After using an “all hands on deck approach,” the White House Rural Council was able to produce a package of new job initiatives that were announced at the White House Rural Economic Forum. The Council’s recommendations, which leverage existing programs and funding, include making HHS loans available to help more than 1,300 Critical Access Hospitals recruit additional staff, and helping rural hospitals purchase software and hardware to implement health IT. The specifics are below:

Increasing Rural Access to Health Care Workers and Technology

Increasing Physician Recruitment at Critical Access Hospitals: HHS will issue guidance to expand eligibility for the National Health Service Corps loan repayment program so that Critical Access Hospitals (those with 25 beds or fewer) can use these loans to recruit new physicians. This program will help more than 1,300 CAHs across the country recruit needed staff.  The addition of one primary care physician in a rural community generates approximately $1.5 million in annual revenue and creates 23 jobs annually.  The average CAH creates 107 jobs and generates $4.8 million in payroll annually.

Expanding Health Information Technology (IT) in Rural America: USDA and HHS will sign an agreement linking rural hospitals and clinicians to existing capital loan programs that enable them to purchase software and hardware needed to implement health information technology (HIT). Under current conditions, rural health care providers face challenges in harnessing the benefits of HIT due to limited access to capital and workforce challenges.  Rural hospitals tend to have lower financial operating margins and limited capital to make the investments needed to purchase hardware, software and other equipment.

The health status of rural residents are intertwined with geography, economy, individual habits and genetics as well as access to care. The result of the dynamic interplay between these factors is a population that tends to experience a higher rate of: accidents, suicides, people with low income, public health insurance eligibility and uninsured than their metropolitan counter-parts.

Policy solutions for rural health have taken many forms including: loan repayment programs (Federal and State); construction of schools, hospitals and clinics; National Health Service Corps; J1 visas (non-US trained physicians); and telemedicine. While each of the policy solutions have its merits and effected rural health disparities to varying degrees, the basic mismatch of providers to residents still exist and create a very real access to care problem.

Hopefully this latest package combined with those provided by ACA will increase access to health care in rural areas.

Helpful Rural Health Terms to Know

Rural Health Clinics (RHCs): Clinics in official “rural designated” areas that provide a “safety net” for health care delivery.  There are approximately 3,800 Rural Health Clinics nationwide that provide access to primary care services in rural areas[i].

Federally Qualified Health Centers (FQHCs): “Safety net” providers such as community health centers, public housing centers, outpatient health programs funded by the Indian Health Service, and programs serving migrants and the homeless that meet the Centers for Medicare and Medicaid Services (CMS) criteria for FQHC designation. The main purpose of the FQHC Program is to enhance the provision of primary care services in underserved urban and rural communities[ii].

Health Professional Shortage Areas (HPSAs): These areas, designated by Health Resources and Services Administration (HRSA), have shortages of primary medical care, dental or mental health providers and may be geographic (a county or service area), demographic (low income population) or institutional (comprehensive health center, federally qualified health center or other public facility). [iii]

Medically Underserved Areas (MUA): Areas that are designated by HRSA in which residents have a shortage of personal health services.  They may be a whole county; a group of contiguous counties, a group of county or civil divisions; or a group of urban census tracts. [iv]

Medically Underserved Populations (MUPs): Groups of people who face economic, cultural or linguistic barriers to health care as defined by HRSA.[v]

Criteria for Rural and Urban Designation

Rural definitions are typically based on the following three concepts; administrative, land-use, or economic[vi]. Each definition provides considerable variation in socio-economic characteristics and well-being of the measured population[vii]. This process becomes more confusing when more than one definition is used during policy creation and evaluation.

However, one of the major criteria for Rural Health Clinics is to meet the Census Bureau’s standard of rural. The standard is straightforward- is a definition based on exclusion. Simply put, in order to meet the definition of rural an area cannot meet the Census Bureau’s definition of urban (see below)[viii].

The Census Bureau does not define suburban[ix].

Urban: All territory, population, and housing units located within an urbanized area (UA) or an urban cluster (UC). UA and UC boundaries encompass densely settled territory, which consist of: 1) core census block groups or blocks that have a population density of at least 1,000 people per square mile and 2) surrounding census blocks that have an overall density of at least 500 people per square mile[x].

Rural: The Census Bureau's classification of "rural" consists of all territory, population, and housing units located outside of urban areas (UAs and UCs). The rural component contains both place and non-place territories. Geographic entities, such as census tracts, counties, metropolitan areas, and the territory outside metropolitan areas, often are "split" between urban and rural territory, and the population and housing units they contain often are partly classified as urban and partly classified as rural[xi].

