ruralroads

Patient praises cardiac partnership

Rural recruitment and retention

Collaboration addresses children’s mental health

NRHA volunteers rebuild homes

SUMMER 2008 A QUARTERLY MAGAZINE VOLUME 6, NO. 2 @hp8\Zg8p^8[^lm8\Zk^8_hk8 ^o^krhg^8bg8hnk8\hffngbmrŸ

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A9111_8994_v3.indd 1 6/6/08 9:17:05 AM Rural Roads is a publication of the National Rural Health Association, a not-for-profit association composed of individual and organizational members who share a common interest in rural health. Rural Roads seeks to disseminate news and information of interest to rural health ruralroads professionals to help establish a national network of rural health care advocates. For more information on joining the NRHA, go to www.RuralHealthWeb.org or call Estelle Montgomery at 816-756-3140. A QUARTERLY MAGAZINE 2008 Board of Trustees VOLUME 6, NO. 2 Officers Paul Moore, President ISSN 1550-6576 Beth Landon, President-elect Sandra Durick, Treasurer Mike French, Secretary George Miller, Past-president 4 Farming lessons still relevant Constituency Group Chairs Raymond Christensen – Clinical Services 5 Project helps farmer with Art Clawson – Community Grassroots disability Greg Dent – Community-operated Practices Marita Novicky – Diverse Underserved Populations 6 Education, advocacy and Kristin Juliar – Frontier networking H.D. Cannington – Hospitals and Community Health Systems Roxanna Jokela – Research and Education Tommy Barnhart – Rural Health Clinics 8 Your voice needed for policy Lisa Kilawee – Statewide Health Resources development Andrew Behrman – Rural Health Congress 10 Collaborative research Rebecca Conditt – State Association Council Chair addresses access, education Graham Adams – State Office Council Chair Kentucky hospitals reap Alan Morgan – Chief Executive Officer 14 Lindsey V. Corey – Editor benefits of collaboration Angela Lutz – Editorial Assistant 18 Partnerships address early Reader information childhood mental health Rural Roads focuses on model rural health practices and programs, creative use of technology, rural health heroes and human interest 22 Commitment to a common stories. The goal of each story should be to motivate, educate vision or inspire those working to improve health care or living in rural America. Rural Roads adheres to standard AP Style guidelines. 24 Primary Care Plus impacts Advance notification of intent to submit an article is appreciated. mental health E-mail [email protected]. The NRHA reserves the right to edit all materials submitted for clarity, consistency and formatting to meet in-house style guidelines. Submission of an article does not guarantee 26 Savannah, here we come publication. We further reserve the right to publish all letters received. 27 Annual Conference impact

Publication schedule 28 Helping new rural physicians Rural Roads Volume 6, Issue 3 Advertisement reservations are due Aug. 4. 29 Is a rural career right for you? Camera-ready ads are due Aug. 18. 30 Patient praises cardiac partnership Advertising opportunities are available. For more information, contact Kim Westhusing at [email protected]. 32 Meyersdale Medical Center’s To submit materials, photos, correspondence, or for more informa- sweet 16 tion, contact [email protected]. 35 Rural health news To subscribe Domestic: $20/year International: $30/year To subscribe to Rural Roads, e-mail [email protected]. Farming lessons still relevant

BY Paul David Moore, D.Ph., NRHA President

rowing up on a farm, the hard work taught me many things, not the least of which is the value of an education. One significant lesson learned: there is no such thing as a harvest without plowing. This undertaking is essential, even though it seems to produce nothing but dirt. Plowing is not exciting work. It expends resources in an effort that goes slowly, gets you dirty, and digs up things you didn’t know were there. Since it’s almost guaran- teed to reveal unplanned obstacles, inherent in the process is the temptation to shallow up the plow to keep from getting stuck or to finish sooner. This method can bring less-than-desirable results, as I once learned after a toad-strangling rain Gwhen I had to re-plow an entire hillside. While plowing always works better when one goes with the contour of the land, it is one of the few activities I can think of that is more tolerable when the wind is in your face rather than at your back. There are many dedicated individuals who have demonstrated both vision and endurance in doing the hard work of plowing to produce quality health care across rural America. Still, we must recognize that rural health care remains rich with fallow ground still waiting to be plowed. There is the networking opportunity with “competitors” in neighboring towns that will serve our communities in mutually beneficial ways. There is the new stakeholder to engage that we are not sure should be entering the field. There is available technology proven to increase efficiency and patient safety, but we just can’t let ourselves spend the money until it becomes a mandate. There are obvious reasons it makes sense to replace outdated infrastructure, but it is hard to think in those terms. Instead we ride around the field with our plows held high, maintaining the status quo that has served us this far, thinking we are doing the best we can, though we may not be. I know of only one crop that grows successfully without plowing: weeds. Perhaps it is time we put our plows in the ground.

RURAL ROADS, SUMMER 2008 Looking forward to a great harvest, Paul Moore

4 NATIONAL RURAL HEALTH ASSOCIATION 5 The committee of more than 80 friends, relatives and and relatives friends, 80 than more of committee The make that network and resources the resolve, Wical’s Nelle and Gary Wical with neighbor Gregg Sparks (front). ready. They also assisted him in applying for the VA’s VA’s the for applying in him assisted also They ready. for veterans who Coverage Millennium Bill Emergency health have not do and facility private a in treated are insurance. was VR Because $73,000. raise to managed neighbors the accommodations, farm necessary the purchase to able to use as needed. the money committee gave the Wicals and family powerful and caring the and AgrAbility up continue farming. to community have allowed Wical

AgrAbility Staff By National ary Wical, an Ohio farmer and Vietnam Vietnam and farmer Ohio an Wical, ary have been Nelle Wical, veteran, and his wife, for hogs and wheat soybeans, corn, raising Project farmer helps disability with Wical’s recovery and return to farming has not been Wical’s Beck also suggested Wical apply for services with the Beck also suggested Wical In mid-March, Sparks contacted Mary Beck, rural In mid-March, While Wical was in the hospital, his neighbor Gregg neighbor Gregg was in the hospital, his While Wical In February 2007, Wical sustained a traumatic sustained In February 2007, Wical easy. He missed part of spring planting in late April easy. when a staph infection landed him back in the hospital was VA local The prosthesis. his getting delayed and was Wical when prosthetic the acquiring in helpful Ohio Vocational Rehabilitation (VR) agency as soon as Ohio Vocational disability- possible. She said VR may be able to provide assistive technology to accommodate workplace related peer Coalition’s Amputee the described she and barriers, as well as the Ohio extension service support program was Wical Fortunately, resources. for agriculture-related Affairs connected to the Department of Veterans already system. (VA) who provided Sparks with several resources. Sparks with several resources. who provided rehabilitation specialist for the National AgrAbility rehabilitation Speculating that lifts for farm vehicles (NAP). Project useful accommo- and an all-terrain wheelchair might be Sparks with Mark Beck connected dations for Wical, and engineer, Novak, NAP agricultural technologist A committee formed, and fund-raising events were were events fund-raising and formed, committee A department, a local planned by neighbors, the fire county beef and pork fertilizer and seed company, support strong a With church. Wicals’ the and producers began system in place, Sparks and a small workgroup Wical. to find help for where researching Sparks amassed a team of 40 friends and neighborsSparks amassed a team of 40 friends and back to farming. united in a single mission: get Wical injury in a PTO driveline, when his pant leg was caught in a bilateral above-the-knee amputation. resulting

more than 30 years on a rented farmstead. than 30 years on a rented more G Education, advocacy and networking

By Alan morgan, Nrha CEO

t is a tough task to sum up the activities of the National Rural Health Association in three words. However, education, advocacy and networking seem to cover it. I NRHA has evolved over time to become the premier national educational source for rural health policy and practice. The organization hosts multiple national educational conferences throughout the year for its membership. These range in size and scope from the NRHA Annual Conference each May to our Rural Health Clinic and Critical Access Hospital Conferences every October. All of these educational events have their own planning committees comprised of NRHA members. They all seek session proposals, which are reviewed and rated for educational merit by the respective planning committees. All of these confer- ences offer the relevant and appropriate continuing education credits for attendees. Advocacy is the heart and soul of this organization. Over the past 30 years, NRHA has been the voice of rural health in our nation’s capitol and provided input into the policy formation process for all rural-health-relevant federal legislation that has passed through Congress. NRHA membership consists not only of policy experts and rural health practitioners, but also the community members affected by national policy changes. Therefore, NRHA is the obvious place for lawmakers to start when discussing our nation’s rural health care system. It is not surprising that NRHA members have already been called upon multiple times this year to testify before Federal Senate and House health committees. Networking is what makes NRHA unique. If you have attended an NRHA conference in the past, you know this statement to be true. We are a welcoming bunch. Rural does not mean “second tier.” I’ve seen this firsthand in travels across the country while at NRHA, and we share best practices and success stories in our ongoing networking efforts. This year, we are in the process of revitalizing our Rural Roads magazine. We are certainly not fixing something that is broken. Rather, we are ensuring this

RURAL ROADS, SUMMER 2008 publication is the best magazine for our members. You deserve a magazine that leads, not follows. We will launch the new magazine in the fall, and we will maintain the tradition of producing an association magazine that highlights the best in rural health care. The activities of education, advocacy and networking are without merit if the ultimate goal is not to achieve excellence in practice. I hope that you enjoy this summer issue of Rural Roads, which looks at collaborations in rural health care. Success and greatness occur often in rural health care, and it is our goal that your membership in NRHA can help you achieve both.

