Health Resources and Services Administration
Office of Rural Health Policy
Charleston, West Virginia
September 7-9, 2003
The 45th meeting of the National Advisory Committee on Rural Health and Human Services (NACRHHS) was held on September 7-9 at the Embassy Suites Hotel in Charleston, West Virginia.
Mr. Morris convened the meeting on Sunday morning. He welcomed the Committee on behalf of the Chairman, Governor David Beasley, who was delayed by bad weather.
Mr. Morris introduced five of the six newly appointed members of the Committee. The new members who where present are:
Tim Size, Executive Director, Rural Wisconsin Health Cooperative, Sauk City, Wisconsin
Ron L. Nelson, P.A., Physician Assistant, Freemont, Michigan
Joseph D. Gallegos, Vice President for Planning and Development, Presbyterian Medical Services, Albuquerque, New Mexico
Susan Birch, RN, MBA, Northwest Colorado Visiting Nurse Association, Inc., Steamboat Springs, Colorado
Arlene Jaine Jackson Montgomery, Ph.D., Professor of Nursing, Hampton University, Newport News, Virginia
Mr. Morris indicated that Heather Reed, Rural Health Administrator, Ohio Department of Health, Primary Care and Rural Health Program, Columbus, Ohio, also has been appointed and will attend the next meeting.
Mr. Morris also acknowledged the official appointment of the five human services members of the Committee: Mr. James Agras, Ms. Bessie Freeman-Watson, Mr. Lenard Kaye, Sister Janice Otis, and the Honorable Larry Keith Otis (who was unable to attend the meeting).
Other members present at the meeting were: Stephanie Bailey, MD, MSHA; Mr. David Berk; Evan S. Dillard, FACHE; Joellen Edwards, Ph.D., NP; Michael Enright, Ph.D.; Keith Mueller, Ph.D.; Ms. Sally K. Richardson; and Glenn D. Steele, M.D., Ph.D. Senator Raymond Rawson, D.D.S was not able to attend. Present from the Office of Rural Health Policy were: Marcia Brand, Ph.D. Tom Morris, MPA; Ms. Michele Pray-Gibson, MHS; and Jennifer Riggle J.D.
Mr. Morris also introduced Mr. David Dudley from the Department of Health and Human Services, Administration On Aging. Mr. Dudley will provide staff support to the Committee on aging issues in rural America.
Following the introductions, Mr. Morris adjourned the meeting for one hour so that the three sub-committees of the NACRH could meet separately to discuss their respective chapter in the annual report.
The luncheon speaker on Sunday was David W. Hughes. Ph.D., Professor and Extension Economist, West Virginia University Extension Service.
Dr. Hughes provided an overview of health and social concerns in the State. He spoke about life-style and health status issues, the many challenges faced by the health care delivery system and issues related to rural social services delivery. Some of the most difficult challenges relate to low income and educational levels in many parts of the State. The State also has a large elderly population, high disability rates, low rates of health insurance, high rates of obesity and health problems such as heart disease that are often related to the use of tobacco products. He presented informative data on the incidence and prevalence of specific health conditions in the State. He also briefly described several rural health and social services programs in West Virginia. He cited the importance of the State's strong educational infrastructure in addressing health and social service needs in the State.
WVRHEP is a unique collaboration between West Virginia State government agencies, institutions for higher education in the State, and local communities. The overall goal of the WVHREP is to meet the health needs of underserved populations in the State. The programs of the WVRHEP are designed to recruit and educate high school students' college students and graduate level students for careers in the health professions and service in rural areas of the State. Ms. Heady briefly described the structure of the WVRHEP and its social responsibilities for meeting needs of the underserved. Within the WVRHEP, state government is responsible for legislative changes and policy direction, and provides funding for its activities.
Dr. D'Alessandri spoke about the responsibility of higher education to build and sustain partnerships with communities and to construct and fill an education pipeline for health professionals to serve those communities. He described the unique collaboration within the WVRHEP between West Virginia University, Marshall College, and the West Virginia School of Osteopathic Medicine. These institutions have come together to incorporate rural health into their educational curricula and to implement pipeline programs for health professionals to serve rural underserved communities of the State. Pipeline programs supported by the WVRHEP identify and educate trainees for practice in rural communities. Dr. D'Alessandri briefly discussed several Pipeline programs involving the Health Sciences and Technology Academy, West Virginia Rural Health Education Partnerships, West Virginia Area Health Education Centers (AHECs), Rural Residency Programs, and Medical School initiatives to support health practitioners in their communities.
Mr. Size asked if the WVRHEP schools have set targets for the number of students electing to work in rural areas. Ms. Heady replied that there are no fixed benchmarks, but there is legislation requiring them to focus efforts on federally certified underserved areas.
