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UnderstandingRuralHealthinaTimeofPolicyandHealthSystemChangeandReform

CommonandChronicHealthCareManagement589AdvancedNursingEducation

UniversityofMary

February13,2017Bismarck,NDGoTo Webinar

Presentedby:BradGibbens,DeputyDirectorandAssistantProfessor

• Establishedin1980,atTheUniversityofNorthDakota(UND)SchoolofMedicineandHealthSciencesinGrandForks,ND

• Oneofthecountry’smostexperiencedstateruralhealthoffices

• UNDCenterofExcellenceinResearch,Scholarship,andCreativeActivity

• Hometosevennationalprograms

• RecipientoftheUNDAwardforDepartmentalExcellenceinResearch

Focuson– EducatingandInforming– Policy– ResearchandEvaluation– WorkingwithCommunities– AmericanIndians– HealthWorkforce– HospitalsandFacilities

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Today’sObjectives/Questions

• HowdoValuesplayaRole?• Howdowedefine“ruralhealth”?• WhataretheCultural,Social,Economic,andDemographic

DifferencesbetweenRuralandUrbanCommunities• WhatisRuralHealthEquity?Disparity?• WhatistheRelationshipbetweenthe“Rural”Community

and“Rural”Health?• WhatarethePrimaryRuralHealthIssuesandNeeds?• WhatareBarriersandFacilitatorstoAccessinRuralHealth?• WhatistheenvironmentforRuralHospitals?• WhataresomeOptionsorModelsforPositiveChange?

UltimatelyOurValuesGuideOurPerceptionsTowardHealth,HealthCare,andPublicPolicy

“Itisnotwhatwehavethatwillmakeusagreatnation.Itishowwedecidetouseit.”

TheodoreRoosevelt

“Visionistheartofseeingthingsinvisible”JonathanSwift?

“Americanscanalwaysbereliedupontodotherightthing…aftertheyhaveexhausted

alltheotherpossibilities”SirWinstonChurchill

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How Do We Define Rural Health

What is Rural Health

• Rural health focuses on population health and improving health statuso “Health outcomes of a group of individuals, including the distribution of such

outcomes within the group” Dr. David Kindig, What is Population Health?o Rely on social determinants of health and their impact on the population

(Health care system, Health Behaviors, Socio-Economic factors, Physical Environment) – “drivers” of health policy (Better Health, Better Care, and Lowered Cost – Three Aims)

• Historically, rural health has focused more on infrastructure: facilities, providers, services, and programs available to the public (all with quality, access, and cost implications) – In the ACA world more emphasis on population health, but infrastructure is still critical as it is the pathway to achieve better population health. o HRSA (ORHP, SORH, Flex, NHSC) – Federal bureaucracy orientationo Infrastructure improvement- health orgs, systems, payment structureso More and more health networks – independence with collaborationo Delivery systems: CAH, clinics, public health, EMS, nursing homes/aging

services, home health, mental health, dental, pharmacy, and others

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What is Rural Health?

• Rural health is not urban health in a rural or frontier areao Social determinants of health vary between urban and rural

(economics/income, education, health systems, environmental conditions)o Rural is older, poorer, less insured, and has a higher level of morbidity for a

number of conditionso Rural culture, relationships, how we do things are distinct

• Rural health needs effective health policy, and health policy needs to rely on competent researcho Policy process that is reflective of rural health needso Policy advocacy that tends to be bipartisano Varity of advocacy groupso Rural health research community

What is Rural Health?§Philosophy: rural people have the same right to expect healthy lives and

access to care as do urban people – fairness frame• Access essential services locally or regionally• Access to specialty services through network arrangements• Health outcomes should be comparable• Quality of care on par with urban• Availability of technology

§ Rural health is very community focused – interdependence frame• Integral part of what a community is and how people see themselves• Community engagement – public input is fundamental• Sectors: Economic/business, public/government, education, faith/church, and

health/human services• Direct services provided to the public and secondary impact for other sectors• Major employer

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WhataretheCultural,Social,Economic,DemographicDifferencesbetweenRuralandUrbanCommunities?

