Terry Hill, Executive Director

One method of acquiring and transferring knowledge used by The National Rural Health Resource Center (The Center) over the past decade has been holding national summit meetings on specific rural hospital topics. This method does not replace formal research, but instead is designed to supplement more scientific research and is usually translated into short white papers for national distribution and discussion.

This past June, The Center, with support from HRSA’s Office of Rural Health Policy, brought a small group of critical access hospital (CAH) financial experts and thought leaders together to address issues related to CAH financial performance. The meeting was prompted by the declining financial circumstances of many CAHs, as well as the new challenges presented by the Affordable Care Act.

Participants included accountants from the major accounting firms serving CAHs, rural CFOs and CEOs, researchers, state Flex program staff and federal officials. The participants did extensive pre-work and then engaged in a structured dialog designed to address the Summit goals. A white paper including the major Summit outcomes was developed and will soon be distributed nationally.

Summit participants agreed that most CAHs are not maximizing their reimbursement, due partially to the complexity of the rules and regulations and due partly to limited use of needed expertise.  CAHs often turn to consulting experts for help, but when negative bottom lines become common, many hospitals seem reluctant to pay for all that is needed. There are also questions as to which CAH financial measures are most important, and which financial consultations are most productive.

The Summit participants identified the following 10 measures as most important to maintaining the financial health of CAHs:

1.    Days in net accounts receivable

2.    Days in gross accounts receivable

3.    Days cash on hand

4.    Total margin

5.    Operating margin

6.    Debt service coverage ratio

7.    Salaries to net patient revenue

8.    Payer mix percentage

9.    Average age of plant

10. Long term debt to capitalization

The participants then identified the financial interventions that would have the most positive impact on the average CAH’s bottom line. These included:

·         Cost report review and strategy;

·         Strategic financial and operational assessments;

·         Revenue cycle management; and,

·         Physician practice management assessments.

The participants recommended ongoing financial education for hospital boards, mid-level managers and senior leaders. On site education was deemed to be optimal, however, there was considerable value seen in good webinar presentations that could be recorded, stored and used on-site with various shifts. Lean training was also recommended as a method of improving business processes as well as a good way of saving money.

The Summit participants concluded the meeting by noting that the American health care system is transitioning from a “Pay for Volume” system to a “Pay for Value” system. In the years ahead, CAHs will be challenged to maximize and document their value, as well as calculate where they fit into the new value-based reform models. In that regard, they will be somewhat like an intrepid explorer, going down treacherous river rapids, with one foot in one canoe (the old system), and the other foot in an accompanying canoe (the new system). At some point, they must cross over to put both feet into the new canoe, but the timing will be critical. Too early or too late a transition and they risk going under.

Honoring Veterans at End of Life

Kami Norland, Community Specialist

How can we best serve the unique end-of-life care needs of our veterans? Through my involvement with the Palliative Care Rural Initiative project in Veterans Integrated Service Network (VISN) 23 over the past year, I learned that one out of every four dying Americans is a veteran, yet 96 percent of veterans are cared for outside of the Veterans Affairs (VA) health care network, according to the National Hospice and Palliative Care Organization. This means that the majority of veterans are cared for by hospice and health care professionals in their hometown.

As health care providers, we work diligently to assess each patient as an individual and deliver high-quality, customized care. No time is more crucial to provide this level of customized service than hospice, where treatment is designed to relieve symptoms and provide comfort and support to individuals with life-limiting illnesses.

It has been pointed out time and again that when people reach the last chapter of their life journey, there is a natural tendency to reminisce, resolve issues, and reference previous experiences of emotional intensity—which, for veterans, includes their history in the military.

Both research and evidence-based practice have demonstrated that a person’s military history can exacerbate physical, psychological, social, and spiritual symptoms toward the end of life. The Department of Veterans Affairs notes, for example, that Vietnam veterans may still suffer from “trench foot,” a fungal infection of the feet from walking in wet conditions; that symptoms of posttraumatic stress disorder may surface; that social isolation and distrust of authority may develop (or redevelop) in veterans who have felt a lack of support in the adjustment from military to civilian life; and that spiritual questions may arise as individuals encounter death outside of the battlefield.