Dr. Kaye asked about the extent to which the schools encourage continuing education for those who choose to practice in rural areas. Ms. Heady responded that each school in the WVRHEP is heavily involved with continuing education for rural providers.
Ms. Birch asked about the use of telehealth as part of the health education infrastructure.
Dr. D'Alessandri said that telehealth programs began in 1990 and about seventeen sites are now connected between the schools and with local communities.
Ms. Crawford described the organizational structure of the HSTA program and how it operates throughout the State. The program is designed to educate and assist students who are seeking a career in health care professions. The Academy has served a total of 1,661 students to date and there are 722 students currently in the program. At present, there are sixty-seven high school teachers participating in the program. She also discussed the WVRHEP infrastructure. There are now 318 WVREHP training sites in 50 counties of the State and 594 field faculty. About 110 students rotate through the program each month. Thirteen regional consortia and local community boards govern the program. Ms. Crawford also talked about the West Virginia AHEC program that is working to strengthen medical residency and other graduate training opportunities in rural areas.
Dr. Foster described the roles and responsibilities of campus faculty in the WVRHEP. Campus faculty members of the medical schools are responsible for coordinating rural rotations for students, and they work with field faculty and site coordinators to ensure the quality of community based training. They also provide support to field faculty in designing educational programs for specific communities and play a lead role in program evaluation.
Dr. Foster spoke about relationships between participants in the WVRHEP and how they are achieving mutual trust and respect. Schools, government agencies and community leaders have had to examine their respective definitions of power in the relationship. Each partner's role has been well defined and significant results have been achieved in the placement of health professionals in underserved areas. A total of 402 West Virginia graduates were recruited for underserved areas during the period 1991-2002. This number includes physicians, dentists, nurses, physician assistants, pharmacists and other health professionals. Outcome data for HSTA high school students show that 97% enter college compared to 52% for all West Virginia students. Five students are currently in medical school and 59% of students are in health career majors compared to 17% for all West Virginia students.
The two former HSTA students shared their experiences with the program. They spoke about the opportunities it provided for them to attend college and how the program stimulated their interest in the health professions.
Mr. Brown related that community members in the WVRHEP are entrusted with oversight of state funds for the program and spend many volunteer hours to develop fiscal and program policies in their communities. Members strive to mentor trainees and to demonstrate the value of working and living in a rural community. They work to recruit trainees for their communities and provide students with opportunities to become community leaders.
Schools Resources Extended to Field Experiences
Robert Walker, M.D., Associate Dean and Chair of Family Medicine, Marshall University School of Medicine
Dr Walker spoke about rural residency programs under the WVRHEP. Medical school rural health tracks allow students to obtain a rural residency during their fourth year of medical school. Technical assistance with residency programs is provided to rural health facilities and consortia. Technical assistance includes a review of health care resources and readiness for residency training in the community. Program staff also recommend appropriate models for residency training at specific sites.
Dr. Brody stated that field faculty of the WVRHEP serve as role models and professional mentors for trainees. They supervise students and residents while meeting their clinical objectives on rotation. They also identify community service needs and assist Site Coordinators as needed. They supervise students on research projects, maintain communications with their schools, and participate in faculty development activities.
Ms. Vestal spoke about the roles and responsibilities of site coordinators in the WVRHEP. Site coordinators recruit field faculty, staff local boards, identify community needs, coordinate housing and other services for trainees, and implement local board policies. They also staff the consortia boards.
Ms. Hutchinson introduced a panel of speakers to discuss West Virginia perspectives on issues that will be addressed in the Committee's annual report.
The Prestera Center for Mental Health Services and Valley Health Systems (a primary care system) have been working together to integrate behavioral health and primary care services. Mr. Shattles said that the two organizations began the relationship by renting space together. Subsequently, they received grant funds that required collaboration between the two systems on solving mental health problems in primary care settings. Grants have also been obtained for school-based services in behavioral health. The program is run by Valley Health Systems, but staffed by Prestera. A central pharmacy has been established at Prestera to meet the needs of both organizations. The two organizations are examining new organizational and financial strategies for further integration.
Mr. Hanson described how the two organizations meet to manage the collaboration and how they continue to look at various integrated models of mental health/primary care. They are seeking new grant support to expand substance abuse services and discussing the use of telehealth to reach additional rural communities. Also, they are exploring ways to collaborate on administrative functions, billing, training, and other activities. He stated that the two systems now have a strong base to build on as they seek additional approaches to the integration of primary care and behavioral health.
Dr. Enright asked if there were laboratory services on-site at the facilities. Mr. Hanson replied that services were not offered on site, but were readily available for all patients.
