Uiversity of Souther Maie USM Digital Commos Access / Isurace Maie Rural Health Research Ceter (MRHRC) 10-28-2016 Iovatios i Rural Health System Developmet: Goverace Sara Kah-Troster MPH Uiversity of Souther Maie, Muskie School of Public Service, Maie Rural Health Research Ceter Adrew F. Cobur PhD Uiversity of Souther Maie, Muskie School of Public Service, Maie Rural Health Research Ceter Follow this ad additioal works at: http://digitalcommos.usm.maie.edu/isurace Recommeded Citatio Kah-Troster, S., & Cobur, A. (2016). Iovatios i rural health system developmet: Goverace. Portlad, ME: Uiversity of Souther Maie, Muskie School of Public Service, Maie Rural Health Research Ceter. This Report is brought to you for free ad ope access by the Maie Rural Health Research Ceter (MRHRC) at USM Digital Commos. It has bee accepted for iclusio i Access / Isurace by a authorized admiistrator of USM Digital Commos. For more iformatio, please cotact jessica.c.hovey@maie.edu.
H Iovatios i Rural Health System Developmet Goverace Sara Kah-Troster, MPH Adrew Cobur, PhD Rapid chages i health care paymet ad delivery systems are drivig health care providers, payers, ad other stakeholders to cosider how the curret delivery system might evolve. This series of briefs profiles iovative rural health system trasformatio models ad strategies from Maie ad other parts of the Uited States. The aim is to assist rural commuities ad regios to proactively evisio ad develop strategies for trasformig rural health i the state. I preparig these briefs we cosulted experts, iterviewed key iformats, ad reviewed the professioal ad research literature to fid robust ad iovative models ad strategies that could be replicated i rural Maie. PROMISING STRATEGIES: Hospital/Health System Collaboratios... 2 Populatio Health Improvemet... 6 INTRODUCTION NOVEMBER 2016 Muskie School of Public Service Maie Rural Health Research Ceter Muskie School of Public Service Health system trasformatios ofte ivolve orgaizatioal ad service system re-structurig withi ad across orgaizatios i the commuity. These chages are ofte drive by ew paymet arragemets ad/or by commuity-led iitiatives that require greater collaboratio across health care provider ad other commuity orgaizatios. As ew orgaizatioal structures ad service systems emerge, ew maagemet ad goverace structures are required, especially if fiacial ad other resources are shared across multiple orgaizatios. The orgaizatio ad goverace of ew health system arragemets is cetral to their effectiveess ad sustaiability. Iovatios i goverace ru the gambit i scope ad complexity from hospitals ad health care systems collaboratig to share services ad cut costs to multi-sector populatio health improvemet iitiatives. I may of the emergig ad iovative models, hospitals or health systems are providig leadership ad resources ad are servig a
cetral coordiatig role. Other iitiatives are rooted i strog govermetal or public health structures. New models of health care goverace are helpig to trasitio local health resources away from their ofte hospital-cetric, legacy cofiguratios towards ew, collaborative delivery systems that reflect the evolvig eeds of rural commuities. 1 Iovatios i goverace are a importat meas toward improvig service delivery, quality, ad reducig costs for the orgaizatios ivolved. I Maie, may of the examples of iovatios i goverace are rooted i hospitals, which is ot surprisig give the state s limited local public health ad couty govermet systems. I their role as commuity hospitals, rural hospitals eed to leverage their existig ties to their commuities to build cosesus for ew models. They also eed to work well with local ad regioal parters such as Rural Health Cliics (RHCs), Federally Qualified Health Ceters (FQHCs), physicia groups, ad social service providers, sharig leadership, iformatio, ad owership of outcomes. Collaboratio with these ad other parters ca help build a more coordiated ad itegrated system of care i the future that will beefit rural residets ad commuities. PROMISING STRATEGIES Hospital/Health System Collaboratios Hospitals ad health systems are parterig with primary care ad other