RURAL Home HealthEvery year 7.6 million Americans receive medical care at home through services provided by a home care agency. Home care services are available in every state, but some rural areas are underserved or don’t have the same access to services as patients served by larger urban agencies, according to Amanda Thomas, director of research at the National Association of Home Care and Hospice (NAHC) in Washington, D.C.

Twenty-five percent of home care agencies label their services as primarily rural. Many urban agencies also serve rural populations in outlying areas, Thomas said. A 2004 Policy Analysis Brief, Medicare Home Health Care in Rural America, released by the Walsh Center for Rural Health Analysis found that most home health users were served by an agency in their home county—54 percent of rural residents and 71 percent of urban residents. One-fourth of rural home care users were served by an urban agency or its branch office.

Home health care serves patients of all ages; about 69 percent are over age 65. Medicare is the single largest payer for home health, paying 80 percent of all visits for coverage of patients who have been disabled two or more years and those over age 65.

Tracking the home care industry as a whole is difficult, Thomas said, because agencies are not required to be Medicare certified or to belong to national organizations such as NAHC and/or the Visiting Nurses Association of America (VNAA).

“Medicare-certified agencies must meet established federal requirements,” Thomas said. “However, there are home care agencies that operate under state standards and are not Medicare certified.There are many differences among home care agencies from state to state as far as the types and numbers of services that are offered and the geographic areas of coverage.”

Despite a steady growth overall in the number of home health agencies nationwide, rural areas are generally not the beneficiaries of this growth rate, according to research compiled by the Rural Assistance Center.

This issue looks at some home care agencies that are successfully delivering skilled nursing care in rural areas and at the challenges the industry faces.

Home Health Services Taking Hold in Rural Areasby Candi Helseth

Mona Rickert, a Pediatric Patient Manager with RAVNAH in Rutland, Vt., holds patient Alex Fenton, who has serious respiratory problems.

Nicolas King was six years old when his vision began to fail. Looking for answers, his parents took Nicolas to one physician after another. A year later, they learned their ordeal had just begun. Nicolas was diagnosed with Battens Disease, a rare genetic disorder that leads to total disability and eventually, death. For nearly five years, the Kings cared for their son in their home at Proctor, Vermont. Nicolas died at home Nov. 25, 2008.

Sara King says she and her husband could never have kept Nicolas at home without the support and assistance they received from Rutland Area Visiting Nurse Association and Hospice (RAVNAH) in Rutland, Vermont.

Last year the Medicare-certified agency made 97,000 home visits in its service area, which includes Rutland County and the towns of Dorset and Rupert in Bennington County. Nationwide, nonprofit visiting nurse associations (VNAs) like RAVNAH care for and treat approximately four million of the 7.6 million people receiving care at home for acute illness, long-term health conditions, permanent disability or terminal illness, according to the National Association for Home Care & Hospice (NAHC).

“We’re very lucky in Vermont because of the high tech pediatric program we have,” Sara King said. “I’ve talked to parents in other states who had terminally ill children and their children had to go into nursing homes or stay in the hospital. At first we had help two hours a week but as Nicolas became more ill, they kept increasing the assistance. They were there for us up to that last night.”

Currently, RAVNAH has 13 children in its Pediatric Hi-Tech program. Home visits range from three to 100 hours weekly, depending on patient and family need.

While home health care has been part of the medical scene since the late 1800s, services have expanded and improved dramatically in the last 10 to 15 years, according to Robert Wardwell, vice president of public affairs at the Washington, D.C.-based Visiting Nurse Associations of America (VNAA), which represents VNAs throughout the United States.

“There are many areas where home health is providing services that used to require a hospital stay,” Wardwell said. “Intravenous chemotherapy, infusion medicine and enterostomal therapies are some examples of current home care services that previously required patients to be hospitalized. And advances in telemonitoring have made it possible to manage health for patients with chronic diseases in the home.”

Technology advances capabilitiesAs technology improves and is adapted for home care use, more patients have been able to stay in their homes, with fewer hospitalizations. Technology also has improved the care that home health patients receive between provider visits.

Because his family was able to use medical equipment in their own home to sustain him, Nicolas King was hospitalized only twice in five years for minor outpatient procedures, his mother said. “As his disease progressed, Nicolas had become blind, couldn’t walk or eat and had regular seizures,” she said. “He was on eight different medications for seizure control. Towards the end, he had a feeding tube and was getting medication every 15 minutes, 24 hours a day. What the nurses taught me and how they cared for Nicolas themselves made all the difference in our being able to keep him home with us.”

