Promising Practices

Promising Practice: Utah SORH Saves Rural Hospital by Obtaining GSDA Certification

i Mar 1st No Comments by

by Beth Blevins

In his first week as director of the Utah Office of Primary Care and Rural Health, Matt McCullough faced a potential crisis: a Rural Health Clinic (RHC) in the southeastern part of the state was in danger of losing federal certification. Fortunately, McCullough found the solution—obtaining a Governor’s Designated Shortage Area (GDSA).

“A Critical Access Hospital (CAH) in Southeast Utah had commenced building a new Rural Health Clinic (RHC), but they found out that the area in San Juan County, where it was being built, wasn’t inside a HPSA (Health Professional Shortage Area) designation,” McCullough said. “So last September they asked our office what we could do.”

Medically Underserved Areas/Populations

It all comes down to numbers—specifically what does and does not qualify geographically as a HPSA, McCullough explained. “To be a geographic HPSA, a county has to have a population-to-provider ratio of 3,500 to 1,” he said. “With 15,000 people in the entire county you only get four providers and then you don’t qualify for a HPSA anymore. San Juan County has a partial HPSA, but it doesn’t cover the area where the new RHC was being built.”

Without the HPSA designation, the new RHC would not have been certified by CMS, “and without that certification, they might not have been able to open or stay open for long, because they would lose all that funding,” McCullough said. To qualify for Medicaid reimbursement, normally RHCs have to be either in a HPSA or a Medically Underserved Area (MUA). But the third option, which not every state pursues, is GDSA certification, he said.

“This GDSA is a huge benefit to the state,” McCullough said. “It qualifies all frontier counties in the state as governor designated shortage areas. Some of our frontier counties are extremely frontier—less than two people per square mile, and they have a number of health disparities.” For example, San Juan County has a Native American population of 49%. Because of this, he said, “HRSA was able to approve the GDSA because these areas are extremely underserved.” And once states receive GDSA approval, it never has to be updated, he said.

Although he told the CAH that it might take up to a year to get the GDSA certification, Utah was able to get it in only three months, a speed McCullough attributes partly to the knowledge he had obtained in his prior job as Senior Research Analyst and Program Coordinator for Utah’s Primary Care Office (PCO), where his responsibilities included HPSA and MUA designations. Another part of that success, he said, was having the PCO and the State Office of Rural Health (SORH) in the same office. “Many SORHs work with RHCs but don’t know all the criteria of designated shortage areas,” he said. “You need a good combination of having SORHs and PCOs working together to get this done.”

Additionally, using a direct connection with the governor’s office helped move the process along more quickly. “I drafted the letter and had the executive director of our Department of Health send it to the governor’s office directly,” he said. “I think that helped, to have his approval come from our office. Our governor is very rural-friendly. The letter was signed and sent back to us to send on to HRSA in only two weeks.” It also helped, he said, that he wrote two letters—one to the governor that explained the process and why the certification was needed, and a second letter for the governor to sign to send to HRSA. “So he didn’t have to write it, which saved a couple months of time,” McCullough said.

Utah also got help from other SORHs and PCOs in how to pursue the certification. “We reached out to Oregon because they had recently done this and they gave me a copy of the letter they sent to their governor requesting the certification and the one they sent to HRSA,” he said. In addition, he found examples of GDSA request letters from other states online. “I took those letters and pulled out the things that I felt would pertain to Utah the most and wrote a letter that made the most sense for Utah.”

Now that the GDSA certification is in place, McCullough said he has already begun to hear from hospitals in the state requesting GDSA approval for their clinics, and he imagines that his office will have one or two requests a year for it.

McCullough recommends that other states think about pursuing GDSA certification. (According to HRSA, only 13 states—plus Utah—now have GDSA certification.) “I’d be more than happy to help them and share the letters we wrote,” he said. “Having those letters is an important first step. Second is figuring out what works for your state. I didn’t use the numbers given in the other letters. I looked at each frontier county in Utah, to see how many could qualify, and adjusted the numbers to make it as beneficial as possible for our state. That’s where I’d be happy to provide guidance and share what worked best for Utah.”

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.

Back to March Branch

Promising Practice: Minnesota Program Aims to Help Immigrant Physicians Practice in the State

i Feb 1st No Comments by

by Beth Blevins

A Minnesota program is aiming to tap the unused potential of international medical graduates who live in the state but can’t practice there.

The International Medical Graduate (IMG) Assistance Program, housed in the Minnesota Department of Health’s Office of Rural Health and Primary Care (ORHPC), evolved out of a nonprofit established by Yende Anderson, IMG Assistance Program Coordinator, and her parents more than ten years ago, while Anderson was in law school. “We noticed there were a lot of resources for immigrants in Minnesota already, but it was mostly for those who were low skilled,” Anderson said. “We saw that doctors in particular have significant barriers.”