providers to create ew orgaizatioal ad goverace structures i Maie ad across the coutry. The followig examples illustrate a few of the approaches uderway i Maie. COASTAL HEALTHCARE ALLIANCE: Sharig Leadership ad Cliical Services Established December, 2015, Coastal Healthcare Alliace is a system withi a system cosistig of MaieHealth s Pe Bay Medical Ceter, a 109 bed hospital i Rockport, ad Waldo Couty Geeral Hospital, a 25 bed Critical Access Hospital (CAH) i Belfast. The two hospitals operate i a uified goverace ad maagemet system, with a shared Board of Trustees. Both hospitals retai their ow subsidiary boards; meetigs of all three boards are held cocurretly. Shared leadership, admiistratio, ad cliical services create opportuities for sigificat cost savigs: the seior teams from each hospital have bee almost completely combied, as has the leadership at the hospital-affiliated log term care etities. The sharig of cliical services has ehaced reveue for each hospital as ew services become available, drawig o providers from both affiliated facilities. William Caro, CEO of MaieHealth, otes that the challege with a model like Coastal Healthcare Alliace lies i gettig the hospital boards to thik about a broader, regioal service area ad strategy; they eed to care as much about health care i a eighborig commuity as they do i their ow. Accordig to Caro, it takes time ad patiece to get this greater good buy-i. The loss of complete local cotrol, especially aroud assets, decisio makig, ad philathropy, ca be a sigificat adjustmet. The model s success depeds o the boards becomig coviced of the beefits of operatig o a larger, regioal scale. I Waldo ad Kox couties, the leadership of the two hospitals listeed to doors ad trasitioed carefully to joit fudraisig, helpig people to feel ivested i the other commuity. At the momet, there is o pla to merge the hospitals, so as ot to jeopardize Waldo s status as a CAH. Losig the special CAH reimbursemet could cost the hospital $15 millio a year i reveue. Medicare allows a paret compay to hold multiple facility Goverace 2
liceses (with separate cost accoutig but operatig as the same corporate etity), ad Maie s Departmet of Health ad Humas Services has idicated to MaieHealth that they are willig to allow a sigle paret compay to hold two differet o-profit liceses without losig their distictive statuses. Such arragemets are possible i other states ad might permit Coastal Healthcare Alliace to explore mergig subsidiaries at some future poit. MAINE RURAL HEALTH COLLABORATIVE: Joit Purchasig ad Cotractig The Maie Rural Health Collaborative (MRHC) cosists of five member hospitals: Houlto Regioal Hospital, Cary Medical Ceter (Caribou), Norther Maie Medical Ceter (Fort Ket), St. Joseph Hospital (Bagor), ad Mout Desert Islad Hospital (Bar Harbor). Three are idepedetly owed ad operated; St. Joseph is a member of Coveat Health; ad Houlto is a strategic parter with Easter Maie Health Systems (EMHS). Norther Maie Medical Ceter recetly etered ito a Strategic Network Partership Agreemet with EMHS. The MRHC LLC was established i February of 2015, ad builds o prior discussios by a large group of idepedet hospitals regardig potetial efficiecies that could be gaied through collaboratio ad resource sharig. The MRHC has a board of maagers with represetatives from all the members, as well as a operatios committee with the CEO ad CFO of each hospital. There is also a part-time executive director, whose role is to help implemet the strategic pla, orgaize the MRHC s strategic iitiatives, ad work o the developmet of by-laws ad other goverace ad maagemet agreemets. All the members cotribute fuds to support the executive director ad ay cosultats. The MRHC s goal is to maitai the systems ad services that work well for the hospitals commuities, with a eye to preservig ad ehacig health care i the commuities they serve. As stated i the 2015 strategic pla, the purpose is to pursue collaborative activities aimed at promotig the effective, efficiet, ad ratioal expediture of their resources i order to preserve ad ehace future access to essetial primary ad prevetive health services withi their