QUARTERLY. Spring 2004 Volume 6 Number 2

Transcription

1 Spring 2004 Volume 6 Number 2 QUARTERLY Minnesota Office of Tourism Photo 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 Health Advisory Committee Member Profile: ORHPC Talks with Steve Hansberry Home: Sandstone Family: Five children, Alarice (22), Sarah (19), Marshall (17), Katherine (13), Shannon (10) and wife of 28 years, Victoria. Hobbies: Family Rural Health Advisory Committee Member Steve Hansberry and family. Steve Hansberry has a long history of public service in both his personal and professional life. A mechanical engineer by trade, Steve has used his education to help improve public facilities for the incarcerated and for mental health patients. While working as a project manager for the State of Missouri-Office of Administration, he worked with both the Department of Corrections and the Department of Mental Health to modernize the largest public mental health facility in Missouri and to upgrade facilities at the Missouri State Penitentiary s capital punishment unit. Steve has worked at the federal Bureau of Prisons regional office in Kansas City, the United States Penitentiary in Leavenworth, Kansas, and the Federal Prison Camp in Yankton, South Dakota. Now in his twentieth year of public service, Steve is currently the facilities manager at the Federal Bureau of Prisons Federal Correctional Institution in Sandstone. Steve s family has lived in rural settings throughout the Midwest since his children were very young. His interest in rural health care is rooted in the cultural change he experienced while moving from metropolitan Kansas City to rural South Dakota. In this new rural setting, he observed patients suffering from major depression, chronic asthma, and cerebral palsy while also assuming the burden of distance to care and limited resources. Reflecting on this, Steve sees discrepancies between urban and rural health care as having roots in a fundamental misunderstanding of rural culture. He feels urban residents do not recognize the degree to which gaps between urban and rural lifestyles have closed, making the two indistinguishable in many ways. Steve was appointed to the Rural Health Advisory Committee (RHAC) in 2004 and serves as a consumer representative. He is also a member of the mental health and primary care workgroup, a subgroup of RHAC, working on improving access to rural mental health services through the primary care system. What do you think are the most important issues facing rural health today? SH: First is the need for a greater understanding of the cultural differences and similarities between rural and urban health care and lifestyles. And second, health care resources are inefficiently over-concentrated in urban areas. Estelle Brouwer, Director Karen Welle, Assistant Director Stefani Kloiber, Editor I believe that although there are gaps between rural and urban settings in such areas as health care, unemployment, poverty, and substance abuse, they are closeable gaps. Bridging these gaps does not require major system rework, just education and awareness. With modern communications, transportation, infrastructure technology, and organizational formats, there shouldn t be any fundamental difference between downtown Minneapolis and Ely. (Steve likes to apply what he calls cutting edge marketing in his words, Just do it. ) We don t need to build new houses. We need to invite others into the ones we already live in. Our health care is the best in the world because of its ability to develop and utilize tremendously sophisticated technology, multiple service delivery models, broad educational programs, cutting edge research, and last, but first, phenomenally skilled people. That means our house is VERY LARGE. There is room in it for many people. 2 See Steve Hansberry (back page)

3 POLICY FOCUS A Snapshot of Rural Hospice Care in Minnesota By Angie Sechler and Stefani Kloiber The Office of Rural Health and Primary Care recently completed a series of rural health profiles spotlighting hospitals, pharmacies, ambulance services, nursing homes, clinics, hospice, and the health professional workforce in Minnesota. Each profile centers on the availability and distribution of health care services and providers throughout Greater Minnesota and focuses on issues affecting their accessibility. A summary of Hospice in Minnesota: A Rural Profile is presented below. Numerous national polls have found that when asked, most people would prefer to die in their own homes. Contrary to these wishes, 75 percent of deaths in Greater Minnesota (outside the seven-county metro area) occur in institutional settings. The best way to assure that a person s wish to die at home with high quality of care is granted is through the use of hospice services. According to the 2000 census, Minnesota has a total population of 4,919,479, and 2,277,425 or 46 percent of that number live in Greater Minnesota. In 2001, approximately 37,505 people died, with 20,822 or 55 percent of the deaths occurring in Greater Minnesota. The leading cause of death in both rural