A Lot to Learn from the Last Frontier

Joe Wivoda, Chief Information Officer

Rural health care faces many challenges, such as workforce attraction and retention, geographic constraints, and the high cost of HIT.  These problems are magnified in Alaska.  With a population of less than 750,000 (47th in the US) and an average density of 1.2 people per square mile, it becomes clear why The Last Frontier presents so many challenges to health care (and I didn't even mention the winter weather).  As part of our Technical Assistance to Rural Health HIT Network Development grantees I was privileged to spend a few days in Alaska getting more acquainted with them and how they overcome some of the challenges to providing healthcare in this beautiful state.

With so much land area and low population density it is difficult to provide traditional access to health care.  Some clinics are hundreds of miles from a hospital, and with Alaska's unpredictable weather flying can be difficult.  The Alaska Native Tribal Health Consortium (ANTHC) has created a vast telemedicine network to support rural clinics.  During my visit with Richard Hall at ANTHC, I learned that they have been doing amazing work to bring primary care services to remote areas using HIT, while coordinating the efforts of several organizations to make it happen.

One of the organizations that ANTHC partners with is the Tanana Chiefs Conference.  I was able to spend the day with Jim Williams at Tanana Chiefs and visited the clinic in Nenana.  At the clinic I talked with a Community Health Aid/Practitioner (CHAP) that provides care to several patients each day.  The CHAP program was designed to overcome workforce shortages that exist in small villages across Alaska and consists of 16 weeks of training plus preceptorship and practicum.  I was impressed with the amount of telemedicine and telepharmacy that was in use at the clinic!

Alaska has a number of critical access hospitals that are located far from tertiary facilities.  The Alaska State Hospital and Nursing Home Association (ASHNHA) has formed a network of some of these smaller hospitals to "support the use of HIT as a tool to improve the quality and cost efficiency".  Like many other rural hospitals, these facilities struggle with finding HIT talent, and most of them have one IT person on staff with limited access to outside resources.  I spent a day with Jeannie Monk and spoke with the member CFOs about Meaningful Use and the financial incentives.  These hospitals are working closely with each other to find ways to share expertise and best practices, even though they are hundreds of miles apart in many cases.

Alaska is a vast, beautiful place.  The geography and size, along with a small population and cold winters, create significant challenges to providing health care to the native and non-native communities.  All three of the networks that I visited in June are doing amazing work to overcome these challenges.  There is much we can all learn from them.

The Healthcare Pyramid- a view from the apex and the base

The Apex of Care

I am a successful physician at the Barrow Neurological Institute (BNI), the U.S largest hospital for neurological disease.  As a senior  radiologist, I have a good idea who are the best doctors and how to get things done at my hospital quickly.  Every year we take care of thousands of patients with brain tumors, epilepsy and spinal cord injuries to name a few.  There is process to care for these patients referred to as best practice.  We hope to optimize their outcome while they are in our care.  I am also the son of a quadriplegic, Sheila Pitt.  Danny Sands, a friend, thought it might be of general interest if I gave some perspective on her story, and my observations since her accident.

Here is some background on my mother.  She has always been a strong, independent person.  Growing up she successfully competed in women’s gymnastics.  She wanted to go into art, but that was not an acceptable career for a good Jewish girl in the 50’s.  Her father suggested she was better suited to be a teacher.  After marrying, she pursued a fairly traditional life as a spouse and mother.

After we moved to Arizona in the early seventies she developed a passion for horses.  She was an Equestrian.  She began riding in her 30’s and continued in the sport for over 35 years reaching a high level of competition.

In her forties she also went back and pursued her dream of becoming an artist.  She got her MFA at the University of Arizona.  She received tenure in her late forties and was made head of the printmaking department at the University of Arizona.  Her work has been shown at national and international shows.  She was also asked to advise the undergraduate studies program for the department, managing over 750 undergraduates.  She was elected to the Faculty Senate.  She is no wall flower.

The day of her accident was a bit bizarre.  I was participating in a new building dedication. Most of the neurosurgery department was in attendance.  Late Saturday morning, I got a call from my sister.  She wanted to tell me mom had an accident.  She had fallen from her horse and the paramedics were there.  I didn’t think much of it, but was able to reach another friend at the scene who put me through to the paramedics.  They were taking her by ambulance the hospital.  She was complete from the neck down.  I collapsed in front of 50 of my peers.

