Promising Practices

Promising Practice: Pennsylvania Office of Rural Health Puts Focus on Rural Human Trafficking

i Mar 4th No Comments by

By Beth Blevins

Human trafficking doesn’t just happen in big cities in the United States—it happens in rural areas as well. Lisa Davis, Director of the Pennsylvania Office of Rural Health (PORH), is working to bring more attention to this issue.

Davis said her interest in human trafficking came unexpectedly, at a presentation given at a Pennsylvania Critical Access Hospital Consortium meeting in November 2017. It was unclear if the topic resonated with the hospital leadership in the audience, she said. “But hospital CEOs came up to me after the meeting and told me they never knew that human trafficking was an issue in rural Pennsylvania or was something they should think about.”

Davis added, “It was clear that their facilities needed to be prepared to identify potential victims and to have systems in place to refer them for the services they would need.”

The administrators then asked if PORH could develop training programs for them. “PORH staff made a deliberate choice to train rural providers on the threat of human trafficking,” Davis said. “We know that we can be a resource for rural hospitals and other providers.”

Since the beginning of 2018, PORH has worked to address the issue in rural Pennsylvania. As a first step, a statewide committee of government, academic, community, and hospital representatives was organized. In November 2018, the group launched the Rural Human Trafficking Initiative with an introductory webinar targeting small rural hospitals, community-based organizations, and others interested in serving potential victims.

Since then, Davis said, “We continue to keep the hospitals informed—we’ve gotten a lot of interest from them.”

Davis also is reaching beyond Pennsylvania to raise awareness of rural human trafficking in other states. She gave a presentation in October 2018 at the Annual Meeting of the National Organization of State Offices of Rural Health (NOSORH) in Cheyenne, Wyoming. “It was the first time anyone had talked about that topic at NOSORH,” Davis said.

“I wanted to have NOSORH begin to think about how State Offices of Rural Health (SORHs) could address human trafficking with the Critical Access Hospitals, Rural Health Clinics, and Federally Qualified Health Clinics with which they work,” she said.

This summer, PORH and its partners will host a summit on rural human trafficking (June 26-27) in State College, Pennsylvania. “We are beginning to put in place some of the training programs that the hospitals can implement to identify point persons in their facilities, and the programs and connections that they need to address human trafficking,” Davis said.

Davis observed, “Human trafficking is often thought of as sexual exploitation but it’s also labor exploitation, which can occur essentially anywhere: in restaurants, domestic service, agricultural production, and more.”

Human trafficking is of special concern in Pennsylvania, Davis said, “because we are a state with two main cities and a number of interstate systems that traverse rural areas. With lots of travel routes into, out of, and through the state, it’s much easier to transport victims from one place to another.” According to the National Human Trafficking Hotline, there were 127 cases of human trafficking in Pennsylvania in 2018, with the majority of those cases sex trafficking.

As PORH staff became more informed about human trafficking, Davis said, they found a large network of individuals and organizations that have been focusing on the issue for a long time.

“We’ve made excellent contacts,” she said. “We’ve connected with Villanova University’s Commercial Sexual Exploitation Institute. We’ve been learning about coordinated efforts between the FBI and other law enforcement agencies to address human trafficking. And we’re working with the Region III offices of HHS and HRSA, which have an intergovernmental task force focused on human trafficking.”

However, she noted, “PORH is still very early in the learning stage and is committed to becoming a trusted resource for rural health care providers.”

Davis concluded, “Every story is heartbreaking and if we can make a difference in even one life, this effort will be well worth it.”

If you see someone who you think might be a human trafficking victim, contact the National Human Trafficking Hotline at 1-888-373-7888 (text to: 233733).

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: NC Office of Rural Health Helps Rural Providers Get Connected to HIT

i Feb 4th No Comments by

By Beth Blevins

Behavioral and other healthcare providers in rural North Carolina are getting connected to the statewide health information exchange thanks to the state’s Office of Rural Health Information Technology (ORH HIT) program.

