Written by Angie LaFlamme and Bridget Hart, National Rural Health Resource Center. This content originally appeared on the 3RNet website.
The 3RNet’s mission is to connect health care professionals searching for jobs in rural or underserved areas with health care facilities. They strive to find the right job for professionals in areas where they will live and work comfortably. Some health care professionals entering the workforce have come from large, urban areas and have never practiced in a rural community. But, for University of Minnesota medical students participating in the Rural Physician Associate Program (RPAP), this isn’t the case.
RPAP is a nine-month, community-based educational experience for third-year medical students. Not only does it allow them to train in rural communities, RPAP students and their families get to experience all aspects of rural community life by living in their host towns during the training period.
“RPAP was one of the most valuable experiences of my training,” said Maren Anderson, who participated in RPAP in fall 2016. “I've always felt I would be best served by training in the environment I plan to work in and for me that is rural Minnesota. I knew I was in the right place when we walked down the hallway of physician offices and they pointed at nearly every door, identifying that physician as either a University of Minnesota graduate, RPAP alumnus, or both. I was the only medical student there which gave me the benefit of the undivided attention of not just one preceptor or attending, but every practitioner I came into contact with.”
RPAP students experience hands-on learning as they care for patients of all ages. They learn clinical medicine, procedures, community health, and the business of medicine. Students experience the full spectrum of rural medical care as they follow patients and their families through a disease process or pregnancy. “In the course of a day I might start the morning with an early surgery or c-section, then start clinic, possibly see a patient or two in urgent care, get called to the ER to sew up a laceration, finish out clinic and write my notes, visit a patient or two on inpatient, and then wrap up the day with a delivery,” said Maren of her RPAP experience.
“I truly felt like a member of the team and got to know my patients and my fellow health workers. I felt so incredibly valued and supported during my time there. I also felt like I became a part of the community in a way that I haven't found since moving out of my hometown,” said Maren. “My official preceptor would have me over to his house for dinner regularly and I helped his family shear sheep to get ready for the fair. I joined a church choir there and a number of choir members became my patients, eagerly announcing to me during practice, ‘I'm coming to visit you next week!’”
From populations ranging from 350 to 30,000, over 110 Minnesota communities have participated in the program as teaching sites with a majority having at least one RPAP alum. Practices vary from small family medicine clinics to large multi-specialty outpatient centers, and hospitals ranging in size from 15 to 140 beds. Students see patients in clinics, hospitals, emergency rooms, nursing homes, hospice, at home, and in the community. Each student is the only student in a community and therefore has a greater opportunity to gain hands-on experience in a variety of procedures and specialties.
“When the Minnesota legislature sought a solution to the need for more rural physicians – particularly Family Physicians – in the late 1960’s, they were wonderfully wise to fund the establishment of the University of Minnesota Medical School’s Duluth campus program and the Rural Physicians Associate Program,” said Jim Boulger, Ph.D., Distinguished University Teaching Professor from University of Minnesota Medical School. Since RPAP’s inception in 1971, over 1,300 students have participated in the program, resulting in two out of three former students practicing in Minnesota, two out of three practicing in rural locations, and four out of five practicing primary care.
Statistics show that health care professionals with an educational background in rural areas are more likely to practice in these areas once they enter the workforce. “These programs have been extremely successful models for training our rural Minnesota medical workforce. Now having trained more family physicians – many of them RPAP graduates - than any other medical school in the United States, the University is a proud partner with greater Minnesota in providing care for all of us,” quoted Dr. Boulger.
Former RPAP student Maren states, “RPAP solidified my faith in my decision to become a rural physician because, for the first time since starting medical school, I felt that I actually understood what it means to be a rural doctor and how that shapes your life—and now I can't imagine wanting to do anything else.”
University of Minnesota, Duluth and Twin Cities Campus’ medical students with an interest in family medicine, primary care, or rural medicine specialties are strongly encouraged to apply to the Rural Physician Associate Program. Visit the RPAP website to learn more about the Rural Physician Associate Program, or if you have interest in supporting the Program.
Aligning and streamlining your planning efforts for long-term success
This article was written by Bonnie Noble, PhD, RN, Founder of The Ondina Group, for the April 2017 edition of “Networking News.” The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center.
We’ve all heard that familiar quote, “Failing to plan is planning to fail." This is likely a contemporary paraphrase of one of Benjamin Franklin's quotes: "By failing to prepare, you are preparing to fail." And then, of course, Winston Churchill said, "He who fails to plan is planning to fail."
OK. You get it. You know planning is important. But, sometimes it feels as if we can spend so much time planning that we don’t have time to get anything done. And, what about all those plans required when we’re seeking funding? Just the other day, a client commented on how the funding agencies “require an odd collection of similar-looking documents—Strategic Plan, Logic Model, and Action Plan.” She groaned when I replied, “Don’t forget about the Evaluation Plan and the Sustainability Plan.”
This “odd collection of similar-looking documents” each have a specific purpose and make an important contribution to program and organizational success. Moreover, it is helpful to understand how these various plans fit together in a sort of “less is more” approach that provides simplicity, clarity, and good design while streamlining your planning and writing efforts.
First, let’s briefly examine the key purpose for each one of these plans.
So, how do these plans overlap with and link to one another? The following Planning Crosswalk describes, visually, how these various plans are related.
It is important that these plans are aligned and integrated. For example, your three- to five-year program goals and strategies identified in your Strategic Plan align with the program-specific impact and outcomes in your Logic Model(s). Likewise, your Work Plan is a more detailed description of the initiatives outlined in your Strategic Plan and the activities described in your Logic Model.
The usefulness of each of these planning tools is enhanced by regularly consulting and comparing them. Developing, linking, and using these planning tools will help to ensure that your programs, and your organization, remain focused on its core mission and reaches its goals and vision.
Two important Baldridge program concepts are especially useful here—alignment and integration.
