Volume 6 Number 2
©Minnesota Office of Tourism Photo
Q U A R T E R LY
Spring 2004
The mission of the Office of Rural Health & Primary Care is to promote access to
quality health care for rural and underserved urban Minnesotans. From our unique position
within state government, we work as partners with communities, providers, policy makers and
other organizations. Together, we develop innovative approaches and tailor our tools and
resources to the diverse populations we serve.
Minnesota Rural Health Advisory Committee
Member Profile: ORHPC Talks with Steve
Hansberry
Home: Sandstone
Family: Five children, Alarice (22), Sarah (19), Marshall (17) , Katherine (13), Shannon (10)
and wife of 28 years, Victoria.
Hobbies: Family
Rural Health Advisory Committee
Member Steve Hansberry and
family.
Steve Hansberry has a long history of public service in both his personal and professional life.
A mechanical engineer by trade, Steve has used his education to help improve public facilities
for the incarcerated and for mental health patients. While working as a project manager for the
State of Missouri-Office of Administration, he worked with both the Department of Corrections
and the Department of Mental Health to modernize the largest public mental health facility in
Missouri and to upgrade facilities at the Missouri State Penitentiary’s capital punishment unit.
Steve has worked at the federal Bureau of Prisons regional office in Kansas City, the United
States Penitentiary in Leavenworth, Kansas, and the Federal Prison Camp in Yankton, South
Dakota. Now in his twentieth year of public service, Steve is currently the facilities manager at
the Federal Bureau of Prisons’ Federal Correctional Institution in Sandstone.
Steve’s family has lived in rural settings throughout the Midwest since his children were very
young. His interest in rural health care is rooted in the cultural change he experienced while
moving from metropolitan Kansas City to rural South Dakota. In this new rural setting, he
observed patients suffering from major depression, chronic asthma, and cerebral palsy while also
assuming the burden of distance to care and limited resources. Reflecting on this, Steve sees
discrepancies between urban and rural health care as having roots in a fundamental
misunderstanding of rural culture. He feels urban residents do not recognize the degree to
which gaps between urban and rural lifestyles have closed, making the two indistinguishable in
many ways.
Steve was appointed to the Rural Health Advisory Committee (RHAC) in 2004 and serves as
a consumer representative. He is also a member of the mental health and primary care
workgroup, a subgroup of RHAC, working on improving access to rural mental health services
through the primary care system.
What do you think are the most important issues facing rural health today?
SH: First is the need for a greater understanding of the cultural differences and similarities
between rural and urban health care and lifestyles. And second, health care resources are
inefficiently over-concentrated in urban areas.
Estelle Brouwer, Director
Karen Welle, Assistant Director
Stefani Kloiber, Editor
I believe that although there are gaps between rural and urban settings in such areas as health
care, unemployment, poverty, and substance abuse, they are closeable gaps. Bridging these gaps
does not require major system rework, just education and awareness. With modern
communications, transportation, infrastructure technology, and organizational formats, there
shouldn’t be any fundamental difference between downtown Minneapolis and Ely. (Steve likes
to apply what he calls cutting edge marketing—in his words, “Just do it.”)
We don’t need to build new houses. We need to invite others into the ones we already live
in. Our health care is the best in the world because of its ability to develop and utilize
tremendously sophisticated technology, multiple service delivery models, broad educational
programs, cutting edge research, and last, but first, phenomenally skilled people. That means
our house is VERY LARGE. There is room in it for many people.
See “Steve Hansberry”
2
(back page)
POLICY FOCUS
A Snapshot of Rural Hospice Care in Minnesota
By Angie Sechler and Stefani Kloiber
The Office of Rural Health and Primary Care recently completed a series of rural health profiles spotlighting
hospitals, pharmacies, ambulance services, nursing homes, clinics, hospice, and the health professional workforce in
Minnesota. Each profile centers on the availability and distribution of health care services and providers throughout
Greater Minnesota and focuses on issues affecting their accessibility. A summary of “Hospice in Minnesota: A Rural
Profile” is presented below.
Numerous national polls have found that when asked,
most people would prefer to die in their own homes.
Contrary to these wishes, 75 percent of deaths in Greater
Minnesota (outside the seven-county metro area) occur in
institutional settings. The best way to assure that a
person’s wish to die at home with high quality of care is
granted is through the use of hospice services.