“Complete” is a term in neurosurgical terminology meaning the patient isn’t moving below a certain level- neck, chest ,waist- and really isn’t supposed to move ever again- they are complete.

There were a series of tests and stabilizing care given in Tucson.  Within 8 hours I had her helicoptered to my hospital 100 miles north. By midnight she was in the operating room with one of my close friends and best spine surgeons in the country, Dr. Nick Theodore.  I honestly believe my mother’s functional status would not be as high without this prompt intervention.

As a senior physician at the BNI, I was able to guide much of my mother’s course through the ICU, step down and rehabilitation facility.  Another friend, Dr Rick Su, prevented her from requiring a tracheostomy by patiently monitoring her respiratory status at a critical time.  This procedure involving a breathing tube inserted into her neck, would have meant several months of additional recovery.

When she arrived at the rehab floor, Mom had minimal movement in one shoulder, but could breathe on her own.  She began a course of aggressive therapy.  Therapists  worked on her limited strength and function most days.

Occupational therapy was perhaps one disappointment.  We wanted to have Mom trained to use voice recognition on the computer.  This would enable her to read and respond to email, in essence, get her closer to reintegration with activities of daily living.  We were told they did not have the staff to train her on the computer and would only offer skills for her to type the keys with a pencil.  We arranged for a local high school to volunteer.   Students would offer computer assistance with the software program in exchange for volunteer hours at the facility with my mother and other patients having similar injuries who asked for help.  It would be a win-win.  This opportunity was passively refused by the hospital occupational therapy supervisor.

She spent several months there with some gains.  She was able to push up her glasses with one arm.  However, after a while, she wanted to go back to Tucson.  Her husband and friends were there.  Phoenix was not her home.

The Base

As a quadriplegic the only place in Tucson meeting her medical requirements and that her insurance would pay for was the county nursing home.  This is a clean but rather Spartan facility.  The staff was nice but limited, and the physician rarely seen.   She was placed in a room with roommate.  This woman had been in a chronic vegetative state (most would call it brain dead) for 15 years with no chance of recovery.  All Mom could hear was the in and out of the breathing machine.  Although she said this was a plus (she didn’t have to be bothered by idle conversation), I know this wore on her.

It felt like a dream to me.  She showed tremendous strength.   One minute she was a professor in front of students.  A horse stumbles and she is unable to move or reach a call button.  The person next to her was one in name only.  After another month, custom changes to her home were completed.  She left the nursing home and remains at home today.  She has 2 care providers on any given day.

Whereas I could monitor and optimize my mother’s care at the BNI, in her new surroundings I am largely reduced to a family member.  Certainly other care providers make themselves available to me.  However, largely her care is reduced to the base – self driven and self monitored with no real “captain” of her ship.  She has a multitude of providers – a urologist, a neurologist, a physiatrist.  Each deals with individual issues they are comfortable handling.  There is no individual overseeing the care process.  This is largely the responsibility of my mother and her husband.  Like most people with chronic illness, they have discovered their own solutions, ways to solve problems they encounter with drugs, services and insurers.  She has a marker board for her list of medications and appointments.  Although we all have financial worries, hers seem somewhat more acute and ever present.

After much cajoling, she returned to work last September.  She teaches a full class at the University of Arizona on printmaking (see picture below).  She asked for and received a student helper in the classroom and one to assist her in making art in her studio from the university’s disabilities resource center.  She has had to be creative in the process.  She participates in the process but needs to be collaborative.  I have asked her to write a piece on how the process of art has changed for her – both as an able bodied person and now as one with disability.  She is thinking about it.

Her health remains good.  She deals with occasional spells related to body temperature regulation and hypotension, but overall has not had common complications of many quadriplegics.

I would like to make one final comment regarding quadriplegia. The word “complete” is a misleading term that should be abandoned. On hearing this term, many of the nurses we met at the Barrow gave up on my mother assuming she would never get any further recovery.  Patients with cord injuries are not complete or incomplete.  They are transected (the cord has been cut) or they have an injured but intact cord remaining.  There is no way to know at the time of an acute event whether the cord is cut or simply injured without advanced imaging.  For those that are not transected, like my mother, every day is a chance to get a new skill, to recover lost functionality.  Hope is a powerful motivator.