It was while advocating for IMGs at the state legislature that Anderson met Mark Schoenbaum (then-director of ORHPC), who agreed to take on an IMG task force. As a result of the task force’s recommendations, the Minnesota Legislature established the IMG Assistance Program in 2015, and ORHPC selected Anderson to be its coordinator.

According to Anderson, the IMG Program is of special importance to Minnesota because the state is experiencing “a perfect storm” of a projected shortage of physicians along with an aging physician population. It would seem that employing IMGs who reside in the state to work in rural and underserved areas would be an easy solution to the problem, but it’s not that simple, Anderson explained. Even if someone has graduated from a medical school that is recognized in the United States or by the World Health Organization, they must pass a two-step licensing exam and complete U.S. medical residency, even if they’ve completed a residency elsewhere.

“This residency piece is where the barrier is,” Anderson said. “There’s not enough money for U.S. graduates to complete residency, so when you add international medical graduates, there’s even more demand for the available supply.” The cost of a residency runs around $150,000 per year per resident, she said.

In addition to limited residency positions, most IMGs also lack U.S. clinical experience, a prerequisite for residency. “One of the legitimate concerns we learned from the task force is that IMGs aren’t always familiar with the U.S. method of practicing medicine,” Anderson said. “It’s a team approach with the patients as well as the other physicians. They really need an opportunity to be in a clinic and become familiar with U.S. medical culture.” The IMG Assistance Program now offers clinical experience through a partnership with the University of Minnesota.

The cause of IMGs is personal for Anderson because her mother was an IMG who was never able to practice in the states. “My mom didn’t complete her residency in Canada (which would have allowed her to practice in the states) but went back home to Liberia to help,” Anderson said. But after she returned, her father, William R. Tolbert Jr., who was president of Liberia, was assassinated during a coup d’état, and the rest of the family was persecuted. Like many others, her mother fled her home country for the United States. In order to remain here, she had to maintain a student visa, so she studied Epidemiology at the University of Minnesota for seven years, despite having a Master’s in tropical medicine from the London School of Hygiene and Tropical Medicine.

By the time her mother finished her program, she had been out of medical school for over 20 years, too late to apply for a residency since most residency programs require that physicians have graduated within five years of application.

Minnesota stands out as the first state to implement a comprehensive program to integrate IMGs into the physician workforce, although at least three other states are in the process of planning a similar program, Anderson said. “We get calls from all over the country and we are happy to offer technical assistance.”

The IMG Assistance Program receives $1 million of state funding each year, with more than half of it going toward funding residencies, Anderson said. IMGs who accept a residency position funded by the program are required to pay $15,000 or ten percent of their annual salaries into a revolving account for five years, beginning in the second year of post-residency employment.

The program also is researching another pathway to licensing, called a skilled pathway, which is being done in Canada, Germany, and Australia as a national program that targets immigrant doctors. “IMGs complete a skills assessment and an exam and if they demonstrate competency, they’re able to practice medicine without completing a residency program,” Anderson said. “In Minnesota we run into issues of credentialing and insurance reimbursement that require board eligibility (which itself requires completing a residency program). So, we want to continue to investigate that route and figure out if this is a possibility.”

“This work is a wonderful example of collaboration,” said Teryl Eisinger, Executive Director, National Organization of State Offices of Rural Health. “A nonprofit organization with a mission to serve IMGs met up with a State Office of Rural Health (SORH) with policy expertise and together they’ve built an innovative program in the SORH to address workforce needs in rural areas.”



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Promising Practice: Wisconsin Office of Rural Health Rallies EMS Providers in the State

i Jan 8th No Comments by

By: Beth Blevins

Rural EMS organizations in Wisconsin are learning to work together and rally for their needs, as evidenced by the recent EMS Day at the Capitol.

The event grew out of an effort begun in 2015 by the Wisconsin Office of Rural Health (WI-ORH) to assess rural ambulance services in the state. That initial work also has generated targeted technical assistance, system-wide collaboration, and other types of advocacy.

Over 100 EMS providers from across Wisconsin gathered in Madison to visit with their legislators for EMS Day at the Capitol.

EMS Day at the Capitol, held on November 1, 2017, had 105 attendees, including representatives from 50 EMS agencies. “Several people said if we get 30 people we’ll be doing well because it’s a long drive and they would have to take the day off—but the registrations just kept rolling in,” said John Eich, WI-ORH Director. “For a first-time event, that was exciting.”

The group met with 97% of their senators and 70% of their representatives. “First and foremost, the purpose was to introduce themselves and start building a relationship, with the promise that ‘you’re going to hear from us more often’,” Eich said. The attendees were from four associations representing EMS providers: the Wisconsin State Fire Chiefs Association (WSFCA), the Professional Ambulance Association of Wisconsin (PAAW), the Professional Fire Fighters of Wisconsin (PFFW), and the Wisconsin EMS Association (WEMSA), as well as the State EMS Advisory Board.