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The Washington, D.C., NRHA The Washington, on the congress. This gives the congress a strong a strong This gives the congress on the congress. concerns the reflects that representation grassroots of the full NRHA membership. The five most recent NRHA presidents also sit sit also presidents NRHA recent most five The State Office Council, issue groups and officers. State Office Council, issue groups ency groups, as well as the State Association Council, ency groups, members from each of the association’s nine constitu- each of the association’s members from new policy. Representatives are proportionally-elected proportionally-elected are Representatives policy. new Manager Affairs , NRHA Government By Tim Fry Once the online policies are complete, the NRHA Rural Health Congress, made complete, the NRHA Rural Health Congress, Once the online policies are In the past, participating in policy creation meant writing a paper, attending meant writing a paper, In the past, participating in policy creation The NRHA is a membership-driven organization. This means all policies The NRHA is a membership-driven organization. Your voice needed voice Your development for policy congress meets face-to-face at association conferences three times each year to consider consider to year each times up of members, decides whether to make them official NRHA policy positions. The three conferences association at face-to-face meets congress a meeting and taking part in debate. Today, technology allows all members to to members all allows technology Today, debate. in part taking and meeting a The NRHA web site lists all policies under development, easily. participate more policies of versions current the read to able are members site, the visiting by and thoughts online edit policy positions or share write their own policy, under review, , and click on the “About with other members. Go to www.RuralHealthWeb.org Congress” Health “Rural the visit Committees,” and “Boards Under link. NRHA” the page on policy position development. and positions of the association come directly from our members. Any member member Any members. our from directly come association the of positions and to and association the within proposals policy advocate and support propose, can health landscape. influence the rural the wider public, meaning you can directly staff has worked most of the year on this legislation to ensure rural providers will rural providers most of the year on this legislation to ensure has worked staff accomplishment for our lobbying in business. It will be a great be able to remain was cut pay physician the preventing decided who staff not was it but staff, important policy; it was you.

his summer, Congress will have considered and most likely likely most and considered have will Congress summer, his payment cut 10.6 percent passed legislation to halt a scheduled providers. to physicians and other rural T

RURAL ROADS, SUMMER 2008 8 NATIONAL RURAL HEALTH ASSOCIATION 9 Most of the time, however, the the however, time, the of Most EDUCATIONAL process in place where leaders of the the of leaders where place in process the issue and association review determine policy. make a decision to presented then is review rapid This at Congress to the full Rural Health becomecan it when meeting, next its the association.permanent policy of stated a association has already works with this position. NRHA staff best the determine to policy stated needs the meet and proceed to way of members. This may mean direct staff, lobbying of congressional comment letters on regulatory in members involving or changes our through advocacy grassroots e-mail Action Alerts. This is when or phone the up pick should you - write a short note to your congres the sional office to help improve health of millions of rural Americans. Savannah, Georgia alendar October 15-17, 2008 Health Conference December 11-12, 2008 Albuquerque, New Mexico Albuquerque, Minority and Multicultural Early bird rate deadline: November 7, 2008 Early bird Early bird rate deadline: September 20, 2008 Early bird C Critical Access Hospital Conference Obviously, the reality of practicing the reality Obviously, legislative and regulatory changes. If and regulatory changes. legislative agenda is totallya suggestion for the will Rural Health Congress the new, policy into a fullwork to develop the is distributedstatement. The agenda policy makersto NRHA members, and Congress of members all and our on available also It’s staff. their and Advocacy”site under the “Policy main the is agenda NRHA The link. document policy makers on Capitol improve to how determine to use Hill in rural America. health care to change medicine and efforts the to tied not are policy national NRHA agenda-setting timetable. issues year, given any Throughout immediate atten- arise that require often brought tion. These issues are by to the attention of NRHA staff issues these of some and members, deal with To do not yet have a policy. response rapid a has NRHA this,

July 15-17, 2008 Savannah, Georgia 2008 Save The Date San Diego, California October 14-15, 2008 Rural Health Clinic Conference Clinical and Quality Conference Early bird rate deadline: September 20, 2008 Early bird Everyone goes to you for answers. Where do you go? Where Everyone goes to you for answers. National Rural Health Association One way of doing this is the the is this doing of way One The association has adopted adopted has association The creation of the NRHA’s annual of the NRHA’s creation legislative and regulatory agenda, way to get involved which is a great Each year, in rural health advocacy. for members all asks staff NRHA the the in included be to suggestions agenda. Suggestions range from to ideas for new rural programs payment methodology Medicare changes to descriptions of how by impacted is practice current many policy positions over the years;many policy positions currently than 70 positions are more so many active. With considered approved positions policy important the Congress, Health Rural the by also Committee, Government Affairs works withmade up of members, to identify priority the NRHA staff policies helping to focus the associa- impact maximum for resources tion’s on Capitol Hill. Collaborative rural research addresses access and education in Idaho

By David Schmitz and Ed Baker

orkforce and medical education have become front and center in many of today’s health care conversations in Idaho. The Idaho legislature recently directed the State Board of Education to commission a study focusing on student demand for medical education and the state’s need for physicians. The findings showed access to physicians and medical education is extremely limited in Idaho, when contrasted with other comparable states as well as the nation as a whole. “Understanding the dynamics that go into rural family physician recruitment and retention is critical to the primary care work force needs of rural America,” says WTed Epperly, one of Idaho’s leaders in medical education and Family Medicine Residency of Idaho program director and CEO. With one of every three Idaho residents living in a rural area, the challenge of providing access is particularly applicable to the broad scope of services provided by family physicians. The genesis of the work on recruitment and retention of family medicine physicians in Idaho grew from meetings with Mary Sheridan, Idaho Department of Health and Welfare Office of Rural Health and Primary Care supervisor. That office provided funding to begin the research. “The results will help us identify resources needed in rural health care facilities and communities to assist them in their workforce efforts,” Sheridan says. Affiliations with the Family Medicine Residency of Idaho and the Center for Health Policy at Boise State University provided a framework to develop a research plan. However, this effort would require extensive collaboration with other groups, so the Idaho Academy of Family Physicians and the Idaho Hospital Association

RURAL ROADS, SUMMER 2008 were recruited to participate in the research. They were excited to partner on an endeavor that was relevant to their missions and critical to the success of these organizations. “When we were presented with this opportunity, we jumped on board because our very small rural member hospitals have a difficult time recruiting physicians due to lack of resources and not necessarily knowing what factors attract physicians to rural areas and keep them there,” says Steven Millard, Idaho

10 NATIONAL RURAL HEALTH ASSOCIATION 11 continued on next page “Visiting my members in their their in members my “Visiting What began as a pilot study of Santos, Idaho Academy of FamilySantos, Idaho Academy director. Physicians executive helped me get rural practices really and each ofto know their issues in an importantthem as physicians she says. way,” physicians family Idaho rural phased multi-year a to expanded understand rural to better effort Idaho, its physicians and its commu- nities with continuous funding by and Health Rural of Office the Primary Phase two of this Care. Top: David Schmitz formerly David practiced medicine in Top: a rural community of Idaho and continues to see responsibilities as associate patients with his new Medicine at the Family director of Rural Family Medicine Residency of Idaho. recruitment discusses rural Left: Ed Baker physician and retention issues with research partners across at Boise State Idaho at the Center for Health Policy University. Photos courtesy of Boise State University.