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RuralandUrbanStrengthsandWeaknesses

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Rural Urban

Weaknesses•Lackofcohesiveness

•Limitedinformalsupport•Competitionamongproviders•Competitionforfundraising•Morecontentious-fractions•Lesssenseof"community"

Strengths•Morestable/diversifiedeconomy

•Availabilityofresources•Availabilityofprofessionals

•Growinganddiversepopulation•Changeisnatural

Weaknesses•Skewedpopulationdemographics

•Fluctuatingeconomy•Resistancetochange

•Shortageofprofessionals•Lackofresources•Over-tappedstaff

Strengths•Stronginformalsupportnetwork

•Fundraising•Cohesive

•Establishedinterdependence•Collaboration

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WhatisRuralHealthEquity?

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Rural Community Health Equity Model

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EnvironmentalConditions• Demographics• Economics• Policy• HealthStatus• Workforce• Finance• Technology• HealthSystemChange• RuralCommunityCulture

&Dynamics

ImpactonCommunityorHealthOrganization• Threattosurvival• Growth/Decline• Identity• Perceptiontowardchange• Perceptiontowardopportunity• Howwerespond

CommunityAction• Whatdopeoplethink,want,orneed?

• Assessments• Forums-Discussions• Interviews

• CommunityOwnership(nothealthsystemownership)• Collaboration• Inclusion• Participation• Interdependence

• CommunityCapacity• Skillsandknowledge• Leadershipdevelopment• Planningandadvocacy• Managechange– nonreactive

Source:BradGibbens,DeputyDirectorUNDCenterforRuralHealth

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PopulationHealth

“Healthoutcomesofagroupofindividuals,includingthedistributionofsuchoutcomeswithinthegroup.”(Kindig,WhatisPopulationHealth?)

•Groupscanbebasedongeography,race,ethnicity,age,language,orotherarrangementsofpeople•Focus– HealthOutcomes(whatischanged,whataretheimpacts,whatresults?)•Whatdeterminestheoutcomes(determinantsofhealth)?•Whatarethepublicpoliciesandtheinterventionsthatcanimprovetheoutcomes?

SocialDeterminants

WorldHealthOrganizationdefinition:

"thecircumstancesinwhichpeopleareborn,growup,live,workandage,andthesystemsputinplacetodealwithillness.Thesecircumstancesareinturnshapedbyawidersetofforces:economics,socialpolicies,andpolitics."

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What is the relationship between the “rural” community and “rural” health?

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RuralCommunityandRuralHealth• Communitiesarecomprisedofkeysectorsthathaveeconomic,social,

andculturalcomponents– togethertheycomprisethetowno Health(withhumanservices)o Business(canhaveoneortwodominantbusinesstypes– ag,oil–

economicimpactofhealthandhealthcare)o Education(schoolconsolidationandsportcoopchangingsomeof

thecommunityidentity)o Government– city,county,specialdistricts– roleofparkboard

withhealthcare)o Faith(socialandculturalconnections– accesstohealth)

• Viablehealthsystemsneedviablecommunities– strongeducation,business,faith,governmentandbusiness,likethosesectorsneedastronghealthsystem(e.g.healthaccessforemployees,generalhealthimprovement,healthcareislargeemployeraddingtobusinessandschools)

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WhyisCommunityEngagementImportanttoRuralHealth

• Healthcareprovidersandorganizationscannotoperateinisolation.

• Evenmoreimportantasweimplementhealthreform– newpaymentmodels– movementfromvolumepaymentstovaluebasedpaymentsasmoreandmoreprovidersareassessedandreimbursedonoutcomesandpatientsatisfaction.

• Communitymembersinputonneeds,issues,andsolutionsmorecriticalthanever–communityinvolvementinfindingsolutions(CHNA)thatreflecttheirneeds– communityownershipnotjustthehealthproviders– hospitalsmustaddress“communitybenefit”

• Buildinglocalleadershipandlocalcapacity– thinkofthenextgenerationofcommunityleadership.