“Fire and EMS don’t have any conflict in doing the work,” Eich continued. “But they sometimes have conflicting goals legislatively. And that can lead to bruised toes and a wariness to collaborate.”

In addition, Wisconsin has two separate EMS associations. “They had had a very acrimonious split many years ago, so part of our goal was to get them working together again,” Eich said. “The bait was the legislation coming up, which was something people were willing to set aside their differences for and show a united front. And they blew us away with how well they did that.”

The group had “three asks” before the legislature, Eich said. “First, the community paramedic bill before the Senate; second, a bill giving tax credits to volunteers; and third, a public safety exemption to state-mandated community levy limits.”

The EMS Day activity received television and other media coverage in the state. Perhaps more importantly, according to Eich, “The people who met with legislators came back with huge smiles on their faces—they were really enthused.”

Although the event was planned in only two months, its seeds were planted two years earlier, when WORH convened a national group of EMS leaders to help design an assessment of what makes a successful rural ambulance service. That work became a springboard for other EMS activities.

“That assessment put us on the map for all the state associations because, in order to do it, we had to email every EMS provider in the state—all 19,000 of them—from paramedics to first responders,” Eich said. “It made them aware of who we are, what we were doing, and helped establish trust in our intent.”

Then in the summer of 2016, Eich was asked to be part of a state legislative study group on rural EMS and firefighters. “That helped to rally EMS folks the following spring, because from that committee came some proposed legislation,” Eich said. “We reached out to those four associations and the EMS Board, and got together every quarter in our conference room. We started with developing a legislative plan, and out of that came the advocacy day for EMS.”

“For all of this, we served as the convener and host.” Eich said. “As with many of our counterparts in other states, we can’t advocate directly, but our university (where WI-ORH is housed) is comfortable with us facilitating a process for others to advocate on their own behalf.”

Funding for most of WI-ORH’s EMS work comes through Flex funding since that federal program was started as a merger of rural hospital and rural EMS federal grants. Their work on EMS Advocacy Day was funded through non-grant sources, such as their fee-for-service work.

The group is already planning to hold the next EMS Day at the Capitol, finding a time that fits the legislature’s biennial calendar.

Wisconsin Office of Rural Health’s assessment tool, Attributes of a Successful Rural Ambulance Service, is available online for free for any ambulance service or organization working with ambulance services in any state.

Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Beth Blevins at to set up a short email or phone interview in which you can tell your story.

Back to January Branch

Promising Practice: Reaching Out to Rural New Jersey

i Nov 1st No Comments by

By: Beth Blevins

Although most folks don’t think of New Jersey as “rural,” the New Jersey Office of Primary Care and Rural Health (NJ SORH) is working hard to reach out to the more than 700,000 residents who live in what the state defines as its non-metro areas.

Christine King, a health educator with the Atlantic County Health Dept., shares information on rural health

As part of that ongoing effort, in September the NJ SORH launched a statewide celebration, New Jersey Rural Health Weeks. The celebration and related events took place September 17th through 30th, timed to coincide with New Jersey’s harvest time, according to Roslyn Council, Rural Health Coordinator at the NJ SORH. “NJ Rural Health Weeks is an opportunity for small towns and farming communities to work together to celebrate their rural and unique characteristics,” Council said. (NJ SORH also participates in National Rural Health Week in November).

The theme of the celebration was New Jersey Celebrates Rural: Touching Lives, Transforming Communities and Renewing Spirits. “Rural communities explored opportunities to innovate, collaborate, educate, and communicate and took the pledge to become involved with the Rural Health Movement,” Council said.  Over 1,500 individuals participated in educational events in rural areas throughout the state that targeted prevention and treatment of chronic disease, and promoted good nutrition and physical fitness. The event also honored local health departments, federally qualified health centers (FQHC’s), hospitals, and other health care providers “who reached above and beyond to deliver quality care services to rural communities, and who work together to ensure access, quality, and equity in rural health services,” Council said. The activities were “funded through partnership with other rural stakeholders,” she said. In addition, pre/post evaluations were conducted at the sites.

Megan Sheppard (l), Health Officer of Cumberland County Health Dept., and Charlotta Birdsall, Chairperson for Cumberland County Board of Health, attend a 5K Run and Walk in Bridgeton, part of NJ Rural Health Weeks in October

The celebration was publicized via banners displayed in 15 towns, live website telecasting of events, and local TV and radio broadcasting. Events also were showcased in the NJ Department of Health’s Health Matters newsletter, local newspapers including the Pine Barrens Tribute and Cumberland County News, and on the websites of rural FQHCs, which shared the unique stories of rural communities, Council said.  In addition, Council attended celebrations and presented a proclamation signed by Governor Chris Christie to show support in the six counties that have rural residents. “The success of these events showed that resources, collaboration, and partnership provided access to health services for rural New Jerseyans,” Council said.