Examples of alignment and integration include linking key goals and objectives in your overall organizational Strategic Plan and your program Logic Model(s). Then, the Work Plan provides more detail on how your stated objectives will be achieved and who will be responsible for doing the actual day-to-day work. Likewise, the Evaluation Plan is a drill-down on how you will collect, analyze, and report data to ensure you remain on target towards reaching stated goals. Finally, the Sustainability Plan describes what actions you will take to ensure long-term viability of your program.
There is great value in aligning and integrating this “odd collection of similar-looking documents,” and doing so will enhance the effectiveness of your organization and its various programs. And, of course, you will more efficiently utilize the most precious resource—your time.
Bonnie Noble, PhD, RN, has an extensive background in the healthcare industry, with more than 30 years of experience working in a variety of healthcare organizations. She has expertise in many quality and performance improvement methodologies, is certified in patient safety, and is a certified professional in healthcare quality. Bonnie has served a National Examiner for the Baldrige National Quality Award and also has managed large federal contracts with the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ). She currently serves as the project director for the Mendonoma Health Alliance, a grantee of the Rural Health Network Development Planning Grant Program through the Health Resources and Services Administration (HRSA).
[i] Balanced Scorecard Institute. Retrieved March 1, 2017 at http://www.balancedscorecard.org/Resources/Strategic-Planning-Basics
[ii] W.K. Kellogg Foundation. East Battle Creek, Michigan. 2004. https://ag.purdue.edu/extension/pdehs/Documents/Pub3669.pdf
[iii] Developing an Effective Evaluation Plan. Atlanta, Georgia: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; Division of Nutrition, Physical Activity, and Obesity, 2011.
[iv] The Grant Helpers.com. Five Key Elements of an Effective Sustainability Plan. 2014. Retrieved on March 2, 2017. http://www.thegranthelpers.com/blog/bid/204687/The-Five-Key-Elements-of-an-Effective-Sustainability-Plan-for-Grants
[v] Baldrige Performance Excellence Program. 2017. 2017–2018 Criteria for Performance Excellence.
Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology. http://www.nist.gov/baldrige
This article was written by Linda K. Weiss, LCSW, Director of Member Services for the National Cooperative of Health Networks Association (NCHN), for the March 2017 edition of “Networking News.” The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center
We all know that communication is one of the keys to success for many endeavors, including, but not limited to, personal and professional relationships, sports, social events, education and business. In the world of rural health, telling a network’s story and communicating the resulting benefits of its activities should be done early, often and in a variety of formats. This applies to networks of all ages, sizes, stages, compositions and locations. Communicating the impact of the network’s collaborative efforts is an ongoing task and should be a component of a written communication plan.
Different priorities for different audiences
To whom do you need to communicate the impact of your network’s activities? For starters, it’s important to include all of the following:
The network’s members are most likely going to view things from the lens we commonly refer to as, “What’s in it for me?” This does not mean that they are not committed to the network or its collaborative efforts, but that they are held accountable for business decisions and ventures by their own, separate governing body. If the return on investment (ROI) isn’t there, they are less likely to remain engaged and a part of the network.
The board, or governing body, of the network is obligated to make visionary and guiding decisions on how the network operates. In order to do that effectively, they need to rely on solid information supported by data.
All persons filling positions in the network, whether they be paid or volunteer, should also receive regular information regarding the fruits of their efforts. This type of feedback can assist with buy-in, innovation, dedication and morale.
It’s important for community members in the service area to be made aware of the positive ways the network is impacting where they live. Increasing people’s awareness of the collaborative efforts organizations are making may have ripple effects, from increased donations to improved reputation, to becoming a preferred place of employment.
Typically, funders provide applicants information regarding what type of data, reporting format, reporting due dates, and method(s) of reporting in regard to the activities and impact of activities supported with their funds. Capturing and tracking this information from the start makes reporting back to the funders much more efficient and accurate.
As the network grows, additional partners or members may be sought. Being able to quickly and effectively inform potential collaborators about the successes of the organization and how they might contribute to and benefit from the network can expedite their decision. Again, this decision will most likely come down to the potential ROI.
Using visual elements to support your data
How do you effectively communicate the results of the network? Visual aids are commonly used to enhance verbal messages. These tools, which range from bulleted lists, to a variety of pictures, graphs, charts and diagrams, can succinctly highlight information. Adding visual images to verbal communications provides listeners data in two formats, activating different parts of their brain to receive and make use of the information. The key to using visual aids is to make them easy to read and understand. They need to clearly communicate “at a glance.” Having too much information that readers must study defeats the purpose of such a tool. Be sure any key codes (color, shape, symbol, etc.) are clearly identified.
For example, here is a bar chart (Graph 1) that quickly and easily depicts the annual growth of a network’s service volume through the first five years of its inception. A chart such as this effectively communicates the network’s successful growth to funders, members, staff, the board and the community at large. Even if they don’t remember the numbers, the image of the orange bars increasing in height is likely to stick with them.
Graph 1. Annual growth of the network’s service volume through the first five years of its inception
Similarly, the following pie chart (Graph 2) quickly conveys the improved continuity of care resulting from this network’s efforts.
Graph 2. Continuity of care
As the saying goes, a picture is worth a thousand words. And in the hustle, bustle world of rural health networks, communicating the results of the organization’s hard work efficiently and effectively is a skill worth improving.
Linda K. Weiss is a Licensed Clinical Social Worker with over 25 years of direct service, supervision and management experience. As a former network director, Linda was instrumental in the original design and implementation of a 24/365 behavioral health crisis services delivery system. Linda earned an MSW from the University of Illinois at Urbana-Champaign and is a graduate of the Johnson & Johnson/UCLA Health Care Executive Program from UCLA’s Anderson School of Management in Los Angeles, CA. Linda has been Director of Member Services for the National Cooperative of Health Networks Association, Inc. (NCHN), since 2015. NCHN is a national asociation of health networks and strategic partners whose mission is to support and strengthen health networks. Founded in the late 1980s, NCHN was incorporated in 1995.
