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

Where does the healthcare continuum really begin?

With prevention?

In the home?

With the Primary Care Provider?

In the Emergency Department?

Although an argument can certainly be made for any of the four choices above, I’d like to challenge your opinion and perspective with a different answer…the continuum for many begins with Emergency Medical Services (EMS).

This past year I had the privilege to be included in two standard setting and forward thinking discussion forums-- AHRQ’s 2010 Annual Conference and HCIE Innovators Event as well as Hope Street Group’s Policy 2.0: Using Open Innovation to Reinvent Primary Care Project. Both of these events offered diverse perspectives from diverse participants in academia, corporations and all levels of government and localities who gathered to discuss and make recommendations to improve the health care system. Interestingly, the first responder perspective of EMS was only a footnote in these discussions. I believe that policy makers and leaders within healthcare all too often fail to look outside their sphere of influence and familiarity for answers or more importantly the critical questions. That said, I know this minimalization was not intended or planned, but a result of historical processes and comfort levels.

The numbers…

EMS contributes 15% or 17.25 million patients to the nations 123.8 million annual Emergency Department (ED) visits (CDC, 2008), yet Fire, EMS or Law Enforcement respond to over 240 million 911 calls per year (NENA, 2009). It’s difficult to accurately breakdown the national percentages of 911 call types, but upwards of 60% of EMS calls are generally considered low-acuity or non-emergent. To put this into a local perspective, the City of Tucson AZ with a population of approximately 530,000 (2005) generates approx. 79,000 Fire and EMS 911 calls per year, 84% or ~67,000 of these are medical in nature and 60% of those, ~46,000 require only Basic Life Support (BLS) care (TFD, 2009).

So what does that really mean? It means that the 911 system provides a substantial safety net for the Nation’s healthcare system. While this should come as no surprise, the volume of patients utilizing EMS, Emergency Departments and the 911 system continues to grow. Over 15 years ago, the National Highway Traffic Safety Administration and the Health Resources and Services Administration joined with leaders from the EMS community to put forth an EMS plan that would require significant collaboration with acute care, primary care and public health. This provided one of the earliest, nationwide, use of the scale-up-and spread model and was published as the1996 EMS Agenda for the Future (NHTSA, 1996).

The past…

To implement that vision and professional template, EMS has continued to grow it’s service provision model from one that was historically created for stabilization and transport of the acutely ill and injured; one that was set-up to intervene only when patients needed emergent support; one that operated in relative isolation from other health care and community resources; one that was not involved in the business of ensuring social service follow-up and one that did not have a working knowledge of community health care providers and regional health care organizations (NHTSA, 1996).

The present…

Today, EMS is integrated with other health care providers, public health and public safety agencies to provide community-based healthcare and management. EMS agencies and providers are involved in activities related to prevention education, illness and injury risk, acute illness and injury care, follow-up, treatment of chronic conditions and community health monitoring. This vision is also shared by the Injury Response Division of the National Center for Injury Prevention and Control/Centers for Disease Control and Prevention (NCIPC/CDC) and the American College of Emergency Physicians (ACEP) who have called for a better understanding of roles and collaboration between Public Health and EMS through their Appleseed Project initiative (CDC, 2004).

The reality …

As you can see, EMS has developed into more than a group of fire departments, rescue services and ambulance companies. While providing these additional and collaborative services, EMS remains the public’s emergency medical safety net.  Looking back to those 240 million 911 calls and the 17.25 million EMS-to-ED admissions, it’s clear that a significant amount of health assessment, care and triage occurs outside the hospital walls. In fact, there are no other healthcare providers that see patients in their own home or living environment quite like EMS. The “scene assessment” which is a fundamental EMS skill reveals more information about a person, their living conditions, their health, their support system and their coping mechanisms than any other assessment tool.  How many Primary Care providers, case managers or health plan administrators have this perspective into their own patient’s lives?

From where I sit with over 30 years of experience as an RN in Maternal-Child Health and EMS, I see several important questions that need further discussion and clarification before we can begin to understand how to move forward in improving the healthcare of our Nation.

• How can we better educate individuals to utilize the 911 system for acuity appropriate reasons?
  
• How do we encourage the use of Primary Care practitioners for non-emergent and urgent medical and injury complaints instead of defaulting to the approach of “if this is a medical emergency, please hang up and dial 911?
  
• How do we share the burden of after-hours and weekend low-acuity patient needs?
  
• How do we facilitate better communication and collaboration between EMS, public health, acute and chronic care case management, behavioral health and community services?
  
• How do we move patients calling 911 for non-emergent or non-healthcare reasons into a public or human services system that will better meet their needs?
  