RAVNAH nurses teach parents and caregivers how to administer care, manage ventilators and do procedures such as changing tracheotomies, suctioning, tube feeding and wound care, according to Pediatric Patient Manager Mona Rickert.

“I’m continually amazed at what parents and caregivers are willing to learn and do to be able to keep a family member or child from being in a hospital or nursing home setting,” Rickert said.

Chronic diseases, such as diabetes, asthma, hypertension and congestive heart failure, are generally associated with high numbers of costly hospitalizations. Eastern Maine HomeCare (EMHC) is improving patient care and reducing costs using telemedicine technology. In the last fiscal year, the program saved the local health system $50,000 as a result of reduced emergency admissions and hospitalizations among home care patients, according to Telehealth Coordinator/Registered Nurse Kim Robertson.

Detecting potential problems earlier also helps reduce unplanned home visits, and travel costs are a major expense for rural home care agencies. Last year alone, EMHC staff drove 1.4 million miles to make 78,098 home visits to 3,729 patients.

“Our chronically ill patients on telemonitors are elderly—their average age is 70—so we didn’t think they would like the telemedicine program,” said Saundra Scott Adams, EMHC executive vice president. “It was a major change for them that required them to be trained to care for themselves and do daily reports. But we’ve found they really like having this personal information and they don’t worry as much between doctor visits.”

Every day at a specified time, Robertson explained, the patient enters data into a monitor placed in his home. Based on the patient’s diagnosis, the data may include various measures such as weight, blood sugar, oxygen saturation level and vital signs, as well as answers to specific questions related to that patient’s diagnosis. The reports are transmitted remotely to the nurse coordinating telemedicine care in EMHC’s 9,953 square-mile service area.

“We’re providing better care at home because nurses didn’t know what was happening between scheduled visits and patients could get into trouble,” Robertson said. “Most of these chronic patients have more than one disease. Now with daily monitoring, we get a report that flags the problems and we take appropriate action immediately. Catching these problems early reduces subsequent hospitalizations.”

Home care is growingNot all home care patients live in a typical home. “Home care patients might live in group homes, senior housing and assisted living facilities, which they consider to be home,” said Amanda Thomas, NAHC director of research. “Many home care agencies may also work in their communities to offer services outside the home such as community education and public vaccinations.”

RAVNAH’s extended services include educational aging programs to help seniors maintain independence, flu vaccine clinics, wellness screenings and a private duty program that offers personal care services, patient transportation and caregiver respite.

The number of home care agencies has grown slowly and steadily since 2000, according to NAHC. Several industry studies, as well as a study by the Joint Economic Committee in 2004, confirm home care is cost effective. Thomas said the cost of 60 days of home care is about $2,600, which is significantly less expensive than a hospital or nursing facility stay.

More importantly, Thomas said, home care services supplement care provided by family and friends, allowing informal caregivers to have some respite from the burdens of providing care. It also allows patients to remain at home and take an active role in their care.

“I haven’t really met anyone who doesn’t fall in love with home care when they experience it,” Wardwell said. “When you see the situations these patients and families are in and how much they appreciate and depend on home care services, it’s enough to bring tears to your eyes.”

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RURAL Home Health

Rural Home Health Care Agencies Stretched to Provide Servicesby Candi Helseth

Diane Giguere, an EMHC HomeCare nurse in Maine, demonstrates telehealth equipment with an unidentified patient.Since two home health agencies in Arizona’s Cochise County closed their doors a few years ago, the home health department at Copper Queen Community Hospital is providing the only home-based services in rugged country where 140,000 rural residents are spread throughout more than 4,000 square miles.

“It just got too hard for the other home health agencies and they closed,” hospital CEO Jim Dickson said. “We’re very rural. But we’ve made the decision we’re committed to continuing home health services. Who else will help these people?”

It’s a question many rural home health agencies are asking as they grapple with increased costs and inadequate reimbursements.

Last summer’s high gas prices contributed to the crunch. According to the National Association of Home Care and Hospice (NAHC), home care and hospice employees make 428 million home visits every year, driving nearly five billion miles. Even though fuel prices have come down, travel expenses continue to be a major budgetary concern for rural agencies. Dickson said 30 to 40 percent of Copper Valley Home Health Care (CVHH) costs are travel-related. Rutland Area Visiting Nurse Association and Hospice (RAVNAH) in Rutland, Vermont, budgets $500,000 a year for mileage expenses, said CEO Ron Cioffi, adding that staff in Vermont’s 12 home care agencies traveled over four million miles last year.

