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Doing Care Differently in Rural Kentucky: Health Policy through a Rural Lens



June 17th, 2013
by M. Gabriela Alcalde

The author is director of health policy at Foundation for a Healthy Kentucky.

On May 7, the Foundation for a Healthy Kentucky and the Kentucky Rural Health Association (KRHA) convened the Doing Care Differently in Rural Kentucky health policy conference. This one-day event, held the day before the National Rural Health Association’s annual meeting in Louisville, had more than 100 professionals in attendance. The event addressed key health policy issues through a rural health lens. Topics included the evolving roles of providers in rural health care delivery, telemedicine, Affordable Care Act implementation, and the changing responsibilities of local public health departments in rural Kentucky.

The day started with remarks from foundation CEO and president Susan Zepeda and KRHA Board President David Gross, who introduced the first-ever KRHA executive director, Tina McCormick. Craig Blakely, dean of the University of Louisville School of Public Health and Information Science, provided welcome remarks, noting that rural communities need organizations that can represent their interests to federal and state policy makers.

Keynote speaker, Wayne Myers, a national rural health expert who in the past has directed the federal Office for Rural Health Policy and is a past president of the National Rural Health Association, focused on the work of rural hospitals: “The old model hasn’t been working; it’s time for a new role for hospitals and other providers in rural communities,” said Myers, noting that “small hospitals must change from sick houses to centers of health.” In his presentation, Myers provided a new vision of a community hospital—rooted in health promotion, disease prevention, and rehabilitation services.

Medicaid expansion was featured prominently throughout the day, with Myers noting that “Medicaid expansion has a big health impact.”  Three days after the conference, Gov. Steven Beshear (D) announced that the Commonwealth of Kentucky will expand Medicaid to provide coverage for adults up to 138 percent of the Federal Poverty Level.

While acknowledging the need to address health care costs, Myers spoke of the necessity to shift the health policy conversation from cost to health impact. He mentioned that research from Harvard University showed that one life was saved for every 176 people added to the Medicaid program—this, he suggested, is the real argument for expanding Medicaid.

Rural populations face higher poverty rates and face greater challenges in health access and outcomes. The overall rural population is declining, standing at 16 percent of the total U.S. population, according to data that Myers cited.

Alarmingly, life expectancy in rural areas is declining—in sharp contrast with overall U.S. life expectancy. People in rural communities are dying on average at a younger age than their urban counterparts, and they are dying younger than previous generations did, data that Myers cited show. This shrinking rural population translates to decreased “political clout.”

A diverse panel of speakers—academic researcher, public health professional, primary care provider, and hospital administrator, followed Myers’ presentation. Ty Borders, the Foundation for a Healthy Kentucky Endowed Chair in Rural Health Policy at the University of Kentucky, discussed new tools available to rural hospitals to assess and monitor the quality of care, increase rural providers’ efficiency, and improve access to care. John Isfort of Marcum and Wallace Memorial Hospital (Irvine, Kentucky), talked about how, through attainment of critical-access hospital designation, his hospital overcame struggles common to rural hospitals. He then went on to describe how the hospital stepped up to become a Level IV trauma care facility with special competency in heart attack and stroke care.

Brent Wright, a family physician and medical educator, presented the TEAM (Technology, Engagement, Advocacy, Management) approach to health care provider education as an important model for rural health care providers. He stressed the effects of the current primary care provider shortage (more salient still under Medicaid expansion) and the importance of attracting talented and committed people both to primary care and to rural communities.

Two recurring themes were the integration of public health and primary care and the importance of adopting population health management approaches in rural health systems. Providing specific examples of how public health works in rural communities, Dennis Chaney, health director of the Barren River District Health Department (in Kentucky), presented the essential public health services, the role of accreditation, and the use of community needs assessment tools, such as MAPP (Mobilizing for Action through Planning and Partnerships). Chaney spoke of the Barren River District’s use of MAPP to bring together cross-sector leadership from hospitals, public health, and the community to address identified health priorities.

Afternoon sessions at the conference included the topics of public health, telehealth, and state health care policy updates. As for public health, Douglas Scutchfield (Peter M. Bosomworth Professor of Health Services Research and Policy, University of Kentucky College of Public Health and College of Medicine) provided a national context for the shifting role of public health, including the Affordable Care Act, accreditation of local health departments, and evidence-based public health practice.

Georgia Heise, director of the Three Rivers District Health Department (in Kentucky), talked about accreditation as a tool to improve public health at the local level. Heise talked about the very real “return on investment” of accreditation, such as increased competitiveness for federal funding; streamlining of the federal grant applications process; accountability and credibility; community engagement; awareness of agency strengths and weaknesses; and visibility.

Finally, Chaney spoke of specific collaborative approaches to address community health needs. He provided examples of the local efforts in the Barren River District to implement an evidence-based, coordinated school health model. He emphasized the importance of inclusiveness, cross-sectoral collaboration, and buy-in at all organizational levels.

In the telehealth session, Tim Bickel of the Kentucky Telehealth Network spoke about the importance of telehealth for rural and underserved populations.  He described telehealth as a tool to provide “the right care to the right people at the right time in the right place.” Kim Boyer, system director of emergency services at St. Elizabeth Healthcare hospital system (in northern Kentucky), presented on the experience and lessons learned so far with its innovative Telepsychiatry Assessment Program, which is funded in part by the Foundation for a Healthy Kentucky through its Kentucky Healthy Futures Initiative. The initiative is a public-private partnership grant program that began in August 2010 with matching funds from the federal Social Innovation Fund. The three-year initiative has supported nine nonprofit organizations around the Commonwealth of Kentucky in implementing or expanding on innovative, replicable strategies to improve the health of the state’s lower-income and rural communities.

Rose Rexroat of KentuckyOne Health/Saint Joseph HealthCare, also a grantee of the foundation’s Kentucky Healthy Futures Initiative, gave participants a glimpse into its nurse-practitioner–led, clinic-based, telemedicine program in Kentucky’s Wolfe and Powell Counties.

The third session focused on current health care policy updates related to the Affordable Care Act. Attendees heard from Lisa Lee, Kentucky Department for Medicaid Services, about what this federal/state program’s role is in rural Kentucky. She emphasized that rural communities have higher percentages of people enrolled in Medicaid, while facing higher poverty rates and less health and social service infrastructure, than urban areas have. Medicaid Managed Care now covers the entire state (with the exception of some Medicaid waiver populations), and with the recently announced Medicaid expansion, we can expect to see the number of rural Kentuckians receiving care through Medicaid increase substantially.

Miriam Fordham, director of the Division of Health Care Policy Administration of the Kentucky Health Benefit Exchange, provided a snapshot of the broad scope of work that the exchange has been undertaking at a fast pace. Kentucky is one of seventeen states with a state-based health insurance exchange; the system will go live on October 1 and will begin enrollment in January 2014.

Patricia Robinson of the Kentucky Health Information Exchange explained how the appropriate use of electronic information can help achieve the goal of safe, efficient, effective, and timely care for Kentuckians. Kentucky currently has a statewide, operational, live health information exchange. Roz Cordini, an attorney with Wyatt, Tarrant & Combs, presented on the KASPER (Kentucky All Schedule Prescription Electronic Reporting) program, as well as the impact of “House Bill 1.” Both aim to address the growing problem of prescription drug addiction in Kentucky.

Doing Care Differently in Rural Kentucky was a successful day of stimulating dialogue about how to maximize policy changes, improve care delivery, and strengthen the health and well being of our rural communities.

 

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