NJ SORH is continuing its outreach to farming communities throughout the year with special attention to farmworkers. Through its cross-sector partnerships with New Jersey’s Maternal Child Health, Office of Diabetes Prevention and Control Program, and the Office of Cancer Control and Prevention, it is participating in activities that include assessing migrant and seasonal farmworkers and their families for case management services; conducting on-site health screenings at rural auctions and feed stores; training farmworkers as Lay Health Promoters that live in the migrant farms; and, offering drive-through clinics at local fair grounds.

Eva Turbiner, President/CEO of Zufall Health Center (ZHC), Roslyn Council. NJ SORH, Esperanzo Gonzalez, ZHC outreach worker, and Michelle Blanchfield, ZHC Director of Special Populations, at a NJ Rural health Weeks event. ZHC dental and medical vans provided free health care services at Brookside Terrace in Newton

Rural partners, including local health departments, FQHCs, and community-based organizations, are offering mobile health and dental vans at migrant farms and other community settings like libraries and food banks, and providing transportation to FQHCs for rural patients who require follow-up or specialist services.  “The New Jersey Rural Health Advisory Committee has identified and implemented solutions that make it easier for migrant and immigrant farm workers to be healthy in places they live, learn, work, and play,” Council said.


As it continues its outreach, NJ SORH faces an ongoing challenge of trying to provide services in areas of a state that the federal government does not necessarily define as rural, Council said. Even the state’s smallest boroughs and villages are contained within Metropolitan Statistical Areas and the townships with the lowest population density revert to the Rural Urban Commuting Area (RUCA) code of their county, she said. In order to serve their rural residents, NJ SORH defines rural counties and rural communities as those having a population density of fewer than 500 people per square mile. “We must focus on a system change to promote optimal healthcare services to these at-risk rural populations,” Council stated. “At the NJ SORH, we are exploring ways of building a population of health.”

Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Ashley Muninger at to set up a short email or phone interview in which you can tell your story.

Back to November Branch

Promising Practice: Rural Health Summits Bringing People Together Across Vermont to Exchange Ideas

i Sep 28th No Comments by

By: Beth Blevins

Bringing people together to learn from one another is the goal of collaboration—a goal that’s being achieved in Rural Health Summits held across Vermont.

At the request of the Vermont State Office of Rural Health and Primary Care (VT SORH/PC), leaders from rural hospitals and local public health district offices have co-convened the Rural Health Summits to explore better ways of sharing resources, information, and priorities.

“The summits give us an opportunity to get on the ground in local communities and talk with folks who are doing the actual work of rural health,” said John Olson, VT SORH/PC Chief. “We hear about their challenges, their successes, and how we can identify opportunities for collaboration.”

The two-hour summits are hosted at local hospitals and involve 20 to 40 representatives of health and social service agencies in the county or hospital service area, Olson said.  “They usually take place during the standing meeting time of the local Community Health Team or similar community-wide health service coordination group, and involve additional partners,” Olson said.

Those partners have included hospital CEOs, CFOs, and CMOs; Community Health Team members including primary care practices, case managers, and social services like housing, food banks, transportation, aging, etc.; and, other health providers including EMS, home health and long-term care agencies, FQHCs, RHCs, and Free Clinics, Olson said.

The core of each summit is the hospital’s Community Health Needs Assessment (CHNA), focusing on its process, work plan, and progress, Olson said. But attention is also given to public health topics like population health, and to sharing information on rural health resources from state, federal, and national partners. After the formal meeting, there are small group discussions with hospital leaders and, if times permits, individual meetings and tours of the hospital or local primary care practices, Olson said.

Additionally, a shared lunch with local partners allows for more informal discussions and networking. At one such luncheon, Olson said, local leaders were able to discuss how they could work together to resolve the problem of increased demand for mental health services in the local emergency department (ED).  “The CEOs of the FQHC and mental health agency talked about the bottleneck between the hospital’s ED and the State psychiatric hospital with empty beds,” he explained.  “They were able to identify certain policies that prevented the use of short-term beds and services at the local mental health agency, which might be resolved by legislative action.”

Since August 2015, two to three summits have been held each year, with plans for them to continue, Olson said. “We have eight CAHs and five mid-size rural hospitals, and we plan to do three to four summits each year,” he said. “We have prioritized the locations by turnover in hospital CEOs and/or District Directors, so we can introduce ourselves and resources to new leadership. The only expense is our time and our mileage, which we pay for using a combination of Flex and SORH money.”

