Loan repayment is a tool to recruit providers to shortage areas. In New Hampshire, recent legislation has boosted its State Loan Repayment Program (SLRP) so that it can be used more broadly and for a wider range of providers.
“About five years ago I asked my peers how they got more workforce funding in their states, and every one of them told me it was the function of partners coming together and picking one to five legislative priorities,” Druzba said. “That’s how they got money and how they started to gain momentum. That’s what we did in New Hampshire.”
The coalition began after a conversation with the Bi-State Primary Care Association (Bi-State) about what investments should be made to strengthen the healthcare workforce there. Increasing funding for SLRP quickly became the focus of their efforts. In addition to Bi-State, more than fifty organizations eventually joined the coalition.
When it came time to lobby before the state legislature, “the people who coordinate the coalition decided which one of that group would testify and made sure there were people in the coalition who were subject matter experts,” Druzba said. “The New Hampshire Hospital Association and leaders of FQHCs spoke about SLRP, and directors of nursing homes advocated for the parts of the bill involving Medicaid funding.”
For her part, Druzba served as the “facts person,” she said. “As a state employee I can’t advocate for specific bills, but I am allowed, with permission, to testify factually about programs. I talked about why SLRP is a good investment, what we know about it as a tool for recruitment and retention, and I shared data about participants.”
The resulting legislation increased the annual SLRP budget from $250,000 a year to $6.5 million over two years. In the first stage of the expansion, the SLRP program is adding primary care RNs (at already eligible sites), Hospitalists at Critical Access Hospitals, and licensed school psychologists who serve Medicaid-enrolled students.
“I haven’t seen anyone else doing hospitalists (with their SLRP programs),” Druzba said. “And including Medicaid school psychologists is also very unique. There is a shortage of them here and children who had qualified to get Medicaid services in schools were going without.”
Previously school psychologists in the state were licensed by the Department of Education, Druzba said. “Now they will be licensed as health providers with the Board of Psychology, which means our office won’t have to do any extra work around credentialing or vetting anybody.” (NH SORH administers the SLRP program.)
The next phase of the expansion in January 2021 will create a pilot loan repayment program for private practice dentists who serve a set amount of Medicaid clients, as well as loan repayment for behavioral health providers at eligible sites who are under supervision to acquire their license.
“The legislation also created a new position in our office (but we are at a hiring freeze because of the pandemic) and we got a promotion for an existing staff member, which is moving forward,” Druzba said.
Because of the pandemic, $4 million was taken from SLRP funding this year, Druzba said. “So we aren’t doing the level of work we would do if we had the entire $6.5 million,” she said. “But I figure even if they take $4 million out, it’s still $2 million more than I had. And so many more people now understand and appreciate the importance of SLRP. The floor of SLRP funding has been raised – it’s all incremental.”
After SLRP funding legislation passed last fall, NH SORH ran a SLRP Summit in January to get stakeholder input on ways to expand SLRP to cover more provider and/or site types. “The Summit gave everyone a baseline understanding of the program and its purpose, brought together a lot of people who have never met but have common goals, and gave us new ideas for the program,” she said. In addition, “there is an ongoing Dental SLRP Advisory group that was formed after the Summit to help us create a private practice dentist pilot.”
In terms of replication, Druzba said that any SORH could do this, especially considering how tiny her office is (there are five staff members in the SORH and Primary Care Office, combined).
“It didn’t cost me any money to do this work—what it cost was an investment in relationships,” she said. “This work was done because it was led by partnerships, but also because of the reputation our office has. When we were asked for our opinion on things and for data, we gave it, and they listened and valued our insight and expertise.”
“You can leverage all of the points in an existing system, but ultimately there will be places that simply need more capacity and resources,” Druzba continued. “In order to get those resources you need a coalition to focus on a set of specific policy goals with a funding ask, and united in their messaging.”
“If groups like workforce coalitions have a conversation on what their strategy is and they coalesce around it and use consistent communication, then they can get traction in their legislature or governor’s office, and get the support to make investments in various kinds of workforce programs,” she said.
In Montana, 52 of 56 counties are classified as medically underserved and ten counties have no physician. This is why nurses play such an important role there, and why the Montana Office of Rural Health/Area Health Education Center (MORH/AHEC) is working to get more nurses in rural, underserved communities.
“Montana is different than other states because of our extreme frontier nature, so nurse practitioners (DNPs) have a full scope of practice here,” said Kristin Juliar, MORH/AHEC Director. “In many communities, they may be the sole primary care practice, and physician supervision is some distance away.”
Using a grow-your-own approach, MORH has joined with the Montana State University College of Nursing (MSU CON), where it is housed, to get more nurses trained and working in rural areas. The effort has been funded by two Health Resources and Services Administration grants, Nurse Education, Practice, Quality and Retention (NEPQR), which prepares BSN-level nurses to work in rural primary care, and Advanced Nursing Education Workforce (ANEW), which trains rural-ready DNPs.