Replacing the shoebox and other issues for the future

Along with my clinical responsibilities, I do research related to the nexus between humans and computers, asking how data and process can be captured to improve care.   I have a particular interest in tools enabling patients to participate in the process of wellness.  I find it more than a little ironic that my mother continues to use paper and a marker board to manage her care. My mother’s experience reflects some of the basic problems with the current approach to healthcare delivery.  In particular, her care was optimized during the acute phase, but is relatively disorganized now that she is coping with a chronic disability.  Further, patient and family efforts to optimize care are not supported by participatory tools.

The current administration is spending billions of dollars to improve the healthcare infrastructure.  There is an expectation that within 5 years every medical practice, from large hospitals to small clinics will be using some form of electronic record.  This should improve care and hopefully reduce costs.  However, in many ways, this is more of the same, an effort focused on the provider, the apex.

Patients and their families need a similar effort that is directed at helping them care for themselves.   Currently, a shoe box is the best we’ve got.  This “box,” full of notes from previous hospitalizations and clinic visits along with CD’s of images, is all too common.  The patient comes to clinic, hands over the box and expects the provider to make sense of the records and arrive at a plan moving forward.  With most appointments no more than 30 minutes, this is not going to happen.  There are a number of companies offering to digitize records.  This is not the answer.  Providers need relevant summaries, dashboards, of how the patient has been doing.

There have been some recent signs of change.  In 2006 the FDA suggested “observations of daily living” (ODL) become part of new drug and device evaluations.  It makes sense to ask the consumer (and not just the researcher) how they are doing with products.  The private sector has also made efforts.  Microsoft, Google, and Relay Health have all introduced solutions that capture information about and from patients.  However, these are not simple to use or significantly relevant to merit sustained traction.

Solutions need to be transparent.  Many people with chronic illness are from a generation that is not comfortable with the internet.  Even cell phones are a bit foreign.  My father-in-law often uses his cell phone as a one way device.  He makes calls and then turns it off to save the battery.  My mother is willing to participate, but the process has to meet her workflow.  My personal belief is that the TV will be the final common device.  Everyone can work a remote.  It will work with other devices in the home through Bluetooth.  It will remind us when to take pills.  It will allow us to meet with our doctor while at home.

The cable box is not a one way device.  I Skype with my mother, but she has to turn on the computer, start the application, turn on the camera.  She should meet me and others on her healthcare station.  Voice recognition software also needs to improve.  It is designed for business, but there are other large markets.  The software needs to be hands free.  She uses it, but not without assistance.  Later this year she and I will be experimenting with a new box from Cisco that should get us closer to this vision.

Solutions need to consider the patient’s ecosystem rather than their illness.  My mother and I don’t care about quadriplegia, but rather living with quadriplegia – how she copes with the various difficulties in her effort towards wellness.  Most approaches do not consider ways to leverage the family and related opportunities or local resources to stay well.

I was told a story by a father of a juvenile diabetic.  His daughter had slipped into coma several times in the past.  Out of concern, he found himself calling her once a week at odd hours to check on her.  The daughter viewed these calls as an intrusion on her independence.  A solution that called out to the father, but only when there was something wrong, would have provided a margin of safety for the daughter while addressing her family’s concerns.

Similarly, advanced electronic platforms message or alert a nurse if the patient’s weight, blood pressure or sugar is abnormal.  Why are family members not included in the messaging layer?  Families are cheap and the most vested in the patient’s well being.

My mother has to find solutions to problems on her own – where to find goods and services, how to deal with common problems.  Google Maps can find and rate a restaurant or the nearest gas station.  Why not use local based services for physicians, wheel chairs, etc.? I raised this issue with Google Health two years ago…nothing yet.

The patient is the largest untapped resource in the healthcare debate.  After all, they are the most vested party, the one with the illness.  Providers are merely a part of the process along the way.


If you ever feel like life has overwhelmed you please visit my mother's website
sheilapitt.com

Health Reform, the Supreme Court and Networks—Finding Comfort in the Chaos

Sally Trnka, Senior Program Coordinator

(This content was originally published in Cooperative Connections Newsletter)

Raise your hand if you are exhausted from the never ending news coverage, heated campaign promises, and scores of misinformation being broadcast pertaining to health care reform.  (It’s okay…go ahead!)  The complexities and confusion surrounding the recent Supreme Court decision aren’t lost on anyone and the confusion is compounded by election-year rhetoric and posturing that dismantles communication and banishes progress.  Since we’re not running for office, we’ll give it to you direct—and with a sprinkling of enthusiasm for the role of rural health networks in the changing healthcare landscape.  