commuities. MRHC s iitiatives focus o shared savigs through joit purchases ad cotractig, icludig collectio ad deials maagemet, commo employee beefits, ad the developmet of commo stadards ad approaches for codig. Work i 2016 will cotiue may of these programs ad will implemet a telemedicie grat that the MRHC recetly received. CARY MEDICAL CENTER AND PINES HEALTH SYSTEM: Sharig Fiacial Resources ad Specialists Cary Medical Ceter (Cary), a 65-bed acute care hospital i Caribou, Maie, ad Pies Health Services (Pies), a commuity-based, multi-specialty physicia practice ad FQHC servig Aroostook Couty, have a log-stadig, mutually beeficial relatioship i which they share resources to esure that the commuity ad the hospital have adequate primary care ad specialty staff to maitai a sustaiable health system. Accordig to Pies CEO James Davis, each orgaizatio is made stroger by servig the commuity together. Pies was fouded by Cary 31 years ago, i a era whe hospitals were lookig to add oacute care etities to offer a wider rage of services. Over time, Pies has become a large multi-specialty physicia group with more tha 40 providers divided about evely betwee primary care ad specialists. Although it is uusual for a FQHC to have specialists, their Goverace 3
presece (techically outside the FQHC grat) allows patiets to access eeded services quickly withi the same system. This arragemet fuctios well due to the strog ogoig relatioship with Cary, which maitais a agreemet to exchage services ad staff. Pies status as a FQHC allows for better reimbursemet for publicly isured ad uisured cliets, ad has allowed Pies to be less fiacially depedet o Cary. Reflectig Cary s role i its foudig, the Pies board has two members appoited by the Cary board: the Cary CEO ad oe additioal Cary board member. The Pies ad Cary boards iteract frequetly, with a mothly board member exchage (i.e., a member of oe board atteds the other orgaizatio s board meetig), ad a joit board strategic plaig retreat every other year. The latter gives them a chace to talk about stregths ad opportuities for servig their commuities. Cary s CEO, Kris Doody ad Pies CEO James Davis work very closely together. Cary ad Pies collaborate to create workable budgets for Pies. Pies providers geerate about 80-85% of Cary s reveues. I retur, Cary provides Pies $2 millio aually i commuity beefit paymets to support primary care, ad a additioal $5 millio that eables Pies to recruit specialists. I rural Maie, it would be very difficult for a specialist to be successful with a purely office-based practice, but the relatioship with Cary offers specialists access to a hospital-based practice as well. Pies curretly employs specialists i areas such as ophthalmology, urology, gyecology, ad geeral surgical services. Ogoig fiacial pressure o hospitals to improve quality ad reduce costs creates challeges ad opportuities i this arragemet. Capitalizig o its primary care resources, Pies is workig closely with the hospital to decrease emergecy room use; Davis estimates that a third to a half of all emergecy departmet visits could be dealt with i primary care settigs, where patiets would get more comprehesive, ogoig care at a lower cost to the system. The hospital, i tur, works with MaieCare patiets to eroll them i Pies or other practices so they have a medical home ad cotiuity of care. Maie is ot aloe i offerig ew models for orgaizig ad goverig hospital, primary care ad other health services. The followig examples highlight iovative strategies from aroud the coutry. THE WESTERN NORTH CAROLINA (WNC) HEALTH NETWORK: Hospitals Collaboratig to Improve Populatio Health WNC Health Network, a 501(c)3 i Wester North Carolia, is a collaboratio of 17 hospitals that exist[s] to covee stakeholders ad provide support for our members ad parters to improve health ad healthcare across our regio. Fouded i 1995, WNC Health Network s cotiued focus is to provide backboe support for regioal health improvemet, covee ad support workgroups tied to strategic iitiatives, ad parter to address access ad workforce eeds. Curret iitiatives iclude: WNC Healthy Impact, a partership betwee hospitals ad