Kailyn Mock, MORH Project Coordinator, said the best ANEW candidates are already working in rural settings. “We are trying to leverage their skill set,” Mock said. “They have dug their heels into their town, are working already as an RN, and want to continue work in their communities. They can provide a different level of service to their communities as a DNP.”
“Our DNP program is an all-online program so it’s especially suited to advance their education in rural,” Juliar said. “We have DNP students from all over the state. If you are a DNP in a rural setting you need a broader set of skills than you would need in a more urban clinic. The ANEW grant is focused on establishing academic clinical partners with Critical Access Hospitals (CAHs), Community Health Centers (CHCs), tribal and Indian health, and Rural Health Clinics (RHCs), and developing the curriculum to help those nurses working in those settings.”
ANEW students do their schoolwork from their homes and communities and do not go to class unless there is a skills lab requirement a couple of days in a row at the start of the semester, Mock said. “We also set up clinicals outside of where their usual job is, to help them find an experience outside of what their normal practice looks like,” she said.
For the NEPQR grant, students are enrolled in a traditional brick and mortar program based on campus, Juliar said. MORH works with MSU CON on the outreach component of the grant, and to help develop undergraduate nursing didactic education so that it is in line with the needs of rural and underserved sites in Montana, she said.
“There’s a focus on establishing more clinical sites, and getting more students out into primary care settings, like CHCs, CAHs, RHCs, and tribal health sites,” Juliar said. “We also are looking at trends in healthcare transformation and care coordination models, and how nurses can be up to speed on these developments in how health care is delivered.”
Undergraduate nursing students who elect to be in the Rural Primary Care Track receive additional education through the AHEC Scholars Program, which focuses on interprofessional education and team-based care, Mock said. “These students also have priority preference for completing the clinical component of their coursework in rural locations.”
NEPQR grant funding began in July 2018 and ANEW grant funding began in July 2019, Mock said. Both are four-year grants. “Our first ANEW cohort started at the end of last summer with 15 in the first group, and we have 21 students lined up for 2020-2021,” she said.
The NEPQR grant supports rural immersion costs for undergraduate nursing students, including travel costs to rural sites for clinical rotations, and conference registration fees. The ANEW grant covers all tuition, plus up to $9,000 for books and clinical travel.
The grants represent a partnership between MORH/AHEC and MSU CON to address critical rural health workforce issues, Mock said.
Providing healthcare to all parts of Montana is challenging, with 1,068,778 people spread across 145,546 square miles. Finding nurses to work in rural Montana is especially challenging because most nurses in the state work in urban areas and the nursing workforce is aging, with the average age of all nurses around 49 years old.
But Mock sees hope in getting more rural students into nursing school. “Our best success stories are those who grow up in rural returning to rural,” she said.
by Beth Blevins
The Oregon Office of Rural Health (OORH) has created a new repository that houses state and federal telehealth policy and payment resources in response to rapidly evolving changes during the COVID-19 pandemic.
COVID-19 Telehealth Policy and Payment for Oregon Clinics and Hospitals uses ArcGIS StoryMaps, an interactive platform with sections on the CARES Act, the Oregon Disaster Relief Waiver, state and federal payment resources, and pertinent webinars and events. It went live on April 3, 2020.
“When COVID-19 started, there was a rapid fire of policy changes coming out,” said Rose Locklear, OORH Field Services Program Manager. “I wanted to create a resource to organize all the information in a way that made sense to me. And I realized that just putting them up on our website as links wasn’t going to be useful—if I couldn’t quickly find what I was looking for others would probably experience the same thing.”
Locklear said she also realized that the situation was constantly evolving, meaning that something published at the beginning of March would no longer be relevant a couple of weeks later. “So I wanted to put these resources in something that was easy to navigate and update on my end without having to go through our IT, because by the time they might update it I would need to make another change,” she said.
Locklear chose the ArcGIS StoryMaps platform because it offered her “something to throw everything into,” she said. “The story map allows you to import text, images, hyperlink to sources, and embed multimedia content. On the left side you can import text and on the right side you can put in maps, web pages, or videos. It’s not perfect, but works well to organize and house quality information, and it’s free.” (The public account of the ArcGIS platform, which she used for the story map, is free for personal, noncommercial use.)
“I’m not a data person—my background is in public health,” Locklear said, “but I enjoy visualizing data and making it easy for people to understand. In public health, in general, that’s often a challenge. We’ve got so much information—how do we organize it and display it so people can easily find it?”