Steven Millard, Idaho Hospital Association president Hospital Association Idaho Millard, Steven These findings findings These Idaho physicians were satisfied Idaho physicians were or very satisfied overall with their their with overall satisfied very or wide a provided They practices. scope of medical services to rural obstetricsIdaho citizens, including C-sections (37 percent), (52 percent), coverage (49 percent) room emergency These percent). (89 care hospital and use robust a reported also physicians and care clinical for technology of In purposes. education continuing addition, rural hospital administra- an overwhelmingtions reported level of satisfaction with their family - as 18 of 19 respon medicine staff they reported dents (94.6 percent) with satisfied very or satisfied were their staff. validated were qualitative through more at interviews site rural 25 than throughout visits the with state the Neva of assistance

The Idaho Rural Family Physician dramatic The analysis produced Workforce Pilot Study, completed in in completed Study, Pilot Workforce 2007, surveyed both practicing physicians and administrators of rural hospitals to identify demo- graphics, scope of practice, recruit- and somewhat unexpected results. Ninety-two rural family medicine physician physicians (37 percent our to responded rate) response of these and 94 percent survey, Hospital Association president. president. Association Hospital - this collabora through “Hopefully, the will receive they tive research, them allow to necessary information attributes specific the on in focus to in have to offer their communities physicians’ with match to order and needs.” interests rates satisfaction and factors ment included This areas. several in experience training pre-recruitment in Idaho as well as use of technology and economic factors pertaining to rural practice. hospitals have a difficult time recruiting physicians…” recruiting time a difficult physicians…” have hospitals “We jumped on board because our very because on board jumped “We rural small member collaborative effort, led by the Family Medicine Residency of Idaho and Boise State University, focuses on the community factors that most Share your story. influence recruitment and retention of rural family physicians. Conducted as on-site interviews, it is hoped this information will As you read this magazine, NRHA staff is help policy makers and recruiting entities have already working on the revitalized Rural a broader sense of what it takes for a physician Roads for fall, which will share members’ to select and stay in a rural Idaho practice. This team of researchers and educators is inspiration, insights and experiences. So also looking to better understand the character- we need to hear from you. istics of physicians who choose the lifestyle and profession of rural family medicine. The third u Who most influenced your career year of this study will aim to identify factors choice? that help to explain and perhaps predict the u high satisfaction seen amongst these physicians Tell us about your most memorable who give so much to provide such a breadth of career moment. care across the many miles of this rural state. u Have you shared your medical “As we near the end of phase two, the expertise in the war or on an project has exceeded my expectations,” overseas mission? Sheridan says. “The success of the project is attributed to the dedication of project staff and u Share your mantra. the collaborative partnerships, as well as the u encouragement and support from Idaho critical Do four-legged friends frequent access hospitals.” your waiting room? Share your As Idaho moves forward in supplying its success stories with pets and healing. citizens access to the services they need, u Are you proud of a collaboration upcoming policy decisions will shape the in your community? Could it be education and the provision of its medical replicated throughout rural America? provider workforce. “This endeavor could become a Rosetta u Tell us about your effective breast stone of understanding and unlocking the cancer screening and prevention critical factors that not only draw but keep RURAL ROADS, SUMMER 2008 programs. family physicians in some of the most under- served parts of America,” Epperly says. u Has your facility made any strides to go green? David Schmitz, M.D., is associate director of Rural Family Medicine at the Family Medicine Residency of Idaho. Send responses to any or all of these Ed Baker, Ph.D., is director of the Center for Health questions to [email protected]. Policy at Boise State University.

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Network development grants are designed to improve improve to designed are grants development Network The network marks its fifth anniversary in July. It is one of The network marks its fifth anniversary in July. “Smaller hospitals don’t have the affiliations that larger hospitals do,” explains hospitals do,” have the affiliations that larger “Smaller hospitals don’t After a series of roundtables, and with assistance from the Kentucky Hospital the and with assistance from After a series of roundtables, To address the situation, the administrators did something they had not done address To “The small guys were getting lost in the shuffle,” says Jennifer Tweedy, Tweedy, says Jennifer getting lost in the shuffle,” “The small guys were It started modestly enough. Facing tight budgets and legislative changes earlyIt started modestly enough. Facing tight Jennifer Tweedy, executive director of the South Central Kentucky Rural Healthcare Network, Rural Healthcare Network, Central Kentucky executive director of the South Jennifer Tweedy, CEO. the 42-bed facility’s stands outside Clinton County Hospital with Randel A. Flowers, Gross A. David Photo by hat began as a cost-saving experiment among a collection of of collection a among experiment cost-saving a as began hat into a formal rural health network Kentucky hospitals has grown providers. care regional health substantial benefits to that produces access to care by bolstering rural health care providers. providers. by bolstering rural health care access to care Administration’s Services and Resources Health the to According web site, the grants “further ongoing collaborative relationships… three active network development grantees in Kentucky and onethree grants network Pruitt, Sherilyn to according nationwide, 77 of for the Federal Office of Rural Health Policy. coordinator Vicky McFall, chief executive officer of the 49-bed Monroe County Medical Center. County Medical Center. McFall, chief executive officer of the 49-bed Monroe Vicky beds our putting by hospitals, smaller allow to mechanism collaborative a was “This group.” to get the advantages of a larger together, Association and Kentucky Office of Rural Health, the administrators applied forAssociation and Kentucky Office of planning grant. At that $85,000 network development a one-year, and received In Network. Healthcare Rural Kentucky Central South the launched they time, grant worth federal network development a three-year received 2006, the group $180,000 annually. before: They held a face-to-face meeting. before: then-director of respiratory therapy for Cumberland County Hospital, a critical- of respiratory therapy for Cumberland County Hospital, then-director border. near the Kentucky-Tennessee access provider this decade, hospital administrators in south central Kentucky were feeling squeezed.south central Kentucky were this decade, hospital administrators in things, that their rural facilities could not independently among other They knew, in nearby population centers. support many of the specialty services offered

reap collaboration benefits of South Central Kentucky hospitals Kentucky Central South W

RURAL ROADS, SUMMER 2008 14 NATIONAL RURAL HEALTH ASSOCIATION 15 continued on next page Still, officials say they are now Still, officials say they are “I never would have thought to just a put it this way: “It’s Tweedy When all five hospitals participate, but we’re not going to compete over over compete to going not we’re but good a have you “If says. he them,” it will draw patients.” facility, their contact to likely more much counterparts at another network hospital. informa- call for advice or to share Cumberland Garland, Erik says tion,” information Hospital’s County - pro “We’ve technology director. being civil to polite.” from gressed matter of knowing your neighbor. so many things to work are There want competition you don’t toward; to be a stumbling block.” More for the money the network is the equivalent of a primarya Therefore, facility. 166-bed due costs reduced been has benefit and shared purchasing to group the example, For equipment. Cumberland County and Monroe “This is the kind of network we say administrators The hospital some draw to like I’d “Sure The South Central Kentucky Rural Healthcare Network’s service counties and approx- seven area encompasses Network’s Rural Healthcare The South Central Kentucky Gross A. Smith and David R. Tena Graphic by border. imately 92,000 residents along the Kentucky-Tennessee provided health information technol- health provided ogy assessments for the member literacy health hosted hospitals, health seminars for area awareness and conducted professionals care behavioral health surveys of an It also is assisting 11-county area. member hospitals in the develop- health records. ment of electronic says Larry Allen, like to see develop,” of the Kentucky Office of director have hospitals “These Health. Rural in care health rural strengthened reducing by communities their duplication and fragmentation of services.” ‘Knowing your neighbor’ their facilities have never had a particularly competitive relationship. For instance, Randel A. Flowers, says CEO, Hospital County Clinton his facility does not even have a budget for advertising. the adjoining counties, patients from technology director Hospital’s information information Hospital’s To be eligible for these grants, To In addition to the Cumberland Cumberland former a Tweedy, nonprofit a as incorporating Since Erik Garland, Cumberland County Erik Garland, separately.” able to afford able to afford would have been would have system than we we system than networks must include at least three networks must include at least three providers care health owned separately or or other entities that provide care health of delivery the support is example Kentucky The services. network” “horizontal a as to referred similar are members its of all because might network” “vertical a providers; also include clinics, health depart- ments or ambulance services. County hospi- County and Monroe tals, the South Central Kentucky Clinton 42-bed the includes network County Hospital and two critical- Russell County and access providers: five The hospitals. County Wayne facilities combined serve nearly in seven 92,000 rural residents contiguous counties. County Hospital employee, is now and director, executive network’s the an information technology specialist last spring. was hired has network the organization, that focus on integrating clinical, information, administrative and members.” financial systems across “We got a better got “We Look No Further. Look No Further. for for Alternative Scanning Scanning the Market Radiology Radiology Coverage? 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NHRA Rural Roads ad:NHRA ad 5/7/08 3:15 PM Page 1 Page PM 3:15 5/7/08 ad ad:NHRA Roads Rural NHRA Vicky McFall is chief executive is McFall Vicky officer of the 49-bed Monroe the County Medical Center, largest member of the South Rural Health- Central Kentucky care Network. David Photo by Gross A. In a region with an undersupply of health care with an undersupply of health care In a region a gynecologist hired Clinton County also recently federal In spite of its successes, the network’s says. Flowers like to see it continue,” “I’d really “We got a better system than we would have been have would we than system better a got “We 12-month period, the network During a recent David A. Gross is the University of Kentucky Center for A. Gross is the University of Kentucky David marketing research, of director Health’s Rural in Excellence and community engagement. providers, particularly specialists, the administrators providers, further for ripe issue an is recruitment physician say share network hospitals currently collaboration. Three are counties Russell and Clinton and radiologist, a cooperatively pursuing a urologist. says Flowers radius. 60-mile a in one only the — shared be could potentially services physician’s the with the other network hospitals. search to Tweedy leaving April, next expires funding for grant opportunities. Other sustainability alterna- and hospitals member for dues annual include tives provided assistance of types specific for lines service to individual members. Future considerations County hospitals jointly purchased a dictation dictation a purchased jointly hospitals County savings in resulted which server, a share and system of nearly $50,000. Garland says. separately,” able to afford member to $140,000 than more of savings provided amount that of most with says, Tweedy hospitals, information technology software, coming from also network The services. consulting and hardware technical support to Clinton much-needed provided 55,000-square- County Hospital during its recent foot expansion project.