health departmets workig towards a visio of improved commuity health; WNC Healthy Kids, a populatio health program desiged to reduce ad prevet childhood obesity; Director Workgroups, for key persoel such as emergecy departmet directors, Ifectio Prevetio ad Cotrol ( The Bug Club ), ad Chief Medical Officer (CMO)/Chief of Staff (COS); ad priority area workgroups aroud topics such as metal health/substace use disorders, access to care, ad workforce. Past successes iclude a group purchasig program that has grow to become its ow etity, Capstoe Health Alliace, ad WNC Data Lik (2006-2014), the first regioal health iformatio exchage i North Carolia. For more iformatio: http://www.wch.org/ Goverace 4
THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC): Collaborative Techical Assistace Efforts Fouded i 1979, the RWHC is oe of the earliest rural hospital etwork models. RWHC is owed ad operated by 40 rural, acute, geeral medical-surgical hospitals, ad maitais affiliate memberships with additioal hospitals ad healthcare systems. With a visio of rural Wiscosi commuities becomig the healthiest i America, the RWHC s missio focuses o beig a strog ad iovative cooperative of diversified rural hospitals, ad o beig the advocate of choice for its rural members. The RWHC emphasizes the developmet of a collaborative etwork amog both freestadig ad system affiliated rural hospitals. It offers programs i the areas of professioal services (such as codig cosultatio, legal services, ad fiacial cosultig); educatioal services (such as professioal roudtables, leadership series, ad a cliical educatio series); quality improvemet services (such as the CAHPS hospital survey, meaigful use, ad a quality idicators program); ad techology services (such as data ceter services ad a techology maagemet program). Together these are more affordable ad higher quality tha they would be if each idividual hospital were hadlig them aloe. For more iformatio: http://www.rwhc.com/ SPRINGFIELD MEDICAL CARE SYSTEMS (SMCS): FQHC-Hospital Collaboratio SMCS i Vermot is a itegrated health system, servig southeaster Vermot ad southwester New Hampshire that icludes Sprigfield Hospital ad a large, multi-site FQHC. SMCS is structured as a o-profit FQHC, govered by a FQHC-compliat board of directors, with the hospital operatig as a fully owed subsidiary corporatio with its ow board. There is a sigle executive team, ad the boards of the FQHC ad the hospital collaborate with each other. This uusual structure places prevetive ad primary care, rather tha acute care, as the focus of the delivery system. At the time of the itegratio (completed i 2012), it was oe of the first approved FQHC-hospital collaborative models. Sprigfield Hospital offers ipatiet ad outpatiet care, 24-hour emergecy care, adult day care, ad a broad array of specialty care services, with ipatiet ad outpatiet metal health services provided at a satellite facility. Five of the FQHC locatios are curretly participatig i the Natioal Committee for Quality Assurace Medical Homes program. For more iformatio: http://www.sprigfieldmed.org/ WILDERNESS HEALTH: CAH Collaboratio Wilderess Health is a collaborative of idepedet health care providers, primarily CAHs, i Northeaster Miesota ad Northwester Wiscosi. The hospitals work together to advace patiet ad commuity health outcomes, improve the patiet experiece, ad lower costs, with a emphasis o rural health issues that affect their commuities. The Wilderess Health board icludes represetatives from each member orgaizatio; each member has oe vote. Network reveue to fud programs comes from member dues, which are based o orgaizatio size ad reveue, ad some grat fudig. Wilderess Health holds roudtables ad issue-focused groups for its members, icludig a huma resources roudtable ad a CFO roudtable. Shared iitiatives iclude a opioid maagemet program which is implemetig cosistet practices across members for supportig chroic opioid patiets; a data itegratio iitiative to eable better care coordiatio ad care plaig for patiets; ad work with key commuity stakeholders to improve the cotiuum of care ad idetify gaps i care. 2 For more iformatio: http://wilderesshealthm.org/ Goverace 5