Another challenge was that the CARES Act has increased the number of healthcare facilities that can provide telehealth services during the pandemic. “You’ve now got folks who never did telehealth before, who need to understand the basics about payment rules and regulations because these differ by payer,” Locklear said. “So, I had to create something that incorporated all these pieces.”
The intended audience is anyone who wants a crash course in telehealth policy or any Oregon providers impacted by the state and federal policy changes. Other State Offices of Rural Health (SORHs) are welcome to use and adapt this story map.
“There are a lot of inventive things a state could do to make it their own,” Locklear said. “There’s definitely a learning curve if you’ve never worked with ArcGIS StoryMaps. However, replicating one like this without geographical data is much easier. There are tutorials online that offer help, and I would be more than happy to answer any questions from anyone who might be interested in the project.”
The telehealth policy and payment resource is a component of ORH COVID-19 Resources for Rural Health. Other sections on that site include information on EMS, Critical Access Hospitals, Grants, Policy, and Rural Health Clinics.
After the pandemic subsides, OORH will keep using the story map as a repository for telehealth policy and information.
The South Carolina Office of Rural Health (SCORH) created its Coronavirus Resources for Rural Communities and Providers website in the early days of the state’s pandemic response to provide a clearinghouse of critical information specific to rural healthcare providers, said Bridget Winston, SCORH Director of Communications.
“We wanted to cut through the overwhelming quantity of information being disseminated, and just share what our providers needed to be able to serve their rural patients—guidance on testing, PPE, billing, etc.,” Winston said. “Once we got past the first few weeks of the crisis response, we reorganized the page to share information by topic, rather than by source, and included information relevant to both rural healthcare providers and rural social service providers.”
Topics on the page now include behavioral health, food access, employment, financial assistance for small businesses and individuals, legal resources, resources for the elderly, and resources for veterans.
When asked how the site could evolve in the future, Winston said, “I imagine we will be in response mode for months (maybe years) to come, so we will likely keep the page, although we will continue to edit and tweak the information included so that we remain relevant and useful to our rural communities.”
The Arizona SORH (AZ SORH) at the Arizona Center for Rural Health is implementing multiple COVID-19 information gathering and dissemination activities.
“We are reviewing and sharing timely resources and information related to COVID-19 and secondary emerging issues, and are working to keep our website updated,” said Jennifer Peters, AZ SORH Program Manager.
An example of this is the resource spreadsheet AZ SORH created using Google Sheets, which is being updated with Arizona-relevant information, Peters said.
“We were receiving so much information and were looking for a way to organize it for our own office and for our partners,” she said. “We are also using synchronous technology such as webinars and Zoom conferencing, and have co-hosted one virtual town hall with tribal health leadership. We expect to be doing more events like this in the coming weeks and months.”
AZ SORH also is using its website (https://crh.arizona.edu/ppe) to provide information on PPE donations.
By Beth Blevins
Public health students at Oklahoma State University (OSU) are tackling real-life problems at Critical Access Hospitals (CAHs) in the state. In collaboration with the Oklahoma Office of Rural Health (OORH), Master of Public Health (MPH) students enrolled in the Designing Public Health Programs course are creating projects that address challenges faced by the hospitals.
“The programs that the students create are in direct response to priorities identified in the hospitals’ Community Health Needs Assessments (CHNAs),” said Lara Brooks, OORH Rural Health Analyst. “The students are divided into groups of two to four during the semester, and they then work on a priority from one of the previous year’s CHNAs.”
The program focuses on CAHs that do CHNAs (particularly nonprofit CAHs, which are required by the IRS to do a CHNA every three years). “Every fall I make a spreadsheet pulling out the priorities identified in the CHNAs and share that with the course instructor, who goes through and weeds it down according to what could be applicable to students in the course,” said Brooks.
This year’s topics addressed sexual health and education for adolescents, smoking cessation, opioid prevention for young adult males, physical activity, healthy lifestyles, and adolescent and parent counseling as prevention for future drug and alcohol abuse. Past programs have included mental health first aid, the creation of a Narcotics Anonymous (NA) group, and a dental hygiene program for nursing home residents.
“The really interesting part is the creativity in the projects,” Brooks said. For example, one group that was assigned “physical activity” as a priority utilized the state parks as an opportunity to get outside. “They went to that community and looked around and saw that the sidewalks aren’t great so they thought outside the box. They visited the nearby state park, got maps, and created a program around being active using the state park.”
Another year, a group from the class created a program on healthy eating that included grocery store tours, working with the local grocery store to host events and to highlight healthy products. “The fresh set of eyes and ideas are what make the collaboration so interesting,” Brooks said.
