The Massachusetts Rural Health Landscape

Cathleen McElligott, DirectorMassachusetts State Office of Rural HealthMassachusetts Dept of Public HealthCathleen.mcelligott@state.ma.us

January 2011 – UMMS Rural Scholars Program

Rural Massachusetts

Mass. often thought of as urban because dense concentration of people in metro Boston and eastern cities, BUT....

713,968 people live in the 65% of state's landmass classified as rural (Census Bureau).

Nearly half of MA towns are rural (46%) by a federal definition, primarily in western, central, and coastal southeast MA.

Rural MA population density is only 109 people per square mile, comparable with other rural areas of the U.S. (density for urban MA= 2,115 ppsm)

A Few Notes on Rural Definitions There are MANY!

Typically based on factors such as… Population size Population density Distance from core cities/commuting distance

A Few Key Federal Definitions

Census Bureau Rural Is not in an urbanized area or an urbanized cluster

Office of Management and Budget (OMB)

Rural Is outside of a metropolitan statistical area

University of Washington School of Medicine Rural Health Research Center (WWAMI)

Supported by USDA/Economic Research Service and HRSA/Federal Office of Rural Health Policy

Rural Meets a Rural Urban Commuting Area Code (RUCAs) for rural

(codes 4 through 10 in the taxonomy)

National Rural Health AssociationDefinition of Rural, Policy Statement, November 2005

NRHA strongly recommends that definitions of rural be specific to the purposes of the programs in which they are used.

Programs targeting rural communities and providers do so for particular reasons…..these reasons should be the guidance for selecting the criteria for a programmatic designation.

This will ensure that a designation is appropriate for a specific program, while limiting the possibilities that other unrelated programs adopt a definition, which is not created to fit that program.

Rural Categories

Non-Rural

Large Rural

Small Rural

Isolated Rural

New England Rural Health RoundtableAnalytic Rural Definiition

Developed for the Rural Health Data Analysis ProjectBased on RUCA 2.0 Categories

.

Main Rural Health System Issues

Low population density

Distance and isolation

Rural Healthcare Because population is smaller and spread

out, program fixed costs can be higher per person served

Building a system with lower volume while maintaining quality and accessibilty

In addition to access to care and good health outcomes The economic impact of the health system

in rural MA needs to be considered

Largest employer and economic engine in rural areas

Rural MA Socioeconomic Barriers

Incomes lower

Rely heavily on tourism, service, agricultural, and fishing economies

Some rural towns are former small mill towns where the mill has closed or greatly downsized

Higher proportion of self-employed, family workers, and small businesses; often do not provide health insurance

Number of persons in rural areas with advanced education lower than the State average

Geographic Barriers forRural MA

Such as:

Mountains, hills, oceans, winding country roads, long distances, lack of public transportation

Low population densities Patchwork quilt of small towns Lack of inexpensive and fast telecommunications,

(broadband, high speed internet, cell phone)

further isolate rural communities from more centralized or regionalized state programs.

Publicly Financed Care & Services

With the economic demographic the rural population is more dependent on publicly-funded health services, as are the providers.

Berkshire County, 50.5% of pregnant women have publicly financed prenatal care compared to 34.2% statewide.

High proportion of elderly population; Medicare is payer of major importance.

Rural Appropriate Models Allow rural communities to develop models that work for

them and not scale down urban models. Within state and federal programs, rural communities need to

be allowed to develop rural-appropriate models and demonstrate rural best practices.

Build on strengths of rural communities e.g., innovativeness, good collaborators, strong community support and involvement, good at developing new programs, strong sense of place and community, good system thinkers, etc.

Need support for innovative and coordinated workforce programs to build on what has been started with rural health organizations.

A Special Population

When DPH is identifying health disparities it needs to consider RURAL as a special population ...with a geographic health disparity.

Health problems in rural areas are as real as other areas, just not as visible because the populations are smaller.

Rural areas deserve to be counted, studied, and reported on in state data reports. “You will find health disparities only where you look.”

“When you see one rural area you have

seen one rural area.”

Some similar characteristic needs, challenges, and strengths as a group.

But, always have to look at each rural area so you do not mask needs or challenges for particular rural parts of the state.

