Health Resources and Services Administration
Office of Rural Health Policy
Fort Collins, Colorado
June 10-12, 2007
The 56th meeting of the National Advisory Committee on Rural Health and Human Services was held on June 10-12, 2007 in Fort Collins, Colorado.
Governor David Beasley, Chairman, convened the meeting at 1:00 p.m. on Sunday. He began the meeting by extending appreciation to the staff from the Colorado State Office of Rural Health for helping to organize the meeting.
Mr. Tom Morris from the Federal Office of Rural Health Policy introduced several new members of the staff and announced that Mr. Thomas Pack and Ms. Andrea Halverson would be leaving soon.
The Committee members present at the meeting were: Susan Birch, RN, MBA; Paul Craig, Ph.D., A.B.P.P.; Bessie Freeman-Watson; Joseph Gallegos; Sharon Hansen; Julia Hayes; David Hewett; Thomas Hoyer, Jr., M.B.A.; Lenard Kaye, D.S.W.; Clint MacKinney, M.D., M.S.; Arlene Jackson Montgomery, Ph.D.; Michael Meit, M.P.H.; Karen Perdue; Ron Nelson, P.A.; Sister Janice Otis; Larry K. Otis; Patti Patterson, M.D.; Tom Ricketts, Ph.D.; Heather Reed; and Tim Size. Present from the Office of Rural Health Policy were: Tom Morris, M.P.H.; Nina Meigs; Judy Herbstman; Thomas Pack; Michele Pray Gibson; Carrie Cochran; Jennifer Chang; and Erica Molliver.
Mr.Weskott presented information about the Colorado State Demographic Office and its responsibilities for forecasting population and economic changes in the State. He identified and described demographic characteristics of the three major economic areas of the State. These are the Metro Front Range, the Western Slope and Central Mountains, and the Eastern Plains and San Luis Valley. He described the major industries in each area and their different needs and issues related to the labor force. He then highlighted demographic data on the aging of the population in Colorado and presented a forecast that by the year 2030 every five-year age group over age 65 will have nearly tripled compared to the year 2000. He talked about the huge growth of retirees coming to the State and presented data to compare the aging Colorado population with the U.S. population as a whole. He concluded by saying that the Metropolitan Front Range and scenic areas of the Western Slope will continue to grow, and that the struggling agricultural regions of the eastern part of the State will also capture some of the increase in the number of retirees coming to the State.
Governor Beasley asked about the tax and economic implications of population decline in some eastern parts of the State coupled with growth in the west. Mr. Weskott acknowledged the difficult challenges to both economic sectors, highlighting that housing for seniors in the east will be a significant problem.
Mr. Hoyer asked whether the State would produce sufficient health workers to serve its growing population. Mr. Weskott responded that Colorado has a good community college system that is meeting some of the needs currently and is well positioned to meet additional demands in the future.
Mr. Hewett asked about the water supply needed for population growth. The speaker replied that the State has plenty of water, but there is a poor distribution system for eastern parts of the State.
Peggy Godfrey recited a few selections of her poetry to evoke the moods and values of rural Colorado.
Dr. Wallace spoke about health care access, systems integration, and community partnerships in northern Colorado. The service areas of Weld and Larimer Counties are facing a perfect storm in terms of population growth, high percentages of the population under 200 percent of the federal poverty line, and large numbers of uninsured. The mission of the Colorado Health Alliance is to ensure that all underserved residents have access to care through an integrated service delivery system. The Alliance is comprised of public and private health and human services providers in the two counties. The Alliance strives to develop collaborative systems of care, workforce development strategies, and programs for improved quality of care. The group has made recommendations to reform privacy barriers to integrated care, eliminate funding silos, develop national health care workforce strategic plans, and to assist rural communities in developing the capacity to train, recruit, and retain a competent workforce.
Dr. Westfall began his presentation with a brief description of all 64 counties in Colorado. Twenty-nine are considered rural and 23 others are considered frontier. There are 12 urban counties. Fifty counties are entirely or partially designated as Primary Care Health Professional Shortage Areas. Twenty-one do not have an acute care hospital and every rural county has job openings for a wide range of health care professionals. Dr Westfall provided data on mortality rates in the High Plains of Colorado and reviewed significant demographic and economic indicators for rural Colorado. He noted that rural residents are more likely to live in poverty, more likely to describe their overall health status as fair or poor compared to their urban counterparts, and more likely to lack health insurance. Geographic barriers to health care and the lack of public transportation are important issues in rural areas of the State. The Hispanic and indigent patient pool is putting immense pressure on rural health care providers. He also spoke about the acute shortages of mental health and dental health providers in rural areas. Other barriers to health care are inexperienced rural hospital boards, rural hospital administrator turnover, town rivalries, unrealistic residency requirements for family physicians, adverse weather conditions, water shortages, and poor communications capabilities. Dr. Westfall discussed rural solutions involving hospital board development, incentives for rural hospital administrators, collaborative outreach grants, and changes in physician residency requirements. He also recommended the need to provide incentives for specialists who will train rural physicians and residents, and the need for resources to help current rural practices to provide a similar scope of services as Federally Qualified Health Centers.