“For many local partners,” Olson said, “these summits are the first time they have heard about CHNAs or resources available from the State and HRSA (Health Resources and Services Administration). We definitely hope that relationships between local partners and state partners will be strengthened, and that new collaborations will be formed.” Anecdotally, Olson said, the summits have been successful, but the Office plans to implement an evaluation process for them in the coming months.

While the summits provide a networking opportunity for local participants, Olson said, they also offer benefits for those who attend from Vermont State Department of Health offices. “My colleagues from the Central Office have enjoyed the opportunity to be in local communities and learn how our programs work together to impact them,” Olson said. “We get to meet leaders of many local healthcare and social service providers, as well as make better connections between programs at the state and local levels.”

The collaboration often begins before the meetings even start. “We have great conversations in the car ride there, and typically meet for coffee before we start the day to see what we can get out of this and what we can learn from each other,” he said. “It gives us an additional opportunity to collaborate across programs and with our local public health colleagues.”

Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Ashley Muninger at to set up a short email or phone interview in which you can tell your story.

Back to October Branch

Promising Practice: Helping Rural Hawaii THRIVE

i Aug 31st No Comments by

By: Beth Blevins

Residents in rural communities across the Hawaiian Islands have been sharing their “stories of health” in community meetings as part of an effort to build a framework of health derived from community values and practices.

“A common thread in all these meetings is that having a connection to what matters is really what can make good, positive change in the community,” said Gregg Kishaba, Rural Communities Health Coordinator at the Hawaii State Office of Primary Care and Rural Health (HI OPCRH).

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The meetings, sponsored by the Hawaii Public Health Institute (HPHI) and supported by HI OPCRH, are part of a larger, long-term strategy for achieving “Pilinahā”—a nonclinical, universal view of health and wellness developed by the communities themselves. The objectives of Pilinaha are: deepening a connection to place, to the past, to others, and to the best parts of one’s self. As part of the initial phase of this strategy, 17 community forums, which included discussions and storytelling sessions, were held on all six islands.

“We had the connections in a lot of rural communities already so they (HPHI) wanted to partner with us,” said Scott Daniels, FLEX Coordinator at the HI OPCRH.  “We were part of the original planning committee. We had to do a lot homework beforehand to figure out how many meetings we would be having and who would lead in the community.”

HI OPCRH staff, trained in the THRIVE (Tools for Health Resilience in Vulnerable Environments) method in 2015, helped facilitate the meetings. “THRIVE really does involve the whole community,” Daniels said. “It provides an interactive method for communities to get out there and record and discover their community.”

“THRIVE is a unique tool that focuses on community and the concept of health equity,” Kishaba added. “The process guides communities to assess and identify root causes through a health equity lens. THRIVE allows for multi-sector partnerships to develop, facilitates a deeper understanding of the social determinants of health, and builds a foundation for future action and activities.”

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For example, Kishaba explained, “if a community chooses to focus on a particular disease, like diabetes, THRIVE has an online tool that walks you through what kind of questions should be addressed. Or if a community says ‘it’s not all about the disease state, it’s more about where we live, our economy, education’—you can take that path. But that will eventually connect you back to a health issue, like asthma, which can be exacerbated by roaches or dust.”

Most communities chose not to focus “on the disease or on deficit or scarcity, but on the positive side of health,” Kishaba said. “So, we might start off a meeting, by asking: ‘When was the last time you felt good about yourself or you were healthy?’ Many of the seniors at the meetings went back to a time when they were younger and had the freedom to ride bicycles or walk safely in the community.”

“It’s useful getting the community to think of those other factors that contribute to the health of the community,” Daniels said. “It’s getting back to social determinants. The focus is on trying to establish a framework where people live healthy in their environment and the people that they are around so that creating those connections will ultimately improve A1c counts.”

Daniels said that they have found their THRIVE training useful for other efforts, including Community Health Needs Assessments (CHNAs). “It’s another tool and another way to look at health in your community,” he said. “We have been using THRIVE training to help hospitals break out of the hospital-clinic-medical thing and think more about the environment.”

The National Public Health Institute provided funding for the 17 meetings and the statewide forums, and the original THRIVE training was coordinated by the Hawaii Public Health Institute, Kishaba said.

HI OPCRH is supporting the creation of a video that captures what was learned from these community meetings. “Our office understands the importance of storytelling through digital media, so we provided the resources to tell this in a digital format instead of just having a booklet or pdf,” Kishaba said. “We sent film crews to the meetings, based on everyone’s input, to pick and choose unique stories that will captivate audiences.” The film will serve as a roadmap and springboard for future activities, Kishaba said.

“Once the video is developed, we will go back to those 17 communities to show it,” Kishaba said. The video also will be shown at statewide conferences and be available for free on the HI OPCRH website.