and metro areas was heart disease; cancer was the second leading cause. The increase in the aging population, particularly in the rural areas, is a powerful indicator of the need for hospice services. In Minnesota, nearly 80 percent of the people who die are over the age of 65. Adding to that statistic, 41 percent of Minnesota s population over the age of 65 live in a rural area. The Minnesota Commission on End of Life Care, a statewide group that addressed end of life care issues, concluded in 2002 that the less populated the county, the less likely death will occur at home. Hospice Hospice is a specialized form of care for people with "Helping dying patients to stay at home and providing high-quality end of life care is challenging in rural areas. Hospice programs that could help patients to remain in their homes do not cover all of Minnesota, and many rural hospice programs struggle financially because of the small numbers of eligible patients." Minnesota Commission on End of Life Care terminal and life-threatening conditions. The focus of hospice care is on treatment and support to provide comfort rather than to cure the disease. Most hospice patients are able to live their final days at home. Hospice programs provide the medical expertise, support and teaching to enable families to care for their loved ones at home. For those who cannot be cared for at home, hospice care can also be provided in a nursing home, residential setting, or hospital. Most hospice services are provided to individuals in their homes. The type and frequency of hospice services are tailored to meet the needs of the person who is dying and his or her family. According to Hospice Minnesota, a statewide organization representing hospice care providers, hospice provides: expertise in comfort care, including medications and therapies to relieve pain and symptoms; twenty-four hour support in the form of on-call services; coordination of help and services needed in the home, and necessary medical equipment such as hospital beds and oxygen. In Minnesota, all hospice programs are required to be licensed by the Minnesota Department of Health. Most hospice programs in Minnesota are also federally certified in order to provide services under the Medicare Hospice Benefit. The majority or 83 percent of licensed hospice programs in Minnesota are outside the Twin Cities metropolitan area. In 2002, 38 percent of the 11,359 hospice patients served were in rural areas and the average caseload for rural programs was 12 patients (Hospice Minnesota). See Snapshot of Rural Hospice Care (page 7) 3

4 PROGRAM FOCUS Bridging Distances in Healthcare A successful model to address the rural nursing workforce shortage By Stefani Kloiber Even if it [the program] is grueling, it has given meaning to my life, a focus for the future that I never believed would be possible. - Nursing student We are in the home stretch and it feels good! I already have a job at the Granite Falls Hospital. I will work part-time as an aide until fall and after taking my boards I will work full-time as an RN. - Nursing student These are just some of the many positive comments Carol Dombek has received from students enrolled in Bridging Distances in Healthcare, an innovative program that offers rural residents the opportunity to earn their Registered Nurse (RN) degree close to home. The goal is to provide nursing education locally so rural residents don t need to leave their home and family in order to receive a degree and start a career. The program is a win-win situation for everyone. Students benefit by receiving a nursing degree with the promise of a job at graduation. The community benefits by filling a nursing position that has previously gone unfilled and retains a resident. A Shortage of Nurses The demand for RNs both nationally and statewide is strong; however, the supply of RNs is not currently meeting the demand. According to the Minnesota Department of Employment and Economic Development (DEED), in 2004 there are nearly 48,620 RNs employed with approximately 2,000 vacancies throughout Minnesota. A recent study of the Minnesota RN workforce by the Office of Rural Health and Primary Care (ORHPC) revealed that an aging workforce, low RN graduation rates, increased wage growth, high staff turnover, and employee demand have all contributed to a shortage of RNs. The shortage of nurses is exacerbated in Greater Minnesota where the pool of trained RNs is smaller. In addition, the rural RN workforce is about one-and-a-half years older than their urban counterparts and closer to retirement. In Greater Minnesota the availability of RN programs is scattered. In most cases, students would need to either move away from their home or travel a minimum of two hours one way to attend classes. After a student moves away from home to attend school, the likelihood of returning to practice in rural Minnesota drops significantly. The lure of a metropolitan area is a challenge for rural health care. The opportunity to work in a variety of settings or specialties and earn higher wages RNs in the metro area often