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ynn M. Harter By L Partnerships address address Partnerships in Appalachian childrenin Appalachian With tears in her eyes, the mother lamented, “Sarah doesn’t seem to trust tears in her eyes, the mother lamented, “Sarah doesn’t With her job them that she would help. As a family navigator, Meeks reassured “Witnessing this sort of violence generally has the same sort of impact as as impact of sort same the has generally violence of sort this “Witnessing Her parents were at a loss for what to do. Montgomery-Reagan referred them at a loss for what to do. Montgomery-Reagan referred were Her parents Sarah age early an at that clear became it couple, the with talked Meeks As aren Montgomery-Reagan, a pediatrician with University University with pediatrician a Montgomery-Reagan, aren Osteopathic Associates and the Ohio University College of Medical repeated had She Sarah. about concerned was (OUCOM), Medicine and was still experiencing academic and social twice kindergarten difficulty in the first grade. anybody; she thinks everybody lies to her. We know something is very wrong, know something is very wrong, We anybody; she thinks everybody lies to her. abuse itself,” Meeks told the parents. “It is possible that Sarah is experiencing a Meeks told the parents. abuse itself,” is understand to you for important is What disorder. stress post-traumatic of form to very quite normal responses abnormal and traumatic are responses that Sarah’s circumstances.” to start.” know where but we don’t theis to be a primary Sarah can access ensure point of contact for the family and she asked the couple she needs. During the intake interview, medical resources to Sue Meeks, a registered nurse and well child and behavioral health specialist to Sue Meeks, a registered Meeks’ intake of OUCOM. During with the Community Health Services program at school. difficulties some of Sarah’s interview they discussed the parents, with abuse. Although they fought for two yearshad witnessed physical violence and drug of her biological mother for in the care for custodial rights of Sarah, she remained the in abused physically was mother the time, that During life. her of years three first her Services Sarah from removed of Sarah. By the time Children’s the presence anxious and unable to bond. she was malnourished, depressed, care, mother’s She was generally inattentive in class and had difficulty forming relationships and and relationships forming difficulty had and class in inattentive generally was She could not com- Sarah usually As a result, communicating with adults and peers. standards. behind developmental plete tasks and was falling increasingly early childhood mental health issues health mental childhood early

K

RURAL ROADS, SUMMER 2008 18 NATIONAL RURAL HEALTH ASSOCIATION 19

continued on next page After the initial referral from from referral initial the After Resources Health federal The Montgomery-Reagan and Meeks Meeks and Montgomery-Reagan like her. like her. Montgomery-Reagan, Meeks devel- plan for care oped a comprehensive Sarah that included her family and the expertise of a pediatrician, early childhood mental health specialist, a and educators therapist, physical speech, language and hearing specialist. Meeks provider, frontline As an IPAC will continue to serve as the family’s - primary of contact as profes point to sionals work interdependently the complex challenges address facing Sarah. Office Administration’s Services and a of Rural Health Policy awarded $540,000 grant to Ohio three-year, University to support the IPAC and children serves IPAC network. - of direc of the board members are Partners tors of the Interprofessional (IPAC). for Appalachian Children health network is a rural IPAC community composed of university, aimed atand consumer partnerships Ohio’s southeastern strengthening meet to system delivery care health the needs of Sarah and children

Top left: Sherry members questions from staff Shamblin answers at Top a Head Start Ohio. program in Athens, background left; Melissa receptionist, right: Grace Matheny, Top L.P.N., center; and Billie Owens, Martin, registered medical assistant, R.N., Sue Meeks, at right; listen to a child screening presentation by far left. second left; Jody Hart, center; Jennifer Cain, Bottom: Beth Helber, discuss issues with from right; and Sherry far right, Shamblin, Ohio. children at a Head program in Athens, Hamel-Lambert Lawrence by Photographs “It is critical for Sarah to have a“It is critical for Sarah with family the provided also She at Ohio University. evaluation health mental thorough same behaviorsbecause many of the ADD and with anxiety, associated are A disorder. stress post-traumatic will help ensure evaluation thorough diagnosis,” Meeks said. a correct information about their legal rights to an evaluation of Sarah at school. Meeks allowing form a signing After with history medical Sarah’s share to her father sighed, other providers, “For the first time in a long time, specialist at Tri-County Mental specialist at Tri-County Health Services and a speech, specialistlanguage and hearing we have hope. Thank you.” After identifying health care care health identifying After “I don’t believe that we can just “I don’t providers who previously had had previously who providers worked with Sarah, Meeks went to with work connecting her parents an including professionals, other health mental childhood early focus on Sarah,” Meeks said. “We “We said. Meeks Sarah,” on focus family historymust also address and to Sarah’s factors that may relate difficulties.” about Sarah’s basic health and and health basic Sarah’s about developmental history including hearingspeech, language and eating patterns,abilities, sleeping and illnesses, toilet training, chronic social school and motor coordination, behaviors. history and current

“There are not a lot of people people of lot a not are “There at the Hocking-Athens- Teachers into environments already inhabited inhabited already environments into by children. in servingwho have expertise young specialized of kind any in children service- like mental health, particu she says. larly in southeastern Ohio,” care health mental bringing by “But centers and specialists into childcare or consultation provide them having training to teachers, then you are address to services up shoring mental health concerns and you developing the capacity of other are like teachers. providers frontline just to compared huge is impact The provider care health mental a keeping in a clinic.” Start Head Action Community Perry served programs many of one Program, more. agree by Shamblin, couldn’t

Over the next three three next the Over in addition to several Ohio Ohio several to addition in departments University provide that clinics and and training professional services. By integrating expertise clinical their IPAC resources, and coordinated affiliates offer comprehensive and services early that address health mental childhood issues and concerns. members IPAC years, IPAC members are integrating members are IPAC will develop more fully fully will develop more program navigator care family a and mechanisms intake including facilitate interdisciplinary protocols, and assessments health mental for plans care comprehensive infrastructure an develop children, support of billing and scheduling for different by employed providers agencies, and expand training of providers care health and childcare for social regularly children to screen and developmental risk. assessments and mental health care services young into settings where including are, already children and preschools offices, care primary centers. Sherrychildcare Shamblin, an early childhood mental health specialist employed by Tri-County Mental Health and Counseling member, board Services and IPAC of importance the underscored bringing mental health specialists behavioral health specialist behavioral Services program well child and Services child and program well Sue Meeks, RN and Community Health RN and Community Health Sue Meeks, Rural health networks like IPAC IPAC like networks health Rural sitting around one table.” sitting around have that much passion that have just can’t fail when you just can’t what we do. And you what we us is passionate about us is passionate offer an alternative way to organize an alternative way to organize offer for resources mental health care traditionally underserved populations. agencies community 13 includes IPAC their families in Athens, Meigs, counties in Hocking and Vinton these of population The Ohio. 127,000 counties approaches people, including 7,021 children region under age 5. Like the broader are counties these Appalachia, of characterized by higher levels of unemployment and poverty and lower levels of education in compari- son to national baselines. All four of designated federally are counties the as medically underserved areas. Residents generally have less access due to few to mental health care experience resources, material main- geographic isolation from infrastructures, medical stream of distribution uneven face and rural across providers health care and urban settings. “Everyof single one

RURAL ROADS, SUMMER 2008 20 NATIONAL RURAL HEALTH ASSOCIATION 21

Meeks credits IPAC’s success in IPAC’s Meeks credits about special is what think “I The Ohio Department of Health prior to IPAC is that people were were people that is IPAC to prior their doing silos own their in really own thing, and we had families who then then went there, went here, a over there went then here, went never really still and years period their with on going was what knew has child. So the network approach made a difference.” already part to the passion and commitment of its affiliated partners. is that we all have similar IPAC from coming be not may It passions. the same place, and the passion may but thing, same the at aimed be not we’ve been successful because we all deeply about mental health care one single “Every says. she issues,” we what about passionate is us of fail when do. And you just can’t you have that much passion sitting one table.” around acknowledged the success of IPAC the network the annual by awarding Distinguished Rural Health Program in 2007. Award Scarce resources and services services and resources Scarce we network, the forming “By critically important,” says Meeks. says critically important,” “Straightening out kids’ responses the sort of early will prevent responses automatic and ingrained that become so habitual over the other than different no It’s years. cancer have you If fields. medical you have a and you catch it early, - better chance of successful treat ment. If you have diabetes and you have early intervention, you are to have a better going probably the same with mental outcome. It’s lose time if you don’t health. You Kids often learn to read catch it early. once and times, certain at speak or that time is gone, it becomes much the for easy that be to it for harder child again.” to early childhood mental related agencies community rural led health and university partners in southeast- ern IPAC. Ohio to create and powerful more a become have collective voice that has allowed us to access funding and to integrate services so families can have more services,” successful and streamlined Shamblin says. “What we found