• Communication– listeningtothecommunity– educatingthecommunity.

• Simpleanswer:Youneedtobeengagedbecauseyouneedtosurvive.

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WhatarethePrimaryRuralHealthIssuesandNeeds?

What are Some Important Rural Health Issues? • Access to and availability of care• Financial concerns facing rural hospitals and health systems• Health workforce• Quality of Care• Health Information Technology• Networks – rural hospitals, urban hospitals, clinics, others• Emergency Medical Services – EMS, ambulance, quick response units• Community and Economic Development• Health System Reform

Sources: 2008 Flex Rural Health Plan, 2009 Environmental Scan, and community presentation feedback surveys 2008-2016

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PreliminaryCHNAIssues(2014-2016)• 41CHNAanalyzedoutof45• 182rankedneeds(range2to9rankedneedsperCHNA,most4-5)• Issues

o BehavioralHealth 23outof41o MentalHealth 20o HealthWorkforce(physician/providerR&R,specialists) 17o ObesityandOverweight 13o ElderlyServices(availabilityofresources) 10o Wellness(Lifestyle,exercise,physicalactivity) 10o Costs(healthcare,insurance,prescriptions) 9o Childcare/daycare 9o JobswithLivingWages 8o AbilitytoRecruitandRetainYoungFamilies 8o Illnessanddisease(heartdisease,cancer,diabetes) 6o Housing 4o Poverty 2

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What are Some Important Rural Health Issues? (CHNA)• Health care workforce shortages (28 of 39)• Obesity and physical inactivity (16 of 39)• Mental health (inc. substance abuse) (15)• Chronic disease management (12)• Higher costs of health care for consumers (11)• Financial viability of the hospital 10)• Aging population services (9)• Excessive drinking (7)• Uninsured adults (6)• Maintaining EMS (6)• Emphasis on wellness, education, & prevention (6)• Access to needed equipment/facility update (6)• Marketing and promotion of hospital services (5)• Violence, traffic safety, elevated rate of adult smoking, lack of community collaboration, and

cancer tied with (3) • Lack of day care/housing (2)Source: CHNA conducted 2011-2013 (39 of 41 ND hospitals)

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WhatactasBarriersorFacilitatorstoRuralHealthAccess

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CommonAccessBarriersandFacilitatorsinRuralHealth

• Financial• Availabilityoffacilitiesandproviders• Demographics• Communityviability– (e.g.,economics,communityidentity,community

engagement)• Geography,distance,andtransportation• Populationhealth– healthstatus• Caregivers(e.g.family)• Communication(e.g.healthcareliteracy,translation,andmore)• Qualityofcare• Privacyand/orsocialstigma

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What is the Environment for Rural Hospitals?

• ND CAHs are complex and serve as a “Hub” service system for health and some human service functions for rural communities

• ND CAHs serve a more vulnerable population –population health is a major concern for rural North Dakota

• ND CAHs make a significant economic contribution to their communities and service areas

• ND CAHs face many financial concerns

Rural Hospital Environmental Considerations

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CAHsareService“Hub”providers• 35of36CAHs(97%)ownand/oroperateanotherhealthbusiness

o 87%(32CAHs)operate57primarycareclinics(42RHCs)o OneCAHsharesanadministratorwiththeFQHCo 36%(13CAHs)own/operateanursinghomeo 31%(11CAHs)haveboth aclinicandnursinghomeo 28%(10CAHs)ownseniorapartmentso 25%(9)own/operateambulanceso 22%(8)operateassistedlivingo 19%(7)operatebasiccareo 6%(2)offerhomecareservices

• Policymakers– stresstheequityframeandtheinterdependenceframe

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CAHsServeaMoreVulnerablePopulation

• 63%ofpeople65andolderliveinruralND (about42%ofCAHinpatientbaseisMedicare)

• About368,000NDarerural(outsidetheMSAs)–about356,000areurban–(USDAEconomicResearchService,September2014)