Brooks visits the students on the first day of class giving them an overview of OORH and its grant programs, describing a CHNA, and talking about common themes and priorities across the state. She then returns on the last day of class when students give their presentations. Brooks also acts as an intermediary between the students and the hospitals since the students do not have time to visit them themselves. She delivers their projects to the hospitals’ CEOs, “making sure they know they can ask follow-up questions,” Brooks said. “At the end, they will have a binder of the program the student group created, along with implementation steps, a budget overview, an evaluation plan, and the students’ own needs assessment.”
The collaboration between OORH and the course creates a three-fold opportunity—for the students, the hospitals, and for OORH. “From the hospital’s perspective, they have the opportunity to have a group of students creating a program just for them,” Brooks explained. “From the student’s perspective, they have the chance to create a real program for a real community to address a real need. And at OORH, we get the opportunity to introduce rural areas of the state to a group of students each spring.”
Stephany Parker, who taught the course this spring, said that the collaboration “brings students and communities closer together in an applied way and opens up communication channels with OORH as an essential resource for public health professionals.” Parker continued, “OORH is our connection to those real-life settings, circumstances and community leaders. The programs and materials students develop are creative, comprehensive, and provide clinic partners with a plan for implementation consideration.”
Andrew O’Neil, a recent student in the course, concurs. “(The course) gave me an understanding of health outcomes, determinants of health, and resources available to implement programming in rural communities, which will be useful as I continue my studies and research addressing rural-urban health disparities,” he said.
So far about 80 students have participated in this coursework/collaboration since its inception in 2016. OORH’s work with this collaboration requires no special funding. “When I deliver the binders to the hospital CEOs, it’s in conjunction with a site visit to the CAH, something that would normally be funded under the Flex program,” Brooks said.
Because OORH is part of the OSU Center for Rural Health, it probably makes a collaboration like this easier, Brooks said. “A program like this is probably easier to replicate with the university-based State Offices of Rural Health since they have that relationship on campus.”
“Nonetheless,” she added, “I know that a lot of folks who work for their state health departments are alumni of public health programs in their states, so if anyone wanted to replicate this it would be fairly simple, just by making a relationship with that program.”
by Beth Blevins
“Come to supper!” is the invitation extended recently by the Virginia State Office of Rural Health (VA SORH). As a result, folks across rural Virginia have gathered to eat barbecue and discuss what is going on in their communities.
“We figure that people relax when they are eating, and that the conversation will flow a little freer than it would if someone is standing up in front of the room and asking questions,” said Heather Anderson, VA SORH Director.
The community suppers, based on the World Cafe method, sprang out of the SORH’s efforts to update the Virginia Rural Health Plan (VRHP), Anderson said. “We know what the data says, but we don’t know what is working in a community necessarily,” she said. “We wanted to hear from people we don’t always hear from—and who typically don’t get to hear from one another.”
“We already have access to people in the healthcare system since we work with hospitals and providers,” she continued. This time, she said, they wanted to hear from school district personnel, mental health professionals, business owners, and patients.
“We are trying to get beyond our typical healthcare sphere to make this a community-driven project,” she said. “We want to spark community involvement, collaborate where we are needed, and ultimately empower the communities to improve their health status.”
The suppers have been held “in places that reduce barriers,” Anderson said. “We don’t want it to be at the hospital necessarily but at the VFW or the library or a church, if that’s where the community gathers.”
They use local food, served by a community group, as a way of giving back to the community. “Since the first meetings have been held in Southwest Virginia, the local food has been barbecue,” she said. “Maybe by the time we get to Accomack (on the Eastern Shore) it will be seafood!”
The counties where the suppers are held (seen in purple on the state map, right) were chosen by using several data points, including Appalachian Regional Commission’s distressed county index, the Robert Wood Johnson Foundation’s County Health Rankings, and the Virginia Health Opportunity Index (HOI). “We felt like that gave us a state, national, and regional look at Virginia,” she explained.
Then they took the data, ranked the areas where they knew they wanted to go, and asked themselves, “where are we missing?” and “how can we engage the small business owner on Main Street and get their perspective?” Anderson said. “As the SORH, we want to learn what is working for the community, the hidden gems, not just what isn’t working, which is what the traditional data looks at. That’s how we could include a place like Amelia County, which is in the shadows of Richmond, but is still very rural. There are areas that get overlooked because they may not meet the federal definition of rural, but we consider them rural.”
As community members gather for supper, they are given the same three questions to discuss among themselves at each table: “Name one to two things that will improve the health of your community; what are the good things about your community; and what is wellness and what does it look like here,” Anderson said. “At the end we bring it all together with a local facilitator. The expectation is that we want to hear local things we might not have heard before.”
The community suppers so far have had an average of 30 people in the room, with a total of 120 participants. The conversations are being funded with Flex carry-forward funds, with SORH funds likely picking up some of the sustainability going forward, such as printing resource documents to distribute.