According to the 2000
census, Minnesota has a
total population of
4,919,479, and
2,277,425 or 46 percent
of that number live in
Greater Minnesota. In
2001, approximately
37,505 people died, with
20,822 or 55 percent of
the deaths occurring in
Greater Minnesota. The
leading cause of death in
both rural and metro
areas was heart disease;
cancer was the second
leading cause.
terminal and life-threatening conditions. The focus of
hospice care is on treatment and support to provide
comfort rather than to cure the disease. Most hospice
patients are able to live their final days at home. Hospice
programs provide the medical expertise, support and
teaching to enable families to care for their loved ones at
home. For those who cannot be cared for at home,
hospice care can also be provided in a nursing home,
residential setting, or hospital.
"Helping dying patients to stay at
home and providing high-quality end
of life care is challenging in rural
areas. Hospice programs that could
help patients to remain in their
homes do not cover all of Minnesota,
and many rural hospice programs
Most hospice services are
provided to individuals in
their homes. The type and
frequency of hospice services
are tailored to meet the needs
of the person who is dying
and his or her family.
According to Hospice
Minnesota, a statewide
organization representing
hospice care providers,
hospice provides: expertise in
comfort care, including
medications and therapies to
relieve pain and symptoms;
twenty-four hour support in
the form of on-call services;
coordination of help and
services needed in the home,
and necessary medical
equipment such as hospital
beds and oxygen.
The increase in the
struggle financially because of the
aging population,
particularly in the rural
small numbers of eligible patients."
areas, is a powerful
indicator of the need for
—Minnesota Commission on End of Life Care
hospice services. In
Minnesota, nearly 80
In Minnesota, all hospice
percent of the people
programs are required to be licensed by the Minnesota
who die are over the age of 65. Adding to that statistic,
Department of Health. Most hospice programs in
41 percent of Minnesota’s population over the age of 65
Minnesota are also federally certified in order to provide
live in a rural area. The Minnesota Commission on End of
services under the Medicare Hospice Benefit. The
Life Care, a statewide group that addressed end of life care
majority or 83 percent of licensed hospice programs in
issues, concluded in 2002 that the less populated the
Minnesota are outside the Twin Cities metropolitan area.
county, the less likely death will occur at home.
In 2002, 38 percent of the 11,359 hospice patients served
Hospice
were in rural areas and the average caseload for rural
programs was 12 patients (Hospice Minnesota).
Hospice is a specialized form of care for people with
See “Snapshot of Rural Hospice Care”
(page 7)
3
PROGRAM FOCUS
Bridging Distances in Healthcare
A successful model to address the rural nursing workforce shortage
By Stefani Kloiber
“Even if it [the program] is grueling, it has given meaning to my life, a focus for the future that I never
believed would be possible.” - Nursing student
“We are in the home stretch and it feels good! I already have a job at the Granite Falls Hospital. I will work
part-time as an aide until fall and after taking my boards I will work full-time as an RN.” - Nursing student
These are just some of the many positive comments Carol Dombek has received from students enrolled in
Bridging Distances in Healthcare, an innovative program that offers rural residents the opportunity to earn
their Registered Nurse (RN) degree close to home. The goal is to provide nursing education locally so rural
residents don’t need to leave their home and family in order to receive a degree and start a career. The
program is a win-win situation for everyone. Students benefit by receiving a nursing degree with the promise
of a job at graduation. The community benefits by filling a nursing position that has previously gone unfilled
and retains a resident.
A Shortage of Nurses
The demand for RNs both nationally and statewide is strong; however, the supply of RNs is not currently
meeting the demand. According to the Minnesota Department of Employment and Economic Development
(DEED), in 2004 there are nearly 48,620 RNs employed with approximately 2,000 vacancies throughout
Minnesota. A recent study of the Minnesota RN workforce by the Office of Rural Health and Primary Care
(ORHPC) revealed that an aging workforce, low RN graduation rates, increased wage growth, high staff
turnover, and employee demand have all contributed to a shortage of RNs.
The shortage of nurses is exacerbated in Greater Minnesota where the pool of trained RNs is smaller. In
addition, the rural RN workforce is about one-and-a-half years older than their urban counterparts and closer
to retirement. In Greater Minnesota the availability of RN programs is scattered. In most cases, students
would need to either move away from their home or travel a minimum of two hours one way to attend
classes. After a student moves away from home to attend school, the likelihood of returning to practice in
rural Minnesota drops significantly. The lure of a metropolitan area is a challenge for rural health care. The
opportunity to work in a variety of settings or specialties and earn higher wages – RNs in the metro area often
earn substantially more per hour than those in rural areas – can be very appealing.