The VA also cites the following contributing factors that may influence a veteran’s behavior and responses to end-of-life issues:

·         Entry status: enlisted or drafted-  drafted veterans may experience higher levels of distrust of authority than veterans who enlisted.

·         Branch of service and rank- Each branch of service has its own distinct culture. Veterans do not always share their rank with friends and loved ones yet sometimes reactions to life events are better understood when this status is revealed. Regardless of rank, each veteran carries a responsibility for fellow soldiers although they cannot ensure their well-being and safe return.

·         Combat or noncombat experience- veterans who were directly exposed to the effects of combat may experience elevated levels of anxiety and posttraumatic stress disorder but noncombat veterans can experience these symptoms as well.

·         Type of war or time served- each war or conflict carried its own significant burdens which may be re-experienced by veterans at the end of their lives.

·         Prisoner of war experience- we cannot begin to imagine what our POW veterans have experienced physically, mentally, and emotionally.  At the end of life, these experiences may be the ones that color their memories.

For health care providers, being aware of an individual’s military history and the elements to which the veteran was exposed can assist in proper diagnosis and intervention. Establishing a process to inquire about an individual’s military history has proven successful for numerous health care providers. The VA, in collaboration with the National Hospice and Palliative Care Organization, has developed a simple Military History Checklist that reviews the above factors for each patient to enable providers to best serve Veterans’ unique health care needs. The Military History Checklist is available online at www.wehonorveterans.org and through numerous electronic health record platforms.

In addition, it is important to invite veterans approaching the end of life to tell their stories, to celebrate their accomplishments, and to express appreciation for their service to our county. Thank you veterans, for your service to our country. 

Contact Kami Norland for more information about how the National Rural Health Resource Center is involved in honoring veterans end-of-life care needs.

Health Care Provider Retention

Angie LaFlamme, Program Coordinator II

In September I attended the 17^th Annual National Rural Recruitment and Retention Network (3RNet) Conference in beautiful Tacoma, WA. This conference is always great for reconnecting with colleagues and friends to catch up, share stories and best practices as well as discuss and learn about all things recruitment and retention. The conference agenda was packed full of extremely knowledgeable speakers on a variety of topics including recruitment and retention, National Health Service Corps news, immigration updates and rural education to name a few.

One of the agenda items that really intrigued me was a presentation called Retrofitting Retention Resources by Sharon Vail, Executive Director of the Rimrock Health Alliance. She shared an effective tool for the retention of physicians in rural communities where each factor within the matrix was assigned a color, as well as a numeric value and was broken into 5 divisions: Geographic, Scope of Practice, Medical Support, Hospital/Clinic/Community Support and Future Opportunities. The assessments are not tied to performance reviews, but used to help physicians be as successful as possible. The Rimrock Health Alliance believes that knowing your strengths and challenges as a health care facility is extremely important and that the importance of a good retention plan will leave nothing to chance.

At The Center we recognize the importance of a good retention plan and believe it is vital in retaining providers and protecting that investment both from a business and community perspective. The estimated costs of replacing one primary care physician can result in a minimum of $20,000 to $30,000 in recruitment costs and a loss of $300,000 to $400,000 in annual gross billings plus additional expenses related to ancillary employment within the community.

Health care provider turnover is disruptive to health care delivery, continuity of care and patient loyalty within the community. Other negative effects such as low morale and decreased efficiency only add to the reasons to why it is so critical to have an effective provider retention plan aimed at decreasing turnover and preserving a stable health care provider workforce. Keep in mind that retention plans will only be successful if an organization and surrounding community are committed to it.

The Midwest Retention Toolkit is an excellent tool to help guide you in creating your own retention plan. It was created by The Center and the National Rural Recruitment and 3RNet under contracts with the Indiana State Department of Health; Minnesota Department of Health, Office of Rural Health and Primary Care; and Wisconsin Department of Health Services, Primary Care Office; and the Wisconsin Primary Health Care Association through funding from the National Health Service Corps.

This toolkit includes worksheets, sample surveys, agendas, and plans that may be utilized with all of these types of providers although many of the samples are based on physician retention. The tools ensure they are properly orientated to the practice, integrated into the community along with their family and recognized for their service and impact on local health care. The toolkit also features a national resource section with websites and contact information.

