rural health care. The Top Issues Workforce shortages in all health care fields, inadequate Medicare/Medicaid reimbursements, rising health insurance costs, lack of access to mental health and chemical One person commented dependency in their questionnaire, services, and the Our company had to anticipated health consider dropping (health needs of a growing elderly population care) coverage for were overriding employees, and we are a issues in all the health care provider. forums. Other How ironic. concerns unique to each community came up as well. For example, cultural and language barriers creating health disparities were major issues in both St. Peter and Grand Rapids. In Crookston, the lack of coordination among EMS systems, volunteer retention and recruitment, and equipment needs were of significant concern to many. Top Strategies/Solutions Discussions about health care issues often led to suggested strategies and possible solutions. One of the solutions most frequently mentioned was the need to change the Medicare/Medicaid reimbursement system - interstate funding equalization and equitable rural-urban reimbursement were top priorities. Many of the small discussion groups identified creative workforce recruitment and retention incentives, such as increases in loan forgiveness or making additional distance learning See On The Road (page 7) 3

4 PARTNERS PAGE Bigger Is Not Necessarily Better: Small Hospitals Work Together To Improve Care In Rural Minnesota By Jill Zabel and Annette Kritzler According to the American Heart Association, heart disease is the number one killer of Americans. One heart condition, congestive heart failure, though a very serious condition, can be managed through medication, diet, and exercise. Another common condition, atrial fibrillation, can be an early warning sign of serious heart disease. Last year, ten of Minnesota s smallest hospitals took on the task of improving care for patients with these conditions as part of an innovative pilot quality improvement collaborative for Critical Access Hospitals (CAHs). The collaborative, known as the Heart Failure and Atrial Fibrillation Collaborative for Critical Access Hospitals, brought ten Minnesota CAHs together for a common goal: to improve the quality of care for patients hospitalized with heart failure and atrial fibrillation. The long-term goal was to build the capacity of these hospitals to improve their processes for other quality improvement initiatives in the future. Stratis Health, the Medicarecontracted Quality Improvement Organization for Minnesota, and the Office of Rural Health and Primary Care jointly sponsored the collaborative, which was a pilot project developed as a part of the Minnesota Medicare Rural Hospital Flexibility Program. A federally designated Critical Access Hospital or CAH is a rural hospital licensed for 15 or fewer acute care beds. In order to qualify for CAH status, a hospital must make emergency medical services available twenty-four hours a day, adhere to new certification requirements, enter a network agreement with an acute care hospital, and maintain an annual average length of stay of 96 or fewer hours per patient. In return, a CAH is granted greater staffing flexibility and receives cost-based reimbursement for Medicare acute inpatient and outpatient services and some Medicaid services. There are currently 46 CAHs in Minnesota. The first ten Minnesota hospitals to achieve Critical Access Hospital status were invited to participate in the quality improvement collaborative. The hospitals included were: Lake View Memorial Hospital, Two Harbors; Pine Medical Center, Sandstone; Riverwood Health Care Center, Aitkin; Lakewood Health Center, Baudette; Mahnomen Health Center, Mahnomen; Wheaton Community Hospital, Wheaton; Renville County Hospital, Olivia; Tracy Municipal Hospital, Tracy; Westbrook Health Center, Westbrook, and Zumbrota Hospital, Zumbrota. The Collaborative Model The quality improvement collaborative was loosely based on a model developed by the Institute for Healthcare Improvement (IHI). The IHI model successfully demonstrated that by using the collective wisdom of collaborative participants along with an advisory group of experts, dramatic improvements in the quality of care could be made. The model uses interactive learning sessions with action periods between the sessions. The first step in building the collaborative As hard as it is to get away was for each from my facility, I know CAH to put that one day spent in this together a team of people workshop saves me three interested in days back on the job. improving the Collaborative participant care provided patients at their facility. Each of the teams included both clinical and administrative leadership a physician, nurse, pharmacist, management sponsor, and other members as appropriate (e.g. medical records, lab, etc.). It was key that each team include a physician willing to provide clinical expertise and serve as a mentor, and a hospital administrator committed to the quality improvement effort and willing to provide the resources and support. Following the model, the CAH teams gathered for four learning workshops. The first workshop featured a local cardiologist presenting on Improving the Value of Healthcare Provided for Patients with Atrial Fibrillation and Heart Failure. In addition, the agenda included quality improvement education and data abstraction and analysis training. Subsequent workshops built on the quality improvement methodologies, successful interventions, and discharge planning and working within the community. Each workshop provided time for sharing and networking among the participants. 4