Communication, collaboration, connectivity, consistency and caring are all functions of healthcare, yet as the patient numbers and range of patient complaints increase, we all need to utilize each others skills, knowledge and expertise to meet the needs of our patient population. Reaching out to our colleagues may be the first step toward improvement, integration and understanding of our healthcare system.

http://www.911dispatch.com/info/fact_figures.html

http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf

http://cms3.tucsonaz.gov/sites/default/files/imported/data/demographic/eecpop00_05.pdf

http://www.nena.org/911-statistics

http://www.cdc.gov/injury/publications/index.html

http://www.nremt.org/nremt/about/emsAgendaFuture.asp

http://www.tucsonaz.gov/fire/AnnualReport.pdf

A $20 million gift from Robert and Myra Kraft, will be used to attract doctors and nurses to Massachusetts community health centers, the cornerstone of the push to reduce health costs and care for newly insured patients. The donors hope that this gift will inspire others to help raise primary care to the forefront of the health care system.

The gift to Partners HealthCare System Inc. will be used to pay off up to $50,000 of the medical school loans of physicians and nurse practitioners, as well as finance fellowships in targeted specialties and for master’s degrees. In return, caregivers must work for two to three years in a health center or other community-based setting to care for needy patients. The gift will create the Kraft Family National Center for Leadership and Training in Community Health to oversee the programs. A portion of the funding will support community-based programs at Dana-Farber Cancer Institute.

Over the next five years, Partners chief executive Dr. Gary Gottlieb estimates, the Kraft donation will support more than 100 physicians, nurse practitioners, and other providers caring for about 200,000 patients.

For more information: http://www.boston.com/business/healthcare/articles/2011/01/09/krafts_give_20m_to_draw_doctors_into_community/

On May 3, 2010, Hope Street Group convened our Bipartisan Working Group of business, political and civic sector leaders to address the urgent need to reinvent primary care.  The Working Group looked at opportunities to maximize innovation in addressing resource shortages and acute, preventative, and chronic care delivery.

Once again, Hope Street Group leveraged the tremendous expertise and knowledge base of our community of advisors.  Participating in the discussions on the night were:

Byron Auguste | Director, McKinsey & Company

Dr. Sree Chaguturu | Attending Physician, Massachusetts General Hospital; Manager, McKinsey & Company

Aaron Doty | Health Care Advisor, Hope Street Group

Susan Edgman-Levitan, PA | Executive Director ,The John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital

Dr. Paul Grundy, MPH | IBM's Global Director of Healthcare Transformation; President, Patient-Centered Primary Care Collaborative

Dr. Jeff Harris | Former President, American College of Physicians

Dr. Matthew Hunsaker | Director, RMED, National Center for Rural Health Professions, University of Illinois, College of Medicine at Rockford

David Javdan | Manager Director, Alvarez & Marsal, LLC;

Dr. Bob Kocher | Special Assistant to the President, National Economic Council

Peter Lee | Executive Director, National Health Policy Pacific Business Group on Health

Monique Nadeau | Executive Director, Hope Street Group

John Podesta | CEO, Center for American Progress

Diane Rowland, ScD | Executive Vice President, Henry J. Kaiser Family Foundation; Chair, MACPAC

Andy Slavitt | CEO, Ingenix

Simon Stevens | Executive Vice President, UnitedHealth Group

Dr. Kate Tulenko | Deputy Director, CapacityPlus (USAID)

David Walker | President and CEO, Peter Peterson Foundation

Dr. Steven Weinberger, FACP | Deputy Executive Vice President, Senior Vice President for Medical Education & Publishing American College of Physicians

Participants considered the impact of the lack of a coordinated market in primary care, and the impediments to take up of innovation. They discussed the way in which geographic distribution and variation in the distribution of types of practitioners exacerbates the impact of workforce shortage in primary care.  They also looked at how other players in the complex health care market may react when changes to primary care begin to take effect.  Participants agreed that it was important to address the barriers to the spread of innovation (including drawing on the experiences of other countries), rather than duplicating the efforts of existing innovation leaders.

You can view a copy of the full Executive Summary here.

There is a lot of chatter, especially on Policy 2.0, about possible solutions for the primary care shortage including business model changes as well as increasing incentives for medical school graduates to enter the field, however an option not getting much traction is the role nurse practitioners could potentially play.

The Yakima Herald-Republic, Wash. posted a really interesting article on expanding the roles of nurse practitioners to allow them to practice on their own, outside the scope of a physician practice group where most are typically found. One of the things I found most compelling about the article was a citation of a study by the Congressional Office of Technology Assessment which estimated that "nurse practitioners can deliver as much as 80 percent of the health services provided by primary-care physicians."

Given those numbers, expanding the roles of nurse practitioners should definitely be a potential solution to delve further into.

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