Health Care Safety Net

69 acute care hospitals in MA 9 are smaller community hospitals in rural communities (SHIP eligible) 3 are Critical Access Hospitals (1 a former CAH) 1 is a certified as Rural Medicare Dependent Hospital (has submitted CAH

application) Also 2 moderately sized PPS hospitals in rural areas

52 CHC organizations with 184 access sites in MA 6 CHC organizations serving rural with 10 rural sites 1 is a CMS certified Rural Health Clinic About 4 applications in for new CHC rural expansion sites Still huge rural gaps, working on…..

A few other: rural school based health centers, outpatient hospital clinics, VA vans, Wampanoag Tribe, etc.

MA SORHThree Federal Grants

1. State Office of Rural Health Program

2. Massachusetts Rural Hospital Flexibility

Program

3. Small Rural Hospital Improvement Program

Mass SORH Established in 1994 at Mass DPH Funding

Federal Office of Rural Health Policy/HRSA MDPH state matching funds

Builds partnerships to improve access to health services, build better systems of care, and improve health status in rural communities.

State Office of Rural Health Functions Use various communications strategies for information

dissemination Provide educational and networking opportunities Coordinate resources and activities Provide technical assistance for a wide range of needs Strengthen local, state, and federal partnerships Assess and document rural health needs Maintain a focal point for rural health – policy, rural-relevant

programs Further strengthen a framework that links rural communities with

State and Federal resources Strengthen rural health care delivery systems Develop local capacity/leadership for addressing solutions to rural

health problems

MA SORH Programmatic Areas of Focus

Healthcare workforce - recruitment/retention and pipeline

Safety net development Chronic disease prevention and management Oral health care Injury prevention Elder health services Veterans services Rural Hospital Flex Program –hospitals, rural health

systems, EMS Small Rural Hospital Improvement Program

Visit SORH On Facebook:

www.facebook.com/RuralHealthMDPH

The Web:www.mass.gov/dph/ruralhealth

Rural Hospital Flex Program Financial and Operational Performance

Improvement

Quality Improvement

Health System Development and Community Engagement

Financial and Operational Performance Improvement Conversion of an additional hospital to CAH TA for market analysis, strategic performance assessment and

planning, new service feasibility studies, management training

Rural Hospital Board Development Modules (NEPI) Implementation of state and federal healthcare reform CEO/CFO Network Continued monitoring of fiscal and operational data of MA

small rural hospitals Cultural competency and translation services Patient and Family Councils

Flex Program: Quality Improvement

MA Rural Hospital Pharmacist Network Anti-Coagulation Program Diabetes Management Project 24/7 Staffing Strategies Automation and Use of Technology 34B Program implementation

HIT and implementation of electronic health records (meaningful use)

Massachusetts Primary Stroke Services (PSS)

CAH Medicare Beneficiary Project - Hospital Compare measures

Flex Program: Quality Improvement Institute for Healthcare Improvement Rural Expeditions and

Passport (NEPI) HCAHPS/Patient Satisfaction Patient Care Transitions

STAAAR Initiative (State Action on Avoidable Re-Hospitalizations)

Rural Relevant Measures

Health System Development and Community Engagement EMS Services Integration/Coordination EMS Quality Improvement Projects Swing Bed Program Development CAH-Community Health Center

Collaboration

Critical Access Hospitals (CAHs) Unique CMS designation for small rural hospitals to

improve the viability of these lower volume facilities and bring additional resources into the community

Eligibility in a rural area, <25 beds +10 DPU, 96 hour LOS, more than 35 miles by road to next nearest hospital or a rural necessary provider

Process for designation coordinated by SORH in collaboration with DHCQ and OEMS at DPH

Currently we have 3 CAHs, 1 previous CAH, and working with 1 additional CAH applicant

Benefits of CAH Status Cost-based reimbursement from Medicare which has

the potential to increase revenues Focus on local community needs and enhanced

networking with other parts of the healthcare system More flexible staffing and services, within state

licensure laws Capital improvement costs are included in allowable

costs for determining Medicare reimbursement Access to Flex Program and other targeted grant

funds

Small Rural Hospital Improvement Program (SHIP) Makes annual grant awards of approximately $9,000 per

eligible small rural hospital (less than 50 beds in a rural area as defined by MA state law/regulations) .

Patient Protection and Affordable Care Act re-defined the use of these funds starting in FY2010.