“Whenever we get afraid or or afraid get we “Whenever Athens Head Start teachers teachers Start Head Athens initiatives and partners diverse The “It is just incredible to have have to incredible just is “It threatened or worried, the physical threatened childhood early from response traumas comes right back. So, is early things those catching provided numerous examples of numerous provided successful interventions facilitated united by their emphasis are of IPAC on early childhood mental health interventions.care Sherry come in and observe our give and teaching in the classroom we could dous pointers about things children the to talking are we when different manage to ways and teacher a Helber, Beth says things,” Start site. “I’veat the Athens Head centers in people other with talked have don’t they and region the in access to a mental health specialist feel like they need one. So and really resource This lucky. extremely feel I is just critical to what we do.” by Shamblin. Consider the following story Cain: “Recently, told by Jennifer couldn’t just who boy little a had we concentrate, and he would fight and be even able to really kick. He wasn’t for very long. part of the classroom And Sherry in and we did came evaluations. We some screening talked and parents, his with worked options and finally about different He is on him to a doctor. referred the made and now medication better kindergarten to transition than he would have otherwise.” Commitment to a common vision: a rural hospital’s path to long-term success

By Raymond T. Hino, CEO of Mendocino Coast District Hospital, and Michael Philps, president of MJ Philps and Associates LLC

endocino Coast District Hospital (MCDH) was built 37 years ago in Fort Bragg, a rural North Coast California community, after the passage of a bond measure to support construction of a 54-bed, 42,000-square-foot hospital at a cost of $2.5 million. The scenic area is known for its rugged coastline, quaint neighboring Mendocino village and easy access to Redwood forests and wine country. Over the years the hospital downsized to 49 beds, remaining a viable provider of a full array of services, including active surgery and obstetric programs, an Memergency room and a four-bed ICU. During the past six years, however, the Mendocino coast economic environment declined dramatically. In 2002, after more than 100 years of operation, Fort Bragg’s largest employer, the Georgia-Pacific lumber mill, closed. Historically, this coastal area served as a mainstay for commer- cial fishing. In recent years, however, the fishing industry has declined as well. As the economic fortunes of this coastal community declined, so did the financial success of MCDH. The hospital is located two to three hours from urban areas, insulating it from major medical center competition. The only access to this area is via winding, two-lane country roads. With a declining local population and deteriorating economy, the hospital began to suffer major financial losses. MCDH is a publicly-owned district hospital, allowing the entire community to discuss how this small hospital, which is so vital to the area, could survive. One potential solution included instituting a new parcel tax for property owners, but the tax failed to get the necessary majority approval of 66 percent of voters. Other

RURAL ROADS, SUMMER 2008 options included developing “boutique” services that could be offered in a vacation setting or affiliating with a large hospital system. Inquiries were sent to all major systems serving northern California, but they were reluctant to align with a small hospital in an economically declining area. In early 2006 concerns about the hospital peaked. Financial woes were mounting, with losses exceeding $100,000 per month. Fiscal year 2006 ended with an audited loss of over $5 million. In June of 2006, shortly before the arrival

22 NATIONAL RURAL HEALTH ASSOCIATION 23 - MCDH has achieved remarkable MCDH has achieved remarkable This year MCDH will be evaluating real issues preventing MCDH from MCDH from issues preventing real and operationalachieving financial strategic a was result end The success. eight key goals.plan that included the most important Not surprisingly, with of the goals was reconnecting included goals Other community. the physical plantfinancial performance, services and programs new renovation, and retention. recruitment and staff CAH to conversion since success designation and its emphasis on community inclusion and transpar ency. For fiscal year 2007, the hospital ency. line bottom positive a announced exceeding $1 million and including This $613,000. of gain operating an first operating gain was the hospital’s in 10 years. The hospital is continu- are there ing to do well; however, still many challenges ahead. Perhaps California’s is challenge largest the budgetarycurrent woes, which percent 10 a to lead likely could state’s the in cut across-the-board Medicaid (MediCal) program. how community attitudes have the hospital, as well changed toward of acceptance as the community’s new change strategies and aggressive a maintain to needed measures the and condition financial healthy achieved momentum forward positive over the past two years. For more information, contact Hino at more information, For 707-961-4630 or [email protected]. Michael and Kathleen Philps ofMichael and Kathleen 2007 retreat, During the March consultants in the past and wantedconsultants they couldto show the community strategic planning do a professional funds expending without process was This budget. hospital the from support. key to getting community - MJ Philps interviewed representa hospital’s the of each of tives which included stakeholder groups, meet to early arriving and late staying The purpose of with night shift staff. demonstrate to was meetings these the that staff and community the to recovery would movement toward Philps be inclusive and transparent. the with met also representatives and committee planning hospital’s team management a facilitated strategic planning session. more of group a led team Philps the than 60 citizens, including hospital employees, management, board, commu- volunteers and interested nity members, in a discussion of the

An opportunity for involvingAn opportunity for of Raymond T. Hino as CEO, Hino T. of Raymond to decision a made board MCDH’s hospitalapply for critical access October, That (CAH) designation. 25th MCDH became California’s critical access hospital. the local citizens in the hospital’s the hospital’s the local citizens in as in early 2007, recovery emerged management and board hospital the formal a on embark to decided The strategic planning process. possible made was effort planning the FLEX grant from a through California Office of Rural Health with the support of Health Program California and Yepez Michele manager President Vice Association Hospital Governance and Health Rural for This financial Peggy Wheeler. support enabled MCDH to bring MJ The board. on Associates and Philps and state the between collaboration this secure to essential was MCDH spent had hospital The funding. on dollars of thousands of hundreds Primary Care Plus impacts mental health in rural Indiana

By Kathy L. Cook

n Indiana’s Fayette and Rush counties, it is difficult to get mental health and medical services due to the lack of availability of providers and the small population numbers. I Both counties are designated as health professional shortage areas, and only two providers there take Medicaid. In response to this need, a Health Resources and Services Administration rural outreach grant was awarded for a collaboration of three organizations that came together to implement mental health services in two existing rural health clinics. The organizations were Dunn Mental Health Center, Family Health Services-Rural Health Clinic and Affiliated Service Providers of Indiana (ASPIN), a former HRSA grant recipient that has provided technical assistance. The goal of the project was to improve the health and wellness of people living in the rural communities of Fayette, Franklin and Rush in Indiana, especially the low income and elderly, by focusing on decreasing barriers, providing preven- tion and early intervention education, increasing treatment effectiveness and replicating the program in other areas of the state. Primary Care Plus is in year two of the grant and has seen success in many areas. The main barrier that has been impacted is offering mental health services in a health care setting to reduce stigma associated with treatment. Even though the local mental health center provides services in the area, patients were reluctant to utilize them because they would be classified as seriously mentally ill. Barriers are also being reduced by offering transportation and child care for individuals to seek mental health counseling and conducting outreach education and communication

RURAL ROADS, SUMMER 2008 programs to spread the word to the community. Advertisements were placed in the local paper, schools and groceries stores. The program offers several benefits to providers and patients. Treatment effectiveness has improved due to the receptiveness of the medical physicians and the availability of therapists. This availability enables close interaction with psychiatrists and advance practice nurses, who can assist the primary care physician with patients who are high users of service. Transitioning these patients to mental

24 NATIONAL RURAL HEALTH ASSOCIATION 25 Primary Care Plus’ third year will Primary Plus’ third Care focus on replication and dissemina- focus on replication model. This will tion of the program be accomplished in several ways. A include to developed be will manual samples of the administrative pieces a developed to make this project for available be will It reality. CD for any mental on purchase Also, provider. health or health care centers health mental Indiana several the receive to targeted be will statewide a through information training program. Kathy Cook has been instrumental in the Kathy of Affiliated Servicedevelopment a provider Providers of Indiana (ASPIN), sponsored network consisting of nine community mental health centers and four addiction providers serving 32 of the Indiana. in counties designated rural 46 Cook is serving her second year on the of board Association Health Rural Indiana directors and has participated in the strategic planning efforts of the Indiana Affairs. Rural of Office Determining the barriers allowed Primary Care Plus to work toward Primary Plus to work toward Care population elderly the to marketing those break to began that ways in barriers. One of several marketing on primary focused care efforts - a community break was providers referrals for means offered which fast, on information and program the to to attached stigma the removing and Flyers care. health mental placed in informational posters were bingo primary offices, churches, care frequented venues other and areas commu- A population. elderly the by nity educational event hosted by the allowed group Services Health Family participants to learn how the health health primary integrating was center and mental health. If applicable, care determine to made also were calls for no-shows. The top the reason travel expenses, were reasons three home crises and affordability. Determining the barriers Primary allowed marketing to the Care Plus to work toward that began to elderly in ways population break those barriers.