Cosideratios for Applicatio i Maie Maie has may small commuities ad providers that lack the capacity ad volume to egage i value-based paymet ad delivery system iitiatives. Parterships amog health care providers ca be helpful i gettig to scale, but they require agreemets amog diverse orgaizatios. Clear ad strog goverace structures ad systems that give all parties a voice at the table are critical to success. Shared goverace models etail risks to participatig orgaizatios, with beefits that are ot guarateed. They require a ability to embrace a regioal perspective, a log-term strategy, ad a appreciatio that positive outcomes will beefit a wider commuity tha the orgaizatio has previously supported. Maie has a robust ad diverse primary care system, icludig hospital-owed ad idepedet practices, FQHCs, ad Rural Health Cliics, that offer opportuities for iovatio. Likig primary care, other providers, ad hospitals i ew structures ad goverace arragemets holds promise for creatig a better coordiated system of care that is more sustaiable i the curret eviromet of value-based paymet. Policy iitiatives, such as Maie s Accoutable Care iitiatives, create opportuities for iovatio i goverace but may require orgaizatio ad state level policy chages to allow for differet structure ad goverace models. PROMISING STRATEGIES Populatio Health Improvemet Icreasigly, goverace structures are extedig beyod hospitals ad physicia practices to iclude other commuity parters. While aimig to improve care maagemet for hospital ad primary care patiets, these iitiatives also seek to better coect healthcare, public health, ad social services to address the log-term health of the commuities they serve. The followig example illustrates oe approach i Maie s Somerset Couty. SOMERSET PUBLIC HEALTH-REDINGTON-FAIRVIEW GENERAL HOSPITAL (RFGH): Hospital-Sposored Public Health Partership RFGH, a idepedet CAH i Skowhega, ME, spearheaded the developmet of Somerset Public Health (SPH), a local public health partership fuded by the hospital as well as federal, state, foudatio, ad other sources. RFGH serves as the orgaizatioal home for SPH, partially fudig ad employig SPH s executive director ad a admiistrative assistat. It also provides huma resources support, pays for the agecy s office space, ad serves as the fiscal aget for grats ad other fudig. The director of SPH reports to the hospital s director of educatio, ad a hospital board member sits o SPH s advisory board. SPH emerged from prior work doe by cliicias based at RFGH i developig a cardiac welless ad outreach program, whose program director was able to develop a broad-based partership of muicipal, busiess, ad commuity orgaizatios throughout the couty to udertake wide-ragig health improvemet iitiatives. The goverace structure set up betwee RFGH ad SPH has allowed RFGH to secure fudig for a wide variety of SPH s health iitiatives, icludig the Somerset Explorer Bus Service, a local public trasportatio system developmet of SPH i partership with the Goverace 6
Keebec Valley Commuity Actio Program, local busiesses, muicipalities, ad New Balace to improve commuity access to health ad recreatioal facilities, grocery stores, ad other vital services; ad the regioal Parterships to Improve Commuity Health (PICH) iitiative i which SPH collaborates with Easter Maie Medical Ceter, MaieGeeral Hospital, ad Health Reach Commuity Health Ceters providig support for SPH s evidece-based chroic disease prevetio programs. RFGH s support of SPH s activities is crucial to its ogoig success, ad helps it to build key parterships with stakeholders ad other healthcare orgaizatios. 