Written by the staff of MHP Salud. A version of this article originally appeared on the MHP Salud blog.
There is no question that the Community Health Worker (CHW) movement has expanded its profile in recent years. From the front lines of the Ebola fight abroad to the constant changes in health care reform here at home, the profession gained profile, utility and respect.
Less prominent, but equally important, has been the growing role of the CHW supervisor. Supervisors are an indispensable component of the CHW profession that requires as much attention, care and training as the CHWs themselves receive.
With more than 30 years’ experience designing, running, evaluating and improving CHW programs, as well as more than 20 years’ experience spreading that knowledge via technical assistance to other organizations around the country, MHP Salud has gained insight, experience and a deep understanding of CHW supervision.
From all our experience, we collected this list of six tips for supervision success, which includes insights from MHP Salud staff who supervise CHWs every day. These six tips can be used to strengthen, solidify and promote the CHW model through the professional development of their supervisors.
1. Not everyone is right for the role.
Just as CHWs must possess innate qualities and life experiences to be successful, their supervisors need some baseline skills and qualities as well.
First, if a CHW supervisor is working with a population that is multilingual, the supervisor must have the ability to communicate in the language used by the CHWs he or she supervises. Additionally, in order to read the landscape of the community served, he or she should have a strong knowledge, understanding of or experience with its culture.
Solid time management and independent working skills are also vital to serve as an effective CHW supervisor. Much of a program manager’s day is spent juggling CHW supervision, reporting to funders and the organization and attending local meetings in order to maintain community partnerships and relationships. These broad responsibilities are only effectively met through careful planning and an ability to prioritize independent work.
Apart from life experience and skills, MHP Salud’s Chief Programming Officer Colleen Reinert says there are some innate characteristics needed. “In relation to specifically supervising the CHWs,” she said, “I would say the most important thing is to trust the work of the CHWs.”
To maximize their impact, CHWs spend much of their time away from the supervisor out in the field. Because of this, neither role will function if a supervisor constantly checks that the CHWs are doing what they said they would be doing. Regular check-ins and management tools are still necessary in CHW supervision, but without trust, no one will be able to get their work done.
Reinert says flexibility is also key. “The work of CHWs is not necessarily a nine-to-five job,” she said, “so a supervisor has to also be flexible in the work that their CHWs are doing.” For example, CHWs may not be able to come into the office at a set time in the morning if they stayed out late the night before at a health fair event. The CHWs are inherently flexible around the schedule of the community they serve, and the supervisor must mimic this flexibility.
2. It’s different from other supervisory roles.
Apart from the other organizational requirements for employees, Reinert says a good CHW supervisor needs to be able to recruit quality CHWs. This requires an ability to spot those characteristics that make a CHW successful: compassion, trustworthiness, empathy and the abilities to motivate other individuals and navigate the health system and social services. “Identifying these things isn’t something you can learn at school or receive training on,” said Reinert.
Once hired, measuring and understanding the CHWs’ performance requires additional specialized skills and experience. Good supervision might include holding team and individual meetings to grasp the realities on the ground in the communities served and the CHWs’ impact on it.
“In another position, effective work might be monitored via sales, or number of phone calls, but in CHW programs, there might not be something so concrete,” said Reinert. “It’s more of an art and less of a science.”
CHW supervision hinges on the supervisor understanding that even though a CHW’s impact may not be as clearly legible as other roles in the health care field, a good supervisor will seek to understand this impact through trust and the ability to listen. “Something I have seen over the years is, as much as CHWs appreciate support and seek support, they’re also generally not very willing to express concern when they’re not receiving the support that’s needed,” said Reinert.
She says it is important for managers and upper managers to remember to ensure that there is that time or environment to allow the CHWs to express their needs or concerns that they have within the community and within their organization.
3. Good CHW supervisors champion the work of their staff.
As the CHW movement is expanding and being applied in a larger variety of organizations, health care systems and federal governments, it will be key to find ways for both CHWs and their supervisors to maintain the integrity of the CHW profession. “I don’t want to see it turn into something that it’s not,” said Reinert. “Supervisors have a huge role in ensuring that that doesn’t happen.”
To successfully do this, the supervisor must understand the work of a CHW. They may have been a CHW themselves. If not, they need to have spent enough time getting to know the work of a CHW so that they can appreciate the unique role CHWs play and the challenges and successes that come with that role.
It is also important that supervisors advocate for their CHWs—both internally and externally. Within some organizations, like MHP Salud, who are wholly focused on and invested in the CHW model, advocating for the role of their staff may not be a challenge. In others, such as hospital systems, CHW program services may be a small component of the organization’s work. In these cases, the rest of the employees may lack a full understanding of what a CHW is actually doing, and it is often up to the supervisor to educate them.
Supervisors are also key in promoting the CHW professional movement outside of their own organization. “It is important to have CHWs participate in conferences, whether to present on their own program, to network or to gain more professional development,” said Capacity-Building Assistance Program Director Anne Lee.
Experienced supervisors who understand the CHW point of view can also amplify that viewpoint in group-settings to ensure that the CHW voice is heard.
Instinto Maternal Program Director Randi McCallian says she has learned that supervising CHWs is about more than simply ensuring a job gets accomplished.
“As a supervisor, I try to remember that my role is two-fold,” said McCallian, “to reach program goals and ensure fidelity to the program plan, but to also allow for the professional growth and experience of those I supervise.”
4. There is more than one way to run and supervise a program.
As the profession grows, it is increasingly common for programs to employ CHWs with varying levels of responsibilities. A multi-tiered model is used to distribute the responsibilities of CHWs based on the time commitment and expectations of their position, which can range from a part-time volunteer to a full-time staff member.