The 5-4 Supreme Court ruling upholding the Affordable Care Act determined that the individual mandate, the most controversial part of the ACA, was a valid exercise in Congress’s power to tax (although it is not a valid exercise of the Commerce Clause, which was the clause that many opponents were expecting would deem the mandate unconstitutional).  In addition to upholding the policies and provisions that are scheduled to take effect in the coming years, the ruling solidified that the money, payment modifications and workforce modifications that have already gone into effect will not be rescinded. 

Okay, so that much you know, but what does all of this mean for rural?  There are a variety of rural-specific provisions within the ACA that will move forward as scheduled because of the ruling.  A compressive list of the rural-relevant provisions can be found on the website of the National Rural Health Association (NRHA).  Because it’s a long list, we’ll walk through a few of them, and why they are critical to the success of rural health care facilities. 

Approximately 25% of the country’s population resides in rural areas however, there are more rural Americans who are uninsured and underinsured than their urban counterparts.[1] The ACA contains provisions for the guaranteed issue and coverage renewability, along with the prohibition of exclusions based on pre-existing conditions.  This will help to ensure that more citizens are covered.  Increased coverage, however, does not equal access and workforce shortages will continue to be felt acutely in rural communities.  Currently, less than 10% of physicians serve the country’s rural population and with increased insurance coverage, the strain felt by providers will be even greater.  Included in the ACA are investments in the National Health Service Corps which will assist medical students with scholarships and loan repayment programs should they decide to practice in rural communities.  The ACA also designates critical access hospitals, for the first time, eligible sites for Corps assisted physicians.  The ACA also calls for increased funding for Area Health Education Center’s (AHEC) to improve the pipeline of potential future health care leaders, although the House of Representatives recently voted AHEC out of the running for funding for next year.  (Hopefully the Senate will reinstate funding.)  The improvement in the rural healthcare workforce will be vital to support the higher rates of chronic disease exhibited in rural communities[2].  With an increased focus on primary care and prevention, the ACA incentivizes patients to seek care before their condition becomes chronic or requires treatment from a specialist. 

Networks will play a crucial role in all of the health reform models as rural providers and hospitals become valuable players in both accountable care organization (ACO) and Medical Home demonstration projects.  The development and participation in ACO and the Medical Home concept all require collaboration, staff and resource sharing, collective innovation, and willingness to challenge the status quo.  Increasingly, rural hospitals will have to prepare themselves for a challenging future, based on value, quality transparency, and physician-hospital partnerships while maintaining a successful business model in the current system.  It’s is somewhat like navigating two canoes downstream with a leg in each canoe…it could end up being very painful!

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[1] Lenardson, J., Ziller, E., Coburn, A. & Anderson, N. Profile of Rural Health Insurance Coverage: A Chartbook. Rural Health Research and Policy Centers. June 2009. 

[2] Glasgow, N., Johnson, N., Morton, L. Critical Issues in Rural Health. Wiley-Blackwell. May 2004. 

A special thank you to the National Rural Health Association for their breakdown of the rural-relevant provisions in the ACA. 

Telemedicine- Are We Hammering the Right Nails?

As early adopters go, I am on the right of the curve, not quite a geek, but close.  I tend to buy technology based on impulse rather than value.   Not surprisingly, I am a telemedicine supporter.  I believe in the promise of better care through improved access. But, I have a confession.  To date, it appears my late adopter friends have been more right than wrong.  Expensive projects with limited value, telemedicine's promise of remains largely unfulfilled.  For the technology to reach a tipping point, a routine tool rather than a novelty, several things have to change.  The technology will continue to improve, but perhaps importantly, the telemedicine proponents should change their message and learn to talk the talk of the late adopters.

I just got a grant- now what?

        In part,  telemedicine's failures start with funding.  As with many disruptive innovations, early telemedicine required big thinking and big budgets.  The technology was first developed by the military to treat wounded service man and woman remotely. A laudable goal, but the not easily transferred to the private sector.   After the military, academic centers became the primary owners.  Telemedicine fit well with "centers of excellence" looking to provide care at a distance.  Funding came through grants, rather than sustainable business models.  Unfortunately, many (if not most) of the projects live and die by grant support.  Typical programs do not generate enough clinical revenue to stand on their own.  Clinical providers often engage out of a sense of mission to care for the underserved.  However, attempts efforts to expand efforts to broader provider communities often meet with limited success.  Without revenue, altruism goes only so far.

