The Membership Organization of State Offices of Rural Health
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.
The legislation arose from the efforts of the New Hampshire Health Care Workforce Coalition, said Alisa Druzba, Director of the New Hampshire State Office of Rural Health (NH SORH).
“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.
With the growing COVID-19 concern brewing around us, here are some rural-relevant resources that might be helpful.Additional updates, resources and information will be added to this page as they become available…
Visit the CMS Current Emergencies landing page for Medicare and Medicaid related COVID-19 information. CMS has issued several guidance announcements and “special” announcements in the last few weeks dealing with this and many other potential challenges our providers may face.
Several additional resources – from assistance with supply chain to potential payroll tax reductions – are being introduced every day. Sometimes more than once a day. Keep an eye out to pertinent information that might be relevant to providers and stakeholders in your state.
CMS – Lessons from the Front Lines: COVID-19 every Friday, 12:30 – 2:00 PM Eastern This call series is an opportunity for CMS officials to hear directly from physicians and other clinical leaders as they share their experiences, best practices, strategies, and insights related to COVID-19. These calls are held weekly on Fridays at 12:30 PM Eastern and specific topics vary. To join the calls: Participant Dial-In: (877) 251-0301 Access Code: 8672948 Webcast Streaming
CMS – Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I
We are about preparation not panic. Please reach out to Tammy Norville (tammyn@nosorh.org), NOSORH Technical Assistance Director, with questions, for discussion or for additional assistance.
Calling for a National Focus on the People Inspiring the Power of Rural Movement!Help us in our nationwide search for this year’s inspiring Community Stars in connection to the Power of Rural movement and National Rural Health Day 2020. As in year’s past, we’re asking our rural health partners and stakeholders to identify those who are making a positive health impact in their rural community, and to nominate them for consideration to be included in the 2020 Community Stars book! This annual publication will be released on National Rural Health Day – November 19, 2020.
HELP US REACH OUR GOAL of 50 STARS!
In 2019, NOSORH received over one hundred nominations representing 44 states. Help us reach our goal of featuring 1 Community Star (individual, organization or consortium) from each of the 50 states!
To learn more about Community Stars, read past books, browse FAQs and more, visit www.powerofrural.org/community-stars/
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.”
Students like these at the MSU College of Nursing are finding more opportunities to train and work in rural areas of the state. Photo by Kelly Gorham, MSU
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.
In response to the novel coronavirus (COVID-19) pandemic, NOSORH is hosting weekly listening sessions with the 50 State Offices of Rural Health to identify the challenges and opportunities that SORH are hearing from their constituents. These reports document the resulting identified rural challenges and concerns, innovative rural strategies, opportunities for collaboration, needed rural resources, and identified areas of concern or suggestions for SORH-managed federal programs.
Peer-Identified Resources
Communications and Stakeholder Outreach
Workforce Resources
Telehealth
Rural Community-based Responses
Grants Management
Rural Health Care Infrastructure
Data Tools
Looking to share your rural successes, challenges or concerns? Rural stakeholders can send an email directly to HRSA at RuralCOVID-19@hrsa.gov
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.
Homepage of the StoryMap
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.
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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.”
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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.
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For additional information on COVID-19, please visit NOSORH’s COVID-19 Resources and SORH COVID-19 Response pages.
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.”
MPH students Andrew O’Neil and Desiree’ Lyon recently created this poster as part of their Designing Public Health Programs at Oklahoma State University.
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.”
National Rural Health Day continues to be successful because of support from our members and partners. NOSORH is proud of the reach and impact this program has year after year as we work to bring new programs, ideas, events, and opportunities to celebrate the #PowerofRural – 2019 was no exception!
Below you’ll find a new fact sheet that highlights the impact of National Rural Health Day 2019 at the local, state and national level. Check it out!
National Rural Health Day Impact Fact Sheet
Mark your calendar for Thursday, November 20, and stay tuned for the roll out of resources for the 2020 National Rural Health Day and Power of Rural campaign!
Thank you for all you do to transform this moment into a movement!
NEW Issue Brief
We know it’s important to get those rural counts, but what can you do?
While working with State Offices of Rural Health (SORH), NOSORH discovered an unmet need for more in-depth technical assistance (TA) to build SORH capacity as well as provide an extension of the SORH to rural providers. This led to the development of the Tiered Technical Assistance Program– a set of innovative services, TA strategies, and resources to help SORH engage rural primary care providers.
The fundamental focus of NOSORH’s work is to maximize the capacity of SORH. This new program is planned to bridge, supplement, strengthen and grow existing SORH efforts, partnerships and resources, at the request of the SORH. It is not meant to replace currently offered TA or compete with other TA providers or established relationships. This service set is designed to provide support services for unmet need(s) to SORH and the communities they serve while strengthening the SORH TA infrastructure. The program has been informed by the work of the leaders and partners of NOSORH’s Primary Care Committee (formerly known as the Rural Health Clinic Committee).
All TA services are provided and/or coordinated by Tammy Norville, NOSORH Technical Assistance Director. Tammy maintains Registered Medical Manager, Registered Medical Biller, Registered Medical Coder, Certified Professional Coder, and Certified Professional Coder – Instructor certifications. Tammy directly served rural communities during her almost 15-year tenure at the North Carolina SORH. The cornerstone of her experience is operational efficiency in various healthcare settings, allowing flexibility and innovative approaches to project management and challenge resolution.
For more information or to register for the program, please contact Tammy Norville (tammyn@nosorh.org).