The Membership Organization of State Offices of Rural Health
by Beth Blevins
People in Arizona communities are becoming more aware of their health insurance options through Project SHARE (Students Helping Arizona Register Everyone).
Project SHARE, run by the Arizona Center for Rural Health (AzCRH), trains University of Arizona health sciences students as Certified Application Counselors (CACs) that provide information on enrollment through the Affordable Care Act (ACA) marketplace. Alyssa Padilla, who supervises the SHARE program for the Arizona State Office of Rural Health (AzSORH) under the AzCRH, said that the program helps not just the patients but also the students, who become more rural and health insurance literate.
Second-year UA College of Medicine – Phoenix student and SHARE leader, Jaymus Ryan Lee
“SHARE gives the students a better understanding of social support services and how to connect individuals with those services,” Padilla said. Through SHARE, the students earn volunteer credits that allow them to graduate with distinction. But, more importantly, Padilla said, graduates of the program “are better equipped to answer patients’ questions about coverage on the spot.” To become a SHARE participant, students take five to 10 hours of online federal training in addition to in-person session training, Padilla said.
When surveyed afterwards, participants have said the program has given them a better understanding of the ACA, health insurance premiums and deductibles, and the value of expanding Medicaid in Arizona, Padilla said.
Lauren Dominick said she has already benefited from the program. Dominick, an MD candidate and Project SHARE leader for the UA-College of Medicine–Phoenix, joined last year hoping to develop the skills that will help her better serve current and future patients. “I have gained so much knowledge of how the marketplace works and how to navigate it,” Dominick said. “I’ve helped patients complete their ACA applications and seen the empowerment they experience as they take better control of their health care. The program opens up their opportunities to seek preventative health care rather than just when they have an acute, major issue.”
Unfortunately, Dominick said, as a medical student she has seen many patients with very advanced diseases who were unable to access care earlier. “This is heartbreaking, especially when their condition could have been prevented or effectively managed if they had had access to health care.” Dominick added, “Helping sign people up for insurance makes me feel like I am making a difference and hopefully having a positive impact on their health even before I see them in the clinic or the hospital.”
Kendra Marr, SHARE leader, presents on the SHARE project
Kendra Marr, an MD/PhD student at the UA College of Medicine-Tucson and Tucson SHARE leader, said that another benefit she has found with SHARE is the “wealth of opportunities for collaboration with other clubs and services within the College of Medicine,” including the Commitment to Underserved People (CUP) health clinics. Marr has been working with the free, student-run CUP clinics to form a partnership so that SHARE can refer patients to them and vice versa, and has been holding her SHARE enrollment office hours at the clinics.
Project SHARE has benefited the university as well. “The University of Arizona is a White House Healthy Campus because of Project SHARE and UA Campus Health’s efforts to improve access to health insurance coverage,” Padilla said.
Right now, Project SHARE offers in-person, outreach, education, and one-on-one enrollment services in Pima County and in-person outreach services in Maricopa County, Padilla said. The CACs also can volunteer to staff the Cover Arizona phone number, where they answer insurance questions and schedule appointments for patients across the state.
Typically, 15 to 25 students work for SHARE each year, Padilla said. So far, 90 students from the UA Colleges of Medicine, Nursing, Public Health, and Pharmacy have gone through the SHARE program since its inception in 2015.
In her role with the AzSORH, Padilla oversees the licensing, recruitment, training, and mentoring of the SHARE participants. Most of the funding for the program comes from SORH grants, Padilla said, with small additional amounts of funding from UA College of Medicine CUP, which pays for things like food for the students during their trainings.
Padilla said she hopes other SORHs will consider replicating Project SHARE. The AzSORH has created templates on the processes involved and how-to directions, which Padilla will provide to any interested SORHs. Meanwhile, Padilla said that AzCRH is planning to extend the reach of SHARE to remote areas of her state through partnerships with Critical Access Hospitals and rural faith-based communities.
Since the ACA has been in effect, Padilla said, the uninsured rate in Arizona has been cut in half (to 10 to 11 percent), similar to the national average. “It’s important to note that we have a conservative Republican governor, and we have expanded Medicaid,” she said. “Our hospitals are no longer in the red because we have patients that are now insured due to Medicaid expansion and the ACA.”