Funds to assist with implementing: Prospective Payment Systems and delivery system changes to

implement Value Based Purchasing: quality improvement, quality outcomes Accountable Care Organizations: network/service development and

reporting and HIT systems. Payment Bundling

SHIP Hospitals in MA 9 small community hospitals in rural MA:

1. Athol Memorial Hospital, 2. Baystate Mary Lane Hospital, 3. Clinton Hospital, 4. Fairview Hospital, 5. Martha’s Vineyard Hospital, 6. Nantucket Cottage Hospital, 7. Nashoba Valley Medical Center, 8. North Adams Regional Hospital, 9. Wing Memorial Hospital.

How Do We Determine Which Issues? 1. Trends in health care environment 2. Opportunities, opportunities, opportunities3. Needs assessments – qualitative and

quantitative4. Constituency interests and priorities5. Interests of Partners6. Priorities of funders, MDPH, EOHHS 7. Staff backgrounds

Key Rural OrganizationsFederal Office of Rural Health Policyhttp://ruralhealth.hrsa.gov/ National Rural Health Association http://www.nrharural.org/ New England Rural Health RoundTable http://www.newenglandruralhealth.org/ Rural Assistance Centerhttp://www.raconline.org/

New England Rural Health RoundTable Rural health association for the 6 New England States linked

with the National Rural Health Association

Vibrant member driven organization with committed board of directors, excellent professional staff, and active committees with a broad range of activities

The New England Rural Health RoundTable is the forum for promoting healthy rural communities and solutions to the unique health challenges facing rural New England.

NERHRT’s Objectives Serve as a unified voice for the promotion of rural health needs and issues

in New England.

Identify rural health needs and issues in New England.

Share timely information about key state and federal rural health policies and programs.

Educate and advocate for rural health.

Encourage networking and collaboration in support of rural health.

Primary Stroke Services

Developed with assistance from Mass SORH Fairview Hospital (CAH) Results Oct. 06-07:

25 stroke patients 12 with ischemic stroke 5 patients received t-PA 7 patients discharged home 13 patients transferred to BMC 3 patients admitted to Fairview Hospital

Symptoms onset to t-PA: 2 hours, 19 minutes

Emerging Challenge...Rural Dialysis (Chronic Disease Management) Encapsulates most rural issues Chronic disease management Rural access Staffing High importance...Low volume...High Cost

Western Mass EMS CouncilRecruitment and Retention Survey, Spring 2006

92% response rate from EMS organizationsfunded by Mass SORH

Service Level39% of respondents - Basic Level Only18% of respondents - Intermediate Level is highest level43% of respondents - Paramedic Level

Personnel Status49% respondents have paid staff22% of respondents have a mix of paid and volunteer staff27% of respondents have volunteer staff

People-Per-Dentist Ratio

30% of cities/towns in Massachusetts don’t have enough dentists to care for the people who live there.

Mapping Access to Oral Health Care in Mass., Catalyst Institute, Oct. 2006

Distribution of MassHealth (Medicaid) Dentists

The majority of MassHealth dentists in Massachusetts are clustered in urban areas.

Mapping Access to Oral Health Care in Mass., Catalyst Institute, Oct. 2006

Emergency Department Visit Rates for Fall-Related Injuries by Region

Massachusetts: 2003-2005

2,7502,5112,713

3,1912,860

5,027

2,913

3,992

2,410

0

1000

2000

3000

4000

5000

6000

Vis

its

pe

r 1

00

,00

0

*** ***

Age-adjusted to the 2000 US standard population. Source: Division of Health Care Finance and Policy. Calendar Year 2003-2005. Emergency Department Visits

*

**

Statistically different from State (p ≤.05) Red (*) = Statistically worse; Green (**) = Statistically better than state

*

*

Hospital Discharge Rates for Motor Vehicle-Related Injuries by Region, Berkshires, and Pittsfield

Massachusetts: 2003-2005

74 77

57**

88*

151*

73

91*

110 *

93 *

0

20

40

60

80

100

120

140

160

Dis

ch

arg

es p

er

100,0

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Statistically different from State (p ≤.05) Red (*) = Statistically worse; Green (**) = Statistically betterSource: MDPH Bureau of Health Statistics, Research, and Evaluation