Telemedicine reduces travel costs

To conserve limited resources, home health agencies are looking for ways to reduce expenses without compromising care. Many of them are turning to telemedicine.

Copper Valley Community Hospital applied for and received $183,108 last fall from the Distance Learning and Telemedicine Grant Program administered by USDA Rural Development. Part of the grant monies was used to purchase 18 telemonitors.

“Our patients live on farms and ranches spread all over the country and many of our patients have chronic diseases and need ongoing monitoring,” Dickson said. “A lot of these patients have to drive at least 20 to 40 miles just to see a health care provider.”

The phone- and video-based monitors in patients’ homes decrease patient travel, too. For instance, CVHH has a high number of patients with diabetes. Physicians can visually examine wounds via the telemonitors and prescribe treatment, eliminating patient travel to a clinic and reducing the potential for amputations related to untended wounds. Diabetic and other home patients also can use the monitors to check and enter their vital signs, and to answer specific, easily worded questions about their conditions. Some questions are meant to be educational, so patients can learn more about their disease process. The monitors beep to remind patients when to enter the information. If any of the information entered is out of parameters set by the physician, the agency calls the patient.

“Having these telemonitoring units in their homes reduces their readmission rates to the hospital and if we can eliminate a home visit or two, that cuts our expenses substantially too,” Dickson said. “We’re looking for more grants to purchase more monitors.”

Eastern Maine Home Care (EMHC) consists of four home care agencies that merged into one agency two years ago to achieve better financial viability. “We’re very rural and all our agencies were small,” said Saundra Scott Adams, executive vice president. “With reimbursement issues being what they are, we had to merge for financial survival.”

Telemedicine has helped maintain viability. EMHC launched its telemedicine project in 1999 with a $450,000 three-year Robert Wood Johnson Foundation grant.

“We were the first in the state to do telehealth and that decision was driven by how rural we are,” Scott Adams said. “Our telemedicine program has really helped us achieve better patient care with fewer visits.”

EMHC has 24 telemonitors in homes, all of them funded by grants. A recently approved grant will fund 12 more monitors. RAVNAH has 20 telehealth monitors in patients’ homes and Cioffi said they need more of them.

But telemonitors are expensive and Medicare doesn’t reimburse for telemedicine services. Federal regulations that Medicare uses to establish reimbursement still define home health services as “provided on a visiting basis, in a place of residence used as a patient’s home.” Agencies that provide telehealth home care are often providing staff

time out of their own pockets, or to private pay patients, according to Amanda Thomas, NAHC director of research. One of NAHC’s federal Legislative Priorities, listed on its web site, is for the government to “Recognize Home Telehealth Interactions as Bona Fide Medicare Services.”

“I think telehealth should become reimbursable in the future, hopefully soon, as we may see a lot of new changes with the new administration regarding health reform,” Thomas said. “Home technologies will continue to grow and Medicare is going to see evidence that chronic diseases can be managed better at home and more cost effectively than in facility-based care.”

Reimbursement system must improveShrinking reimbursements, along with staff shortages and mileage costs, are hitting many home care agencies hard. “Medicare’s rural add-ons helped but Medicare has eliminated them,” Cioffi said. “And Medicare is cutting home care reimbursements again. Here in Vermont, the Medicaid state budget is in trouble too. On Medicaid alone, this agency lost over a million dollars in the last two years.”

Medicare is the largest single payer of home health care services and many other payers use Medicare standards for their reimbursement systems, Thomas said. NAHC is lobbying Congress to reinstate Medicare's rural add-on, which expired in January 2007. The add-on provided a 5 percent increase in reimbursements to home care providers that serve people in rural areas.

Additionally, Medicare’s fixed payment rates haven’t been adjusted to accommodate increasing expenses, such as fuel costs and higher salaries necessary to attract employees to a job that often requires them to drive their own vehicle several hours a day on poor roads. In fact, in January 2008, Medicare home health payments were cut by 2.75 percent.

Meanwhile, rural home care agencies do fundraising and grant writing to boost budgets. Cioffi, who meets regularly with Vermont’s legislators and Congressional delegation to increase their awareness of home health needs, encourages rural providers to be proactive and lobby their state legislators to support improvements in home care reimbursements. User demand for home care is growing, these advocates say, and rural Americans deserve services equivalent to their urban counterparts.

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Why Does He Want That Job?I had every intention of writing about something other than the crashing world economy, almost anything else, really. However, as we recently watched that remarkable American ritual of the peaceful transition of political power, my wife uttered a rhetorical question that I could not shake. Watching Barack Obama take the oath of office, she mused to no one in particular: “Why in heaven's name would he want that job?”