The ORH HIT program evolved from the North Carolina 2015 Health Information Exchange Act (HIE Act), which mandates that healthcare providers that bill for Medicaid or receive state funds for services must connect to NC HealthConnex, the statewide HIE, by June 1, 2019, to continue to receive payments.

“The ORH already saw a need for more HIT support, but the HIE Act made a compelling case for a team to help smaller, rural providers with HIT needs,” said Lakeisha Moore, HIT Program Manager at the NC ORH since August 2017. “We work closely with the NC HealthConnex team to support all healthcare providers, especially rural/safety net providers.”

While the NC HealthConnex team can pay for providers to get connected to the HIE, it lacks specific funding for healthcare providers to purchase an Electronic Health Record system (EHR), Moore said.  “So, our team worked with the NC HealthConnex team and other stakeholders to design a complementary program to assist certain providers with funds to procure an EHR to get them connected.”

NC ORH HIT Program Details

Last year, the HIT program offered the Behavioral Health EHR Funding Program, and 243 providers applied to get financial as well technical assistance to purchase an EHR and get connected to the state’s HIE, according to Allison Owen, NC ORH Deputy Director.

The grant offered three tiers of funding, from small to large providers, Moore said. Of the 243 behavioral health providers that applied, 178 were awarded. “The majority of this funding was awarded to organizations with 11 or fewer providers, which was encouraging for us, because it showed that we were helping a lot of those smaller provider practices that might not be able to invest in EHR technology.”

In the future, the HIT program hopes to offer grants to providers that were excluded from Meaningful Use funds such as Long Term Post-Acute Care Providers and Home Health Care Providers, Moore said. “We still find providers whose patient records are still on paper and we have to meet them where they are.” Other providers have implemented an EHR but need additional help in making the switch from fee-for-service to a (CMS) value-based care model, she said.

Grantee Map

Moore attributes the HIT program’s success to the many partnerships it has forged. For example, her office reaches out to rural physicians through partnerships including the state’s Primary Care Advisory Committee, Medicaid listservs, Medical Society, and Area Health Education Centers (AHECs), as well as via social media channels and marketing tools. The Rural HIT Team meets regularly with members of the HIE Authority, along with the state’s AHEC staff, to share information and update one another on the status of key joint initiatives, Moore said.

“We have a really good relationship with the NC AHEC and their technical team,” Owen added. “We look at how we complement each another with our strengths and our skill sets. We come together to talk about challenges and successes, and we’ve had many brainstorming sessions. I would recommend that other states look to AHECs because often they are really strong for technical expertise.”

NC ORH HIT receives 90/10 funding—90% CMS dollars with a 10% state match, distributed through the state’s Medicaid HIT plan, Moore said. The program is in its second two-year funding cycle and will work with the Medicaid HIT team managers to update performance measures in July, the middle of the current cycle, Moore said.

“I’m excited that our Medicaid HIT team reached out to ORH and thought this was a program worth investing in,” Moore said. “I feel that other states may want to collaborate with their Medicaid team because that’s exactly how we received our funding and continue to receive our funding.”

Moore concluded, “Our program has been primed for more opportunities to support rural healthcare providers with Health IT, with a lot of the changes in our state and nationally. Providers need to utilize EHRs and HIT to help better take care of their patients and for population health management.”

Owen agreed, saying that telehealth will become more and more important, especially in rural areas. “Our state didn’t expand Medicaid, but we have transitioned to a managed care framework—we’re right in the heart of that,” Owen said. “One thing managed care organizations (MCOs) have to do is demonstrate that they can provide a broader range of care for their Medicaid population. Telehealth, we think, will be key in helping MCOs demonstrate that they can provide that access. Great opportunities abound!”

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.