When used effectively, this model allows a program to maximize resources, extend the reach of CHWs and create a greater program impact. “Regardless of the CHW tier,” said Reinert, “what’s important to remember is that all CHWs still require a supervisor, coach or mentor—somebody providing support.”
Just as program form can vary, so can the communication between supervisors and their CHWs. With recent advances in technology, it is easy to have proper communication with the CHWs if they receive appropriate tools. “Several years ago, it could have been that a supervisor sends an email a CHW, and it took a week for the CHW to get access to the email in order to respond,” said Reinert.
These days, especially if an organization can provide proper communication to a CHW, such as a smartphone and internet services, it’s possible for a CHW to remain in the field and communicate with their supervisor remotely a majority of the time.
Though Colonia Community Project Program Director Moises Arjona, Jr. spends the majority of his time supervising CHWs remotely while they provide door-to-door outreach in the field, he finds it invaluable to change up his supervisory style occasionally and shadow his staff in the field in order to understand the realities of their work up close. “Once you actually work alongside the CHWs, you can appreciate the work that they do and see the barriers they encounter,” he said. “For example, I saw what it was like to go along door-to-door and have the door closed in my face constantly.”
5. Initial plans don’t always pan out, and that’s okay.
With more and more health agencies adopting CHW programs of their own as a way to address social determinants of health, lofty program objectives are sometimes hampered by realities on the ground.
“Often, a development team has designed a program with goals and expectations,” said Reinert, “but when the program begins, and the CHWs are out on the ground doing their work, the numbers that the development team originally identified are unrealistic.”
Supervisor flexibility comes into play in these instances. Otherwise, if a supervisor
continues to push a team of CHWs to meet those goals without making accommodations for the reality of the situation, the CHWs could burn out.
To prevent this, supervisors must be able to listen to their staff to understand the barriers they encounter in the community, so that they can adapt their goals, bring on more staffing or work together to find a solution to a problem.
Instinto Maternal Program Director Randi McCallian says she’s learned that listening is key to revising expectations and solving problems.
“Listen to the CHWs and through them, the community,” she said. “CHWs have a close relationship and understanding of the strengths and needs of a community, so if anything needs to be addressed, their input on strategies that will work is invaluable.”
6. Support is out there.
Currently, there are more opportunities than ever for CHW supervisors to develop their work. Local, state and national CHW associations, conferences and other meetings provide supervisors a chance to network with others in the field in order to receive peer support and learn from best practices.
In 2015, MHP Salud developed several materials and trainings geared toward supporting the work of CHW supervisors, all of which are released on our Resource Portfolio. These tools assist managers in their hiring, supervision, evaluation and greater professional development.
The new Supervision Manual for Promotor(a) de Salud Programs is an 88-page resource available for free download from MHP Salud’s Resource Portfolio. It covers everything from recruiting CHWs to resolving programmatic challenges as they arise, and the Manual’s appendix includes nine tools ready to be personalized for any CHW program. MHP Salud also offers personalized trainings for supervisors across a wide set of managerial topics.
MHP Salud is a national nonprofit organization that implements and runs Community Health Worker programs. These programs provide peer health education, increase access to health resources and bring community members closer. MHP Salud also has extensive experience offering health organizations training and technical assistance on Community Health Worker programming tailored to their specific needs
Rhonda Barcus, Program Specialist
For the past three years, I had the opportunity to work with the Kansas Department of Health and Environment (KDHE) and Sara Roberts, Director of Kansas Office of Primary Care and Rural Health and more recently with Jennifer Findley from Kansas Hospital Association on a Revenue Cycle Management (RCM) project. We supported 19 hospitals in Kansas with technical assistance to assess their current practices and benchmark those against best practices in RCM.
For all the 13 hospitals participating in years one and two, I had the opportunity to talk with their leadership teams at six and nine months about their progress of implementing the best practice recommendations. The progress and outcomes for most of them were astonishing! What really stood out to me were the common themes from the most successful projects. I wanted to share the top three themes with you.
Revenue Cycle Management (RCM) involves the process of patient charge capture from beginning to end, from creation to payment. It includes a number of steps that begins with patient registration and continues through the delivery of care to billing and to eventual payment. It is a process that involves a number of hospital departments: business office, clinical providers, registration, utilization review and coding to name a few. Because of its complexity and the number of staff that “touch” this process and the reliance on detailed, specific and accurate information at each step, hospitals may find that small errors can result in big financial losses, wasted staff time and decreased staff morale. A well-run RCM impacts patient satisfaction while a fragmented process results in frustration and patient dis-satisfaction.
The first step that every team took was to create a revenue cycle team. The team included business office folks, yes, but also included staff from clinical areas, registration, health information management (HIM) and information technology (IT). This team met weekly. Every leader said the success of this project was dependent on frequent meetings so that RCM issues could be addressed quickly and as close to real time as possible. The team looked at any issue or problem involving RCM over the last week and took immediate steps to remedy it. This kept them focused and they were all aware of the need for constant and consistent attention to make steady progress.
A second factor in their success was the focus on pre-registration. Patient information, coverage for upcoming procedures, co-pays and deductibles were all identified prior to a patient coming for their scheduled procedure when possible. Checks and balances were put in place to ensure accurate collection of information since one small error could impact the success of the entire revenue process. Staff were included in discussions about this so that they were very aware how they affected the success of the process.
A final theme, and was the hardest for many hospitals, was requesting payment from the patient! The hospitals were very transparent with the patient prior to coming for services about their financial responsibility at the time of service. Great care was taken to make sure all staff involved had the right education, training and re-education to do this effectively and with sensitivity. The hospitals also talked openly with patients about needing to pay prior balances and some future scheduled procedures were contingent on something being paid on previous balances. More than one hospital noted that this is part of their culture now and the community and patients just accept it. One CEO noted that almost all patients now come prepared with some type of payment. They noted that while many hospitals fear losing patients if they take this step, when done with sensitivity and skill by staff, that fear has been unfounded.