• 46%ofNDveteransareruralcomparedtoabout30%nationwide• 11.1%ofruralNDliveinpoverty;11.2%ofurbanND(ruralmuchhigherin

1999,1989,and1979)• Healthdisparities

o RuralNDhigherratesforhealthbehaviors:smoking,bingedrinking,drinkinganddriving,notwearingaseatbelt,notexercising

o RuralNDhigherratesforgeneralhealthconditions:disability,overweight/obesity,havingonlyfairorpoorhealth,andnumberofdayswithpoorhealth

o RuralNDhigherratesforspecifichealthconditions:highcholesterol,highbloodpressure,arthritis,cardiovasculardisease,anddiabetes(2010CDCBRFSS)

• Policymakers– stresstheequityframe

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CAHCEOsPerceptionsofIssues– 2014Survey

• 34Issues,Top10o Accesstomentalorbehavioralhealthservicesforinpatientand

outpatient(Mean=4.1on5.0scale)o Accesstomentalorbehavioralhealthservicesforsubstanceabuseo Hospitalreimbursement– 3rd partypayero Hospitalreimbursement– Medicaido Impactoftheuninsuredo Impactoftheunderinsuredo Primarycareworkforcesupplyo Hospitalreimbursement– Medicareo Nursingworkforcesupplyo Ancillaryworkforcesupply

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NDCAHsMakeaSignificantEconomicImpact• 50%ofCAHshavelocaltaxsupport(2014survey)– 36%in2011and11%

in2005- $30,000to$550,000/yr (10over100,000ayear)• 9salestaxand5milllevy(4didnotidentify)• 85%haveahospitalfoundation(Source2014CRHCAH/PPSHospitalSurvey)• NDCAHshave,onaverage,abouta$6.4million(wageandbenefits)

impactontheircommunity– primary/directandsecondary/indirect)–1.5%multiplier

• NDCAHsproduce,onaverage,about224jobs(direct/indirect)tolocaleconomy

• StatewideCAHscontributeabout$230milliontoeconomyand8,000ruraljobs(Source:CRHRuralHospitalFlexibilityProgram,CAHFourKeyFactors)

• 1ruralphysiciancanhaveanimpactofabout$2.4million($1.5millionrevenuesandabout$900,000inpayrollforclinicandhospital)

• 1ruralphysiciancangenerateabout4clinicjobsand13hospitaljobs(Source:RuralHealthWorks) 30

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CAHsFaceManyFinancialConcerns

• Nationally,from2010thruJanuary2017,70ruralhospitalsclosed• NDCAHsoperatingmargins(-1.67);nationally+0.68(2011data)• NDCAHsOperatingMarginswere(-0.67)• SDCAHsoperatingmargins(+2.76)• MNCAHsoperatingmargins(+2.88• NDCAHstotalmargins(-0.02);nationally+2.33• NDCAHsTotalMarginswere(+0.15)• SDCAHstotalmargin(+3.17)• MNCAHstotalmargin(+3.45)• NDCAHsranks4th inoldestphysicalplant• NDCAHsranks20th indayscashonhand• CAHsinNDincreasinglocaltaxsupportandhospitalfoundations• (source:FlexMonitoringTeamDataSummaryReportNo.13,2014)

WhatDoestheCenterforRuralHealthdotoAssistRuralCommunities?

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CRHAssistancetoRuralCommunities• CommunityEngagementToolKit• CommunityAssessments

o CommunityHealthNeedsAssessmento SpecialFocus(e.g.,assistedliving,wellnesscenters,other)

• Focusgroups• Keyinformantinterviews(one-on-one)• Strategicplanning(organizationalplanningandcommunityhealthplanning)• Grantwritingworkshops• Grantproposalcritiquesandbackgroundsearches

o RuralAssistanceCenter(www.raconline.org)• Communityforumand/ormeetingfacilitation• ProgramEvaluation• SpeakersBureau– annualmeetings orspecialpresentations(ruralhealth,healthpolicy,

NativeAmerican,aging,communitydevelopment/engagement,evaluation/programsustainability,HIT,qualityimprovement,TBI,networkandsystemdevelopment,veterans,andothersubjects– justask!)