One barrier was that the elderly population was not accessing the of age-specific because program belief systems or because they had a wide range of wellness issues that in time much demanded already primary visits and expense care with medications, transportation, many elderly who etc. Therefore, care primary their by referred were come to choose not did physicians When interviewed, to the program. speculated providers care primary that the elderly population sought faith-based services mental before was suspected Also services. health the cost of the transportation and to their medicalpharmacology related seeking them from issues prevented mental health services even when referred. health professionals allows more allows more health professionals other for open appointment times include benefits Other patients. and administrative of sharing members board expertise, operations - organiza serving provider on both overwhelming tions boards, community support and positive patient feedback. Join us for Rural Health Clinic and Critical Access Hospital conferences lan now to attend the Rural Health Clinic Conference Oct. 14 and 15 and Critical Access Hospital Conference Oct. 15 through 17 in Savannah, Ga. Each conference is the best of its kind P and was designed exclusively for the needs and concerns of administrators, leadership and staff. The Rural Health Clinic Conference will feature two days of integrated billing and cost reporting strategies for rural health clinics. From the basics of billing and cost reporting to advanced techniques that maximize reimbursement and keep clinics financially viable, the RHC conference will offer valuable insights, new strategies and a question and answer opportunity with renowned financial consultants. The Critical Access Hospital Conference will feature two sessions with Brian Lee, one of the country’s leading experts in the field of world-class patient satisfaction and employee retention. As the CEO and founder of Custom Learning Systems Group, Lee and his team have helped hundreds of hospitals and health care organizations achieve service excellence through the Accountability Protocol, which directly links accountability and patient satisfaction and explains how to improve accountability, control and communication systems. The conference will also include a session comparing and contrasting facility renovation and replacement. Part of the information in this session is based on the findings of the Stroudwater and Red Capital Group Rural Hospital Replacement Facility Study, which is available on the NRHA web site and reveals how replacement facilities impact the opera- tions and bottom lines of critical access hospitals. In response to member suggestions, conference attendees will also have the chance to attend a full session on either renovation or replacement based on their individual needs. Other session highlights include making long-term care feasible and outsourcing the revenue cycle, as well as the latest on health information technology funding. “The best benefit of the conferences is you can interact with your peers and you know the agenda will be relevant to the challenges we face,” says David Sniff, president of Midwest Consultants for Rural Health Inc. To register, visit the NRHA web site at www.RuralHealthWeb.org.

Experience Savannah

RURAL ROADS, SUMMER 2008 Turn your trip to the conferences into a vacation, as Savannah, Ga., offers plenty to do and see. Take a unique dolphin-watching cruise along Savannah’s historic riverfront and watch Atlantic bottlenose dolphins play around Tybee Beach. Also see notable landmarks, forts and lighthouses, such as the 200-year-old Tybee Island lighthouse. Spend an afternoon lounging and listening to live music on Tybee Island, which has a three-mile beach, and explore the nightlife at 17 Hundred 90 Inn, a restaurant and tavern in a restored mansion from the 1790s. Be sure to pay attention to the scenery -– Savannah is home to many monuments and fountains, and Spanish moss adorns the branches of the trees. For more on what to do around the conferences, visit www.savcvb.com.

26 Volunteers work to rebuild homes

early 50 NRHA members volunteered to help “It’s wonderful that the NRHA Annual Conference rebuild homes devastated by Hurricane Katrina could return to New Orleans because tourism has to Nduring the Annual Conference in May. come back to sustain the economy so residents can Volunteers from as far away as Australia worked on return home,” NRHA CEO Alan Morgan says. “And I’m three houses in St. Bernard Parish, a community adjacent really proud that our members were willing to get their to New Orleans’ Lower Ninth Ward where 100 percent hands dirty and give back even further by helping in of residences and businesses flooded. these homes.” “I’m grateful for the assistance the volunteers pro- vided to rebuilding St. Bernard Parish and for their contribution to restoring hope to three families who lost everything,” says Stacy Fontenot, Louisiana Rural Health Association executive director, who coordinated the effort with the St. Bernard Project, a local nonprofit organization dedi- cated to rebuilding homes damaged as a result of the August 2005 hurricane. Two teams used wire brushes to break up and kill mold on bare studs and then treated the wood to prevent further mold damage in two houses. Another group installed insulation and drywall to a home that had already been treated to prevent mold.

Annual Conference welcomes 900 to Louisiana

he 2008 NRHA Annual Conference attracted 900 rural health professionals and students to New Orleans’ lively, NATIONAL RURAL HEALTH ASSOCIATION Thistoric French Quarter from May 7-10. The conference featured more than 95 sessions, which covered topics from mission-centered marketing to oral health care to government affairs, and the expertise of many speakers, including a keynote address from U.S. Surgeon Gen. Steven Galson. When members weren’t in educational meetings, they enjoyed a local jazz band, hurricane bar and a yoga class. The 2009 NRHA Annual Conference will be May 5-8 in Miami Beach, Fla.

27

To save money many new physicians hire untrained untrained hire physicians new many money save To the handle can physician new the beginning, the In nurse, can come The second employee, a registered but they should costly, Competent employees are medical practice management consultants. George Conomikes is president of Conomikes Associates, Associates, of Conomikes is president George Conomikes first few months in practice; however, to have healthy practice; however, first few months in should physicians care primary show studies practices, this meet To day. per patients more or 25 see to able be is a to maximize productivity exam room goal, a third is room exam fully-furnished a of cost daily The must. depreciation and rent including $55, to $40 than more no can be gained This of equipment, furniture and fixtures. the rooms exam two only With visit. brief a than less in to be room physician is often waiting for an exam the downtime translates to lost revenue. and prepared, Staffing is no substitute for an employee individuals, but there hire The first with significant medical office experience. Many newshould be someone with multiple skills. with out starting by early succeeded have physicians one knowledgeable person. front the work can employee first the and rooms, exam desk and answer the phone. licensed The busy. get to starts physician the when on most patient education, some can provide professional most to answers and patients chronic of management patient phone inquiries. A skilled nurse allows the nurse the Ideally, skills. their maximize to physician is the data collector; the physician is the analyst and solver. problem not cost centers. producers, be looked at as revenue guideposts that can make or hurt are Facilities and staff a new practice.

By George Conomikes Hospital Administrator Master’s degree in Services Health Delivery, Business or related field. years Five experience plus in services health delivery hospital in rural demonstrating responsibility and increasing administration results in financial, clinical quality and operational improvements. Bilingual is preferred. in rural settings or or call www.phs.org . A proud past. An exciting future.

Albuquerque Albuquerque | Clovis | Española | Ruidoso | Socorro | Tucumcari any hospitals try who to support physicians in solo practice, but the new rural new are for making major costlyphysician is known

Helping new physicians succeed 1-800-708-1151 PHS is committed to ensuring a drug-free workplace. EOE. Lincoln County Medical Center – Ruidoso, New Mexico is an Healthcare Services, integral one of the nation’s top integrated part 10 of healthcare Presbyterian Mexico’s networks only private, we healing, of years 100 celebrate we As system. and non-profit healthcare New invite you to join us in enhancing the health of the communities we serve. We offer an excellent compensation package and as benefits well as living the rewards out that come compassionate caring. our from 100-year tradition learn about more this unique opportunity at To of quality, Lincoln County Medical New Center Mexico – visit: Ruidoso, New physicians look at the cost of space as a majorNew physicians look at the cost of space Here are a few guidelines to minimize errors. a are Here M overhead expense. To save, they often decide to have have to decide often they save, To expense. overhead This may be adequate for the only two exam rooms. Space requirements mistakes. If there are too many mistakes it can lead to too many are mistakes. If there a for opting and community the leaving physician the and the If that happens, the community job elsewhere. hospital lose.

RURAL ROADS, SUMMER 2008 28 Rural Roads 7/1/2008 1945608-PH30739 PREHES 3.5” x 4.75” v.9 Robyn Wisniewski NATIONAL RURAL HEALTH ASSOCIATION 29 ou? your mark and show the locals how it shouldyour mark and show the locals how it likebe done. The community has seen many if youyou come and go. They will wait to see stay. to seriousness and courage the have they will have a little friendly, While they are bit of a wait-and-see attitude. Be patient, and genuinely interested. polite, receptive be Rural towns have their own wisdom. You’ll than community whole the of part more much result, a As city. large a in be would you People public. you do will be more everything but you have only one forgiving, can be very impression.” first a make to chance “Don’t come in like gangbusters, ready to make in like gangbusters, ready come “Don’t Above all, don’t take such a move lightly. Your Your such a move lightly. take Above all, don’t Become involved in the community. Get a sub- Become involved in the community. Attend events, scription to the local newspaper. activities for fear of avoid community and don’t in colleagues out Seek relationship. dual a having - for mentoring and profes your own profession sional support. Don’t be shy. Take the lead in seeking out your your out seeking in lead the Take shy. be Don’t colleagues. - grace and tact. As one profes Handle yourself with sional advised:

Dr. Sabrina Schleicher is a business coach and licensed Dr. psychologist in Riverton, Wyo. n n n the on impact profound a has presence professional The experience will change your career community. the is community rural a to move the if better the for right fit for you.