Anderson said that one thing they have learned already from the suppers is how faith communities are filling in service gaps in rural Virginia. “In Wythe County, we learned there’s a very strong food bank that’s been around for 20 some years that has blossomed into clothing and social services for people,” she said. “I don’t know that we would have found that out if we hadn’t had the opportunity to have these conversations.”
VA SORH is gathering so much information from the suppers that they will be using it beyond the creation of the VRHP, by sharing information about best practices and community champions in the areas they have visited, Anderson said. “Our SORH will take the qualitative information and promote a champion, either a person or an agency, on a monthly basis on our website,” she said.
“We’re hearing really wonderful things about the communities,” Anderson said. “We know they are lacking transportation, there’s an opioid epidemic, there aren’t enough providers. But we don’t always know what is working well—we are trying to get that out of these conversations. We’re trying to get people in the room that need to talk to each other. Sometimes we make things too complicated, and miss the boat by not talking to people.”
Fifty-five counties in rural Missouri are now without a hospital. Death rates are higher for rural Missourians than urban in each of the top ten causes of death. These and other statistics are included in a new report that looks at the health status of rural Missourians.
Health in Rural Missouri: (Biennial Report 2018-2019) looks at demographic characteristics and other factors, as it has in prior reports. But this year the entire report was done through the lens of social determinants of health (SDOH), according to Kathryn Metzger, Programs Manager at the Missouri State Office of Rural Health (MO SORH), which issued the report.
“In prior years it was mostly done by the numbers—people pulled the numbers and interpreted them,” Metzger said. “This time, we wanted to identify those things most impacted by SDOH, and use that in discussing everything going forward.” The 2018-2019 report focuses on five of the most important SDOH impacting rural health: economic stability, neighborhoods and built environment, health and healthcare, social and community context, and education.
For example, Metzger said, in the section that discusses education, “We put education levels alongside diabetes rates so you can see that as educational attainment decreased, the diabetes rates increased,” she said. “That’s really important when you’re looking at programming—you start getting into health literacy issues. You want to make sure that people understand the medical advice they are getting, especially with diabetes, which is complex and difficult for everyone to understand.”
Another big change with this year’s report, beyond content, Metzger said, “and one that was important to best serve Missouri’s communities, was to make it easier to read.” In previous years’ reports, she said, “it was a very technical document, written in an academic style, that would have required a pretty high level of health literacy and an understanding of statistics.”
“We want to try to expand the audience,” she continued. “The goal was to use plain language so that the information will be accessible to anyone on the ground doing the work in the community. We also wanted to make sure that when we couldn’t use words that were plain language, we would include a glossary that links to them.” Terms that appear in the glossary are italicized in the report.
Another more visual change is that the new report features award-winning photos from the Missouri Department of Agriculture’s Focus on Missouri Agriculture Photo Contest. “We used photos of people in Missouri taken by people in Missouri,” Metzger said. Rural scenes, including a large photo of a smiling Missouri farmer on the Table of Contents, are used throughout its pages.
Although MO SORH is required by statute to issue the report every two years, Metzger said, “this is much more than we are required to do—it could be done in a five-page overview. But it gives us an opportunity to speak to our lawmakers about our needs and also to share information with our community. I think it keeps Missouri’s finger on the pulse of what is actually happening across the state.” This year’s report is 88 pages.
The report being issued biennially also points out significant changes in health status, Metzger said. “If you have a county that has had a really low rate of something but then, all of a sudden, in a two-year time span, you see it go to a high rate, it draws your focus,” she said.
Metzger said that in recent years the reports have been longer also because their data capacity as a state has changed. “We have a lot more access and we’re using state-specific data sources,” she said. The current report draws on MOPHIMS (Missouri Public Health Information Management System) and the Missouri County-Level Study, she said.
The report was partially funded through SORH funds, Metzger said, with the rest of the funding coming from other state budget sources.
In the coming weeks, Metzger said she hopes to pull together factsheets from the report as well as present webinars that will discuss how to use and interpret the data.“It’s my hope that this year’s report will be easy to understand by everyone at the grassroots level interested in furthering the health of their community—whether it’s a hospital, a non-profit, or a walking club,” Metzger concluded. “I hope that it is used for writing grants, for developing programming, and maybe identifying some opportunities to make an impact in ways people hadn’t previously thought.”
by Beth Blevins
Funding from HRSA’s Rural Communities Opioid Response Program (RCORP) program has helped several State Offices of Rural Health (SORHs) recently start—or strengthen—their work related to substance use disorder and opioid use disorder (S/OUD). Those who receive the RCORP Planning grant have a year to create or strengthen a consortium focused on SUD/OUD. (HRSA currently offers an RCORP Implementation grant that some SORH have received as well.)