5 Between workshops, monthly conference calls with the hospital teams were held. As hospitals expressed a specific education need, additional conference calls were scheduled with expert speakers presenting. The conference calls provided time for hospitals to share their progress and to ask for input from other participants if they had run into a problem or concern. These check-in times became an important milestone for the hospitals. Each CAH team used a variety of strategies to improve the processes of care in their hospitals. One strategy was to focus on the patient s experience from admission through diagnosis, treatment, and follow-up. Another strategy was to identify interventions to improve heart failure and atrial fibrillation care. The interventions, also known as quality measures, were based on current guidelines and evidence based research and generally accepted as a standard of care. The Results of the Collaborative One challenge in focusing on small hospitals in a quality improvement project of this kind is the low volume of patients, making measurement more difficult. To overcome this challenge the data from the ten hospitals was aggregated and analyzed. The data showed that from January 2001 through August 2002, 266 patients were treated for heart failure and 470 patients were treated for atrial fibrillation. Results of the data show that the Quality Measure collaborative was a success. An improvement from baseline to end-of-collaborative monitoring was found for all the quality measures. The table above demonstrates the results of the collaborative. What did the participants say about the collaborative? As hard as it is to get away from my facility, I know that one day spent in this workshop saves me three days back on the job. It s nice to know we are not alone we face similar problems. I thought it was just us. We found better responses on patient satisfaction surveys after nursing staff implemented the revised patient education. And, from Michael Hedrix of Pine Medical Center, The project was a good thing. I enjoyed seeing the progress on the storyboards; it gave us a feeling of success. (See Michael Hedrix profile on page 2) Future Collaborations Collectively, small rural hospitals can make a difference in the overall quality of care provided to Minnesota residents. Quality improvement is a continuous process. This collaborative provided a first step in improving care for heart failure and atrial fibrillation patients. The hospitals realize that continued work needs to happen to raise and maintain the measures. Building on the success of this collaborative, the hospitals are using their new knowledge to facilitate other quality improvement initiatives for their patients. In addition to the measurable outcomes, this collaborative also demonstrates the success of partnerships. The collaborative has shown that hospitals, a state agency, and a Quality Improvement Organization can work together for a common goal and achieve success. The word is out on this innovative model of Baseline End-ofcollaborative Increase use of left ventricular function assessment in patients with heart failure 36% 43% Increase the use of ACE Inhibitors in ideal patients with left ventricular ejection fraction of less than 40%. 77% 100% Improve patient education for patients discharged with heart failure (all elements needed to be present) 3% 17% collaboration; it has gained national attention at conferences in Washington, Florida, and Arizona as well as statewide interest in Minnesota. Stratis Health is using the new knowledge gained from this collaborative to launch another collaborative with 22 additional Critical Access Hospitals. This second collaborative, which started in March 2003, will again focus on heart failure and will add inpatient adult immunizations as a new focus. Once again, the Office of Rural Health and Primary Care will provide support for the participating hospitals. Increase the number of atrial fibrillation patients discharged on Warfarin or who have a plan for Warfarin after discharge 77% 85% Increase the number of patients that have a plan for a follow-up visit after discharge. 39% 68% Jill Zabel is the Flex Program coordinator for the Office of Rural Health and Primary Care. She can be reached at (651) /jill.zabel@state.mn.us Annette Kritzler is a project manager for Stratis Health. She can be reached at (952) / mnpro.akritzler@sdps.org 5

6 Welcome to new staff member Linda Norlander By Estelle Brouwer Photo caption It s spring, which means it s time for new beginnings, especially in lovely but frigid Minnesota. I d like to take this opportunity to introduce you to someone who represents a new beginning in the Office of Rural Health and Primary Care Linda Norlander, one of the newest members of our staff. DIRECTOR S CORNER Linda joined us in December as supervisor of the Rural Health Program Development unit. What that means in practice is that Linda Norlander Linda works hand-in-glove with the state Rural Health Advisory Committee to carry out the research and analysis they need in order to do the important work of advising the Commissioner of Health on rural health issues. It also means she supervises a small but hardworking group of research and administrative staff, serves as a member of our office s management team and, as the only nurse on our staff, brings the valuable perspective of a licensed health care provider to many of our internal discussions. Linda is well known in the world of end-of-life care, both here in Minnesota and across the nation. Before coming to our office, she served as director of the Minnesota Partnership to Improve End of Life Care, and earlier, as supervisor of a Medicare certified hospice program. In addition to her role as a health care provider and manager, however, Linda has another passion writing. She s been a writer for most of her life, but only recently started writing nonfiction. And for that she s already won two awards: For her book Choices at the End of Life: Finding Out What Your Parents Want Before It s Too Late, she won the 2003 Caregiver Friendly Award from Today s Caregiver magazine. For her book To Comfort Always: A Nurse s Guide to End of Life Care, she received an award of merit from the International Society of Technical Communicators. Over the next several months, Linda will be spending a good deal of her time working with the Rural Health Advisory Committee to discover and highlight ways to improve access to mental health services in rural Minnesota. I encourage you to start to get to know Linda by giving her a call or dropping her an . While you re at it, let her know your thoughts about how we can improve access to rural mental health services. Linda can be reached at or linda.norlander@state.mn.us. Estelle Brouwer is director of the Office of Rural Health and Primary Care. She can be reached at (651) or estelle.brouwer@state.mn.us 6