- -

BY Sabrina Schleicher

aking the move to a rural area is a big step that involves many lifestyle changes. Here are some sugges- some are that involves many lifestyle changes. Here is a big step a rural area aking the move to such moves. who have made professionals tions from

Consider your ability to be self-directed in fur Consider your ability to be self-directed decision-making. Bring your spouse to visitdecision-making. Bring your spouse to thering your knowledge in your field. It is more Are area. rural a from training access to difficult your acquire to state of out travel to willing you you willing and able to training? Are preferred pay for these expenses if your employer does not? Keep in mind that being a professional in a rural Keep in mind that being a professional a and first generalist a are you means often area specialist second. Consider your ability to be flexible and adaptable. For community. rural a in slower move Things example, some communities do not have over If you are married, involve your spouse in If you are job.the community prior to accepting your weather conditions Extreme night mail delivery. may shut down the community for days at a time. you able to be flexible with your work in such Are circumstances? Consider your interests and the interests of your your of interests the and interests your Consider - activities com Does the community offer family. other there are not, If interests? your with patible you can develop? interests Talk to other professionals who have moved from from moved have who professionals other to Talk area. an urban to a rural several people of varyingLearn from the area about backgrounds. who are to those within your profession Talk Ask about ethical issues, living in the area. already licensure and profession your to pertaining laws support professional putting Begin requirements. you move. in place before

n n n n n n n n M for y right career rural Is a Hospital chief of staff

Dr. Ralph Monteagudo, Lincoln Ralph Monteagudo, Dr. emergency, time emergency, is a deadly foe.” “In a cardiac

partnership

he adds. “We’ve said a resounding, ‘no,’ to that ‘no,’ said a resounding, he adds. “We’ve says Dr. Ralph Monteagudo, Lincoln Lincoln Monteagudo, Ralph Dr. says praises

public relations , Lincoln Hospital By Kyp Graber-Shillam Larry noticed the difference right away. That’s because even before Betty because even before That’s right away. Larry noticed the difference Modeling Level One Cardiac Care after a groundbreaking program in the program after a groundbreaking Care Modeling Level One Cardiac “In a cardiac emergency, time is a deadly foe. For patients emergency, “In a cardiac not good,” “Outcomes were In the spring of 2007, Betty felt similar symptoms. This time, LarryIn the spring of 2007, Betty felt similar called for Once Betty arrived in Spokane, the long process of diagnosis began. process Once Betty arrived in Spokane, the long took me right they 10 minutes in the ER waiting room; “I spent probably Ex-husband Larry Marsh knew something was wrong and drove Betty from Betty from and drove Ex-husband Larry Marsh knew something was wrong it felt like indigestion in the front of the chest,” chest,” the of front the in indigestion like felt “It was two years ago, and it c a r d i a c etty Marsh, 63, remembers her first heart attack well. her first heart attack remembers etty Marsh, 63, entered the building, Lincoln Hospital’s cardiac team was preparing the ER. team was preparing cardiac the building, Lincoln Hospital’s entered state of Minnesota, stringent timelines for all partners were put in place to speed speed to place in put were partners all for timelines stringent Minnesota, of state for better patient care. the process The goal was aspirin therapy and a diagnostic EKG within 10 minutes of arrival. system. We’ve gone doctor to doctor saying we’re going to get this done and save gone doctor to doctor saying we’re system. We’ve tape.” struggling to transport patients because of red lives. No more an ambulance and Betty was driven the 15 miles to Lincoln Hospital in Davenportan ambulance and Betty was driven the Heart and Sacred Partnership between Lincoln Care the Level One Cardiac where place. Medical Center had just been put into a cath lab, the clock possibly hours from who live in rural areas, against them,” is already “In the past, rural physicians with a cardiac Hospital chief of staff. hospital were at a larger patient needing transport and treatment of paperworkfaced with a quagmire and phone calls to find a then check with insurance and comply hospital and a cardiologist, with government tape. red back. But it was a long time, hours before they found out I was having a heart they found out I was back. But it was a long time, hours before cath team to get together to do theattack and a couple of hours for the heart procedure.” rural Harrington, Wash., to an emergency room at a major hospital in Spokane, room to an emergency rural Harrington, Wash., one hour away. she says. “I didn’t recognize it as a heart attack at first.” recognize she says. “I didn’t

Patient Patient B

RURAL ROADS, SUMMER 2008 30 NATIONAL RURAL HEALTH ASSOCIATION 31

The partnership was a success, and and success, a was partnership The going to call now on, we’re “From very minimal, and we all know it’s very and we all know it’s minimal, sooner because they got in there and opened it up and made things work again.” Betty sings the praises of both her - hometown hospital and the metropoli such for responsible center medical tan an innovative, lifesaving program. an ambulance and stop at Lincoln Hospital first to get stabilized” Betty says. “Then, if it is a heart attack, and they going on they know what’s - can communicate with the cardiolo Heart so the cath lab gists at Sacred team will know what to expect when we get there.” Dr. Michael Ring, medical director of Sacred Heart’s cardiac services medical director of Sacred Heart’s Michael Ring, Dr. The time from door to door? door? to door from time The is making “This quality program Larry agrees. save to going is program “This Ninety-three minutes from Betty’s Betty’s from minutes Ninety-three arrival at Lincoln Hospital to having stent a and opened artery her worked. inserted. The protocol to cardiac an immense difference Michael Ring, patients” says Dr. Heart’s of Sacred medical director services. “It allows us to cardiac to care deliver the most effective our throughout victims attack heart not just those who show up region, in our ER.” lives, no question about it” he says. “They told me her heart damage was

difference to cardiac patients.” to cardiac patients.” difference “This quality program is making an immense “This quality program “She went over the top of me me of top the over went “She When the EKG suggested suggested EKG the When in the helicopter as I was leaving Panke “Dr. says Larry. Davenport,” to Sacred get told me I couldn’t she was done in the Heart before I cath lab. When I did get there, called the cath lab and talked to a blockage, Dr. Rolf Panke Panke Rolf Dr. blockage, a to phone the up picked continue the chain of lifesaving events. First, catheter team cardiac Heart’s Sacred was called into action. Then, Betty Sacred was immediately airlifted to Heart by partner Northwest MedStar. labcath the to was taken directly She the team was waiting. No where paperwork. tape. No red the doctor who did the procedure. she’d and done, was it said He it just fine.” come through Meyersdale Medical Center’s sweet 16

By Mark Meekins and Karen T. Bruchak, RN, MSN

ith a single-slice computed tomography (CT) scanner, Meyersdale Medical Center routinely had to refer patients from its community to be imaged in different cities. The single-slice CT scanner was not meeting the needs of the community, and staff members at the 20-bed critical access hospital were concerned newer CT technology was financially impractical. Now an affordable 16-slice CT scanner is allowing Meyersdale to improve access to higher-end technology for its community and consequently the diagnostic Wquality of the imaging services provided. Since installing the scanner, there has been an increase in patient volume, and Meyersdale has expanded its imaging services.

Geographic challenges Meyersdale Community Hospital was established in 1952 and joined with Conemaugh’s Memorial Medical Center in Johnstown, Pa., forming the Conemaugh Health System in 1994 and changing its name to Meyersdale Medical Center. With a single-slice CT scanner, Meyersdale could only perform routine exams of the head, neck, abdomen and pelvis. More complex procedures, like CT angiog- raphy or pulmonary embolism chest exams, were referred to other towns. With no imaging centers in the Meyersdale area, patients were forced to travel 20 to 40 miles. The scanning that could be performed with Meyersdale’s single-slice CT

RURAL ROADS, SUMMER 2008 scanner was limited in image quality and speed. “Single-slice CT scanners are virtually obsolete now, and it was becoming more and more disheartening for us to have to send patients miles away for the scans that they needed,” says Mary Libengood, Meyersdale Medical Center president. “Our biggest goal is to serve the people who live here with the best medical care possible, and our limited CT scanning ability was definitely hampering that mission.”