For example, the South Carolina Office of Rural Health (SCORH) had never focused on S/OUD activities prior to receiving the RCORP Planning grant, according to Lindsey Kilgo, SCORH Director of Network Development. For them the grant was “about how we can understand what’s going on in the state,” Kilgo said. “There’s been a lot of information gathering, a lot of consortium and office conversations, a lot of convening and bringing folks together.”
Forging Stronger Partnerships
While creating their consortium, the Virginia SORH (VA SORH) discovered new partners. “There are additional people at the table who might not have been there because of the consortium,” said Heather Anderson, VA SORH Director. “We added to the conversation and got community health centers and other folks that maybe weren’t involved before. We have stronger partnerships in the region.”
Anderson continued, “Because of our experience with the planning grant, another agency was willing to run with the implementation grant. So we said, ‘Go for it. You’re local, you know all the people. We will support you any way we can, give you technical assistance, and help you convene people.’”
For the Michigan Center for Rural Health (MCRH), the planning grant “has allowed us to really bring everybody to the table and wrap our arms around the importance of the challenges in those counties we are working in,” said Crystal Barter, MCRH Director of Performance Improvement. “I think everyone has really bought into it, whereas before everyone was working in their own silo. And now we are working as a consortium and starting to leverage the resources each organization has.”
Hanneke Van Dyke, former SORH Coordinator at the Texas SORH, also talked about the importance of community outreach. “It was important to use relationships we already had and having an openness to expanding relationships to new project areas,” Van Dyke said. “In both of our (RCORP) project areas, community advisory councils—made up of community members and community leaders who are there for every step of the process—have been central. Making sure we built in a few back routes tied back to the community was very important for us.”
No Prior Expertise Needed
When asked what skills are needed for SORHs to engage with S/OUD work, Kilgo replied, “Having the determination to make things better and to make change—and then not being afraid to ask questions, in an effort to build knowledge, partnerships, and relationships.” Kilgo added, “For folks who work in this particular realm, it requires a level of passion and commitment. And when you have that shared passion and commitment, the relationship and trust come fairly easily. We all have a common vision and common theme. We’re moving forward together in a positive manner.”
The ability to seek out experts was also key for Van Dyke. “None of us on staff had worked on an S/OUD issues or had any particular training or experience with it,” she said. “As project coordinator, I’ve taken it on to educate myself through reading and talking with experts. I’m not an expert but I’m pretty comfortable now, knowing who to go to to get the right information.”
Although the North Dakota Center for Rural Health (NDCRH) has been involved with S/OUD activities for the state for a few years, they had no broad expertise in their office when they started their RCORP work, said Lynette Dickson, NDCRH Director. “Our knowledge has grown and continues to grow,” Dickson said.
“Even if you are not an expert in the field you can still have an impact in this arena,” Dickson explained. “Because what we (SORHs) do is convene people, and reach out and find the resources. You can have more confidence that you can have an active role in this—you can convene and connect like we do with anything else.”
For more information, see the new NOSORH Issue Brief, SORH Response to the National Substance Use Crisis. A full spectrum of NOSORH resources to address rural SUD/OUD are available in the Rural Opioids Educational Resources library on the NOSORH website.
by Beth Blevins
Thanks in part to the Indiana State Office of Rural Health (Indiana SORH), rural residents in Allen County, Indiana, soon will have the opportunity to take classes on cooking and healthy eating through the HEALing Seeds program.
The Our HEALing Kitchen (OHK) program, which began in 2015 in urban areas of Allen County, in and near Fort Wayne, has been rebranded as HEALing Seeds for its launch in rural, said Laura Dwire, Community Programs Manager for the St. Joseph Community Health Foundation (SJCHF), which manages and is the fiscal agent for HEALing Seeds. OHK is cosponsored by SJCHF and Parkview Health.
“We knew food deserts were a really big problem in urban areas,” Dwire said. “But rural areas have the same low-access pockets. Some of our areas are 15-20 miles from a grocery store. Because it’s rural and their needs are different, we’ve adjusted the curriculum and rebranded it as HEALing Seeds.” HEAL stands for Healthy Eating and Active Living, she said.
The aim of HEALing Seeds is to provide the seven rural communities of the New Allen Alliance (NAA), a coalition of communities in east Allen County, training and education to encourage healthy cooking, increase access to healthy foods, and ultimately improve health outcomes within the region, Dwire said.
The program uses a “train the trainer” model, Dwire said. “We realized there has to be a trusted individual in the community that facilitates the classes because if I came in and said, ‘Hey we’re having public cooking class,’ the attendance would be low,” she said. HEALing Seeds offers a three-hour training for program facilitators and administrators (which can be the same person), and then facilitators deliver classes in their communities or organizations based on their schedule and timeframe, she said.
