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.”
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.
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.