Come to my beautiful room

        Historically telemedicine has been about the best possible image rather than good enough for a particular use case.  Traditional telemedicine is a room with expensive equipment connected to another (expensive) room.  Each end point requires capital and operational budget.  Almost as importantly, these special rooms require care and feeding.  Rural partners struggle justify the expense as well as retaining qualified technical support staff. Once deployed, these rooms are by definition fixed end points often away from the clinical work spaces.  Care providers must break away to use the room.  Once there, the traditional workflow (front desk, nurse, chart, see the patient) is not incorporated.  As a result, the providers often views this activity as a necessary evil, part of their clinical responsibilities, rather than part of their clinic.

Can't I just use Skype for that?

        Well, no.  Although Skype is widely available (and free), it does not support the regulations related to HiTech, FDA and HIPAA for medical care in the cloud.  However, supported cloud based technology has evolved to leverage common browser based devices (iPhones, android, iPad, laptops) along with public internet (encryption without VPNs).  Workflow, optimizing the expensive care provider expense, can be incorporated, enabling a sustainable business cases.

Learning to talk to laggards

        Fortunately, early adopters (EA) are typically not put in charge of budgets.  Responsible adults requiring a business plan and a return on investment write the checks for most healthcare organizations.  Although frustrating for the EA, the typical CXO has a responsibility to keep the hospital lights on.  Referral (eg...remote stroke care) often does not make business sense, or if it does, the data is convoluted with a long list of assumptions for profitability.  Further, referral requires a number of partners to come together and participate in telemedicine.  This includes the outside facility (who often views the effort with some level of skepticism. after all, they are often asked to pay for infrastructure to lose (via transfer) potential clinical revenue).   The tertiary facility has to pay for infrastructure and align the clinical staff to provide services for another external coverage activity. Finally, the clinical staff on both ends have to be paid and trained to participate in this foreign activity.  All in all, this is not an attractive business case.

        Referral, the basis for point to point telehealth, is a nice to have for most hospital administrators, but not a have to have.  It is weighed against other business opportunities for revenue generation.  Typically at most hospitals there is no director of telemedicine getting up every day looking to build business around referral.  At best, it is one of a number of responsibilities for an over taxed business development person.  

        However, ubiquitous telemedicine  (common devices, common networks) allows the conversation to become a must have for the CXO.  At every hospital, there is at least one person, if not a team, who are focused on throughput, length of stay (LOS), and transition care.  These topics familiar administrators.  These are concepts that fit on spread sheets and are carefully measured on a weekly, if not daily basis.  A tool that addresses these issues can be supported.

        As we move from point to point telemedicine to ubiquitous collaborative care, it is incumbent on the EA to speak in the administrator's language, to lead with the business case rather  than the technology, and to address problems that are the focus of most administrators.  When the telehealth community begins to hammer at these central issues (LOS, transition care), telemedicine will reach a tipping point.  Opportunities for access and referral will be a natural extension of the existing infrastructure

        Frankly, I have abandoned the term telemedicine whenever possible.  There is too much baggage associated with the image of big, clunky devices.  I prefer to talk about enabling medical collaboration.  Ultimately, both EA and laggards need to be included in the vision of better care via collaboration, removing the tele from telemedicine. 

What do you think is more likely to help you or your family- a limited problem like managing stroke remotely, or a way to bring the right person at the right time to the bedside, for whatever ails you?

Medicare Meaningful Use Incentives: A Confusing Minefield for Critical Access

Joe Wivoda, Chief Information Officer

Critical access hospitals (CAH) need to be aware of what is eligible for Medicare Meaningful Use incentives, and it can be confusing. Sure, we need to purchase a certified electronic health records (EHR), but the incentives for Medicare specify that CAHs can get a portion of the "reasonable costs" of acquiring certified technology. There are several catches (just read the FAQ 10163 and you will see what I mean). Here are some very important considerations when signing a contract for an EHR, whether from a vendor or a larger hospital system offering a great deal on their system.