In addition to the common themes in implementation of best practices, all the hospitals were able to identify measurable outcomes. These outcomes included a decrease in accounts receivable, decrease in claim rejection, and an increase in collections. Also significant were the “non-measurable” outcomes. The hospitals all reported that there was better teamwork within and among departments, staff pride in the success of their work and more accountability across the organization!
This article was written by David Mortimer, MDiv, Director of the Hospital Sisters of St. Francis Foundation Innovation Institute, for the January 2017 edition of “Networking News.” The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center.
I grew up on a rural farm in Wisconsin. Two silos next to the barn were a picturesque fixture, and they were designed to store fodder, forage, or grain. Although they may be a critical feature to some farming livelihoods, silos in rural health care organizations are a metaphor for systems, processes, or departments that operate in isolation. These silos tend to drain the organizational lifeblood because a lack of interaction with other groups can result in inefficiency, missed opportunities for innovation, and even stagnation.
Over the decades, rural health care has been experiencing a cultural shift away from silos. This shift has been accentuated by advances in communications technology and remote presence telemedicine. Many rural organizations have been energized by exploring new self-governed collaborative, network, consortium, and cooperative models that actually replace silos with bridges. The basic idea is that collective action is an indispensable tool to counter the great challenges faced by rural communities.
Articulating the need for collective action
It’s no secret the typical rural health landscape in America faces growing challenges and that rural dwellers face a kind of penalty when compared to urban populations. Not only has rural America experienced declining population, jobs, opportunities, and resources, but a digital divide creates barriers in education, business development, and quality of life. (Many young rural friends of mine graduate high school and leave home, and will never even consider settling down in a community with poor internet connectivity.) Due to demographics and the impact of globalization on local economic development, many rural counties are experiencing an eroding tax base and declining representation in state and federal government.
These complex and incremental changes are causing substantial disparities in patient access to health care—particularly behavioral health—and provider shortages. Because they have less access to health care, rural Americans experience the “distance decay” effect—the lower use of health care services with increasing distance—which can result in more advanced and higher levels of disease. Rural dwellers face greater barriers in follow-up care, appointments, and compliance, and have higher rates of chronic disease, readmissions, and emergency department utilization. While these great challenges might seem overwhelming to rural stakeholders and providers, they have become compelling drivers of collective action and bridge-building.
Recognizing opportunities to collaborate
Collective action allows rural organizations to leverage limited capacity, maximize economies of scale, and share resources. The critical first step on this journey is to identify silos and opportunities for collaboration. Literally, this requires getting the right organizational representatives around a table, and this can happen in a variety of ways. I’ve personally been involved with two networks that successfully navigated this step:
The first step toward sustained collective action from a stakeholder’s point of view always involves the realization that there are tangible opportunities. In the CINC and ITN examples above, charter members began to realize that benefits of collaboration included being able to provide many more services with far fewer resources. Alone, members had little or no capacity, resources, or experience in successfully applying for a federal grant opportunity, but together, members combined the necessary resources to both apply and leverage opportunities with matching funds.
Bringing stakeholders to the table
Shared activities open doors to opportunities for grants, collaborative fundraising, and other opportunities. Alone, most ITN and CINC members would not even be eligible for many federal and state and private foundation funding. Together, network members find they are not only eligible to apply for many grant opportunities, they find they have greater resources to pool financial resources to secure matching grant funding and operationalize new projects. (Another advantage is that having different network member calendar year or fiscal year end dates provides additional year-round financial agility in committing matching funding toward a project of interest, despite thin operating budgets.)
In ITN planning meetings, several small rural hospitals without emergency department telemedicine equipment initially thought they brought little value to the ITN network, only later to learn they had exceptionally high value to the greater network because they would score very high in a USDA Distance and Learning Telemedicine grant application. In fact, their rural status serving high-poverty communities also provided great value to ITN’s other federal grant applications. Successful ITN-led grant applications secured equipment, and they were able to participate in the network’s new emergency department tele-stroke program.
As a network matures, other opportunities often follow. Group purchasing may lead to shared costs and mutual savings. With growth, ITN leverages larger patient volumes to secure better vendor price points for telemedicine services. Other shared network resources (such as job descriptions, workflows, billing and payment protocols) help all members accelerate programs and reduce costs and duplication. Depending on the project, some members contribute specific legal or financial services. Others may contribute advocacy, marketing, or public relations expertise.
Keeping stakeholders engaged
Sustained engagement in network activities by pioneer members is driven by continued benefits and prospective opportunities. Without these, members will naturally lose interest and drop out. Economies of scale experienced in the CINC and ITN examples above include collaborative support to develop new services. These networks also share equipment, allow members to share costly software applications, and even services and staff. Lastly, collaboration provides access to new resources that are only available to larger organizations.
Bridge building will always be more challenging than silo building. As Gregory Bonk noted, “Rural health networking is not easy; it requires time, trust, will, and skills.” He added, “Network members must have the ability to separate their individual goals from the common goals of the network, and the vision to see the potential benefits of joint action.” Bonk outlines key elements of network development that include a compelling need, expected benefits, form and function, and key participants.
New and emerging networks can build momentum with smaller “easy wins” that are communicated to all members, and are followed by other good-faith efforts that are inclusive and innovative in meeting member needs. Eventually, silos are replaced by bridges that are shared by all members, and improve client services and reduce costs. As one network member in CINC commented about their old silo thinking, “We’d never go back.”
About the author:
David P. Mortimer, MDiv, is Director of the Hospital Sisters of St. Francis Foundation Innovation Institute. He serves as the Administrative Director for the Illinois Telehealth Network (ITN) and chairs the Communications Committee for the Chippewa Valley Inter-Networking Consortium (CINC). The Hospital Sisters of St. Francis Foundation Innovation Institute provides program investments and infrastructure to support projects that improve outcomes, increase rural access to care and decrease costs through improved efficiencies.