The shortage of nurses is expected to continue into the future. With more nurses retiring in the next 15
years and fewer students graduating from RN programs, the gap may become even bigger. The Bridging
Distances in Healthcare program is one step towards increasing the numbers of RNs.
Growing Your Own
“It is a homegrown program,” says Carol Dombek, the project manager for the Southwest Minnesota Private
Industry Council’s Bridging Distances in Healthcare program. She adds, “We needed to bring training to
rural Minnesota so people stay local. There are many wonderful people in the community that want to
remain in the community. What better way to help them enter into a career that is needed in their
community?” The idea for the program came from a group of rural Workforce Center representatives, who
partnered with healthcare facilities and nursing education programs in Greater Minnesota to obtain a federal
H-1B workforce development grant. The one-time $3 million grant funded by the United States Department
of Labor provides technical skill training, such as healthcare education, for in-demand professions.
The H-1B Bridging Distances in Healthcare project began in 2002. Working with rural communities,
Workforce Centers, healthcare facilities, and colleges throughout the 80 counties of Greater Minnesota,
distance learning sites were developed for the accelerated two-year RN education. In the last two years 14
sites have been developed in 12 communities throughout Minnesota. Sites are located in Fairmont,
Montevideo-Granite Falls, Olivia (from an LPN to RN completion only), Redwood Falls-Olivia, Morris (two
sites), Cook, Bigfork, Cloquet, Mora-Pine City, Melrose, Staples, Wabasha, and Ely.
4
In most cases, students attend
classes and complete their
coursework while also
working part-time. The grant
funds the students’ education,
making it more affordable and
appealing for students to
attend school. Students may
also use other financial
assistance (for example, Pell
grants or scholarships) to
cover living expenses while
attending school and working.
In some instances, the
employer (such as a local
hospital) may also pay a
portion of the tuition with the
promise of filling a nursing
position when the student
completes the program.
sustainability. With the grant ending in 2005, the next step will
be to work with the sites and the partnerships to help ensure that
the program continues. Carol and staff members have begun to
address this through focus groups with WorkForce Centers,
communities, students, healthcare and educational partners.
Through the groups, Carol hopes to learn what is and isn’t
working and to develop new funding sources to meet the needs.
Another next step is the development of the Health Career
Preparatory Academies. Through the Bridging Distances in
Healthcare program, it was discovered that there were many
applicants who would make great health care workers, but lacked
the preparatory skills necessary to enter the program. Through
grants from the Minnesota Department of Employment and
Economic Development and the McKnight Foundation, the
Bridging Distances in Healthcare program is developing Health
Career Preparatory
Academies throughout the
state. The mission of the
Academies will be “to
increase the capacity of rural
Minnesota residents to enter
and move up the health care
career ladder.” The project is
designed for rural residents
who are interested in a
health care career, but need
some help to prepare to enter
into health care education or
employment. The first
academies are expected to
start this summer.
Photo courtesy of Montevideo American-News
The Bridging Distances project partners with nursing education
programs to offer accelerated nursing education, and is designed
to increase the accessibility of healthcare education in rural
Minnesota communities to help meet the healthcare worker
shortage. The goals of the program are to increase nursing
capacity in rural Minnesota and to build coalitions with
healthcare, workforce centers, and education for ongoing system
development and sustainability. Students enrolled in the program
complete their RN education in two years, instead of the usual
three to four years, graduating with an associate degree in
nursing. Courses are offered through classroom instruction,
distance learning, and local clinical experience. Carol does offer a
word of warning, however: “It is a very intense program.
Students can’t expect to work full-time and go to school. It takes
what is often a three-to-four-year program and condenses it into
two years; it is hard work, but the payoff is great.”
Bridging Distances in Healthcare at Chippewa County-Montevideo
Hospital
Currently there are approximately 310 students enrolled in the
program, surpassing its initial goal of training 268 RNs. Within
the group of students completing the RN training, 20 additional
students will move on to complete their bachelor’s degree in
nursing and an additional 10 students will move from a bachelor’s
to a master’s degree in nursing. This is in response to the need
for more nursing education faculty in rural Minnesota. The
graduates with a bachelor’s or master’s in nursing will help to
support the additional RN education sites that will be developed
as a result of the project. The grade point average for the
students is approximately 3.5 and the student drop-out rate is low
– only about seven percent. The first full group of students will
graduate in August 2004, and two students have already
completed their bachelor’s and master’s in nursing.