“Medicaid expansion has really helped our bottom line,” Padilla concluded. “State Offices of Rural Health support that effort and that message ‑ it can do wonders for our rural and underserved communities.”
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Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Ashley Muninger to set up a short email or phone interview in which you can tell your story.
What are three life lessons you would share?
1. Keep an open mind.
2. Look for continued challenges.
3. Exercise and eat right – but don’t give up the wine!
What is the most important thing you are working on right now?
The Rio Rico Fire District just received a 3-year HRSA Rural Healthcare Outreach Grant to provide Community Paramedicine
services for residents of Santa Cruz County, Arizona aged 55 and older who suffer from chronic disease and/or have been identified as high-utilization emergency service users. They have been piloting this project and now we are trying to hone in on the appropriate outcome measures and the best data sources to properly evaluate the impact of the program.
What inspires you and excites you most about working for a SORH?
The diversity of our job is complex with the Tribes in our state and our borders. The questions I receive are challenging and there is never a dull day.
What is the biggest challenge facing SORH leaders today?
I think the biggest challenge is keeping rural healthcare on the radar of legislators and business leaders. It is important to keep this issue front and center to emphasize how important rural is. We have to make rural healthcare a priority and continue to bring it to light. We need to continually explain what SORHs are and what they do by providing valuable technical assistance to the rural communities they serve.
What are you doing to ensure you continue to grow and develop as a SORH leader?
I have always been involved in volunteering in NOSORH committees. It is a great way to understand what the other SORHs are working on. I am the Region D Rep along with John Packham and I’m excited about it.
Arizona is already seeing the benefits of SB 1353 that went into effect this past January. SB 1353 requires health care insurers to cover services provided through telemedicine, if those services would be covered if provided in-person. The AZ SORH helped make this bill a reality by providing information and data to underscore the need especially in rural areas. Dr. Dan Derksen, director of the AZ Center for Rural Health, explained that, “We helped inform the legislative process with workforce studies and identified areas of need. Several of these studies indicated that reimbursement for telemedicine services was the main obstacle to implementation.” The AZ SORH worked closely with the Arizona Telemedicine Program with Ronald S. Weinstein, MD at the helm to ensure that Arizona’s small, rural communities would be able to provide more services locally by using telemedicine.
Derksen continues, “One small hospital, Copper Queen, located 10 miles north of the Arizona-Mexico border maintains a healthy fiscal bottom line by keeping business local and allowing them to diversity their portfolio of services offered to their community.” Derksen believes telemedicine is another tool to help hospitals improve fiscal performance. “Folks are no longer leaving the community to get services elsewhere. It helps keep the business local and allows them to diversify their portfolio. They can tailor the telemedicine solutions to enhance the services that are offered locally and improve the bottom line.” Copper Queen began by offering telestroke services a few years ago and has added telecardiology, teleneurology, teleconcussion, teleburn, telepediatrics and is looking to add teleorthopaedics.
Cochise Regional Hospital in Douglas avoided bankruptcy and experienced a 180-degree fiscal turnaround by bringing in real-time medical expertise by way of videoconferencing, through a virtual cloud of physicians with a Chicago-based central hub. Rather than directly hiring actual doctors and physically moving their families, the experts telecommute to Douglas, thereby giving local residents the affluence that flourishing hospitals have access to. Cochise Regional is the first hospital in the country to have access to all these doctors’ presence at any moment’s notice and because the infrastructure is already there now, it can be deployed to another hospital in just a few days.
The AZ SORH will use its convening function to continue this conversation at the 42nd Annual Rural Health Conference and the Performance Improvement Summit. They are distributing a book that captures the rich, oral history of the Center of Rural Health and preparing for a series of 10 minute talks to discuss the challenges with the Medicaid program, how to get better value out of payment, how to innovate such as testing a rural hospital quality pool, paying for performance across defined health outcomes, and reducing readmissions and healthcare-associated infections. “We are just beginning to see the benefits of this legislation and will continue to track access, quality and reimbursement issues for rural providers,” Derksen concludes.
Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Kassie Clarke, NOSORH’s Communication and Development Coordinator to set up a short email or phone interview in which you can tell your story.
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Back to July Branch
An online brochure, created by the Southwest Rural Policy Network (SWRPN) and distributed by the Arizona State Office of Rural Health, aims to provide quick and easy information on the Affordable Care Act (ACA) for a rural audience there.
The brochure was a response to a W.K. Kellogg Foundation initiative called Rural People, Rural Policy and was developed by the SWRPN’s Health Action Team, according to Joyce Hospodar, AZ SORH Health Systems Development Manager and SWRPN Action Team Chair. Using money from that initiative, the AZ SORH was able to make printed copies to distribute in the state, which so far it has distributed to many organizations including AHECs, FQHCs and hospitals. “All the other material we are seeing on the ACA is so complicated,” Hospodar said. “We’re trying to get the information more understandable to people living in rural communities. As people become more aware of the ACA, we’ll be able to increase their participation in what they’re eligible for, so more people will be getting insurance and be involved with the benefits of the ACA.”
Feedback on the brochure has been positive, Hospodar said. “The momentum is increasing, more people are wanting it. It has been lauded for ease of use.” By popular demand the brochure is being translated into Spanish, and public service announcements are being written from it in both English and Spanish, which will be targeted for national distribution.
Funding for development of the brochure came from the Kellogg Initiative. Despite the up-front costs of web development and printing, Hospodar said, she thinks it will be a good investment. “So many organizations are working to get the word out about the ACA that there’s lots of duplication. We’re trying to streamline it. The brochure can be used to answer questions that patients—and citizens—have about the ACA quickly and easily.”
Hospodar said that both the online and print brochure versions can be modified and used by other State Offices of Rural Health (SORHs), but it will require some funding for the modifications. The New Mexico members of the Health Action Team have tailored the brochure for their state and have made it available online. To access the Arizona and New Mexico ACA brochures, visit the SWRPN Affordable Care Act page. SORHs that are interested in adapting the brochure for their use can contact Hospodar for more information, at hospodar@email.arizona.edu or 520- 626-2432.
Lynda Bergsma, SORH Program Director at the Arizona State Office of Rural Health (SORH), believes that rural programs must learn to prove their worth, especially in today’s funding climate. “Many people in health and public health are starting to understand that they will no longer get money to fund programs for which they cannot show specific impacts and outcomes,” Bergsma explained. “There’s no way of knowing if a program is effective without evaluating it.”
Yet, Bergsma said, “when people like me from academic institutions try to help these wonderful, well-meaning rural health folks understand how to do program evaluation, we often make it so complex and overwhelming that we just confuse them, and they give up before they start.” She gave an example of a university researcher, who visited a county cooperative extension office to explain program evaluation, but many staffers said afterwards that they were more confused than when they started; one staffer was so overwhelmed she was in tears.
The answer, according to Bergsma, is logic models. “Folks leading health and public health programs in rural areas do not need research skills—they need simple, basic evaluation skills,” she said. “They really need a basic logic model to guide them through good program planning, implementation, and evaluation.” (She points to the Kellogg Logic Model Development Guide as a good introduction the subject.) “A logic model will tell them how to measure their project outcomes and impact,” she continued. “It can be applied to all situations. There should be a logic model for every program, whether it is designed to change community, organization or individual behavior.”
To help in that effort, the AZ SORH hosted a webinar in March on “How to Develop Logic Models for a Strong Program Evaluation,” the second in a series of webinars on project funding opportunities. The webinar was the beginning of what Bergsma hopes will be a new and continuing interest in logic models. In addition, the AZ SORH will provide some ongoing technical assistance to those who have participated in the webinar. Although it has been geared for an Arizona audience, Bergsma said that anyone could view the webinar (click here) and use the takeaway for logic models.
Other SORHs who are interested in learning about how to use logic models or provide technical assistance on logic models and evaluation should contact Bergsma at 520-626-2401 or lbergsma@email.arizona.edu