Mr. Nelson commented on the importance of pharmacists in an integrated system of care. Dr. Wallace agreed that pharmacists have to be part of an integrated system and cited some examples from his own community.
Dr. MacKinney asked about incentives for members of collaborative ventures to pool their funds. Dr. Wallace responded that pooling is often possible within existing guidelines for resource use, but he also said that new incentives are needed to encourage collaboration and integration of services.
Mr. Otis asked about the status of rural providers. Dr. Wallace spoke about training programs that are meeting some rural needs, but there is a declining interest in family medicine that will continue to hurt rural areas. He talked about the fact that training for family residents often takes place in settings where there are large numbers of uninsured and no compensation to the site for providing the training experience.
Ms. Brewster-Willeke spoke about the Rural Communities Resource Center in Yuma, Colorado. The Center was founded by a group of women who were interested in exploring alternatives to the standard method of childbirth delivery. As a result of their positive experience in working together, the founders began to think about how their experience could be a model for community collaboration on a wider range of issues. They organized a workshop called “Family Life in the Eighties” in Yuma where everyone who provided a community service was invited. At the end of the conference it was agree that there was a need for one place where people could go to connect with the services already available in the area. She described the current areas of focus for the Center that include: 1) Advocacy and support on homeless issues and support for parents and their families; 2) Domestic Abuse Prevention and Intervention; 3) Early Childhood education; 4) Economic and Social Justice; 5) Family and Community Health and Safety; 6) Youth programs; and 7) Community capacity and systems building. The Center has forged essential partnerships and collaboration with organizations, agencies, and individuals to bring needed programs and services to the area.
Ms. Mulch spoke from the perspective of a Public Health Nurse in describing her experiences in directing the Kit Carson County Health and Human Services agency. She described her relationships with the County Board of Health, the County Board of Human Services, and both State and Federal programs administered by her organization. The organization is extensively involved with all aspects of public health, including family planning, school health, immunizations, emergency preparedness and chronic disease prevention. It is also involved with food safety, septic systems, land use issues, animal odor control, and consumer protection. In the human services area, they are working on eligibility for food stamps and Medicaid, child welfare, child support, and child care. Ms. Mulch provided insights and experiences on a generalist model of service integration that has a particular relevance to frontier communities. She and her employees wear many different hats and are required to have knowledge of a broad spectrum of health and humans services programs. She emphasized the importance of consistency in communication at all levels and the need for real dialogue in the community. She also talked about the importance of cultural values and norms in working within the community. She said that the Committee should take from her experiences the lessons that integrated programs are critical and that committed individuals can make a huge difference in their communities.
Mr. Meit asked about the impact of stove-pipe funding on rural service providers. Ms Mulch responded that flexibility is limited in frontier areas where federal resources are scarce and tax revenues may fluctuate wildly from year-to-year. She advocated strongly for more flexibility in the use of federal funds. She also stressed the importance of accountability in a small community.
Dr. Kaye asked how the speakers would use additional funds if they were available. Ms. Mulch replied that her priorities would be pre-natal care and chronic disease prevention. Ms. Brewster-Willeke said that her organization needs general operating funds that would allow greater flexibility in meeting local needs.
There were two responses to the Chairman’s call for public comments.
Ms. Diane Miller from Steamboat Springs, Colorado spoke about the influx of immigrant groups and their need for services. She expressed the concern that there are no incentives for serving this growing population. She also called attention to the needs of the uninsured in Colorado.
Dr. Jack Berry, a family physician, asked the Committee to please consider the factors of time and distance in the American West that require physicians to have a broader range of competencies and skills.
The meeting was convened at 8:00 a.m. for a briefing on the site visits that were scheduled for the day. The Committee departed for site visits at 8:45 a.m.
The Health/Integration Subcommittees participated in a site visit to the East Morgan County Hospital in Brush, Colorado. There were presentations by: 1) Larry Leaming, Administrator, East Morgan County Hospital; 2) Dr. Marc Ringel, former National Health Service Corps physician; 3) Scott Harold, Director of Support Services, Washington County, Colorado, and 4) Dr. Tillman Farley, Medical Services Director, Salud Family Health Centers..
The Human Services/Integration Subcommittees visited the Northeast Area Agency on Aging where there were presentations by: 1) Jackie Reynolds, Executive Director, Rural Solutions; 2) Fred Crawford, Director, Logan County Department of Social Services; and 3) Margaret Long, Program Manager, Larimer County Office on Aging.
Following the site visits, the Committee returned to Fort Collins for a review of the schedule for Tuesday.
The meeting was adjourned until Tuesday morning.
Governor Beasley convened the meeting at 8:30 a.m. and asked Larry Otis to provide a brief overview of Toyota operations in Northwest Mississippi. The Committee will receive a formal presentation from Toyota at its next meeting.