3 For more iformatio: http://www.somersetpublichealth. org/ I additio, a umber of states, like Vermot ad Miesota have adopted policies that specifically target the developmet of ew delivery systems ad accompayig goverace structures. Some examples from other parts of the coutry follow. MT ASCUTNEY HOSPITAL AND HEALTH CENTER, VERMONT: Hospital Supported Commuity Orgaizatios Mt. Ascutey Hospital ad Health Ceter (Mt. Ascutey) is a o-profit etity affiliated with the Dartmouth-Hitchcock system located i Widsor, Vermot. Mt. Ascutey provides leadership, staffig, ad resource support for several commuity iitiatives, most of which are built aroud local parterships ivolvig diverse commuity orgaizatios. I its role as a coveer, the hospital has sought to build ad maitai relatioships amog commuity providers ad agecies ad widely shares credit for the success of these iitiatives amog participats. The hospital has also played a leadership role i securig grat ad other fudig for may iitiatives, agai distributig that fudig to participatig parters. These iclude the Widsor Area Commuity Partership, a coalitio of commuity agecies ad providers, coveed by Mt. Ascutey, that facilitates strategic plaig, ogoig commuicatio, ad local oversight i promotig the health of the commuity; the Mt. Ascutey Prevetio Partership (MAPP) ad the Widsor Area Drug Task Force, substace abuse iitiatives focusig o policy ad evirometal strategies to shift commuity attitudes ad orms regardig alcohol, tobacco, ad drug use; ad the Widsor Health Service Area Coordiated Care Committee, a iteragecy leadership collaborative dedicated to the triple aim, whose key priority areas iclude emergecy departmet readmissios, quality of life, ad best practice approaches. 3 Staff from the hospital, especially the director of commuity outreach ad the chief of ursig, provide leadership for may of these iitiatives, ad the hospital serves as a fiscal sposor i some cases (such as MAPP). For more iformatio: http://www.mtascuteyhospital.org/ SOUTHERN PRAIRIE, MINNESOTA: Accoutable Care Orgaizatios Souther Prairie refers broadly to a collaboratio amog 12 couties i souther Miesota with a commo goal: to ehace the quality of life ad health of their citizes by facilitatig the itegratio of services ad supports provided throughout their commuities. It icludes two complimetary orgaizatios, Souther Prairie Commuity Care (SPCC) ad Souther Prairie Ceter for Commuity Health Improvemet (CCHI). SPCC is a joit powers orgaizatio formed i 2012 by the couties i the Souther Prairie regio, ad has evolved to be a virtual etwork, focused o achievig improved cliical quality, lower total cost of care, ad ehaced patiet experiece. The orgaizatio operates as a accoutable care orgaizatio that cotracts with Miesota s Medicaid program, part of a state demostratio project desiged to support ad ecourage improved patiet health at lower cost by agreeig to a set paymet for the treatmet of the etire populatio. SPCC Goverace 7
has 27 member providers, icludig cliics, hospitals, metal health ceters, public health, ad area huma service agecies. The board is comprised of the couty commissioers from each couty. Accordig to the collaborative, a key stregth of the orgaizatio is SPCC s ability to mobilize commuity services aroud those with the highest eeds, ad to leverage coectios betwee the goverace of SPCC ad that of health ad huma service agecies, metal health ceters, ad couty hospitals i the regio. CCHI covees commuity parters iterested i makig measurable ad sustaiable improvemets i the health of the residets i southwester Miesota. The goverace structure icludes a charter agreemet that details the relatioship betwee the two orgaizatios (SPCC ad CCHI) ad specifically defies the role of CCHI i furtherig the Souther Prairie missio. Local stakeholders make up the CCHI board of directors, deliverig services i the regio ad workig to advace the goals of the Triple Aim. The CCHI board has equal represetatio from the SPCC board ad operatios represetatives, public ad private providers of care ad services, ad cosumers each playig a key role i advisig SPCC o the best approaches to achieve the orgaizatio s priority goals. 