 Turning Point Initiative. From silos to systems: Using performance management to improve the public’s health. Turning Point National Program Office, p. 3; 2003. http://www.phf.org/resourcestools/Documents/silossystems.pdf
 Wong ST, Regan S. Patient perspectives on primary health care in rural communities: effects of geography on access, continuity and efficiency. Rural and Remote Health (Internet) 2009; 9: 1142. Available: http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=1142 (Accessed 12/31/16).
 Gregory Bonk, Principles of Rural Health Network Development and Management (2000), p. 1.
Data Governance and Ownership: HIT and the Imperative of Strong Electronic Health Vendor Relationships
This article was written by Rene S. Cabral-Daniels, CEO of Community Care Network of Virginia, Inc., for the December 2016 edition of “Networking News.” The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center
Recent healthcare literature is replete with articles regarding the importance of paying greater attention to healthcare data. Many suggest a healthcare organization’s ability to harness data value is the fulcrum to the organization’s success or failure. While these articles encourage greater use of healthcare data, they often fail to inform health entities of the importance of assuring proper data ownership as well as stewardship, integrity and dissemination.
Data requirements: what they are and what they aren’t
Healthcare leaders may mistakenly believe that compliance with the Health Insurance Portability and Accountability Act (HIPAA) health data protection sections insulate them from any potential legal claims. HIPAA is an important, albeit complex, federal law that addresses both health data protection as well as confidential handling of protected health information (PHI). The determination of data ownership as well as necessary PHI protection is further complicated by the use of electronic health records (EHR). Health records no longer reside on a shelf in a doctor’s office but can now be shared by few keystrokes on a computer. EHR usage changes the parameters of astute data governance responsibility from one concerned with data ownership to one focused on data stewardship.
Recent legislation promoting quality-based payments such as the Medicare Access & CHIP Reauthorization Act (MACRA) and the 824-page final rule describing implementation assure the use of electronic health records will continue to grow. The parameters of this growth are carefully prescribed in section 1848(o)(2)(A)(iii) of MACRA and the definition of “meaningful EHR user” under 42 CFR 495.4, which require eligible professionals to report on Clinical Quality Measures selected by the Centers for Medicare and Medicaid Services using only certified EHR technology, as part of being a meaningful EHR user under the Medicare EHR Incentive Program.
EHR use by providers is already rather substantial. According to the Office of the National Coordinator for Health Information Technology, in 2015, 96 percent of all non-federal acute care hospitals possessed certified health IT. While small rural and small urban hospitals had the lowest rates at 94 percent, 96 percent of critical access hospitals had certified health IT. Clearly, EHR vendors and their products are an integral part of data usage and PHI confidentiality, the keystones of data governance efforts.
Data governance: key component of care delivery models
Many healthcare organizations struggle with data governance. A 2014 American Health Information Management Association (AHIMA) survey of over 1,000 healthcare professionals revealed only 11% characterize their data governance programs as being mature while over 50% of the respondents did not have governance practices in place.[i]
The Health Information Management and Systems Society (HIMSS) has an excellent resource on overcoming data governance obstacles. The article is entitled, “A Roadmap to Effective Data Governance: How to Navigate Five Common Obstacles” and defines data governance as “the exercise of decision-making and authority for data-related matters.” [ii] The article analogizes the importance of having an effective data governance program seamlessly embedded within the overall management and operational practices to patient safety as an integrated component of a comprehensive care delivery model in any healthcare system. One obstacle identified is not addressing data governance from an enterprise perspective, which can perpetuate data integrity challenges.
Data integrity: accuracy, quality, and completeness
Assuring data integrity is certainly an essential component of data governance. Data integrity is defined by the Department of Health and Human Services’ Office of Civil Rights as “the property that data or information have not been altered or destroyed in an unauthorized manner.” Note that the alteration is not limited to intentional alteration; unintentional or mistaken alteration can compromise data integrity.
Data integrity is particularly challenging for both providers and EHR vendors when it concerns patient identity. Accurate patient identity is an imperative. Health information exchange cannot be accomplished in a manner that assures integrity without first assuring patient identity integrity. AHIMA defines patient identity integrity as “the accuracy, quality, and completeness of demographic data attached to or associated with an individual patient. This includes the accuracy and quality of the data as it relates to the individual, as well as the correctness of the linking or matching of all existing records for that individual within and across information systems.” While data integrity must be the cornerstone of any institutional health provider’s data governance principles, individual healthcare providers must communicate often with their EHR vendors to be certain that the correct patient’s health information is the information being exchanged.
Data dissemination: the call to collaborate with vendors
The final area regarding data governance concerns data dissemination. This area has the greatest potential for achieving excellence for providers by nurturing a strong partnership with EHR vendors. Data dissemination is occurring at unprecedented rates, and its future upward trajectory is projected to be even greater. MACRA includes a provision that expands the availability of Medicare claims data which took effect on July 1, 2016. This section expands how qualified entities will be allowed to use and disclose Medicare data under the qualified entity program.
Another MACRA provision that advances data dissemination is one that aligns with earlier efforts promoting interoperability. The tenets of the Certified EHR Technology criteria, which promote application programming interfaces that allow for interoperable data sharing necessary for big data analytics and population health management, will likely be coupled with MACRA’s Advancing Care Information (ACI). ACI will count for 25 percent of the Merit-Based Incentive Payment System (MIPS) attestation score in the first year of participation. MIPS advances population health management and care coordination by utilizing health IT that relies on open application programming interfaces (APIs) and an app-based approach to technology. Because APIs can be customized, providers will need to join forces with EHR vendors if they are to realize the financial benefits afforded by MIPS.
In summary, true data governance will not be possible without a strong partnership with EHR vendors. The partnership must go far beyond payment for services and assuring a business associate agreement (BAA) is executed. The BAA must be customized so that both parties have a meeting of the minds regarding data governance and other important factors that are memorialized in writing. Strong data governance must involve meaningful EHR vendor participation if it is to be sustainable.