Few President-elects have faced such daunting challenges. Arguably, George Washington was one, given that he had to create a nation from scratch and literally define the office of the Presidency. Clearly, Abraham Lincoln was another, having to sneak into Washington in disguise to avoid physical harm from secessionist sympathizers in Maryland. And certainly, Franklin Delano Roosevelt was a third, taking office in March 1933, amidst some 5,000 banks that were failing.

Without question, the Roosevelt-Obama connection is the most compelling. By 1933, total production of U.S. farms and factories had fallen by one-third in real terms, more in nominal terms since prices had also fallen. National income was down by a half. The stock market had lost some three-fourths of its value. The supply of printed money fell by one-third and much of that had been yanked from banks and hidden under mattresses. Unemployment idled 12 million (mostly men), which was some one-fourth of a much smaller workforce, and underemployment and falling wages affected many millions more.

Rural areas were particularly devastated. Of some 600,000 foreclosures, many were farms. Exports sagged to 1904 levels as foreign countries mounted protectionist tarriffs when domestic demand similarly collapsed. Annual farm income dropped from $6.1 billion in 1929 to about $2 billion in 1933. Farmers destroyed crops and dairies threw out milk rather than sell at losses. Bidders at farm foreclosures were run off by neighbors in the hopes that farms would be returned to their original owners.

Fast forward to the world Obama faces. By the last quarter of 2008, we witnessed stock market losses that approached 45 percent. Annualized reductions in overall domestic economic activity ran in the 5 to 5.5 percent range, bad though somewhat less than some of our European partners who were facing 6 percent declines. Banks were facing losses of more than one trillion dollars, maybe a lot more since no one really knows. As revenues fell and spending increased, the accumulated gross national debt grew to 75 percent of GDP (Gross Domestic Product).

Eventually, the flood of bad news impacts real people. Unemployment jumped to 7.2 percent with over 11 million job seekers out of work and perhaps another 8 million under-employed. In a November 2008 report, Sharon Parrott of the Center on Budget and Policy Priorities estimated that, based on previous recessions, some 10 million persons will be thrown into poverty if the unemployment rate hits 9 percent, as expected later this year. Of these newly impoverished, three million will be children and perhaps two

million more kids will suffer what is called deep poverty, where families have access to less than 50 percent of the poverty threshold.

Today’s news suggests that a 9 percent unemployment rate later in 2009 might be the best we can expect. Recently, announced job losses have been running at more than half a million per month. And since the beginning of 2009, layoffs have occasionally hit 50,000 or more in a single day.

Let’s look at rural America for a moment. Through November of 2008, almost all job losses (about 99 percent) were in cities and suburbs even though the unemployment rate was slightly higher in rural counties (6.8 percent to 6.6 percent). However, that might be deceiving. Unlike the 1930s, agricultural employment accounts for about 2 percent of the labor force, not 30 percent. Moreover, farm prices did well through the summer before falling into free fall in late 2008. Seasonally adjusted annualized farm income fell to $346 billion in the last quarter of 2008, from a high of $420 billion in the first quarter. The real pain in rural America may be ahead of us.

When Roosevelt took office in 1933, he was challenged most by the conventional wisdom of his day. Despite all the frenzied activity of the New Deal, his instincts always brought him back to the principles of sound money and balanced budgets. When he finally met John Maynard Keynes (the father of deficit spending to combat recessions) in 1936, he purportedly commented that he did not understand a word that British scholar said. Only the spending generated by World War II bought an end to the Great Depression.

Obama is not as shackled by the same ideological constraints that limited Roosevelt. Still, his options are not unlimited. The federal fund rate is already down to 0 to 0.25 percent, no place left to go there. The 2008 net federal operating cost ran some $1.09 trillion in the red and the accumulated debt (overall assets minus liabilities) now exceeds $10 trillion. Future deficit spending will not be without serious long-term costs and assumes there will be willing buyers of our various debt instruments.

Many historians felt that Roosevelt’s greatest contribution was to calm the public and restore some semblance of confidence. Perhaps that will be Obama’s greatest contribution. Still, like my wife, I cannot help but muse—why would he want that job?

Tom Corbett has emeritus status at the University of Wisconsin-Madison and is an active affiliate with the Institute for Research on Poverty where he served as Associate Director. He has worked on welfare reform issues at all levels of government and continues to work with a number of states on issues of program and systems integration.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Assistance Center.