Mr. Otis said that Toyota is heavily invested in health care for its employees and suppliers. The plant to be opened in Mississippi will have a primary care clinic on site and referral arrangements with local health care providers. A pharmacy will also be on site. The Company has disease management programs, integrated disability management programs, and other health care options for its employees. Mr. Otis said that the Company achieves significant cost savings through its proactive approach to health care for employees.
Mr. Size commented that the Toyota presentation at the September meeting in Madison, Wisconsin will attract great interest. He also said that there is a provider pushback on the Toyota model and it will be healthy to have a discussion in Madison.
Dr. MacKinney commented that Toyota has an appropriate emphasis on quality and efficiency, but there is a concern about the lack of choice for employees.
Health Subcommittee: Mr. Hoyer reported for the Health Subcommittee. He said that the main message of the Subcommittee report ought to be that there are two key things to do: 1) work harder to coordinate services, and 2) provide a warning that the success of the current system is the result of twenty years of patchwork exceptions where the system does not work efficiently. Efforts at health care reform need to acknowledge this from the beginning. He asked the Subcommittee members to send him their thoughts on the annual report over the next few weeks.
Dr. Patterson commented that the current system is based upon urban models and this is the time for boldness in the report. Other members reinforced her comments, emphasizing that we cannot solve rural issues without fixing the system as a whole.
Ms. Birch urged the Committee think futuristically about home and community-based health care services and to be careful not to focus primarily on hospital care.
Mr. Size cautioned that the Committee should be careful when looking at hospital issues. Hospitals have become so diverse the word itself can often be meaningless.
Mr. Meit advocated for a broad community health perspective in the deliberations of the Committee.
Mr. Morris noted that much of the conversation taking place in the Health Subcommittee would also fit with the chapter on integration. The report section on health care services to be drafted by the Health Subcommittee will need to be carefully coordinated with the section on integration.
Human Services Subcommittee: Mr. Otis reported for the Human Services Subcommittee. He said that the site visits had been very interesting and that one of the key lessons was the ability of the agencies to pull together funding from multiple sources to pay for transportation and other services. Speakers at the site visit provided comments and examples on the complexity and abundance of rules and regulations affecting their operations. They also talked about the problem of labor shortages and were keenly aware of the need for collaboration. The Subcommittee is leaning toward recommending some demonstration activities that the Department could support to address these issues.
Ms. Hansen said that building leadership capacity in rural communities is essential and can provide the means for taking full advantage of the volunteer spirit in communities.
Mr. Otis commented on the problem that federal and state agencies do not share information about their clients that would be helpful in building more collaborative service systems.
Mr. Morris noted that human service issues are confusing because providers are subject to both State and Federal regulations and it is hard to pinpoint the source of some problems. He asked the Subcommittee to address this issue in its annual report.
Ms. Freeman-Watson said that the Committee needs to become familiar with workforce issues related to human service programs.
Integration Subcommittee: Dr. Ricketts reported for the Integration Subcommittee. He noted that the Committee’s 2005 report had conceptualized the issues but it requires clearer models of the problems. We need to extend this conceptualization to give a clearer explanation of what we mean by integration. The Subcommittee is challenged to come up with the proper tactics for change. It needs to think about what a healthy community would look like and how to address the needs of communities that do not yet have the competence to cope with their own problems. Part of the problem is that there is a tension in the relationship of the federal government and its state and local partners: Governments at all levels need to be better listeners. There is a need to build human assets and capital so that people can be transforming and entrepreneurial in addressing the needs of their communities. The huge investment in volunteerism must be recognized and leveraged in finding integrated approaches for community services.
Ms. Perdue urged that the Committee keep in mind the sustainability of demonstration projects for integrated services. You can have a great demonstration that falls apart if there is not proper planning from the outset. She also urged that the Subcommittee report underscore the positive aspects of rural settings where people who are place-committed are tremendous assets in the community.
Mr. Meit commented that we should not undersell proven solutions by suggesting demonstration projects that may not work as well.
Mr. Otis said that communities that seem incapable of helping themselves must not be ignored because there is always latent ability within a community that can emerge with leadership training.
Dr. Ricketts said that communities can build on the success of their neighbors and we have to find ways that allow neighbors to help each other.
Mr. Gallegos stressed the need for leadership training to help communities address their problems, emphasizing that this is just as important as eliminating funding barriers to integrated services delivery.
Mr. Size reported on plans for the September meeting to be held in Madison, Wisconsin. The meeting location will be across from the State Capitol Building. A large block of time will be allocated for the work of the Subcommittees. There will be a presentation from Toyota, a discussion of welfare reform, and presentations on some innovative programs in Wisconsin. Mr. Size asked for suggestions from the human services members on the kinds of people they would like to hear from at the meeting.
Ms. Birch suggested hearing from vulnerable members of the population. Mr. Size replied that the Committee could hear about the Hispanic community in Wisconsin.
Ms. Perdue suggested that the Committee hear from a Native American population in the State.
There were no public comments and the meeting was adjourned.