What’s Next?
On a Final Note…
The Bridging Distances in
Healthcare program is an
excellent example of a successful collaboration with a single goal
in mind - to increase the RN workforce in rural Minnesota. Carol
emphasizes the importance of the partnerships created to put this
project in motion. She explains, “It has been such a wonderful
project. It has been so exciting to see everyone come together
and work on this and know that it is really filling a need.
Hopefully we can continue to meet that need.” She adds that the
true successes are the sites, the students and the partnerships.
None of this would be possible without their collaboration.
The Southwest Minnesota Private Industry Council, Inc., which
administers the grant, is a private, non-profit organization,
providing job training, assessments, and various employment
services to residents and businesses across 14 counties of
Southwestern Minnesota. The 14 counties include Big Stone,
Chippewa, Cottonwood, Jackson, Lac qui Parle, Lincoln, Lyon,
Murray, Nobles, Pipestone, Redwood, Rock, Swift, and Yellow
Medicine.
An essential component to this program is building in
5
Toward a Healthy Future for Rural Minnesota
By Estelle Brouwer
• In the year 2030, will rural Minnesotans have access to high quality health care in their
communities?
• What will be the most pressing health care needs in rural communities in 2030?
• What will be the most serious health problems?
DIRECTOR’S CORNER
• What will be the greatest health and health care successes or achievements?
While we may not be able to answer any of these questions with precision from our early21st-century vantage point, there are hints of what is to come in today’s demographics (we
are getting older and more diverse) and in the architecture of our current health care
system (messy). There are also steps we can take now to increase the odds that the answer
to the first question above will be a resounding “Yes!”
One major step in that direction — taken together over the past several months by the
Rural Health Advisory Committee, the Medicare Rural Hospital Flexibility Advisory
Committee, the Office of Rural Health and Primary Care, and a number of other groups
and individuals across the state – was to develop a new Rural Health Plan for the state of
Minnesota. Developing a state rural health plan is a federal requirement for participation in
the Medicare Rural Hospital Flexibility Program (otherwise known as the Flex Program, or
the program that brought you Critical Access Hospitals). In Minnesota, we took this
requirement seriously and worked hard to create a plan that we hope can be understood
and used by a broad range of groups and organizations in our state.
The four over-arching goals of Minnesota’s new Rural Health Plan are:
• Assure a strong, integrated rural health care system.
• Ensure a sound rural professional health care workforce.
• Promote effective health care networking and community collaboration.
• Foster increased capacity and resources to assure rural health care access and quality.
We invite you to log on to our Web site and peruse the plan. You’ll find it at
http://www.health.state.mn.us/divs/chs/rhpc/cah/ruralhlthpln.htm. Please think
creatively about how you or your organization can use the plan – whether that be the maps
of rural Minnesota’s demographics, economics, and health professional shortages found in
the Rural Health Landscape section; the profiles of various rural health services, including
hospitals, pharmacies, nursing homes, and hospice programs, or the Rural Health Goals and
Objectives. Let us know what you think of what you see; that will help us create a better
plan next time around.
We know the challenges involved in achieving the Rural Health Plan will be many – there
will always be health care challenges needing attention in rural Minnesota. But the good
news is that rural Minnesota also has plenty of what it takes to meet those challenges –
good heads, good hearts and a solid commitment to good health.
Estelle Brouwer is director of the Office of Rural Health and Primary Care. She can be
reached at (651) 282-6348 or [email protected]
6
Snapshot of Rural Hospice Care
(continued from page 3)
Coverage of Hospice Services
Hospice services are covered under Medicare, Medicaid,
MinnesotaCare, and most private insurance providers. Over 80
percent of all hospice care is provided under the Hospice
Medicare Benefit. Reimbursement of services is based on a per
diem payment that includes the cost of the professional staff,
durable medical equipment (such as hospital beds and oxygen)
and all medications and therapies related to the treatment of the
terminal illness. Under the Medicare Benefit, hospice programs
are reimbursed for four different levels of care: routine, inpatient,
respite, and continuous care. As is the case for rural hospitals, the
Medicare Hospice reimbursement rates are less for rural areas
than for urban.
The same report also revealed that increased expenses due to
greater travel, more expensive telecommunications systems, and
inability to cost share through purchasing cooperatives is also a
challenge. Reimbursement from Medicare does not take into
consideration some of the higher costs of providing services in a
rural community.