Professor Corbett welcomes your feedback. Comments and reactions can be sent to: Corbett@ssc.wisc.edu.

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A Proposal for Medical School ReformOur MD-granting “allopathic” medical schools don’t serve us very well. Various panels have recommended that half our doctors should be in primary care. From the 1960s through the end of the century the schools averaged about 30 percent of graduates practicing primary care. In the past decade these numbers have collapsed. With a few admirable exceptions, most of the schools undervalue primary care. They admit few of the sorts of students likely to become primary care physicians. They train medical students in environments in which primary care is poorly represented and less respected. Student interest in primary care decreases in each of the four years of medical school.

Reasons come down to perverse institutional incentives. Years ago a national accreditation official observed that medical graduates are byproducts for allopathic medical schools. The schools’ core businesses are referral care and research. Discretionary resources such as state appropriations go to build the core business. Referral care is very lucrative. Research brings prestige and job mobility for the faculty. Primary care contributes little to either line of business so there are few primary care docs around medical schools in the classroom, on the wards, or on admissions and curriculum committees. (Osteopathic schools do far better at getting their graduates into primary care, though their students face the same opportunities and economic incentives to specialize as the allopathic students.)

It is true that referral specialists are overpaid, while primary care physicians deserve a bit more. Fixing that very major system flaw, though, will go only part way toward fixing the primary care problem. Our primary care problem predates that reimbursement failure.

I managed MD school programs and represented them before legislatures for most of my working life. I am inclined to go on at great length about these institutional failings and the perverse incentives behind them, but that would be a waste of this space and your attention. Instead I’ll propose a remedy.

First design consideration: Half of the 126 MD-granting schools are state-owned and get state appropriations. These appropriations may constitute only 3 or 4 percent of their annual budgets, but the appropriations are important. They are controlled by the administration instead of the department chairs and are relatively movable. The fact that most medical center money comes from outside sources reflects the wealth of research

and referral care rather than insignificance of the appropriations. In many schools these “program receipts” may be deposited in many different accounts in many different places, often entirely outside any state oversight. I don’t know of other government institutions in this country that are permitted to earn unlimited amounts of money without oversight. Perhaps I should state that I regard state universities including their medical schools and teaching hospitals as public utilities—very complex and sophisticated, but nonetheless publicly accountable.

Second design consideration: Most state medical schools and academic medical centers have their state legislatures outgunned. Academic medical affairs and business practices are too complex for most legislators. Most states lack workforce data. Medical school deans are accorded great deference by legislators for reasons that always escaped me. Some of my bosses were truly admirable people. Some weren’t.

The third design consideration: The federal government has the data resources to know how the medical schools are doing in terms of graduates’ practice patterns. It also has a legitimate interest in improving the schools’ performance. It is by far the largest payer of health care bills in the country, and should be helping all of us get better value for our health care investment.

The proposal: A State/Federal Partnership in Health Professions Education. The states which wish to enter the partnership should set standards for the percentage of graduates of their state medical school practicing primary care anywhere in the country five years after graduation from medical school. End the annual charade of medical school representatives reporting the numbers of graduates “going into” primary care, since most keep going straight into subspecialty training. States should put the schools’ annual appropriations on a formula driven by that previously negotiated workforce production figure.

The federal government will, for states accepted into partnership, provide workforce data and analysis and share in the cost of the states’ appropriations to the schools. Note that the funds should go to the state, not to the school. The essential element is the owner states’ oversight of the performance of its health professions schools. It’s also important that state governments stay out of admissions and curriculum issues, confining themselves to outcome accountability. The model may be adjusted and extended to meet a variety of health professions workforce goals. Targets would be negotiated several years in advance, phased in and adjusted periodically.

Precedents for such partnerships are not numerous but do exist. One is the system supporting colleges of agriculture in our land grant universities.

If 65 state medical schools receive an average annual state appropriation of 40 million dollars each, the federal government might pay half of that for partner states, about $1.2 billion dollars per year. Not all the states will join the partnership, reducing the figure. A billion dollars is quite a bit of money, but compare it to our $2 plus trillion health care bill, much of it squandered on and by our overspecialized physician workforce.

Wayne Myers, a pediatrician, founded the University of Kentucky Center for Rural Health and served as its director. He also served as director of the Office of Rural Health Policy in the Department of Health and Human Services’ Health Resources and Services Administration. He is a past president of the National Rural Health Association.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Assistance Center.

Dr. Myers welcomes your feedback. Comments and questions can be sent to him at myers@raconline.org.