Promising Practice: Loan Repayment Programs in Nebraska Yielding Huge Payoffs

i Dec 6th No Comments by

By Beth Blevins

Loan repayment programs in rural Nebraska are showing huge payoffs: family medicine providers who participate in them are significantly less likely to leave small towns and rural areas than those who don’t.

“We’re trying to maximize the impact and the opportunities for loan repayment in rural and urban underserved areas in the state,” said Thomas Rauner, Program Manager at the Nebraska Office of Rural Health (NORH). “So we are assessing how effective the programs are, and how are they working.”

Towards that end, NORH issued a report in July that examined the impact of incentive programs on retention of family practice providers—the most frequent specialty participating in loan repayment programs and serving in rural areas, Rauner said. The findings showed that these programs are especially effective in rural areas of the state—for example, participating small town and rural area providers are more likely to remain in their positions than non-obligated providers by 23% and 42%, respectively. They remain significantly longer by 2.3 years (small town) and 4.3 years (rural) than non-obligated providers.

A sample visual from the “Analyzing the Impact of Incentive Programs on Retention of Family Practice Providers in Rural Nebraska” report.

One thing that makes the report interesting, Rauner said, is that it offers visual representations of the data. “We’ve been working in the last few years to come up with more visualization components,” he said. “You can look at number, but a picture makes it easier to understand and share with a much broader group.” In the future, he said, they will share data by a place-based and legislative format.

Though the report was issued earlier this year, it has been in the making for nearly two decades with resources from the State Office of Rural Health and Primary Care Office grant programs, Rauner said. “The data on family medicine providers was analyzed by a graduate student intern in our office, using information from the University of Nebraska Medical Center (UNMC) Health Professions Tracking Service (HPTS), which they collaborated with our office to develop over 20 years ago,” he said.

HPTS tracks providers enrolled in all state and federal loan repayment programs during and after their obligation, Rauner said. “Using HPTS, we’re able to track all the healthcare providers in our state,” he said. “The system also allows them not only to track whether physicians who served their obligation out there stay longer in practice than those who did not have obligations, but also gives them the capacity to look at that data over time.”

HPTS data can also be used for economic analysis, Rauner said. “Some of the more interesting findings from the report was that analysis based on years worked shows there is a significant economic benefit associated with rural healthcare providers—a total of $3.6 billion,” he said. “This benefit far outweighs the financial investment in incentive programs.”

HPTS tracks physicians as well as dentists, physician assistants, nurses, graduate-level mental health providers, and allied health providers—those who qualify for loan repayment in the state. Its data also has been used by UNMC authors for reports on primary care nurse practitioners, on physician assistants, and on the status of healthcare workforce in the state.

In addition to HPTS, Rauner said, NORH uses the Practice Sights Retention Management System “to solicit feedback from the providers while serving their obligation, determining if they would like and need to continue receiving loan repayment assistance, and their anticipated and actual retention.”

The data from the two systems benefit both providers and communities, Rauner said. “There are many variables when it comes to assessing workforce needs,” he said. “Each community desires the right care, right time, right place, and the right cost. NORH is continuing to work with communities to develop such a system of care, while working to improve the process and utility of loan repayment programs.”

With the proven success of the loan repayment programs in Nebraska, NORH also has been working to get more healthcare students enrolled in them. “We’ve been trying to simplify it as much as possible,” Rauner said. “We recently combined and changed our loan repayment applications to be a single online application. This will allow NORH to track and process applications for loan repayment and determine the best fit for the provider and the site.”

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 December Branch

Promising Practice: Arizona Center for Rural Health SHAREs Health Insurance Information, Gets People Enrolled

i Oct 31st No Comments by

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.”

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 November Branch

Promising Practice: Team Effort in Idaho Achieves New Funding for Physician Repayment Program

i Sep 28th No Comments by

by Beth Blevins

Remarkably, less than a year after the Idaho State Office of Rural Health (ID SORH) set a goal to find new funding for a physician loan repayment program, the state legislature appropriated $640,000 annually for it.