The HEALing Seeds curriculum is composed of eight sessions, with four to six recipes taught per session, “but the facilitator can bring in their own recipes if they meet the standard nutritional guidelines, and they can create their own schedules—whatever works,” Dwire said. “In the past some organizations have added exercise classes, yoga instructors, and mindfulness training, and some churches have tied it into Bible study. So HEALing Seeds is just the foundation for the organizations to build a movement.”
Seven organizations in the NAA have agreed to hold the classes, including two youth centers, an alternative school, a community center, and a senior living community, Dwire said. “Originally the program was designed only for adults, but then we realized it was impactful to teach life skills to middle schoolers and above because they have the same health issues—obesity, hypertension, diabetes—as the adult population,” she said.
The project is part of the funding NAA received when it was designated an Indiana 2018 Stellar Community, said Joyce Fillenwarth, Indiana SORH Manager. “The purpose of the Stellar program is to encourage and emphasize collaboration among all community stakeholders in planning their vision for future economic and community development.”
“In 2018, our office approached the Indiana Office of Community and Rural Affairs and suggested that the Stellar Designation include a rural health component,” Fillenwarth continued. “Incorporating the community health assessments as a component of community-wide planning will improve the comprehensive nature of the process.” The Indiana SORH grant provides $75,000 (which was split between the two designees the first year) for projects that address health and wellness issues within the respective regions, she said.
NAA chose OHK as the health component for their stellar designation application because it was already a success and was ready to go, said Kristi Sturtz, NAA Rural Liaison. According to Dwire, in the past four years, OHK has expanded to over 40 organizations and 1,500 participants.
The hope is that the program will be sustained after funding has ended, Dwire said. “We have chosen organizations that have the capacity to incorporate the curriculum into their programming,” she said. “We give them comprehensive skills to keep moving without our funding.”
As part of the move toward self-sufficiency, the grant agreement requires each class to have a celebration at the end of the program, which is planned, prepared, and served by the participants, Dwire said. “They can invite family, make a theme, whatever they want,” she said. “We ask that they raise funds for its cost so they can be part of the solution. We also suggest that they partner with a farmer or grocery store or local organization to support their class as well. We’re trying to make it theirs, give them the tools so they can go on.”
Dwire said that she would be happy to share the OHK recipe book and curriculum with any interested organizations. The recipes are available on the SJCHF website.
HEALing Seeds train-the-trainer sessions will begin in December, with the rollout of classes planned for 2020, Dwire said.
By Beth Blevins
In rural and frontier Oregon, as in many other parts of the country, the aging population is rising, bringing new challenges to healthcare and other services. To address these needs, the Oregon Office of Rural Health (ORH) hosts the annual Forum on Aging in Rural Oregon.
“We bring people together who are working on aging issues, to share best practices and learn from each other,” said Robert Duehmig, ORH Interim Director. “It’s important that Oregon’s rural and frontier communities are supportive of the aging population, so folks don’t have to leave when their care needs increase. There’s not a lot of assisted living or senior homes in rural and frontier communities, so when somebody has to leave their home for care, it usually means going quite a distance.”
The Forum was the vision of Scott Ekblad, former ORH Director, Duehmig said. “His vision was to highlight and share rural organizations’ programs with other communities that have similar resources and geographies.” In this way, he said, “rather then keep that innovative work siloed, the Forum offers a way for other folks to hear about this great work—there are a lot of really cool programs and projects going on in rural and frontier communities.”
To address as many aging-related topics in as many communities as possible, each year the Forum is held in a different region of the state, said Rosalee Locklear, ORH Field Services Program Manager. “We rotate to a different area of the state to highlight communities in and around that specific region,” she said. “And we rotate committee members to bring in folks from that local area, because they know the needs of their community best, and they help us spread the word about the Forum.”
The topics chosen for each Forum are based on evaluations from the previous year’s Forum, in conjunction with feedback from the Planning Committee, Locklear said. “After the Forum we ask attendees to fill out evaluations to understand what they liked and what they want to see in the future. Then the Planning Committee and I discuss the data,” she said.
In the evaluations, attendees also share how they will use what they learned at the Forum. After last May’s Forum, which included presentations on loneliness and grief, aging and disability, and clinical considerations for cannabis use, their comments included: “I’m more motivated to work harder against loneliness and social isolation in our community,” and “The pharmacology was helpful, knowing when a client is taking too many medications and who to contact regarding this.”
Tied in with and awarded after the annual aging forums, ORH’s Elder Service Innovation Grants are intended to fund new projects or those building upon existing services. “Through the grants, we’re able to support small organizations that do innovative projects,” Locklear said. “There’s not a lot of funding for those sort of programs.”