Click here to view the THRIVE participant packet

Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Ashley Muninger at to set up a short email or phone interview in which you can tell your story.

Promising Practice: Nevada SORH Digs Up Data on Rural and Frontier Counties

i Jul 21st No Comments by

By: Beth Blevins

County-level data—particularly for rural counties—wasn’t always readily available in Nevada. But the Nevada Rural and Frontier Health Data Book (and the associated Nevada Instant Atlas website) changed all that.

Now in its eighth edition, the Data Book, complied by the Nevada State Office of Rural Health (NV SORH), provides comprehensive information on all counties in the state. The data in its more than 100 tables varies from the broad—e.g., county populations—to the more specific, e.g., number of licensed physical therapists by county. Though issued only every other (odd) year, when the Nevada legislature is in session, the data is dynamic rather than static, according to Tabor Griswold, Health Services Research Analyst at the NV SORH.

“Data goes into the Nevada Instant Atlas on our website first, then we pull it out for the Data Book,” Griswold explained. “We continually add or update new points of data to the website.” In addition, the Instant Atlas, which boasts more than 200 users each month, “is unique because it offers time trending,” she said. “When you bring it up visually, there is a bar that shows all the data going back to when we first started collecting it. When possible, the source of the online data is linked between the website and the original source.”


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Griswold said that users can also use the Nevada Instant Atlas to assess the impact of legislation over time. For example, she said, “the expansion of public nursing programs over the past decade, and changes in advance practice nursing scope of practice have led to dramatic increases in RNs and advance practice RNs, which is documented in the Atlas.”


The Data Book is available electronically as a PDF, as well as a limited number of hard copies. “We bring copies of the Data Book to “Rural Health Day at the Legislature” to share with members of the legislature and the governor’s staff, as well as hospital administrators attending the event,” said John Packham, Director of Health Policy Research at the NV SORH.

The first Data Book rose out of the frustration Packham experienced after he arrived at the Nevada SORH, whenever he needed to find rural data. The state was collecting data for Clark County (i.e., Las Vegas), Washoe County (i.e., Reno), “and the ‘balance of the state’,” Packham said. “But the ‘balance of the state’ was the 14 rural counties we worked with on a routine basis. Whether it was for a grant or a county commissioners’ meeting, we would have to mine existing data to try to find out what was going on at the county level.”

Putting that information into the Data Book made everything easier to access, Packham said. But it also made a compelling case for the state to begin collecting and breaking data down by county, he said, “because there were some pretty substantial variations between a healthy county and an unhealthy county—certainly on health workforce data. It also kick-started our practice of going to the 38 state licensing boards for health professions, getting their data, and breaking it out by county.”

The NV SORH has found effective use of the Instant Atlas for two purposes. “For community health needs assessments, one of our starting points is to abstract or pull out the county-level data, and package it in the form of a county-level report,” Packham said. The Nevada SORH also uses its data to help rural county commissioners who are trying to establish or convene local boards of health. “Of the 14 Nevada counties that are rural or frontier, none have local health departments—their public health services are provided through the state of Nevada,” Packham said. “But there’s been an awakening of interest among them to convene local boards of health—or at least put public health issues before their commissioners. Our office is supporting these efforts to the extent that they need data to start the discussion.”

Packham said that the Data Book is funded through a combination of staff partly supported by federal Flex funds, other types of state dollars, and pieces of grants and contracts. In other words, “funding is complicated,” he said. Since the Nevada SORH is university-based, “we train undergraduates in the data collection process and to understand data base development —that’s a win-win,” Packham said. “They’ve been really instrumental in loading and double-checking all of the new data.”

The Data Book has proven a success, used by legislators, county commissioners, and hospital administrators. Perhaps more importantly, according to Packham, it has improved the visibility of the NV SORH. “Over the 15 years we’ve been doing this, people know that this resource comes from the State Office and the School of Medicine at the University at Reno,” he said. “It’s our flagship publication. It has increased the degree that we’re the first resource that people go to, especially on workforce data.”

Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Ashley Muninger at to set up a short email or phone interview in which you can tell your story.

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Promising Practice: Advisory Group in Washington State Works to Bring Palliative Care to Rural Patients

i Jun 1st No Comments by

By: Beth Blevins

An advisory team run by the Washington State Office of Rural Health (WA SORH) is looking at ways to bring palliative care to rural patients through telehealth and better community engagement.

Palliative care aims to relieve the suffering of patients with terminal or life-limiting illnesses. But in rural areas, palliative care isn’t always available locally, especially for patients who don’t immediately qualify for hospice services.

Pat Justis, director of the WA SORH, was drafting ideas for rural palliative care when inspired to start the Palliative Care Rural Health Integration Advisory Team (PC-RHIAT) after hearing a presentation at the 2016 NRHA Annual Meeting. “Seeing there what Stratis Health had accomplished and learned in Minnesota gave me velocity and concrete ideas on how to get this advisory group together,” Justis said.