“It’s something we’re thrilled about,” said Mary Sheridan, ID SORH Director. “I think it points to the reasons we take advantage of new opportunities, even though we may be unsure of the ultimate outcome.”

Mary Sheridan (third from left) with the Idaho team that attended the NCSL meeting last June.

That opportunity was a three-day meeting in June 2017, convened by the National Conference of State Legislatures (NCSL), on “Challenges and Innovations in Rural Health Policy.”  Sheridan attended the meeting along with three Idaho state legislators, the Primary Care Office Program Manager, and deputy administrators from the Division of Public Health and Division of Medicaid.

The NCSL event, funded through a cooperative agreement with the Health Resources and Services Administration, included presentations from rural health policy experts and state-specific team meetings for developing collaborative action plans to improve rural health. Idaho was one of eight states attending.

“Our team there identified three goals: securing reimbursement and funding for community paramedic programs, securing funding for loan repayment, and expanding telehealth,” Sheridan said. “Afterward, the team typically met monthly to share updates and progress on all project goals. The on-going support from NCSL post-meeting was truly helpful in moving the loan repayment legislation forward.” Members of the team are currently working on the other two goals, Sheridan said.

It was a team effort that got the loan repayment legislation to the floor in the next (January 2018) legislative session. “One strategy was for me to provide a presentation on loan repayment and physician shortages to the Idaho legislature’s Health and Welfare committees,” Sheridan said. “Team members made it happen. They worked with legislative leadership to schedule it on the calendar and NCSL actually came to that presentation and lent their support. The Idaho Medical Association worked actively with legislators on the issue and it went from there.” A legislator who was on the team introduced House Bill (HB 472) to fund the loan repayment program.

“It’s remarkable how fast it went, especially when you realize this is the first time we’ve ever had state funding for loan repayment,” she said.

HB 472 provides state funding for the Rural Physician Incentive Program (RPIP), a program that already existed but which had been paid for with student fees‑Idaho students attending out-of-state medical schools in Washington and Utah at in-state tuition rates had been assessed $1,600 per year, which went into the RPIP fund. In order to qualify for loan repayment, physicians must work in a Health Professional Shortage Area (HPSA) in Idaho and receive up to $25,000 per year for four years.

According to the Idaho Physician Workforce Profile, Idaho has a significant shortage of primary care physicians, ranking 49 out of 50 states for physician workforce. “Approximately 98% of the state is designated as a HPSA for primary care and dental, and 100% for mental health,” Sheridan said. “So loan repayment is hugely important for us, and is certainly a tool for recruitment and retention of physicians in rural and underserved communities.” NCSL estimates that the $640,000 loan appropriation will fund about six more physicians per year, more than double the current number.

Sheridan said that she is pleased that so much has resulted from the NCSL meeting, especially since she initially had few expectations going into the meeting. “In fact, when I first got the invitation I thought, ‘if we’re going to just take Idaho there, why can’t we just meet in Idaho and do this very same thing?’” she said. “But I think it was that structure of being away and focused on an issue, of us learning together and having facilitated discussions to create this plan that provided an opportunity to really focus on rural health in Idaho in a very coordinated and collaborative fashion.”

Sheridan added, “The NCSL event provided a unique opportunity to identify Idaho-specific rural health issues. We’re extremely pleased to have participated. It truly provided leverage and new collaborative opportunities to advance rural health in Idaho.”

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.

Promising Practice: Texas SORH’s Handheld Ultrasound Project – An Innovative Approach to Providing Training & Technology to Small Rural Hospitals

i Sep 4th No Comments by

by Beth Blevins

At a rural hospital in Texas last year, a woman’s life was saved when doctors, using a handheld ultrasound device, determined that her abdominal pain was due to a ruptured ectopic pregnancy and were able to act quickly to address it.