To access the Midwest Retention Toolkit and begin building your retention plan, log onto https://www.3rnet.org/resources.

 “Physician retention is more than keeping physicians from leaving the organization. It is about retaining the hearts and minds, commitment and loyalty of our physicians.” Kaiser-Permanente

EHRs and the Long Road to Quality Excellence

Terry Hill, Executive Director

(This content was originally published for the Texas Organization of Rural & Community Hospitals)

My mom often told me, “The road to hell is paved with good intentions.” Her words come to mind now, as I consider rural hospitals’ long, bumpy road to meaningful use of electronic health records (EHRs).  In the past several years, our National Rural Health Resource Center has worked with dozens of rural hospitals across the United States. Almost all have struggled to meet the challenging deadlines, with insufficient resources and inadequate understanding of how it’s all going to work. Rural hospitals started out in EHR adoption significantly behind their urban counterparts, and they continue to trail in the race to meaningful use and the associated financial incentives.

Many of the obstacles and breakdowns are beyond the control of individual hospitals. National legislation locked in some of the deadlines, incentives and processes, and federal agencies such as the Office of the National Coordinator (ONC) have good intentions, but limited understanding of rural hospital circumstances. We should all be used to this by now. Health policy makers have historically overlooked rural in most of their major plans and policies.

Instead of lamenting the unfairness of the circumstances, let’s look instead at what rural hospitals can control with EHR implementation. At the top of the list is the crafting an inspiring vision as to why all of this disruption is necessary. And, this must be developed and communicated by top leadership, and cannot be delegated to others. Ultimately, EHR implementation has to be about quality and patient safety, not technology. At its best, an EHR system can hardwire quality. Paper medical records have proven to be dangerous and inefficient, and are archaic holdovers from the twentieth century.  Almost all other industries have moved on to electronic records because they are more accurate and provide vastly superior information for decision making. Health care is not an exception; numerous studies have shown the benefits of EHRs, and their role in improving quality and safety is no longer in question.

After leadership develops the compelling EHR vision, it is necessary to plan the road from where the hospital is now, to where it wants to be. This strategic plan for EHR implementation must include improving clinical quality processes, providing education, and communicating to staff why this difficult change is eventually going to be worth the time and effort.  In short, IT HAS TO BE ABOUT QUALITY!  In most hospitals we’ve worked with, this key message is not adequately communicated. The road to meaningful use, to financial incentives or to some techie’s vision of nirvana, does not inspire the staff, nor does it enlist the physicians.

Determining the inspiring destination, charting the course and getting the right people on the bus does not mean that the road will be easy, but it will mean that arrival at the final destination will be worth the long trip, and you may enjoy yourself more along the way.  In this approach to EHR adoption, technology will be appropriately used as a tool and not as a destination. Improved patient care will be the big payoff, and staff and leadership will look back proudly at having survived the turmoil and making their local health care system safer and more efficient. With this approach my mom’s road to hell will turn out to be the road not taken.

Back to the Future- The New Black Bag, an iPad

In the early 60's, my father started in medicine making house calls.

He would carry his black bag from home to home.  It had all he needed to make a diagnosis and get the patient on the road to recovery.  Now, 50 years later, no one can lift this black bag.  It is too heavy with options. Improvements in care have meant more options, so much to know that no single person can have all the right answers.

Overall, Americans have benefited from medical advances.  We are living longer than in the 1960's.  But, it has also had the perverse effect of fragmentation.  Take the example of my mom, a quadriplegic.  

At times her care sounds more like a text on physiology.  There is someone for the lungs, the kidneys and the neurologic system.  Yet, no one is responsible for her.  In part, this is too much for one person, there is not speciality called "quadraplegia" and all that goes with it.  In part, this is how healthcare is reimburse- money is paid for problems, rather than wellness.

However, I see hope on the horizon.  Like Hermione's magical bag in the Harry Potter series, we can give our providers all that they need as they travel from house to house, or at least room to room.  Collaborative technologies can deliver the community, rather than strictly the provider, to the bedside.  In this world, the black bag is replaced by an iPad or other PDA.  The specialist is available for advice, supporting and reassuring the patient and local provider alike.  This is our future.  We need to learn to scale our healthcare ecosystem, to not rely on the best available locally but rather the the best available from anywhere in sustainable ways.  New economic incentives are accelerating these solutions.  Time to upgrade that old black bag, time to go back to the future.