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Clinic Serving Low-Income Children Inspires Rural Dental Practiceby Candi Helseth

Dental student Joshua Whetzel, center, celebrates a successful procedure at the Floyd County Health Department Regional Dental Clinic in Rome, Ga. Also pictured: Dr. Charles Roszel, right, and dental assistant Vienna Watkins, left. (Whetzel is now a dentist).

A rural Georgia dental clinic built to meet the needs of low-income children is also inspiring dental students to practice in rural settings. Four dental school graduates who did rotations at the clinic chose rural public health careers, saying they made their

decisions based on their experiences at Floyd County Health Department Regional Dental Clinic in Rome, Ga., which opened in the fall of 2005.

“When you look at the extreme shortages of dentists in rural areas, it’s pretty impressive that we have four students who chose rural health based on their experience at this clinic,” said Margaret Bean, District Program Manager of the Dental Health Network Partnership (DHNP). “We also have some current students who are considering rural health practices.”

About 5,000 children have received treatment since the clinic opened. DHNP, a coalition of several area providers, formed in 2004 to find a solution that would provide affordable care for rural low-income families and particularly, untreated children. By combining their resources, they were able to build and open the clinic in just a little over a year. DHNP also staffs and maintains the clinic.

“By equipping the clinic as a model practice with an electronic practice management system, state-of-the-art equipment, and five treatment rooms, it became attractive for the Medical College of Georgia (at Augusta) to use the clinic as a training facility,” said Dr. Charles Roszel, a dentist and anesthesiologist. “Our students will treat more serious dental disease than 65 percent of their professors do in their careers. I don't know of any externship offered by any dental school in the country to their undergraduates that covers the things we do and gives dental students a chance to see and treat the kind of complicated problems we see in this clinic.”

Oral health education and preventive services are important to the clinic’s mission. In addition to routine dental care, restorative, surgical and anesthesia services are also provided. Dr. Roszel heads the clinic and Dr. Michelle Martin oversees a mobile van practice that DHNP continued.

“Even when children in this region did get access to dental care in the past, they frequently needed general anesthesia because their oral health problems are so advanced,” Bean said. “The mobile dental clinic traveled to schools, but its services touched a fraction of the children who needed care and there were virtually no options for follow-up care. Only four dentists in the five-county region accepted reimbursements from Medicaid or Peach Care (Georgia’s low-income child health insurance program). We’ve been fortunate to find staff that can provide advanced dental services.”

Clinic patients live in Floyd, Walker, Gordon, Polk and Haralson counties. The latter four counties are all designated as medically disadvantaged, underserved areas and Floyd County has a shortage of dentists and limited care opportunities for low-income families. The DHNP coalition collaborates to provide tangible resources at lower costs. For instance, Floyd Medical Center donates six hours a week of operating room time for young children. The hospital’s public relations department also assists with public education and communications. Rome-Floyd County Commission on Children and Youth (RFCCCY) links the dental clinic with children and youth-oriented area agencies and provides prevention education, clinic referrals and transportation for dental services.

Coosa Valley Technical College at Rome assigns students in dental-related fields to do clinic rotations and work at health fairs and public prevention programs. Northwest Georgia Public Health District 1:1, which originally operated the mobile dental clinic that provided emergency treatment and a school-based sealant program for low-income families, continues to assist with the clinic’s mobile services.

Vienna Watkins, left, and dental student Amelia Granbury (now DDS), right, work on a pediatric patient at the Rome clinic.

Additional DHNP partners include Georgia Highlands College, RFCCCY, Dr. Arleen Wyatte (evaluation consultant), Angela Moore (prevention specialist from the Centers for Disease Control and Prevention), and the county health departments of Walker, Gordon, Floyd, Polk and Haralson counties. Bean said all the network partners have been invaluable to the project’s success.

DHNP funded the clinic through partnerships and a three-year $600,000 HRSA (Health Resources and Services Administration) Rural Health Outreach Grant. The Georgia Board of Health and District Health Office included physical space for the clinic in its new $9.5 million health department facility. Funds from the HRSA grant covered clinic design and some equipment purchases. The grant also totally funded the first year’s salaries and a portion of salaries in the second and third years of clinic operations.

Now that the grant funding has expired, DHNP has developed a business plan to maintain the clinic’s viability. Staff salaries are dependent on generated fees and self-pay patients are billed on a sliding fee scale, Bean said. Clinic revenues come from diversified funding such as Medicaid, Peach Care, private insurance, and credit card and cash payments. The clinic has to collect $623,787.15 annually to maintain current operations. As of July 2008, the clinic had $79,000 in reserve.