4 For example, health care providers assist CCHI i reviewig major health treds i their commuities, ad recommedig actio to address issues of cocer, while SPCC represetatives serve as liaisos to CCHI to promote trasparecy, esure aligmet with the missio, ad facilitate ogoig commuicatios betwee the parter orgaizatios. CCHI provides recommedatios to SPCC o quality improvemet efforts ad programs to address issues that require a collaborative evidece based improvemet effort i areas such as health iformatio techology, evirometal public health, ad gaps i the health care system. For more iformatio: http://www.southerprairie.org/ ALIGNING FORCES HUMBOLDT, CALIFORNIA: Couty-based Iitiatives Improvig Care Coordiatio through Commuity Orgaizatios Aligig Forces Humboldt was a iitiative i rural Humboldt Couty, the orthermost couty i Califoria. Lauched with fudig from the Robert Wood Johso Foudatio, Aligig Forces Humboldt developed a etwork of health care stakeholders, icludig providers, cosumers, employers, ad commuity leaders to develop a coordiated approach to health promotio, disease prevetio, ad early treatmet by egagig the local commuity, ad parterig with area health ad huma services orgaizatios. I Humboldt Couty, health ad huma services operate through a itegrated couty-wide system. Commuity-based health care systems, i tur, were lookig for opportuities to better coordiate programs ad improve parterships. Aligig Forces Humboldt s three programs icluded a patiet egagemet model to support patiets i better maagig their ow care ad becomig peer leaders ad better iformed patiets; a surgical rate project to reduce rates of surgical variatio; ad a super-utilizers project, aimed at coordiatig care to reduce overutilizatio of the emergecy departmet. The projects were chose with a eye towards system redesig opportuities, particularly oes that iteded to iclude both patiets ad the commuity i healthcare decisio-makig. 5 Aligig Forces Humboldt built o the couty s logstadig itegrated commuity partership, based i a cliet-cetered model of health care service delivery that combies both health care ad social services, with close ties to educatio ad other commuity resources. 6 For more iformatio: http://cph.uiowa. edu/ruralhealthvalue/files/humboldtcouty.pdf Goverace 8
Cosideratios for Applicatio i Maie Creative, practical thikig about traditioal health care system structures ca lead to better itegratio of populatio health ad commuity health improvemet iitiatives with traditioal primary ad acute care structures ad systems. The fact that Maie lacks a formal, couty-based public health system may provide opportuities for hospital-public health collaboratio. Although fiacig of populatio ad commuity health improvemet remais challegig, commuities throughout Maie have the potetial to use a combiatio of istitutioal, hospital support, ad exteral grat fudig to jump-start populatio health iitiatives. Hospital-based leadership ad ifrastructure support provides a crucial backboe to may commuity populatio health iitiatives. A fully itegrated system of care, without the usual silos betwee health care delivery ad social services, ca take broader aim at some of the social determiats of health that lead to poor health ad worse outcomes for the populatio. REFERENCES 1. Alfero C, Cobur A, Ludblad JP, et al. Advacig the Trasitio to a High Performace Rural Health System. Iowa City, IA: Rural Policy Research Istitute; November 2014. 2. Rural Policy Research Istitute, Ceter for Rural Health Policy Aalysis. Rural Health Networks ad New Forms of Goverace. Iowa City, IA December 15 2015. 3. Gale J, Cobur A, Pearso K, Croll Z, Shaler G. Populatio Health Strategies of Critical Access Hospitals. Portlad, ME: Flex Moitorig Team; July 2016. 36. 4. Souther Prairie Commuity Care. Itroductio to Souther Prairie. http://c.ymcd. com/sites/www.southerprairie.org/resource/resmgr/docs/spcc-leave-behid_(006).pdf. Accessed August 8, 2016. 5. Rural Policy Research Istitute CfRHPA. Rural Service Delivery Itegratio & Patiet Egagemet. Iowa City, IA: Uiversity of Iowa, College of Public Health; September 25 2013. 6. Weigel P, Fiega C, Richgels J. Accoutable Care Commuities i Rural: Layig the Groufwork i Humbolt Couty, Califoria. Rural Policy Research Istitute;2015. The authors would like to thak iterviewees William Caro, James Davis, ad Peggy Pikham for takig the time to speak with us about their work. Suggested citatio: Kah-Troster S, Cobur A. Iovatios i Rural Health System Developmet: Goverace. Portlad, ME: Uiversity of Souther Maie, Muskie School of Public Service, Maie Rural Health Research Ceter; November 2016. Goverace 9