• CAHQualityNetwork• InternalPersonnelAudit(staffsatisfactionwithworkenvironment)• Education– statewideassessments(hospitalandpublichealth),presentations,research

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What are Some Options for Positive Change? Rural Communities and Vision is the Art of Seeing Things Invisible

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RuralHealthOptions• CapacityBuilding– equityandinterdependence

o CommunityEngagementToolKit(January2015)Ø SkilldevelopmenttobuildlocalcoalitionstoaddresslocalhealthissuesØ BuildingpartnershipsandnetworksØ AssessmentandplanningØ ResourceidentificationØ HowtowriteagrantØ Evaluationandsustainability

• GrantDevelopment– equityandinterdependenceo Grantwritingworkshops andproposalcritiqueso MedicareRuralHospitalFlexibilityGrantsandSHIPgrantso RuralHealthOutreachgrantso RuralNetworkDevelopmentgrantso RuralNetworkPlanninggrants

• CommunityHealthNeedsAssessment– equityandinterdependenceo NEWinstrument– addresshospitalandpublichealthneeds

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RuralHealthOptions• MedicareRuralHospitalFlexibilityProgram

o Since1999,Flexhasprovidedover$5millionindirectgrantstoNDCAHs(andanother$3.5millioninSmallHospitalImprovementProgram-SHIPgrants)

o Impactedover125communitieso 348separatesubcontractswithhospitals(about9.6contractsperCAH)o HelpCAHsdevelopservices,networks,staffandcommunityeducationand/ortraining,

boardeducation,improvefinancialviability(Chargemasterreview),qualityimprovement

o CreatedCAHQualityNetwork– all36CAHsaremembersandworkwiththebig6(regionalCAHmeetings)

o Directassistance:Ø 267communityand/orhospitalmeetingsØ 58communityneedsassessmentsØ 30strategicplanningsessionsØ 16economicimpactassessmentsØ 11InternalPersonnelAuditsØ 34Statewideworkshops

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Rural Health Options

• OutreachGrantso $200,000ayearfor3yearso 3separatelegalentitiesworkingtogether– MOUo Applicantruralandnonprofitbutcanhaveurbanand/orfor-profitpartnero Everyotheryearo 23grantsfundedinNDsince1991o 18of23grantsinvolvedaruralhospital(78%)o 11of23grantsinvolvedacollaborationofaruralhospitalandruralpublichealth

(48%)o Otherpartners:4grantshadambulances,3grantscommunityactionagencies,3

academicunits,2tribalcolleges,2economic/jobdevelopment,2tertiaryhospitals,2publicschools,1pharmacy

o Dickinson– 4separateOutreachgrants,Wishek2o Subjectsaddressed– chronicdisease,diseaseprevention,mentaland/orbehavioral

health,EMS,communitywellness,healthinsuranceaccess,communityhealtheducation,dementia,mobilehealthclinic,primarycareclinicexpansion,nursingeducation,publicschoolnursedevelopment,andother

o 2014applicants– advancedcareplanning,substanceabuse,communityaccesstoMarketplace/MedicaidExpansion,carecoordinationforelderly

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Conclusions• Ruralhealthisasignificantsectorinruralcommunities• Ruralhealthisuniqueordifferentfromurban-basedhealth• Ruralhealthorganizations,includingruralhospitals,arecomplex

organizations• NDrecognizeawidevarietyofcommunityhealthneeds,somerelatedto

populationhealth,andsomemoreorganizationalandstructural• CenterforRuralHealthworkscloselywithruralcommunities,

particularlytobuildlocalcapacity• Ruralhealthprovidershaveusedanumberofgrantstostart

local/regionalinitiatives• Healthworkforceisasignificantissue

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Questions??

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1301NorthColumbiaRoad,Stop9037GrandForks,NorthDakota58202-9037701.777.2569(desk)701.777.3848(generaloffice)

Brad.gibbens@med.und.edu

www.ruralhealth.und.edu

Contact us for more information!

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