“We believe this program is definitely a best practice model for increasing access to oral health services for low-income populations and for providing comprehensive training services for dental students and dental assistants,” Bean said.

To learn more, call Margaret Bean at 706-295-6652.

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AROUND THE COUNTRY

Campaign Targets Unnecessary Hospitalizations Among Home Health Clientsby Candi Helseth

Dr. Paul McGann, a medical officer at CMS, says the agency is aiming to reduce home health hospitalizations through its latest quality campaign.

Every year, the number of avoidable hospitalizations among home health patients continues to increase. The Centers for Medicare and Medicaid Services (CMS) is working to reduce that trend through its Quality Improvement Organizations (QIOs) Program. Specifically, the program has introduced a three-year campaign (called the 9th Statement of Work, or 9th SOW) with a goal to reduce acute care hospitalization rates in participating communities by 2 percent.

Currently, more than a quarter of Medicare's 2.9 million home health patients are admitted to the hospital every year and more than one in four home care patient episodes ends in a hospitalization.

“Rural home health needs are among the top quality improvement priorities we are looking at,” said Dr. Paul McGann, a CMS internist and geriatrician. “We’ve heard from rural providers that making certain technologies mandatory to participate in these studies can create an affordability issue for them. So when we develop best practice models in this next phase of our campaign, we are trying to be sensitive to rural needs.”

The 9th SOW campaign, which began Aug. 1, 2008, and will continue through July 31, 2111, evolved out of issues identified during the agency’s Home Health Quality Improvement (HHQI) program conducted in 2007. The one-year program aimed to reduce avoidable hospitalizations and improve patient care; it included key home health, hospital and physician stakeholders. Approximately 70 percent of the nation’s 8,100 Medicare-certified home health agencies voluntarily participated.

“Among the 5,590 participating home health agencies, we achieved a decrease in avoidable hospitalizations of only 0.09, which was a little disappointing,” McGann said. “But when we checked the 30 percent of non-participants, there was a 1.1 percent increase again. We interpret our campaign as a cautious sign of progress that we did manage to reverse that trend line somewhat.”

CMS created quality improvement educational tools for participating home health agencies and made those tools available through its web site. McGann said 12 topics were selected, based on a study that revealed causes for unnecessary rehospitalizations.

“Improper medication management is a principal cause of unnecessary hospitalizations,” McGann said. “The numbers are staggering with estimates that show between 20 to 40 percent of elderly people are taking unnecessary or conflicting medications. Our Best Practice Intervention helps home health agencies learn how to address that issue at the time of the patient’s admission. Each of the 12 best practice models addresses one of the root causes of unnecessary hospitalizations.”

In addition to medication management, other topics addressed included hospitalization risk assessment, telemonitoring, physician relationships, emergency care planning, teletriage, fall prevention, patient self-management, disease management and transitional care coordination.

McGann said the one-year HHQI was too brief to allow for dramatic improvement to be measured. However, CMS did achieve accomplishments such as perfecting the web site and moving to electronic registrations. “We achieved a lot of efficiencies and improved communication with home health agencies. We believe that contributed greatly to the fact that we had 70 percent participation.”

McGann said that home care agencies can still access those materials free even if they didn’t participate in that HHQI campaign through the HHQI Best Practice Intervention Packages web site.

CMS also has created quality improvement educational tools and a searchable online resource center to support activities to improve care in many health settings through its Medicare Quality Improvement Community (MedQIC) web site. The Home Health section of the web site is devoted to improving quality in home health settings and offers performance measures, success stories and other information on quality improvement measures.

“What we’ve heard from rural providers is that they really appreciate the web-based approach to QI,” McGann said. “Even five to six years ago, this was not a big part of our approach. But making this information and these interventions available on the Internet has improved (their) accessibility.”

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Alan Morgan, MPAAlan Morgan is the Chief Executive Officer at the National Rural Health Association (NRHA), where he serves as a policy resource for the national media, as well as a presenter at both national and state health conferences. Morgan, who joined the NRHA staff in 2001, has more than 17 years experience in health policy development at the state and federal levels, including working for former U.S. Congressman Dick Nichols and former Kansas Governor Mike Hayden. His health policy articles have been published in multiple health journals.

Morgan earned an MPA from George Mason University and a BS in journalism from University of Kansas. He has just begun work on a PhD in Health Policy Research at George Mason.