The current health care workforce shortage also presents an
enormous challenge for rural areas because they face an
increasing shortage of nurses. Hospice licensure requires specially
trained interdisciplinary professional staff and 24 hour/seven days
a week coverage. Small hospice programs often have difficulty
finding qualified personnel to share the 24/7 burden.
What Can Be Done
2004 Daily Medicare Hospice Reimbursement Rates*
Type of
Reimbursement
Rural
Urban
Routine Home Care
$115.74
$130.83
Inpatient
$675.49
$763.57
Respite
$120.24
$132.54
Continuous Care
$515.56
$578.10
*Hospice Minnesota. The rates above are the most common for rural and urban areas but
rates can vary depending on the Metropolitan Statistical Area (MSA).
Challenges
Not all areas of rural Minnesota have hospice programs
available. For those that do, the provision of hospice care
presents a number of unique challenges, such as the lack of
informal caregivers. As a rural public health nurse noted, “In our
region, many of the children have moved away. When someone
is old and frail, they have no one to take care of them.” Hospice
care is based on the premise that individuals who want to remain
in their homes have either family or informal caregivers nearby to
help. However, in many cases the adult children or other family
members of these patients have moved away and are unable to
offer daily care.
The 2002 report, “Use of Hospice Benefit by Rural Medicare
Beneficiaries,” by the University of Minnesota’s Rural Health
Research Center suggests that financial hardship is another
challenge. Under the Hospice Medicare Benefit, programs must
provide an array of services under the per diem mechanism
mentioned previously. A low volume of patients creates financial
hardships in spreading the risk of high-cost patients. For example,
a rural hospice program will receive only $115.74 a day for all
services even if it is paying several thousand dollars to provide
palliative radiation or expensive pain medications.
Hospice services are an important, but often unnoticed,
component of health care services in a community. The comfort
of being at home and receiving care at home can go a long way to
help ease the pain and anxiety of a life-limiting illness for both the
patient and the family. In rural areas, the increase in the aging
population and the lack of family nearby to provide care make the
availability of hospice services essential. The Minnesota
Commission on End of Life Care in 2002 issued four
recommendations regarding improving care and strengthening
hospice in rural Minnesota:
• Create education and development opportunities to
strengthen the rural hospice infrastructure.
• Fund the development of hospice programs in unserved
areas.
• Educate the public on end of life services through locally
based initiatives.
• Educate physicians, nurses, and other health care personnel
in hospice and palliative medicine.
All Rural Health Profiles are available to download from the
Office of Rural Health and Primary Care Web site at
www.health.state.mn.us/divs/chs/rhpc.htm
Angie Sechler is a health services/workforce research analyst
for the Office of Rural Health and Primary Care and the author of
the rural health profiles. She can be reached at (651) 282-6329
or angie.sechler.state.mn.us
Stefani Kloiber is the editor of this publication, and can be
reached at (651) 282-6338 or [email protected]
7
To learn more about the
Office of Rural Health & Primary
Care programs, visit our Web site:
www.health.state.mn.us/divs/chs/
orh_home.htm
Steve Hansberry
(continued from page 2)
What one or two changes do you think would make the most difference for rural
health?
SH: Find a way to increase the presence of decision makers in underserved areas. Have
corporate CEOs spend a week at their more remote facilities; don’t just visit for a day or two.
Demonstrate a top-down commitment to awareness of and interest in meeting rural needs.
Change in mindset, as opposed to change in systems. Introduce a Minnesota geography
component into new employee orientation sessions. Show that a mindset that rural people are
“different” is as damaging as deciding any other culture is “different”.
The Rural Health Advisory Committee advises the Commissioner of Health and other state
agencies on rural health issues, provides a systematic and cohesive approach toward rural
health issues, and encourages cooperation among rural communities and among providers.
Meetings are regularly held at the Snelling Office Park at the corner of Energy Park Drive and
Snelling Avenue in St. Paul and are open to the public. For dates, times, and directions, visit
the Web site at www.health.state.mn.us/divs/chs/rhac/meetings.htm or contact Tamie
Rogers at 651-282-3856/[email protected]
This information will be made
available in alternative format –
large print, Braille, or audio tape
– upon request.
Printed on recycled paper with a
minimum of 20% post-consumer waste.
First Class
U.S. Postage
PAID
121 East Seventh Place, Suite 460
P.O. Box 64975
Saint Paul, Minnesota 55164-0975
Permit No. 171
St. Paul, MN