[i] Centers for Medicaid and Medicare Rural Health Clinic Fact Sheet (April 2009), available at http://www.cms.gov/MLNProducts/downloads/RuralHlthClinfctsht.pdf (last accessed August 2010)

[ii] Centers for Medicaid and Medicare Rural Health Clinic Fact Sheet (April 2009), available at  http://www.cms.gov/MLNProducts/downloads/fqhcfactsheet.pdf (last accessed August 2010)

[iii] U.S. Department of Health and Human Services, Health Resources and Services Administration Shortage Designation: HPSAs, MUAs & MUPs (May 28, 2010) http://bhpr.hrsa.gov/shortage/ (last accessed July 2010)

[iv] Ibid

[v] Ibid

[vi] Cormartie,J.; Bucholtz S.(Economic Research Service) Defining “Rural” in Rural America (2008) Volume 6 Issue 3 available at http://www.ers.usda.gov/AmberWaves/June08/Features/RuralAmerica.htm (last accessed August 2010)

[vii] Ibid

[viii] U.S. Census Bureau Census 2000 Urban and Rural Classification (2009)

http://www.census.gov/geo/www/ua/ua_2k.html last accessed August 2010

[ix] U.S. Census Bureau Census 2000 Urban and Rural Classification: Question and Answer (2009)

https://ask.census.gov/cgi-bin/askcensus.cfg/php/enduser/std_adp.php?p_faqid=623&p_sid=CSWjaK5k&p_created=1092150238&p_sp=cF9zcmNoPSZwX3NvcnRfYnk9JnBfZ3JpZHNvcnQ9JnBfcm93X2NudD0mcF9wcm9kcz0mcF9jYXRzPSZwX3B2PSZwX2N2PSZwX3BhZ2U9MQ!!&p_search_text=rural%20definition last accessed August 2010

[x] U.S. Census Bureau Census 2000 Urban and Rural Classification (2009)

http://www.census.gov/geo/www/ua/ua_2k.html (last accessed August 2010)

[xi] Ibid

This is the third day of the week long exploration of care transitions and medication errors. Knowing the importance and vulnerability surrounding care transitions I will present findings from the literature regarding medication reconciliation and safety culture/teamwork that will illuminate their “true” impact in reducing medication errors. For another look at how Hope Street Group conceives to improve the quality and cost of transitions between acute and other types of care, click here: http://www.hopestreetgroup.org/docs/DOC-2479 .

Medication Reconciliation

Medication reconciliation is a comparison of the patient’s current medication regimen against the admission, transfer and/or discharge orders for the purpose of identifying and fixing discrepancies (Northwest Memorial Hospital, 2011). Medication reconciliation is needed during every transition of care in order to clearly identify what medication changes are permanent, temporary and that duplicate or conflicting medications are not being prescribed. AHRQ projects that 14%

of patients upon being discharged from the hospital have some sort of medication inconsistency due to a lack of medication reconciliation (Agency for Healthcare Research and Qulaity).  Regardless, to date, evidenced based methods for medication reconciliation are lacking

despite the need for it to occur. As a result, the Joint Commission

announced in 2009 that they would no longer score medication reconciliation during on-site accreditation surveys, thereby reversing their 2005 stance (Agency for Healthcare Research and Qulaity).

Safety Culture/Teamwork

The concept of safety culture came from high reliability organizations. Agencies or groups such as air traffic control systems

that operate in hazardous conditions but have few adverse events were evaluated for common traits. Common features of high reliability organizations include

(Agency for Healthcare Research and Quality):

• “Preoccupation with failure—the acknowledgment of the high-risk, error-prone nature of an organization’s activities and the determination to achieve consistently safe operations.
• Commitment to resilience—the development of capacities to detect unexpected threats and contain them before they cause harm, or bounce back when they do.
• Sensitivity to operations—an attentiveness to the issues facing workers at the frontline. This feature comes into play when conducting analyses of specific events (e.g., frontline workers play a crucial role in root cause analyses by bringing up unrecognized latent threats in current operating procedures), but also in connection with organizational decision making, which is somewhat decentralized. Management units at the frontline are given some autonomy in identifying and responding to threats, rather than adopting a rigid top-down approach.
• A culture of safety, in which individuals feel comfortable drawing attention to potential hazards or actual failures without fear of censure from management.”