The hospital had the handheld unit on-loan as part of an innovative pilot project run jointly by the Texas State Office of Rural Health (TX SORH) and the Texas Tech University Health Sciences Center (TTUHSC). The devices, as well as accompanying training, were offered to Small Hospital Improvement Project (SHIP) hospitals in the state.

TX SORH had received approval from the Federal Office of Rural Health Policy to use $95,000 in unencumbered funds from their 2015-2016 SHIP grant for the project, according to Shari Wyatt, Rural Health Specialist at TX SORH. “We had asked ourselves: ‘what can we use this funding for that will help hospitals?’” Wyatt said.  “The GE Vscan Extend handheld unit had just come out. It’s an innovative piece of equipment that a lot of hospitals hadn’t used or even knew about.”

A Texas hospital participates in a training session.

“I love new technology,” Wyatt continued, “but if you don’t get it into the hands of the rural providers and clinicians, they never know about it. Some of the big vendors don’t bother with small rural hospitals—when you’re rural, you’re the little dog. They’re not really going to pay attention to you. That’s another reason I wanted to do it, so rural hospitals actually got to try out new technology to determine its usefulness in their facilities.”

TX SORH contracted with TTUHSC on the two-year project to help provide training on the devices. “Our state is big so we divided it into four regions,” Wyatt explained. “Texas Tech and I went to those four regions along with a sonographer from GE who did basic training on using the handheld unit.” Providers who could not attend in person were invited to participate in webinar training on the device, she said.

With TX SORH funding, eight Vscan Extend devices were purchased by Texas Tech to deploy to the hospitals that had been trained, for a one-month trial period each. A total of 67 hospitals signed up.

Hospital staff participate in a training session.

“They could use it anyway they wanted to for four weeks—any department, any doctor, nurse, or health care professional,” Wyatt said. “We only asked them to complete a brief evaluation sheet and send it back when they returned the device.”

The project was completed in July 2018, and TX SORH recently received the project completion report. The report reveals that more than 90% of the hospitals found the unit to be extremely helpful, and that the device was used mostly for abdominal scans and OB concerns. In addition, users found that the device was helpful for easier IV placement, for quickly scanning a patient for vascular effusion, and for checking an accident victim for fluid in the abdomen, helping avoid more costly, time-consuming imaging studies.

TX SORH negotiated with a vendor and obtained bulk discounted pricing for those hospitals that wanted to purchase the devices after the trial period. “This gave them the ability to purchase handheld ultrasounds at a price they could afford,” Wyatt said. As a result, several hospitals bought the units, with others planning to purchase the device with future SHIP funding.

“Through the negotiation we also were able to provide one year of online ultrasound training with SonoSim for all employees at the hospitals that purchased the devices,” Wyatt said. “I think online training will make a difference. A lot of the doctors really liked the device, but they wanted additional training for it.”

This is not just a one-time project, Wyatt added. The units purchased for the initial training project will be used in future training initiatives as well, she said.

“Many small, rural hospitals are financially hurting and don’t have the means to purchase innovative equipment, or get the opportunity to try out new products,” Wyatt said. “The handheld unit project gave the hospitals’ providers the ability to use the technology and determine its usefulness within their facilities. I feel that these are the types of projects that truly benefit rural hospitals.”

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.

Promising Practice: Michigan Center for Rural Health Plays Unique Role in Hospital Quality Improvement

i Mar 30th No Comments by

by Beth Blevins

In the quest for hospital quality improvement, the Michigan Center for Rural Health (MCRH) is playing a unique role, serving as a liaison between independent Critical Access Hospitals (CAHs) in the state and the state’s hospital association.

“Usually we hear of SORH (State Office of Rural Health) Flex programs subcontracting work to their local hospital association,” said Crystal Barter, MCRH Director of Performance Improvement. “This is the opposite situation—the hospital association subcontracts with our Flex program. Due to the nature of our work, we have a robust relationship with all 21 of the independent CAHs in the state—our Flex program acts as an improvement liaison for them—so it makes sense for MHA (Michigan Hospital Association) to leverage that relationship as they work to improve patient safety and quality across the entire State of Michigan.”