Dr. Edwards asked whether the primary care center was able to contract with Prestera for mental heath services on a cost basis. Mr. Hanson responded that no contracts had yet been signed.
Dr. Meckstroth talked about some of the significant challenges in providing access to dental services in rural areas. Consumer issues include lack of transportation, low incomes, reduced access to private dental insurance and low payment rates. He also said that consumers are not well informed about oral health and its close connection to many physical health conditions. Provider issues include the level of indebtedness of dental graduates, the high overhead costs of establishing dental practices, as well as those of providing service, and low Medicaid payment rates. Medicaid payment rates for dental services are less than costs. He mentioned the need for financial incentives to attract dentists to rural areas. His suggestions included increasing payment rates in rural areas, providing tax credits and student loan forgiveness to providers, and developing continuing education programs to help dentists more efficiently treat specific populations. He emphasized that inter-professional dental health care disputes and turf wars over scope of practice must be replaced with collaborative efforts to address the oral health needs of the underserved. He spoke about the need for fluoridated water supplies in rural areas.
Dr. Brody stated that the dentist-to-population ration in West Virginia is decreasing rapidly in the least populated counties. Only 30% of Medicaid/CHIP eligible children in the State actually receive oral health services. Of the children between the ages of birth and 3 years old, over 89% have not seen a dentist in the last six-month period. Dr. Brody stressed the need to educate and train rural primary providers to assess oral health risks, provide guidance, and integrate preventive oral health services into the regular primary care of small children. Strategies to accomplish this goal include: (1) Integrating pediatric and oral health into routine primary care services for children and using an intervention schedule for oral health that is tied to immunization and well-child visits; (2) Providing age appropriate parent education on oral health; (3) Facilitating parental compliance when children need to be referred for treatment of dental disease; and (4) Community outreach and support for better oral health. Dr. Brody then described some ongoing projects in West Virginia to implement these strategies. Some of the challenges these programs face are lack of reimbursement for preventive oral health services; lack of community knowledge of the benefits of fluoridated water; lack of support from organized dentistry for the use of fluoride varnishes by non-dental personnel, and the lack of dental referral sources for children younger than 3 years of age.
Ms. Richardson asked whether public health offices in the State offer dental services. Dr. Brody responded that these services had been dropped, with only a few exceptions.
Dr. Montgomery asked if there were any partnerships involving urban dentists coming to rural areas a few days each week. Dr. Brody said there was no movement in that direction and no examples he could cite.
Ms. Stottlemyer spoke about problems of the elderly in the State. Forty percent of the population is over age 60, second only to Florida. The population is growing older with 35% of seniors over age 75. The State is losing its younger population. In a few years 2 out of 5 people will be over 60 years of age. There are serious questions about how these seniors will be served. Ms. Stottlemyer directs a small agency with 31 staff. The total budget is $38 million. There are 4 Areas on Aging in the State. She talked about how the aging programs are administered and the services they provide. She mentioned new programs offering care-taking services in the home and addressing Alzheimer's disease. Medicaid is the largest provider of services for the elderly, accounting for all but a small portion of her budget. She stated that the Bureau's programs have good support from the West Virginia medical schools. Some of their biggest challenges are to keep seniors healthier and to work with them on mental health and prescription drugs.
Dr. Ham reiterated that Alzheimer's disease is a huge problem in the State. He spoke about the mission of his agency and presented information on the unequal distribution of primary care physicians in the State. Most counties do not have a psychiatrist. He talked about the need to educate primary care physicians on problems of the aged and efforts to work on this issue with Area Health Education Centers, Geriatric Education Centers, and through continuing medical education programs in the State. Physicians in the State have cited geriatric education as one of their greatest needs. The three medical schools in West Virginia are working together on these issues. Some other problems they are addressing are physician payment for geriatric services, refinement of educational curricula, and the development of new diagnostic tools for Alzheimer's disease. He closed the presentation with a recommendation for more research on rural health gerontology.
Dr. Kaye asked whether non-physician health professionals were benefiting from geriatric education programs. Dr Ham said that students include nurses, dentists, social workers and others. He stressed the importance of working with all professional groups to promote geriatric education.
Governor Beasley discussed the process for preparing the annual report and the role of the subcommittees. He asked the subcommittees to continue their focus on recommendations to the Secretary.
Governor Beasley called for public comments. There were no comments and the meeting was adjourned until Monday morning.
On Monday the subcommittees separated for morning site visits. The Oral Health Subcommittee visited clinics at Cedar Grove and Fayetteville. The Integration of Primary Care and Behavioral Health Subcommittee visited the Lincoln County Primary Care Center and a Primary Care Clinic in Cabin Creek. The Senior Services Subcommittee visited the Roane County Senior Center and the Calhoun County Senior Center.