A Right To Use Agreement is the most common contract for an EHR, at least historically. This type of agreement is similar to what you get when you purchase office software, such as from Microsoft. Surprisingly, you do not technically "own" the software in this case (or any that I will talk about). You merely have a right to use the software. These agreements generally also state that you lose that right to use the software if you quit paying the annual support and maintenance fees. One of the secrets in the software industry (not just health care) is that vendors make money on the maintenance agreement, not necessarily the licensing agreement. This is why vendors will usually negotiate aggressively on the licensing fee, but not on the maintenance. Even though you don't own the software, the right to use licensing agreement fees (not the maintenance fees - those are non-capital) are usually a capital expense and thus eligible for CAH Meaningful Use incentives from Medicare.

If you choose to lease the software over a period of time, then things get a little more tricky. Thankfully, the Centers for Medicare and Medicaid Services (CMS) recently clarified what is a qualified expense in FAQ 10722. Leasing can make sense if the hospital can not afford the licensing fees up front. Many vendors offer leasing packages as an option when that final contract is delivered. However, an Operating Lease is not depreciable, and therefore not eligible for Meaningful Use incentives. Capital Leases are eligible expenses, and it is important that you understand the difference. One of the four following conditions must be met for the purchase to be a capital lease:

• The lease transfers title of the facilities or equipment to the lessee during the lease term,
• The lease contains a bargain purchase option,
• The lease term is 75 percent or more of the useful life of the facilities or equipment. This provision is not applicable if the lease begins in the last 25 percent of the useful life of the facilities or equipment, or
• The present value of the minimum lease payments (that is, payments to be made during the lease term, including bargain purchase option, guaranteed residual value, or penalties for failure to renew) equal 90 percent or more of the fair market value of the leased property. This provision is not applicable if the lease begins in the last 25 percent of the useful life of the facilities or equipment. The present value is computed using the lessee's incremental borrowing rate, unless the interest rate implicit in the lease is known and is less than the lessee's incremental borrowing rate, in which case, the interest rate implicit in the lease is used.

I am not an accountant. Or a CPA. Or a CFO. Or a Medicare Administrative Contractor (MAC). I suggest you talk to one of them to be certain!

"Cloud Computing" is a trend in Information Technology (I hate the term "cloud computing" by the way - it sounds too magical). Software as a Service (SaaS) is another term for this type of software delivery. Basically, the equipment is housed somewhere besides your facility, in a secured data center. This type of "software delivery" is becoming more common now that high-speed Internet is more readily available. Is this type of agreement eligible for incentive dollars? Think about it: You don't own the hardware, or the software, and you usually pay a monthly fee to use it. That is a clear operating expense, not depreciable, and not eligible for Meaningful Use incentives under the Medicare rules for CAHs. These agreements often make sense: They are a reasonable expense, the implementation costs are usually low or nonexistent (since there is little customization allowed), the hospital does not need to worry about backups or having a Unix geek (like me) on staff, etc. These reasons may offset the value of the incentives, actually! Also, some vendors are structuring the agreements so that you CAN receive some incentives. If you are considering entering into this kind of agreement, ask questions about whether you can still receive Medicare incentives. Also ask about security, reliability, support, and a million other things that should be in another post...

Finally, all of these contract concerns apply when you are entering into an agreement with a larger hospital system. The key is whether or not the expenses are depreciable, and as a CIO, that is a term that I struggle to understand. Feel free to look at 42 CFR 413, or the Federal Accounting Standards Board (FASB) rules. For me, it's easier to understand the Theory of Special Relativity, but thanks to the CMS Frequently Asked Questions site I think I am starting to get it...

Minnesota Action Coalition: Support for the new health care delivery models

Sally Buck, Associate Director

Last fall I was asked to join the Minnesota Action Coalition and while the title wasn’t specific to the type of action, I gathered that it would be focused on nursing as the recommendation came from one of The Center’s Board Officers the Dean of Nursing at The College of St. Scholastica. As I reviewed the materials, I discovered that the Action Coalition was developed to effect long-term changes to meet the Institute of Medicine (IOM) 2010 Recommendations on the Future of Nursing. The goal of the report is to “transform the nursing field to prepare nurses to lead change and advance health for all Americans.” The Action Coalition in Minnesota is just one of forty-eight nationwide and supported by the Robert Wood Johnson Foundation (RWJF) in cooperation with the American Association of Retired Persons (AARP) and the AARP Foundation. This partnership of a leading health foundation and AARP was surprising to me at first; however, I quickly realized, it was highly strategic union. The AARP brought strong technical assistance in advocacy and policy development to the state coalitions and RWJF is supporting the technical assistance instead of providing grant funds to the Action Coalitions.