The Forum is funded through three sources: paid registrations, organization partnerships, and the Medicare Rural Hospital Flexibility Program, Duehmig said. “We absolutely have to have partners to make it possible,” Locklear said. “We like to reach out to organizations in communities where we host the Forum to showcase their support of this event.” Partners have included hospital and health systems, health care organizations and foundations, government aging organizations, and education institutions, she said.
Right now, ORH is the only State Office of Rural Health (SORH) that hosts a forum dedicated to aging in rural and frontier communities. “To my knowledge there are not a lot of SORHs that are specifically addressing their aging population this way, but other states are interested in supporting their aging communities,” Locklear said. ”For example, the Washington SORH has done an evaluation of their state’s home health and hospice agencies.”
“I’d be happy to have a conversation about what we do with anyone who is interested, and to help other people do something similar,” she added.
When ORH first began the Forum on Aging in Rural Oregon, Duehmig said, they did not know it would be an annual event. “But as long as the need is out there and we can meet that need through this particular mechanism, we will keep doing it,” he said. “I think the support for it is still strong and the need for that kind of information remains vital.”
Want to know what to expect at an Oregon Office of Rural Health (ORH) conference? Check the ORH app! The app offers information on the ORH-sponsored Oregon Rural Health
Conference and Forum on Aging in Rural Oregon, including meeting agendas, speaker bios, and sponsor information. The app also includes information on ORH and ORH staff, and instant access to ORH videos and ORH’s Twitter and Instagram accounts.
According to Robert Duehmig, ORH Interim Director, the app was created as part of ORH’s larger goal to become more paperless. “We don’t want to waste paper so we can be environmentally sound,” Duehmig said. “But the other reason is that our conferences are never near the office, so we would have to travel with all that stuff or ship it out.” Additionally, he said, “more and more people don’t want to go to a conference and bring home tons of stuff, so we make it easier for them to view that information on their mobile devices.”
The content of the app changes with each new conference. Since the last conference (as of this writing) was the ORH Rural Aging Forum, it is now featured on the app.
Currently, ORH is the only SORH that offers its own app and it is one of the few apps devoted to “rural health events.” The app is available on both Android and iOS platforms. (Search for “Oregon Office of Rural Health” in either app store).
By Beth Blevins
Using Lean, a concept originally developed to eliminate waste in Japanese manufacturing, the New York State Office of Rural Health (NYSORH) recently embarked on a project to find more efficiency in the way its operates. The effort was part of the New York State’s broader Lean Initiative.
“This seemed very bureaucratic when we first began and we were not entirely enthusiastic about it,” said Karen Madden, NYSORH Director, “but we knew that it was something that we needed to do. So we decided to have open minds about it. We took a lot of time to be prepared and reviewed all of our data prior to our first Lean meeting, which allowed us to hit the process running.”
Although the New York State government (NYS) began its Lean efforts in 2013, it was the first time that NYSORH had used Lean. “It hadn’t gotten to us yet,” Madden explained. “Some of the projects they did were high profile and larger scale, and things that had very long processing times. But the eventual goal is to have every person who works in the NYS Department of Health trained on Lean or have them do at least one Lean project.”
For its first effort, NYSORH applied Lean principles to how it develops amended contracts, with the goal of eliminating excessive back and forth with contractors on contract requirements, Madden said. “It ended up improving our process, which we initially didn’t think needed improving, and was a great team building exercise,” she said.
Although completed last summer, NYSORH continues to apply Lean principles to its contract work, Madden said. “We continue to monitor each step of the process and compare actual times with targets that we established as part of our Lean process,” she said. “We identify outliers and discuss the issues that are causing delayed processing. Additionally, we periodically review our guidance to our grantees because that was something that we improved and that helped improve the timeliness of our approvals.”
The NYS Lean project began with four pilot agencies and has now grown to include over 41 agencies and authorities across the state. Madden said that some examples of processes that have been “leaned” in NYS include processing times for contract review and approval, voucher review and approval, application reviews, and site surveys.
Lean also has been used in other state government agencies, including Iowa and Colorado, and federal agencies including the U.S. Environmental Protection Agency.
Although NYSORH has received no additional funding for its Lean work, Madden said, “Lean has become part of how we operate now.”
When asked if other SORHs should use Lean principles, Madden answered, “We all have processes that we need to follow that we don’t necessarily have much control over, but there are likely ways that the process can run more smoothly if you take the time to break it down and find out where things slow down and why.”
“It doesn’t take a formal process or facilitator to do that,” Madden added. “It just takes a little time and an open mind to maybe do things differently and get out of the ‘that’s the way we’ve always done it’ mindset.”
“We are all part of larger organizations and need to do things that we don’t necessarily want to do, but very often something that seemed negative can be very positive if you are fully present,” Madden concluded.