7 On The Road (continued from page 3) opportunities available. Other ideas centered on community development-involvement strategies, coordinated health service delivery, and the need to increase the numbers of mental health and chemical dependency practitioners. Alexandria The first community forum site was the Douglas County Hospital in Alexandria. Twenty-seven attendees of this forum were most concerned with the shortage of workforce affecting all health care fields, limited access to mental health and chemical dependency services, inadequate reimbursements, and the growing health care needs of the elderly. When asked what do you think will improve health care in your community? one respondent wrote, I would say we really need more psychiatrists, psychologists, and geriatric physicians who specialize in the elderly population and particularly those with mental health issues. St. Peter St. Peter s new community center was the second forum location. A local co-sponsor, Region 9 Development Commission, presented the audience with the recent results of a 2002 Regional Health Behavior survey designed to monitor health status, identify health problems, and establish health promotion priorities in 27 counties of south central and southwestern Minnesota. The survey served as a great example of local communities working together to improve health status throughout south central and southwestern Minnesota. Allowing communities to maintain autonomy to problem solve and find solutions with assistance from agencies such as ORHPC, Region 9 and regional health agencies [will help improve health care] said one audience member. The greatest health care concerns among St. Peter attendees were workforce shortages, rising insurance costs, poor health behaviors, and the quality of care and cultural/language barriers for immigrants who have relocated to the area. Crookston Despite the day s sub-zero temperatures, a warm, welcoming crowd turned out for the third forum held at the Crookston campus of the University of Minnesota. Again, the greatest concerns expressed were workforce shortages, inadequate reimbursements, and rising health insurance costs. Other issues topping their list were the lack of coordination between health care providers and communities, the recruitment and retention of EMS volunteers, and the impact of state budget cuts to mental and elderly health programs. A respondent to the questionnaire speculated about the logic of recent state budget proposals, At a time when offering services in place to seniors in the most independent setting, usually their home, is the method of choice, state funding is being cut to programs [i.e. Meals on Wheels] that support that model. Grand Rapids The final forum was held in the community of Grand Rapids at their area library. Unlike the previous forums, the highest-ranking issue concerning the Grand Rapids attendees was the lack and cost of health insurance. As one person commented in their questionnaire, Our company had to consider dropping [health care] coverage for employees, and we are a health care provider. How ironic. Other issues of concern emerged in the following order: workforce shortages, growing health care needs of the elderly population, the need for more mental health and chemical dependency services, and cultural/language barriers to health care. Next Steps The forums were a valuable opportunity to gather community Angie Sechler takes notes during a small group discussion of health care issues in Grand Rapids. input to feed into a new Minnesota Rural Health Plan. The Office of Rural Health and Primary Care intends to continue seeking rural community involvement and has already begun planning for the next series of community forums. Look for us coming to a town near you. Angie Sechler is a health services/workforce research analyst for the Office of Rural Health and Primary Care. She can be reached at (651) / angie.sechler@state.mn.us 7

8 To learn more about the Office of Rural Health & Primary Care programs, visit our Web site: orh_home.htm Michael Hedrix (continued from page 2) In addition, I think the collaborative demonstrated that there can be an advantage to being a rural hospital - one is that our interests are more likely to be focused on patient care, and not drained by competition. Another advantage is that as a group we can support and help each other to improve and ensure quality health care. Because we all face some of the same challenges, this support is helpful in facing future challenges. What changes would you like to see come from the CAH Quality Improvement Collaborative? MH: It is my hope that this type of collaboration be applied to improve the processes for quality improvement initiatives in other health care areas. It was and continues to be a great method to help us achieve our best practices. On a final note, a special thank you should go to Stratis Health for their facilitation of this collaborative. They worked hard to create a supportive and secure environment that was very collegial and focused on patients and improving care. 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. The Rural Hospital Flexibility Program Advisory Committee provides program planning, development, and implementation consulting, issue identification, problem solving, and evaluation development for the Minnesota Rural Hospital Flexibility Program. Meetings are held three to four times a year at the Snelling Office Park at the corner of Energy Park Drive and Snelling Avenue in St. Paul and are open to the public. For dates, times, and directions visit the Web site at or contact Cindy LaMere at /cindy.lamere@state.mn.us 121 East Seventh Place, Suite 460 P.O. Box Saint Paul, Minnesota First Class U.S. Postage PAID Permit No. 171 St. Paul, MN