The Future of Nursing Campaign for Action, which supports the Action Coalitions, is designed to transform the nation’s health care system so that all Americans have access to high quality, patient centered care where they live, work, learn and play across the lifespan. The Action Coalitions have committed to develop and implement specific strategies to address the IOM recommendations. These are not short term efforts such as increasing nursing class size through scholarships. The strategies need to address: scope of practice; higher levels of education and academic progression; leadership in the redesign of the healthcare system; and, workforce planning and policy making through data and information. Any of these areas alone would entail a challenge to states let alone tackling all four through curriculum changes, program development, licensing issues, technology and communication. Therefore the Coalition representatives are diverse and include nursing education (community college, private college and university based programs), the hospital association, board of nursing, aging services association, and rural health.

This initiative is timely with the movement towards new health care delivery models within health care reform such as health care homes and accountable care organizations. AARP and RWJF were wise to focus on nursing to impact change in health care. Nurses encompass the greatest number of health care professions certainly in acute, public and long term care settings and as such they are the face of health care to Americans. In rural communities, with workforce shortages and the small staff size, it is imperative that nurses are able to practice to the extent of their education, have access to nursing education, and be prepared for leadership. Health professionals in small rural health care facilities are largely focused on primary care and practice without a fleet of medical residents and specialized advanced practice nurses and physicians, yet they are caring for the oldest and therefore the sickest patients as well as those with barriers to access such as culture, income, transportation, or language. In addition, many hospitals are staffed with nurses who are prepared at the associate degree level. As urban hospitals add access to baccalaureate education, rural hospitals needs the same access.

From my perspective, our Minnesota Action Coalition, although committed to the strategies including enhanced curriculum to increase the proportion of baccalaureate prepared registered nurses, has stumbled over governance structure and decision making. This stems from a lack of communication and leadership issues. Gaining consensus among nursing leaders is no small feat between an academic health center, state universities, private colleges and community colleges.  In order to establish a unified message, we need to build trust, support ongoing and open communication and focus on the goals. This is imperative in order to establish a unified message and collaborate to impact nursing practice, leadership and education. 

After my initial hesitation to participate in the MN Action Coalition, I’m now excited about the opportunity and appreciative of the expertise and support provided by AARP and RWJF to advance the Future of Nursing: Campaign for Action.

Strength In Numbers

Tracy Morton, Program Manager II

Strength In Numbers, the theme of this year’s National Conference of State Flex Programs, was clearly illustrated this past week in moving and motivational messages. The conference, held in Bethesda, Maryland, brought together the 45 state grantees of the Medicare Rural Hospital Flexibility (Flex) Programs to share their stories and hear from national experts on transforming quality improvement, building financial and operational improvement and supporting health system development for the 1,329 critical access hospitals (CAHs) throughout the country. The impact of the National Flex Program goes beyond the 1,329 communities where the CAHs reside to the other rural communities captured in the CAH’s market share, to the millions of Americans that call rural home and to even their suburban and urban families and friends who count on, and expect, quality health care for their loved ones. The 45 State Flex Programs individually and nationally impact this expectation. Talk about Strength In Numbers.

High quality health care in our country is becoming an expectation, evidenced by national initiatives such as Partnerships for Patients and the Medicare Beneficiary Quality Improvement Project (MBQIP). The federal government is also trying to control the cost of health care provision, as well as the cost of the health care system, with the coupling of quality and access to care through accountable care organizations (ACOs). While the hospitals need to be thinking about process and reporting changes for quality improvement, care transitions and patient accountability, they also need to think about moving from a volume-based to a value-based payment system. As Eric Shell from Stroudwater Associates pointed out, “rural hospitals need to think about the Triple Aim being played out in the market place, even when the market place doesn’t realize this is occurring”. Well, if this isn’t daunting, then I’m not sure what is.

The “message” at the conference wasn’t negative; it was inspirational. It was Strength In Numbers. It was about coming together; not trying to do the work alone. It was about sharing resources, best practices and stories; about being a catalyst for change and a change agent; thinking strategically about the State Flex Programs and the National Flex Program. The conference was about setting priorities and maximizing the impact of each of the 45 State Flex Programs on the 1,329 CAHs and their rural communities and partners. Because at the end of the day, and at the end of the conference, it came down to doing the right thing; about providing quality, affordable and accessible health care to the rural residents of America.