On Monday afternoon the Full Committee conducted a site visit to the Minnie Hamilton Health Care Center in Grantsville, W.V. The members were given a tour of the facility and had the opportunity to speak with its staff. Minnie Hamilton is a unique organization that was created when the local Community Health Center prevented the town's hospital from closing and assumed management responsibilities for the hospital. The new organization resulting from the takeover encompasses a Critical Access Hospital and a Federally Qualified Health Center. It is working to overcome barriers to the integration of services in primary care, dental care, and behavioral health. The Clinic staff provided insights on regulatory and reimbursement issues that impede integration of services. Some federal and state requirements are prohibitive, while others are unclear.
On Tuesday morning the subcommittees met separately to continue work on their respective reports.
Following the subcommittee meetings, Mr. Morris convened the full Committee and asked for summary reports from the subcommittees.
Ms. Richardson reported that the group had focused on the recommendation section of its report and was considering recommendations asking the Secretary to: (1) Call a high-level summit meeting on oral health; (2) Use prevention funds at the Center For Communicable Diseases to address oral health; (3) Develop a model practice act for dental hygienists; (4) Fund model case studies of successful programs to integrate oral health and primary care; (5) Develop financial incentives for dentists to practice in shortage areas; (6) Support a capital program for start-up clinics; and (7) Address the public health aspects of fluoridated water. The subcommittee also discussed the need to support dentists in the development of business plans and to increase oral health priorities within Title VII. These ideas are still tentative and other recommendations are under consideration.
Dr. Edwards reported that the group is working on final text for its report and developing recommendations. The group is focusing on four or five recommendations and working to make them as specific as possible. One recommendation will look at payment policies and there will be a recommendation on scope of practice for behavioral health practitioners. The group is also considering recommendations on the National Health Service Corps and the Title VII and Title III programs.
The report chapter on aging is just getting started. The subcommittee intends to use the chapter to discuss the demographics of aging issues, with emphasis on rural differences. The report will draw upon lessons learned at the site visits attended by the subcommittee. There will be several key areas of focus: (1) Improving partnerships among agencies that serve the elderly; (2) Key access issues for seniors; (3) The fragile infrastructure for aging services; (4) The need for skills building and retraining of providers; and (5) Need for greater emphasis on marketing of available services.
Mr. Morris asked the Committee for its ideas on issues that should be raised in the chapter on emerging issues that will appear in the annual report.
Mr. Size expressed concerned that rural providers are not well prepared for public reporting on health care quality measures. He suggested that the federal role in providing needed assistance should be addressed.
Dr. Kaye stated that issues around documenting performance and outcome are especially challenging in human services where interventions are less concrete.
Ms. Richardson said the ability of rural providers to deal with HIPA requirements is an important issue that was seen first-hand during the site visits in West Virginia. Resources to demonstrate quality and comply with HIPA are lacking in rural communities.
Dr. Kay said that the availability of adequately trained people to deliver services to the elderly in rural areas is at a crisis point. We may need to expand the definition of appropriate providers.
Ms. Birch cited the problem of cost shifting for health services to local governments due to Medicare and Medicaid not covering their costs. Mr. Size added that the private sector will not accept cost shifting as it becomes more sensitive to fees.
Mr. Nelson emphasized the need to address payment policies more broadly. There are significant issues with Medicaid prospective payment systems for Rural Health Clinics and Federally Qualified Health Centers.
Dr. Edwards supported the need to address payment policies across the board. Payment policies need to reflect the true cost of doing business with low-density populations.
Mr. Agras stated the need for more comprehensive training of human service workers. He also mentioned that retired seniors who are seeking work need to be aware of opportunities for serving the elderly.
Ms. Richardson talked about the need for social policies and cultural education to effect changes in rural populations.
Mr. Size and Ms. Birch spoke about the need to address the relationships between health and economic development in rural areas.
Mr. Agras expressed interest in looking at models for integrating health and human services and offering a continuum of care for the elderly.
Mr. Morris said that the staff would compile the recommendations on emerging issues and report to the Committee through a conference call.
Mr. Morris informed the Committee that a draft letter to the Secretary on the West Virginia meeting would be sent out for its review.
Mr. Morris also informed the Committee that leaders in the Department of Health and Human Services would be invited to the February meeting to help the Committee identify topics for consideration during the coming year.
Mr. Morris indicated that the June meeting of the committee would be in Nebraska.
On behalf of the Committee, Mr. Morris thanked Ms. Richardson for hosting the meeting in West Virginia.
There were no public comments and the meeting was adjourned.