In September 2016, MHA’s Keystone Center was awarded a (HIIN) contract by the Centers for Medicare and Medicaid Services (CMS). The goals of HIIN are focused on reducing the rates of readmissions and hospital-acquired conditions (HACs) such as pressure ulcers, sepsis, and surgical site infections. Under the contract, the Keystone Center partnered with the Illinois and Wisconsin hospital associations to form the , with the aim of reducing HACs by 20 percent and readmissions by 12 percent from a 2014 baseline.

MICAH QN Member, Amanda Knuth, Spectrum Health Reed City, providing peer education on Infection Prevention and Antimicrobial Stewardship at the MICAH QN Annual Meeting.

“The Keystone Center is a national leader in quality and patient safety,” Barter said. “We’ve had a long partnership with them on a variety of initiatives, but this is the first time they’ve formally sub-contracted with us to ensure that the independent CAHs in our state have a resource outside of their entity to work on HIIN.”

The program builds on what Barter calls a “long-standing quality network” that MCRH, with Flex funding, supports for all CAHs in the state. MCRH hosts quarterly meetings, a listserv, and strategy group meetings for the quality network. “We want to make sure that HIIN work is engrained in the quality network and they don’t feel like they are two separate initiatives,” she said.

Barter continued, “When we talk about HIIN work, it’s more of a cultural change within an organization versus a specific initiative that we’re working on and then move away from. We want it to be the foundation for all of their other patient safety work as well.”

HIIN requires hospitals in the program to follow a matrix, submitting monthly data with the goal of improving their baseline. “What I do on a regular basis,” Barter said, “is monitor the data submission metrics, then work with Keystone staff to put improvement actions into the hospitals based upon the data.”

MICAH QN Executive Committee members holding the Certificate of Achievement recognizing Michigan as a Top 10 State for CAH Quality Performance.

In addition, Barter meets with MHA staff regularly and they attend the quarterly network meetings. “There’s that face-to-face communication that happens quite often,” she said. “We sit down and look at the data and determine if it’s something that can be improved upon by either bringing in a consultant or learning from their peers, or we determine what an appropriate resource might be and go from there. At the end of the day it’s up to the MHA staff to give it the final say because they have the funds, but they do keep us looped in on that conversation and appreciate the insight that we can provide.”

Kristy M. Shafer-Swadley, coordinator of patient safety and quality at MHA Keystone Center, praised the strong partnership between the MHA Keystone Center and MCRH. “We continually apprise each other on any updates, needs, or initiatives,” Shafer-Swadley said.  “MCRH and the MICAH Quality Network have established trust within the group of CAHs, and members feel safe to share and collectively help and support one another. Working together helps our members know we’re a unified team and they can come with questions to either of us.  MCRH and MHA Keystone Center interact with CAHs in different areas at various times, therefore it’s beneficial for us to support each other in order to best support our hospitals.”

Barter said she hopes other SORHs will consider this kind of arrangement because it offers financial benefits. “Absolutely other SORHs could do this,” she said. “SORHs may be used to taking an aspect of their Flex grant and sub-contracting it to the hospital association to implement, and not vice-versa. SORHs can leverage their value and reputation among rural providers to obtain the sub-contracts themselves and get additional revenue.”

Another benefit, Barter said, is the learning opportunities this arrangement affords. “I’ve been able to learn a ton about the concepts within patient safety that before I only knew of in a broad fashion,” she said.  “It’s a good opportunity for SORHs to build internal capacity as well.”

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

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 (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 () 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 —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 to set up a short email or phone interview in which you can tell your story.

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 , 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 (WSFCA), the (PAAW), the (PFFW), and the (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, , 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.