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PC-RHIAT includes a cross-section of perspectives from three domains: palliative care expertise, rural health expertise, and telehealth expertise. “Our role is to be a catalyst—primarily, to do the support to bring the right conversations together, link resources, and give the whole process structure,” Justis said. “We’re laying a framework, and providing tools, coaching, and facilitation for the rural hospitals, clinics, and community team members. The community teams will develop an action plan based in the community and rural community health care organizations. And the teams will decide how quickly they move and how much to take on.”

In addition, Justis affirmed, “we are going to work closely with rural home health and hospice agencies. There’s no way that we’re trying to supplant what they do. What we want is to collaborate and help build complimentary care processes.”

PC-RHIAT also aims to work on sustainable, multi-pronged funding. Justis said that might include grant funding for capacity building, such as helping a Critical Access Hospital or Rural Health Clinic send nursing staff or providers to a national training for palliative care; bringing in case consultation services like Project Echo; and providing paid internship stipends to engage students.

One barrier to funding, however, is that there is no defined Medicare benefit for palliative care, Justis said. “As it stands now, palliative care services under Medicare are covered on a piecemeal basis under the auspices of other types of Medicare-funded services: outpatient care by a physician or non-physician provider, or home health or hospice care if the patient meets the specific eligibility criteria for those programs.”

“So,” she said, “we’re also going to work on payer strategies both within our state and looking at whether we can organize multiple states on an approach to Medicare. We’re hoping to get a national change in policy for funding so palliative care outside hospice is a covered service under Medicare.”

After consensus on the conceptual model, the advisory team will convene its first work group this month. “There are two hospitals that have already done some work, and a few other early adopters,” Justis said. “One of those will move quickly because they’ve laid a lot of groundwork for it already. The pace at which communities take this up will depend on where they are developmentally, and on community engagement and how many resources they have for it.”

The overall goal, Justis said, is to have a model where the work groups are the instigators and tool providers. “(The advisory team) wants to gradually hand off the heart of the work to the community teams as we put our focus on policy change.”

According to Justis, the advisory team is currently being funded with in-kind contributions. “The new SORH budget has a small amount committed,” Justis said. “We have a grant writing plan and strategies to work with payers. And a small amount of Flex funding has helped CAH staff with travel costs, although most meetings, but not all, are done via Zoom.”

The advisory team is bringing to fruition Justis’ long-time interest in palliative care. “I began working with hospice as a concept as an undergrad and did internships around it in graduate school,” she said. “It has long been a desire of mine to look at ways for people to stay in their community without being sent away for treatment that might not be what they need or want.”

Justis added, “The conversation should be about quality of life. ‘How can we get you more comfortable? What are your goals? How can we support those?’ That’s true for patients and family. That’s what I love about palliative care and hospice—the goals of patients and family are at the center of what happens.”


Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Ashley Muninger at to set up a short email or phone interview in which you can tell your story.

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Promising Practice: Montana’s Rural Health Initiative Promotes Healthy Lifestyles and Communities

i Apr 28th No Comments by

By: Beth Blevins

A farmers market, a community garden, chemo care kits—these projects and others were started with the help of Mini Grants from the Montana Office of Rural Health’s Rural Health Initiative (RHI). The grants were awarded last fall and earlier this year to a total of seven community organizations across the state, using leftover funds from the first Montana Healthy Communities Conference, held in the fall of 2015.

Bigfork/Ferndale Community Square Foot Garden

“The conference has been a great way to integrate the resources and the network and the people within the RHI community with national and foundation resources,” according to Natalie Claiborne, MT-ORH Assistant Director. RHI worked and partnered with several foundations to fund the conference, including the Federal Reserve Bank of Minneapolis, the Robert Wood Johnson Foundation, and the Montana Healthcare Foundation. “We’re not just looking at health in terms of hospital care, but also how you leverage resources like the Federal Reserve that do economic development in those communities, to create a healthy community in all aspects,” Claiborne said.

“RHI is unique in and of itself,” said Amy Royer, RHI Project Director. “It’s been ongoing and has a lot of state interest and partners, but now we’re taking it to the next step with the conference, and by utilizing those resources and other state partners.” The next conference is planned for October of this year.

The conference, and the Mini Grants that sprang up from it, are the latest initiatives from RHI, a local health and wellness resource center that has been run by MT-ORH since 2008. Through its web site, the program showcases local wellness initiatives via RHI Program Profiles, provides evidence-based program ideas, and offers monthly health and wellness webinars. In addition, it publishes a weekly online newsletter.