Alan Pitt Health 2.0 - YouTube

A Gaping Hole in Achieving MU Beyond 2014

Joe Wivoda, Chief Information Officer

The new Stage 2 requirements for meaningful use have a significant focus on patient engagement and information exchange. There are also more requirements for physicians and others to use their electronic health records (EHRs) more completely (e.g. increased use of computerized provider order entry), but the requirements for information exchange and patient engagement represent a significant challenge, and exciting opportunity, for hospitals and clinics, both rural and urban. The requirement to have 5% of unique clinic patients (5% of hospital discharges) actively view their health information will take concerted communication and marketing efforts, but the electronic exchange of summaries of care at transitions will be the most difficult.

The reason this requirement will be the most difficult is because many of the players, such as long term care and home care, have no financial incentive to implement EHR technology that can accommodate electronic exchange. The rule states that 10% of transitions to a new care setting must have a care summary transmitted electronically. Consider a rural hospital as an example: Rural populations are often older than urban, and many care transitions are to home care or long term care (LTC). The numbers are difficult to find, but according to Examining Post Acute Care Relationships in an Integrated Hospital System (Feb. 2009, available from http://aspe.hhs.gov/health/reports/09/pacihs/report.shtml), 35.2% of Medicare patients were discharged to either long term care or home care. Considering that the majority of discharges are to the patient's home, long term care and home care represent the majority of discharges to other facilities.

Many long term care facilities have EHRs that are used for documenting care, but like hospitals and clinics, they vary in their capabilities and level of adoption. Most LTC EHRs are designed around payment requirements; documenting primarily what is required to get reimbursed by Medicare and Medicaid. Since meaningful use does not apply to LTC or home care, their EHRs are not focused on information exchange. Thus, we are faced with the requirement of exchanging information with facilities that have no financial incentive to implement expensive upgrades to their EHRs to accommodate the hospital's requirements so the hospital can get more money. That is a tough sell.

We know that this is the right thing to do for patient safety and efficiency. Hospitals should be looking at their referral patterns and talking with long term care facilities about the benefits of exchanging information electronically. Networks are perfectly positioned to facilitate these conversations. Know that it will take time to implement the technology required, both at the hospital and the LTC facility, so start planning now. Without partnering with LTC it will be nearly impossible to meet the information exchange requirement in Stage 2.

There Are Points for Speed

I am radiologist, an MD specializing in CT and MR interpretation. When I was training, I had a Professor who would say "there are no points for speed."    What he meant was, if you missed something, the lawyers didn't care how fast you read the case, just whether you got it right.  Unfortunately, he is wrong.  Speed matters in medicine, a lot.

Doctors are paid for speed.  The current reimbursement system pays us on how much we do, not necessarily how well we do it.  There are metrics related to outcomes and complications, but they tend to be relatively infrequent outliers and disconnected from the care and reimbursement process.  

In the case of radiology, there is an expectation of a certain number of cases/day by each physician.  A radiologist’s productivity posted and often related to bonus pay.  

ED physicians are paid on the number of patients seen per shift.  Doctors have learned to order tests first, and then see the patient second- it is faster.  THis is one of the reasons there has been a 5 fold increase in CT for emergency room patients over the last decade.  Imaging has largely replaced the physical exam  (‎www.emedmag.com/PDF/043070006.pdf).  This results in over utilization of expensive imaging studies and lab work for the patient and for the payer.  

With bundled payments, hospitals are on the hook for this over ordering .  Hospitals are paid a set fee for diagnostic code (stroke, pneumonia, etc..)  irrespective of the number of studies ordered by the doctors caring for the patient.  Ultimately, it may be cheaper for hospitals to incentivize their physicians to slow down and make the right decisions rather than simply order another test.

The medical legal system, thought to protect the patient from mistakes (due to speed) perversely accelerates this process.  Doctors are rarely, if ever, sued for ordering tests.

Doctors are human.  They respond to individual incentives like everyone else.  If the system pays for volume, we will continue to get more volume.  If we want quality, intelligent decision making, incentives need to be aligned for quality.  Unfortunately, as long as there are points for speed, we'll all lose.