Community Care Network of Virginia, Inc. (CCNV), a community health center-owned and governed provider network, was legally incorporated as a statewide network organization in 1996 consistent with the Affiliation Policies of the Bureau of Primary Health Care. CCNV has a long, successful history of providing integrated, network-based services and programs to Virginia’s health centers, including the acquisition and implementation of a centralized practice management system, help desk, and support infrastructure commencing in 1999. Rene Cabral-Daniels currently serves on the NCHN board of directors.
 Cohasset Associates, "2014 Information Governance in Healthcare Survey." American Health Information Management Association, May 2014; at http://www.ahima.org/~/media/AHIMA/Files/HIM-Trends/IG_Benchmarking.ashx
 See 'definitions of Data Governance.' The Data Governance Institute; at
Tis the season to be grateful. Here are just a few of the reasons we have to be grateful for this year.
I am grateful, appreciative and impressed with the Minnesota hospitals that are participating in the Integrative Behavioral Health (IBH) project! As a former clinician, I know the difficulty addressing behavioral health issues, especially when resources are limited. I also know the impact they have on the individual’s quality of life as well as the lives of their families and communities. Thank you for all you do!
I would like to send a thank you to all the networks across our country who are working at improving the access to health care for rural America. The diversity of projects and locations makes it a fascinating group to work with. Their outcomes are amazing. We will have a healthier population in Rural America because of them.
I am grateful for our rural health partners that work with The Center to support the power of rural (FORHP, NRHA, NOSRH, RHIHub, Rural Health Value, Flex Monitoring Team, NCHN, NORC).
I’m incredibly inspired by and grateful for The Heart of New Ulm Project, born out of New Ulm, MN. The 10-year initiative is producing financial and health outcomes that are preventing disease versus treating it after it occurs. The project was just awarded the Most Meaningful Life-impacting Improvement award at the Health Analytics Summit. This rural community is a perfect example of how collaboration and partnerships really can change an entire population’s health!
I’m grateful for all of the organizations and groups like the National Center for Farmworker Health, Research for Indigenous Community Health Center, Arizona Rural Women’s Health Network, and countless others that work to improve the health of vulnerable populations, including rural communities. It’s inspiring to see their outcomes and accomplishments.
I’m grateful and amazed by the passion and persistence of those we work with here at The Center. No matter what our mission and vision statements say, we’re all shooting at the same target; enabling our rural providers to provide the very best quality of care to their communities and keeping rural areas healthy and vital.
Thank you to the thousands of rural health providers (hospitals, clinics, community health centers, health professionals, including EMS volunteers and community health workers) who are dedicated to providing care and improving health outcomes in rural America.
I’m grateful my grandparents have a critical access hospital in the next town from where they live, instead of the next closest hospital another 30 miles away.
I’m grateful for the honor of working to support rural health care. It is an honor to work in an industry that makes a difference in the lives of 2.5 million people not only at just one point in time - they day they are seeking care - but for their future and the future of their loved ones.
I am grateful to the Minnesota Accountable Community for Health (ACH) Teams. These 15 teams have worked so diligently over the past three years to provide Minnesotans with better value in health care through integrated, accountable care using innovative payment and care delivery models. The work they’ve done is not only ground-breaking but truly inspiring. True leaders and pioneers in rural health.
This article was written by Sally Buck, Chief Executive Officer at the National Rural Health Resource Center
Today is National Rural Health Day, an event coordinated by the National Organization of State Offices of Rural Health (NOSORH) to Celebrate the Power of Rural. The National Rural Health Resource Center (The Center) is proud to support this important day by highlighting the community-based solutions and committed providers that overcome the unique health care challenges that rural citizens face. These challenges include a shortage of primary care and mental health physicians and dentists as well as higher rates of poverty and uninsured.
Rural providers are committed to the goals of the United States Health and Human Services, Centers for Medicare and Medicaid Services (CMS) initiative of Better Care, Smarter Spending and Healthier People. At The Center we have seen this demonstrated by working with hundreds of rural health networks, small rural hospitals and State Offices of Rural Health (SORH) as a grantee technical assistance provider. Despite critical access hospitals (CAH), community health centers and rural health clinics being left out of many new innovation payment and care models initially due to their low volume or cost based reimbursement structure, there are many organizations leading the way towards value-based payment and care with an emphasis on quality and outcomes. These include:
Key partners for The Center are SORHs and state Flex Programs in our work to support rural communities and providers with services, information and resources to increase collaboration, improve quality reporting and improvement, recruit health professionals and support access to care by stabilizing hospital operations and finances through technical assistance, education and funding. This national network of rural health organizations and leaders are key to the power of rural.
We see that our vision of “collaborating and innovating to improve the health of rural communities” is happening throughout the country through the dedication, innovation and partnerships and strongly demonstrates the power of rural.
 CMS (2015). Better Care. Smarter Spending. Healthier People: Paying Providers for Value, Not Volume [fact sheet].
 Mueller, Keith and Fred Ullrich (2016). Spread of Accountable Care Organizations in Rural America, Brief No. 2016-5, RUPRI Center for Rural Health Policy Analysis.
 Mueller, Keith and Fred Ullrich (2016). Spread of Accountable Care Organizations in Rural America, Brief No. 2016-5, RUPRI Center for Rural Health Policy Analysis.
 Rural Health System Change Embedded in State Innovation Models (2016) Keith Mueller, RUPRI Center for Health Policy Analysis, Rural Health Value, [PDF - 494 KB]
Strengthening Your Problem-Solving Muscles: How an understanding of Lean can support network objectives
This article was written by Becky Gourde, program coordinator at the National Rural Health Resource Center/Rural Health Innovations, for the November 2016 edition of “Networking News.” The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center.