earn substantially more per hour than those in rural areas can be very appealing. The shortage of nurses is expected to continue into the future. With more nurses retiring in the next 15 years and fewer students graduating from RN programs, the gap may become even bigger. The Bridging Distances in Healthcare program is one step towards increasing the numbers of RNs. Growing Your Own It is a homegrown program, says Carol Dombek, the project manager for the Southwest Minnesota Private Industry Council s Bridging Distances in Healthcare program. She adds, We needed to bring training to rural Minnesota so people stay local. There are many wonderful people in the community that want to remain in the community. What better way to help them enter into a career that is needed in their community? The idea for the program came from a group of rural Workforce Center representatives, who partnered with healthcare facilities and nursing education programs in Greater Minnesota to obtain a federal H-1B workforce development grant. The one-time $3 million grant funded by the United States Department of Labor provides technical skill training, such as healthcare education, for in-demand professions. The H-1B Bridging Distances in Healthcare project began in Working with rural communities, Workforce Centers, healthcare facilities, and colleges throughout the 80 counties of Greater Minnesota, distance learning sites were developed for the accelerated two-year RN education. In the last two years 14 sites have been developed in 12 communities throughout Minnesota. Sites are located in Fairmont, Montevideo-Granite Falls, Olivia (from an LPN to RN completion only), Redwood Falls-Olivia, Morris (two sites), Cook, Bigfork, Cloquet, Mora-Pine City, Melrose, Staples, Wabasha, and Ely. 4

5 The Bridging Distances project partners with nursing education programs to offer accelerated nursing education, and is designed to increase the accessibility of healthcare education in rural Minnesota communities to help meet the healthcare worker shortage. The goals of the program are to increase nursing capacity in rural Minnesota and to build coalitions with healthcare, workforce centers, and education for ongoing system development and sustainability. Students enrolled in the program complete their RN education in two years, instead of the usual three to four years, graduating with an associate degree in nursing. Courses are offered through classroom instruction, distance learning, and local clinical experience. Carol does offer a word of warning, however: It is a very intense program. Students can t expect to work full-time and go to school. It takes what is often a three-to-four-year program and condenses it into two years; it is hard work, but the payoff is great. In most cases, students attend classes and complete their coursework while also working part-time. The grant funds the students education, making it more affordable and appealing for students to attend school. Students may also use other financial assistance (for example, Pell grants or scholarships) to cover living expenses while attending school and working. In some instances, the employer (such as a local hospital) may also pay a portion of the tuition with the promise of filling a nursing position when the student completes the program. Currently there are approximately 310 students enrolled in the program, surpassing its initial goal of training 268 RNs. Within the group of students completing the RN training, 20 additional students will move on to complete their bachelor s degree in nursing and an additional 10 students will move from a bachelor s to a master s degree in nursing. This is in response to the need for more nursing education faculty in rural Minnesota. The graduates with a bachelor s or master s in nursing will help to support the additional RN education sites that will be developed as a result of the project. The grade point average for the students is approximately 3.5 and the student drop-out rate is low only about seven percent. The first full group of students will graduate in August 2004, and two students have already completed their bachelor s and master s in nursing. What s Next? An essential component to this program is building in Bridging Distances in Healthcare at Chippewa County-Montevideo Hospital sustainability. With the grant ending in 2005, the next step will be to work with the sites and the partnerships to help ensure that the program continues. Carol and staff members have begun to address this through focus groups with WorkForce Centers, communities, students, healthcare and educational partners. Through the groups, Carol hopes to learn what is and isn t working and to develop new funding sources to meet the needs. Another next step is the development of the Health Career Preparatory Academies. Through the Bridging Distances in Healthcare program, it was discovered that there were many applicants who would make great health care workers, but lacked the preparatory skills necessary to enter the program. Through grants from the Minnesota Department of