He lives in Northern Virginia with his wife Kathy (who volunteers at the local hospital) and their three sons. In his spare time he enjoys golf, gardening, watching movies and going to the beach. He is also seriously interested in University of Kansas and George Mason basketball, as well as Nationals baseball. In addition, he says that his family plays a lot of the video game “Rock Band” together on weekends, performing such fare as Van Halen, Poison and Jon Bon Jovi, with some Lynyrd Skynyrd occasionally thrown in.

What led to your interest in health policy and, specifically, rural health policy?My mother worked in the billing office of the rural community hospital, and she also had four open heart surgeries so I spent a lot of time growing up around hospitals. Because of this, I’ve had an interest in health care since I was a kid. From that perspective, you see what quality health care can mean for people, especially people living in rural areas. When applying for a Congressional Aide job in 1991, health care was one of the issues I chose to handle, and I have been involved in health care policy since that time.

Does being a native of Kansas strengthen your perspective on rural health issues in any way? I’m from Holton, Kansas, which has a wonderful Critical Access Hospital. I think the fact that I’m the fifth generation born and raised in Holton (and all my relatives still live there) has put a personal perspective on the issues I work on today.

Growing up, Holton only had one stoplight, and one blinking light. Now it has two stoplights, so it is still rural.

How did you get from Kansas to Washington?I have a degree in journalism and interned at the Emporia Gazette and the Holton Recorder. I planned to become a reporter, but I had an internship in the Governor’s office my last semester in college and was offered a job there after graduation. When he lost his reelection bid, I packed two bags and came to Washington, D.C., looking for work. I was fortunate to land a job my first week out here with the new Kansas Congressman, Dick Nichols.

How has NRHA changed since you started working there? NRHA is simply a different organization today. During my first Board of Trustees meeting at NRHA in 2001, the Board discussed the option of temporarily shutting down the association. We were without an Executive Director and we were badly in debt. The membership at that time was around 1,200, and we were borrowing money to make payroll. From an advocacy perspective, there was only a staff assistant and me in the D.C. office.

Today, we have a staff of 15 and we’ve maintained a retained budget surplus for the past four years. Our membership is above 17,000. Simply stated, we now focus on achieving our mission of improving rural health, rather than stewing on how we “keep the doors open” at NRHA.

To what do you attribute its growth and success?I wish there was an easy answer to the recent success of NRHA. But the reason for the growth comes from a combination of the highly qualified staff I work with at NRHA, voluntary leaders on the Board with vision and a collaborative organizational culture within NRHA. There is a great relationship and trust between staff and the Board of Trustees. That trust has allowed staff to launch new educational conferences, engage in new grant activities and attempt new membership recruitment strategies. Growth has occurred throughout the organization, so there is no one specific reason or activity that I can point to for this success. It is very much the effort of many.

What does the CEO at NRHA do?My primary job as CEO is to ensure that the Board-approved association work plan is completed each year, and that we remain focused on our vision as an association. I serve as the primary contact for the national media, and I oversee the day-to-day operations.

What are some of the things you’ve accomplished at NRHA, or for which you are most proud?Looking back at the past four years as CEO, I am most proud of the amazing growth of the organization, the outstanding staff that has joined NRHA during this time and the caliber of volunteer leaders that have engaged in NRHA as well. When things go well within an organization, good things happen. The good simply get better, and that has been the case at the NRHA.

What is NRHA focusing its efforts on for the next year?Actually, that can be answered in the document, NRHA 2009 Legislative and Regulatory Agenda, which can be found on our Legislative and Regulatory Agenda web page.

Why does the NRHA have offices in Kansas City and D.C.? What’s the difference between the offices?The NRHA D.C. office focuses primarily on government affairs and policy, while the KC office focuses on administrative functions of the organization. It’s my opinion that for a national organization to be successful in advocacy efforts, you must maintain a D.C. presence. However, to bring all of the administrative functions into the D.C. office would be cost prohibitive for an organization of our size. I would assume this is the same reason that most national associations have a similar two-office arrangement.

If you had a wish list you could present the new administration, what would the top three items be on the list?

1. Increased funding for federally funded rural health programs.2. Adequate and fair payment policies for rural providers.3. The implementation of a comprehensive federal workforce policy with a strong

linkage at the local level.

What do you think is the biggest challenge facing health care in the United States in the next five years?To me, it seems that the issue of attracting, training and retaining a quality health care workforce remains the biggest challenge for our nation’s health care system in the next five years. This issue gets to the heart of quality, access to health care and the retention of expertise within the system. Obviously, workforce shortages have long been an issue for rural America, but now we are seeing that this is an issue throughout our health care system.

— Interviewed by Beth Blevin