Rural health networks are often formed in response to collective challenges or needs arising out of the communities they serve. As part of health care’s current transition from a focus on volume to a focus on value, networks help drive and facilitate performance improvement efforts that contribute to CMS’s approach of Better Care, Smarter Spending, and Healthier People throughout the delivery of health care. Because Lean efforts usually require little, if any, direct financial investment, the related processes and tools can be a useful option for small organizations working to improve the health outcomes of their rural communities.
What is Lean?
In short, Lean is first and foremost a way of thinking that helps solve problems. Many of the ideas that we now categorize as “Lean” were developed out of the automaking industry. Shortly after World War II, Toyota began developing the Toyota Production System, or TPS, which was influenced by several thought leaders in industrial engineering. Although most people associate Lean with the practice of reducing waste and improving process efficiency, at the heart of the Toyota philosophy are a group of management principles characterized by (1) continuous improvement and (2) respect for people.
Their success with the system inspired other automakers and eventually other industries to adopt similar techniques. (Lean is often associated with a similar methodology called Six Sigma, which was developed in the US in the 1980s and 1990s.) Specialized systems of Lean (Lean Healthcare, Lean Sigma Healthcare, etc.) focus on applications particular to the processes involved with caring for patients.
Applying Lean to rural health networks
For networks with a small number of staff (if any), modest infrastructure, and little influence on the direct provision of patient care, how can network leaders derive benefit from learning about the principles and practices of Lean? Interestingly enough, the Lean way of thinking dovetails with the objectives of rural health networks and provides new approaches for building network capacity. The actions listed below offer ideas for how networks can use Lean practices to their best advantage.
1. Tackle complex problems
One of the notions of Lean is that problems are best solved when groups of people representing diverse roles or perspectives come together to identify issues and implement actions to address those issues. This format of problem solving is a common benefit arising out of rural health networks: networks often serve as ideal settings for candid and strategic discussions regarding the challenges being faced in the community. The network participants around the table have the power to collectively enact solutions that take into account multiple factors and perspectives.
The key to addressing problems using Lean is to work on the underlying root causes under your control, rather than wasting time developing plans to alleviate 20 or 30 symptoms of those root causes. There are several Lean tools that facilitate the process of root cause analysis in ways that offer simple frameworks for dialogue and planning.
2. Lead a culture of continuous improvement
Networks function most effectively when they help articulate members’ shared vision for the future of their communities. A shared vision expresses an ambitious and hopeful destination that all members are committed to using as a beacon for developing strategies and activities. The vision and goals are revisited periodically to assess progress and appropriateness, with new goals or elements revised as progress is made and circumstances change.
This iterative process of striving toward better and better outcomes is at the very core of Lean principles. Network leaders are often in the position of facilitating and carrying forward that drive. Understanding Lean’s models for nurturing a mindset of continuous improvement can help guide network leaders through culture reinforcement and change management efforts among members.
In fact, culture is often regarded by Lean experts as the highest priority for organizations wishing to become more effective and efficient: without an open commitment to progress and the empowerment of all participants to take part, performance improvement efforts are doomed to failure.
According to Toyota, this transformation can be accomplished through the “respect for people” principle. Network leaders may recognize the tenets of “respect for people” as their own best practices for network collaboration:
3. Offer education
As central sources for knowledge sharing, networks often allow member organizations to pool resources to pay for training or education that they otherwise couldn’t afford on their own. Because Lean has shown such positive outcomes throughout health care, coordinating and hosting educational opportunities on performance improvement can be a valuable service provided by a network to participating members and partners. The existing network configuration also provides a natural support system for members to get ongoing input from network leaders and from one another as they implement projects to improve outcomes in their own organizations.
If performance improvement support is something a network is interested in pursuing as a value-added service, it may even be a worthy investment for a network director to become certified in Lean or Lean Six Sigma so that they can serve as trainers and project leads for members, preventing members from having to seek out external consultants on a case-by-case basis.
4. Gather and share outcomes
Part of tracking the outputs and outcomes of a network’s work includes selecting measures and gathering data. The “simple” task of determining which metrics are most appropriate can be an intensive and tiresome process in and of itself, before the data collection even begins. Lean training incorporates an entire emphasis aimed at supporting users in what makes a good metric and which factors to consider.
Many of the recommendations around Lean metrics offer valuable guidance for networks involved in evaluation planning:
It’s also helpful for a network to serve as a repository of member data on selected measures that are relevant to the network’s goals. This process of collecting and sharing member information can encourage benchmarking and sharing of best practices among member organizations working in similar areas.
The information-collector role also allows networks to collect the designs of and results from the various improvement efforts being undertaken by member organizations, providing members with a quick way to see what’s been working well (or not so well) in their regions.
You don’t have to become an expert to begin benefitting from an awareness of Lean principles and tools. In fact, performance improvement efforts are often most effective when you start small. If you’ve never been introduced to Lean or a similar methodology before, you may want to look into free or low-cost leaning opportunities (like books or online resources) to see if it would be a valuable investment in your professional development. Or if there’s someone within your network’s member organizations with a background in Lean, you could consider inviting them to a network meeting to review a few ideas that are relevant to a particular network initiative. Selecting one or two new performance management tools to practice with can also help you decide whether to seek out additional training or expertise.
Jamie Martin, Lean Six Sigma Black Belt, SigmaMed Solutions
John Roberts, Lean Healthcare Black Belt, Midwest Health Association Management
Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction by Mark Graban, 2009, Productivity Press
The Six Sigma Book for Healthcare: Improving Outcomes by Reducing Errors by Robert Barry, Amy C. Murcko, and Clifford E. Brubaker, 2002, Health Administration Press
The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer by Jeffrey K. Liker, 2004, McGraw-Hill
The National Rural Health Resource Center (The Center) is a nonprofit organization dedicated to sustaining and improving health care in rural communities. Rural Health Innovations, LLC is a subsidiary of the National Rural Health Resource Center.