Employment and Economic Development and the McKnight Foundation, the Bridging Distances in Healthcare program is developing Health Career Preparatory Academies throughout the state. The mission of the Academies will be to increase the capacity of rural Minnesota residents to enter and move up the health care career ladder. The project is designed for rural residents who are interested in a health care career, but need some help to prepare to enter into health care education or employment. The first academies are expected to start this summer. On a Final Note The Bridging Distances in Healthcare program is an excellent example of a successful collaboration with a single goal in mind - to increase the RN workforce in rural Minnesota. Carol emphasizes the importance of the partnerships created to put this project in motion. She explains, It has been such a wonderful project. It has been so exciting to see everyone come together and work on this and know that it is really filling a need. Hopefully we can continue to meet that need. She adds that the true successes are the sites, the students and the partnerships. None of this would be possible without their collaboration. The Southwest Minnesota Private Industry Council, Inc., which administers the grant, is a private, non-profit organization, providing job training, assessments, and various employment services to residents and businesses across 14 counties of Southwestern Minnesota. The 14 counties include Big Stone, Chippewa, Cottonwood, Jackson, Lac qui Parle, Lincoln, Lyon, Murray, Nobles, Pipestone, Redwood, Rock, Swift, and Yellow Medicine. Photo courtesy of Montevideo American-News 5

6 Toward a Healthy Future for Rural Minnesota By Estelle Brouwer In the year 2030, will rural Minnesotans have access to high quality health care in their communities? What will be the most pressing health care needs in rural communities in 2030? What will be the most serious health problems? What will be the greatest health and health care successes or achievements? DIRECTOR S CORNER While we may not be able to answer any of these questions with precision from our early- 21 st -century vantage point, there are hints of what is to come in today s demographics (we are getting older and more diverse) and in the architecture of our current health care system (messy). There are also steps we can take now to increase the odds that the answer to the first question above will be a resounding Yes! One major step in that direction taken together over the past several months by the Rural Health Advisory Committee, the Medicare Rural Hospital Flexibility Advisory Committee, the Office of Rural Health and Primary Care, and a number of other groups and individuals across the state was to develop a new Rural Health Plan for the state of Minnesota. Developing a state rural health plan is a federal requirement for participation in the Medicare Rural Hospital Flexibility Program (otherwise known as the Flex Program, or the program that brought you Critical Access Hospitals). In Minnesota, we took this requirement seriously and worked hard to create a plan that we hope can be understood and used by a broad range of groups and organizations in our state. The four over-arching goals of Minnesota s new Rural Health Plan are: Assure a strong, integrated rural health care system. Ensure a sound rural professional health care workforce. Promote effective health care networking and community collaboration. Foster increased capacity and resources to assure rural health care access and quality. We invite you to log on to our Web site and peruse the plan. You ll find it at Please think creatively about how you or your organization can use the plan whether that be the maps of rural Minnesota s demographics, economics, and health professional shortages found in the Rural Health Landscape section; the profiles of various rural health services, including hospitals, pharmacies, nursing homes, and hospice programs, or the Rural Health Goals and Objectives. Let us know what you think of what you see; that will help us create a better plan next time around. We know the challenges involved in achieving the Rural Health Plan will be many there will always be health care challenges needing attention in rural Minnesota. But the good news is that rural Minnesota also has plenty of what it takes to meet those challenges good heads, good hearts and a solid commitment to good health. 