“There are a lot of wonderful health and wellness initiatives out there, but to translate that from an urban setting into a rural or frontier setting with different perimeters and limited resources can be challenging,” Claiborne said. “To be successful in a rural setting, a different set of programs might have to be implemented, whether it’s a walking trail, a community garden, or a backpack food program for kids.”

RHI provides a network between communities so they can describe their barriers and share their successes, Royer said. “A lot of rural communities don’t know what’s going to fit for them,” she added. “Someone might say, ‘We don’t know how to get a diabetes education program started.’ But I can refer them to our site and say ‘this town and this town did it, with limited resources and with a similar population. Here is their contact info.’ With every profile, we make sure that it’s easy for another town to emulate the programs and knows who to contact.”

With the Mini Grants, RHI also aims to get organizations to network within their communities to make sure that their projects are sustainable. “For example,” Royer said, “the Richland County Backpack Food Program (which received one of the recent Mini Grants) was able to get local schools and grocery stores to pledge to keep the program going.” The program serves 75 children who are at risk for inadequate nutrition on weekends and holidays. Each backpack includes non-perishable food, which the children return each Friday to refill. The Richland County program is now one of several backpack food programs profiled by RHI on its website.

“It circles back,” Royer said. “Each success story serves as an example for others.”

RHI also is an active presence on Facebook, Twitter, and Instagram. This month, as part of Mental Health Awareness Month, RHI is holding a contest that invites users to post photos on Instagram showing what they do to improve their mental health. Past RHI contests have included a Health Care Careers Interview Contest and a Rural Health Photo Contest for National Rural Health Day.

“By using networking and social media, we’re a facilitator between not just Montana resources, but state and national information applicable to these small communities,” Claiborne said.

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Promising Practice: Virginia SORH Taking Aim at Opioid Overdose

i Apr 3rd No Comments by

by Beth Blevins

Through lay rescuer training and the distribution of lifesaving kits, Virginia is taking aim at opioid overdoses in the state. Now it is increasing its outreach into rural parts of the state through the Virginia State Office of Rural Health (VA SORH).

Between 1999 and 2013, the number of deaths from opioid overdoses in Virginia increased by 1,578 percent. “When we looked at the data we found that the opioid epidemic was hitting our bigger cities and our rural areas—especially in Appalachia (the southwestern part of the state) and the Shenandoah Valley,” said Michael Mallon, Assistant SORH Director at the VA SORH. In the Shenandoah Valley, the opioid epidemic is defined primarily by heroin and other illicit drugs, while in the Appalachia region, it’s prescription opioids, Mallon said.

The state’s REVIVE! project trains professionals and others (including family members of addicts) to recognize and respond to an opioid overdose with the administration of naloxone, a drug that can save lives if given in the first few minutes after an overdose. The lay rescuers who take the training also receive a kit that contains gloves and directions—but, until recently, no naloxone.

Mallon said that it has been difficult to provide naloxone both because its cost has skyrocketed in recent years (the cost of the injectable version has risen 600 percent), and because of existing state policy—prior to last November, obtaining it required a prescription from a physician. Since then, Mallon said, the Virginia Commissioner of Health has issued a statewide standing order declaring opioid overdoses a public health emergency, making it possible for anyone to go to a pharmacy to get it, with counseling on its use, from the pharmacist.

“But the cost issue hasn’t gone away,” Mallon said. So, he said, the VA SORH requested authorization to use its state funds for one year to buy naloxone for those who take its REVIVE! training. “We’re hoping we can use this as a catalyst to find someone else to fund it in the future,” he said.

Even with this temporary funding, there is still some difficulty in providing the drug from a logistic standpoint, Mallon said. “A lot of states are allowed to find funding, buy naloxone, and distribute it,” he said. “In Virginia, nonprofits cannot access it directly, but still must get it from a pharmacy, and only the pharmacies can distribute it.” Fortunately, Mallon said, REVIVE! has found a mail-order pharmacy that offers discounts to government agencies for the nasal spray version of naloxone, and it can ship the drug directly to those who have received the trainings.

After July 1st, the VA SORH and its partners will be able to dispense naloxone directly to the lay rescuers at the trainings themselves because the Virginia General Assembly has passed a law allowing coalitions and nonprofits to dispense it. “This will provide another access point,” Mallon said.

“This has been an important and developing issue to curb the effects of the opioid epidemic,” Mallon added.  “It’s a matter of reviewing the framework of policies, trainings, and partners in your state and piecing together a plan to increase access.”

The VA SORH is planning to offer 10 REVIVE! trainings in rural areas this year. Each session will train up to 25 lay rescuers, Mallon said.

“We believe addiction is a chronic disease, and one that is treatable,” Mallon said. “We have to do more to expand treatment and, while we figure out the methods to do that, we owe it to our citizens to do as much as we can to prevent overdose deaths. Naloxone doesn’t cure addiction, but it prevents people from dying.”

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