Even though safety can be defined and measured by survey and providers at all levels, creating sustainable cultures of safety has proven difficult

(Agency for Healthcare Research and Quality, 2011). Poor perceived safety culture has been linked to increased error rates (Agency for Healthcare Research and Quality, 2011).  Team training is a proven intervention to improve an organization culture regarding safety by raising situational awareness (Agency for Healthcare Research and Quality, 2011). Teamwork training also emphasizes the role of human factors such as fatigue, management styles, organizational cultures and perceptual errors such as mishearing instructions. This can be addressed using simulations or classroom/lecture style sessions.

Tomorrow, I’ll cover shovel ready interventions such as TeamSTEPPS and provide a research-based comparison of each intervention discussed this week in a handy chart for you to use.

I know there are dedicated supporters of each intervention. Let us hear what you have to say! Log in and share below.

Agency for Healthcare Research and Quality. (2011 February). Nursing Home Survey on Patient Safety Culture. Retrieved 2011 10-August from Agency for Healthcare Research and Qulaity: http://www.ahrq.org.gov/qual/patientsafetyculture/nhsurvindex.htm

Agency for Healthcare Research and Qulaity. (n.d.). PSNET, Patient Safety Primer, Medication Reconciliation. Retrieved 2011 10-August from Agency for Healthcare Research and Qulaity: http://psnet.ahrq.gov/primer.aspx?primerID=1

Agency for Healthcare Research and Quality. (n.d.). PSNet, Glossary, High Reliabiltiy Organizations. Retrieved 2011 10-August from Agency for Healthcare Research and Quality: http://psnet.ahrq.gov/popup_glossary.aspx?name=highreliabilityorganizations

National Priorities Partnership. (2011 10 August). National Quality Forum, Overuse. Retrieved 2011 10-August from National Quality Forum: http://www.qualityforum.org/Topics/Overuse.aspx

Northwest Memorial Hospital. (2011). MATCH Medicatin Reconciliation Toolkit. Retrieved 2011 14-March from Northwest Memorial Hospital: http://www.nmh.org/nm/making+the++case

I will explore some key causes and solutions to medication errors associated with care transitions using components of Hope Street Group’s analytical model: “Amplify” our productivity- Improve the quality and cost of transitions between acute and other types of care.

Care transitions have been identified as points in the health care continuum that can increase risk of medication errors due to poor coordination (California HealthCare Foundation, 2007). Approaches to improving medication errors during care transitions include: checklists, computerized order entry, medication reconciliation, improving the “safety culture” and teamwork (Agency for Healthcare Research and Quality).  This post will discuss the overall impact of post-hospital adverse events. Subsequent posts this week, will discuss the feasibility, appropriateness and evidence for the leading potential solutions/interventions based upon a review of the literature.

The overall incidence of post-hospital adverse events has been reported to be 20% within 3 weeks of discharge(Forster, Murff, Peterson, Ganhi, & Bates, 2003). Moreover, the same researchers stated that nearly 75% of those adverse events could have been prevented or ameliorated (Forster, Murff, Peterson, Ganhi, & Bates, 2003).   It has also been argued that care transitions are especially important for elderly patients and other high-risk patients who have multiple medications and comorbidities (Halasyamani, et al., 2006).  Despite the lack of official numbers, researchers agree that the risk for post-hospital adverse events continues to mount as the elderly and other high-risk patients make the transition to a nursing home(Halasyamani, et al., 2006).

However, a combination of individual, team and organizational issues contribute to the challenges of lowering the risk of medication errors during care transitions to nursing homes and long-term care facilities from hospitals (Table 1).

While the research focus here is between hospitals and nursing homes, lessons can be applied to any situation where there is a transition of care in the health eco-system.

As we look to see if these approaches to improving medication errors during care transitions really help this week, please tell us about your experiences with:

• checklists,
• computerized order entry,
• medication reconciliation,
• improving the “safety culture”/teamwork  and;
• shovel ready interventions (i.e. TeamSTEPPS)

California HealthCare Foundation. (2007). Fast Facts: Coordinating Care Transitions. Oakland: California HealthCare Foundation.

Agency for Healthcare Research and Quality. (2011 February). Nursing Home Survey on Patient Safety Culture. Retrieved 2011 14-March from Agency for Healthcare Research and Qulaity: http://www.ahrq.org.gov/qual/patientsafetyculture/nhsurvindex.htm

Forster, A., Murff, H., Peterson, J., Ganhi, T., & Bates, D. (2003). The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Annals of Internal Medicine , 138 (3), 161-167.

Halasyamani, L., Kripalani, S., Coleman, E., Schnipper, J., vanWalraven, C., Nagamine, J., et al. (2006). Transition of Care for Hospitalized Elderly Patients: Development of a Discharge Checklist for Hospitalists. Journal fo Hospital Medicine , 1 (6), 354-360.