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 Snapshot of Rural Hospice Care (continued from page 3) Coverage of Hospice Services Hospice services are covered under Medicare, Medicaid, MinnesotaCare, and most private insurance providers. Over 80 percent of all hospice care is provided under the Hospice Medicare Benefit. Reimbursement of services is based on a per diem payment that includes the cost of the professional staff, durable medical equipment (such as hospital beds and oxygen) and all medications and therapies related to the treatment of the terminal illness. Under the Medicare Benefit, hospice programs are reimbursed for four different levels of care: routine, inpatient, respite, and continuous care. As is the case for rural hospitals, the Medicare Hospice reimbursement rates are less for rural areas than for urban Daily Medicare Hospice Reimbursement Rates* Type of Reimbursement Rural Urban Routine Home Care $ $ Inpatient $ $ Respite $ $ Continuous Care $ $ *Hospice Minnesota. The rates above are the most common for rural and urban areas but rates can vary depending on the Metropolitan Statistical Area (MSA). Challenges Not all areas of rural Minnesota have hospice programs available. For those that do, the provision of hospice care presents a number of unique challenges, such as the lack of informal caregivers. As a rural public health nurse noted, In our region, many of the children have moved away. When someone is old and frail, they have no one to take care of them. Hospice care is based on the premise that individuals who want to remain in their homes have either family or informal caregivers nearby to help. However, in many cases the adult children or other family members of these patients have moved away and are unable to offer daily care. The 2002 report, Use of Hospice Benefit by Rural Medicare Beneficiaries, by the University of Minnesota s Rural Health Research Center suggests that financial hardship is another challenge. Under the Hospice Medicare Benefit, programs must provide an array of services under the per diem mechanism mentioned previously. A low volume of patients creates financial hardships in spreading the risk of high-cost patients. For example, a rural hospice program will receive only $ a day for all services even if it is paying several thousand dollars to provide palliative radiation or expensive pain medications. The same report also revealed that increased expenses due to greater travel, more expensive telecommunications systems, and inability to cost share through purchasing cooperatives is also a challenge. Reimbursement from Medicare does not take into consideration some of the higher costs of providing services in a rural community. The current health care workforce shortage also presents an enormous challenge for rural areas because they face an increasing shortage of nurses. Hospice licensure requires specially trained interdisciplinary professional staff and 24 hour/seven days a week coverage. Small hospice programs often have difficulty finding qualified personnel to share the 24/7 burden. What Can Be Done Hospice services are an important, but often unnoticed, component of health care services in a community. The comfort of being at home and receiving care at home can go a long way to help ease the pain and anxiety of a life-limiting illness for both the patient and the family. In rural areas, the increase in the aging population and the lack of family nearby to provide care make the availability of hospice services essential. The Minnesota Commission on End of Life Care in 2002 issued four recommendations regarding improving care and strengthening hospice in rural Minnesota: Create education and development opportunities to strengthen the rural hospice infrastructure. Fund the development of hospice programs in unserved areas. Educate the public on end of life services through locally based initiatives. Educate physicians, nurses, and other health care personnel in hospice and palliative medicine. All Rural Health Profiles are available to download from the Office of Rural Health and Primary Care Web site at Angie Sechler is a health services/workforce research analyst for the Office of Rural Health and Primary Care and the author of the rural health profiles. She can be reached at (651) or angie.sechler.state.mn.us Stefani Kloiber is the editor of this publication, and can be reached at (651) or stefani.kloiber@state.mn.us 7

8 To learn more about the Office of Rural Health & Primary Care programs, visit our Web site: orh_home.htm Steve Hansberry (continued from page 2) What one or two changes do you think would make the most difference for rural health? SH: Find a way to increase the presence of decision makers in underserved areas. Have corporate CEOs spend a week at their more remote facilities; don t just visit for a day or two. Demonstrate a top-down commitment to awareness of and interest in meeting rural needs. Change in mindset, as opposed to change in systems. Introduce a Minnesota geography component into new employee orientation sessions. Show that a mindset that rural people are different is as damaging as deciding any other culture is different. The Rural Health Advisory Committee advises the Commissioner of Health and other state agencies on rural health issues, provides a systematic and cohesive approach toward rural health issues, and encourages cooperation among rural communities and among providers. Meetings are regularly held 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 Tamie Rogers at /tamie.rogers@state.mn.us 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. 121 East Seventh Place, Suite 460 P.O. Box Saint Paul, Minnesota First Class U.S. Postage PAID Permit No. 171 St. Paul, MN