32 NATIONAL RURAL HEALTH ASSOCIATION 33 continued on next page The new scanner has also allowed Another benefit of the new because they were able to perform perform to able were they because a for study imaging necessary the patient who would have otherwise a in facility a to referred been town. different to speed up the the Meyersdale staff images acquire they which at pace With images. those of clarity the and pulmonary a single-slice scanner, embolism chest scans had a limited acquisition speed and a slow gantry That led to thick time. rotation were images those and slices, image on rendered and reconstructed not workstation. a 3-D post-processing the 16-slice scanner, With Meyersdale is generating quality and reconstructed are that images to suit the radiologist’s rendered preference. scanner is the weight limit of 440 pounds, which gives Meyersdale the patients. These ability to scan larger days, Meyersdale turns away few tremendous a is This patients. numerous considering benefit that rural studies have reported As a 20-bed critical access hospital in rural southwest- Medical Center serves Meyersdale ern Pennsylvania, radiology a regional population of 7,500. Meyersdale’s team is proud to expand the service offerings and to their community. care provided of the level improve Heather Smith, chief financial officer, and Mark Meekins, director and Mark Meekins, chief financial officer, Heather Smith, with the 16-slice CT. of radiology,

The 16-slice CT is now enabling allowed Meyersdale toallowed Meyersdale room CT existing the use major any making without system The modifications. was installed in January, four took process the and - days, including de-installa and scanner old the of tion quality assurance checks. benefits Technology Meyersdale to perform, on average, scans per month for a total 20 more In month. each scans 230 about of increase addition to the 9.5 percent in CT imaging volume, the 16-slice to Meyersdale allowed has scanner was it scans of types the enhance now also It performing. already to perform coronary allows the staff The exams. (CTA) angiography CT performed first time Meyersdale staff was exciting, CTA a leg runoff Another benefit of the 16-slice 16-slice the of benefit Another It turned out that a 16-slice CT The purchasing process was was process purchasing The Further, once a patient was was patient a once Further, CT was its small footprint, which which footprint, small its was CT could meet all of the medical center’s could meet all of the medical center’s imaging needs. Meyersdale was able to lease the system for a price that than more amount manageable a was single-slice the for payments the scanner. daunting at first, and Meyersdale need would they that expected staff high-end for budget the strain to technology or settle for a low-end model. Quality vs. cost referred to another facility, they rarely they to another facility, referred returned to Meyersdale Medical individuals typically Those Center. their health caredecided to have all at a facility offering needs addressed options. comprehensive more

“In the eyes of the people in this to be able to serve them right here here right them serve to able be to in our community.” Mark of radiology Meekins is director Medical Center in at Meyersdale specialist, who wanted the patient to to patient the wanted who specialist, scan the having By scan. CTA a have completed at Meyersdale, the patient without done study the have could having to travel again. having this technology community, and the expanded capabilities that than life,” go with it is truly larger very exciting says Libengood. “It’s Pa. Meyersdale, Bruchak is national director for Karen T. Solutions Customer hospitals, community Inc. USA, Solutions Medical Siemens Group,

Mary Libengood, Meyersdale Medical Center president Medical Mary Meyersdale Libengood, Of course, no CT scanner will be the allowed CT 16-slice The community, having this technology this and having community, go with capabilities that the expanded it is truly than life.” larger 60 to 40, which would further further would which 40, to 60 stream. the revenue increase frequent for offline is it if productive service Meyersdale is a and repairs. rural hospital that lacks an on-site but so far there service engineer, have been no issues with service have helpdesk the to calls and resolutions. led to prompt the expand to staff Meyersdale the improve and offerings service to the commu- delivered level of care a major academic Recently, nity. western in center medical Pennsylvania called Meyersdale had patient The patient. a refer to a see to Meyersdale from traveled “In the eyes of the people in this of the people “In the eyes

With a broader range of CT a broader With Still in the early phase of deploy- The new scanner allows Mark Meekins, director of scanner allows MarkThe new Meekins, gain higher diagnostic confidence due to radiology, to the speed of image acquisition and the clarity of those images. By upgrading to a 16-slice CT scanner, more com- CT scanner, By upgrading to a 16-slice and pulmonary CT angiography like plex procedures, now performedembolism chest exams are at Meyersdale. offerings coupled with enhanced enhanced with coupled offerings capabilities, image post-processing Meyersdale performs an average of with their break- 10 scans per day, nine to eight at estimated point even procedure The current scans per day. procedures routine mix is 80 percent sophisticated and and 20 percent to is plan The studies. invasive the mix to 70 to 30 or increase ment, Meyersdale Medical Center Center Medical Meyersdale ment, increase an experienced already has patternsin referral due to the new to continues word As scanner. base, the referral throughout spread and as Meyersdale continues to enhanced the about physicians educate CT scanning capabilities, the referral volume is expected to increase. Referral and reimbursement benefits communities have higher rates ofcommunities have higher in facility larger much a fact, In obesity. the Meyersdale service now refers area MedicalMeyersdale to patients heavier Center for CT scans.

RURAL ROADS, SUMMER 2008 34 NATIONAL RURAL HEALTH ASSOCIATION 35

continued on next page

news Ka’u Rural Health Community Association, Inc.Ka’u Rural Health Community institutions KRHCAI collaborated with health care House Hawaii March, in celebration graduation the At - Qualifying for benefits will help pay monthly premi This information prepared by the U.S. DepartmentThis information prepared by of Health and Human Services. Hawaii legislature recognizes Ka’u Rural legislature recognizes Ka’u Rural Hawaii Pilot Nurse Association’s Health Community Shortage Program (KRHCAI) launched its inaugural Pilot Nurse Shortage Shortage Nurse Pilot inaugural its launched (KRHCAI) the from students adult 17 with January in Program Ka’u District. curriculum a in students train to Hawaii across from Institute taught by Hawaii Health Care and provided was student Each RN. Flesher, Berdena instructor complete 114 lab hours and 24 clinical to required also students were hours. In addition to this experience, Red American and Corp. Reserve Medical the in enrolled in participated and training preparedness disaster Cross Literacy Program. the KRHCAI Wellness/Health Jessanie Marques, Bob Herkes presented representative with certificates signed by KRHCAI executive director, KRHCAIstate senate and house members congratulating Shortage Program on the establishment of its Pilot Nurse to alleviate the nursing shortage. and efforts ums, annual deductibles and prescription co-payments. ums, annual deductibles and prescription find out if you To know. Many people qualify and don’t call apply online at www.socialsecurity.gov, qualify, Social Security at 1-800-772-1213 or visit a Social the about more learn To assistance. for office Security drug plans and how to join, call prescription Medicare 1-800-MEDICARE (TTY 1-877-486-2048) or visit www. medicare.gov.

Rural health Rural One woman with Medicare was struggling to pay for One woman with Medicare Medicare is paying 75 percent or more of prescription or more is paying 75 percent Medicare Heady, associate vice president for Rural Health at associate vice president Heady, Behringer, executive director of East Tennessee State of East Tennessee executive director Behringer, “We are delighted that Bruce and Hilda were chosen chosen were Hilda and Bruce that delighted are “We NRHA past presidents Bruce Behringer and Hilda Hilda and Behringer Bruce presidents past NRHA Centers for Medicare and Medicaid Services national Medicare education campaign NRHA past presidents named to Veterans named to Veterans NRHA past presidents Rural Health Advisory Committee her prescriptions even with a drug plan and her $800 her prescriptions State local the at counselor A benefit. Security Social her to talked Program Information Insurance Health about how to apply for additional benefits. Once she in lived she as long as house, her of value the that heard it, would not be used to determine if she was eligible, she applied and qualified. drug costs for Americans with limited incomes and resources. West Virginia University and executive and state program and state program University and executive Virginia West Rural Health Education Virginia of the West director as served Centers, Educations Health Partnerships/Area before testified first and president NRHA 2005 the the was and 2001 in issues veterans’ rural on Congress lead author on the NRHA policy paper on the topic. University’s Office of Rural and Community Health and and Health Community and Rural of Office University’s of vice president Community Partnerships and assistant the Division of Health Sciences, served as the 1992 active in the organization. and remains NRHA president to seeing the recommendations of this talented team.” to seeing the recommendations for this important role,” says NRHA CEO Alan Morgan. says NRHA CEO Alan Morgan. for this important role,” this commis- to create “The NRHA first asked Congress in 2005, and we now look forward sion within the VA R. Heady were named to the Department of Veterans Veterans named to the Department of R. Heady were Rural Health Advisory Committee, new Veterans Affairs’ James B. Affairs of Veterans which will advise Secretary committee 13 of two are Heady and Behringer Peake. members selected by Peake. Medicare prescription drug coverage and VA benefits By Tammy Twait, pharmacist, Centers for Medicare and Medicaid Services

On December 8, 2003, President Bush signed into eligible for and enroll in VA health care coverage, which law the Medicare Prescription Drug Improvement and is separate from Medicare. By law, VA does not bill Modernization Act of 2003, also called Medicare Part D. Medicare. Medicare Part D provides extra help paying This landmark legislation provides seniors and individu- for out-of-pocket prescription drug costs to Medicare- als with disabilities a prescription drug benefit, more eligible persons with limited income and resources. For choices and better benefits under Medicare. VA purposes, limited income is based on VA’s pension As of January, there were approximately 44.2 million amount. Limited-income veterans will have no drug Medicare beneficiaries eligible for Medicare Part D. Of co-payments if they have Medicare Part D. A veteran’s this 44.2 million, 1.59 million have creditable prescrip- decision to participate in Medicare Part D will not tion coverage through participation in the Veterans change his or her VA prescription drug coverage. Affairs prescription pharmacy benefit. Because VA Finally, there are some circumstances veterans may prescription coverage is creditable coverage, veterans wish to consider when deciding to enroll in a Medicare who choose not to enroll in Medicare Part D when they Part D prescription drug plan. If they live far away from are first eligible will not have a late enrollment penalty. a VA facility or live in or move to a nursing home, they Veterans enrolled in the VA health care system may may benefit from Medicare prescription drug coverage. choose to enroll in Medicare Part D in addition to their It is important to remember that veterans with both VA benefits. Medicare Part D and VA benefits cannot have a single Eligibility criteria are different for VA medical benefits prescription covered by both programs. A prescription and Medicare. Medicare prescription drug coverage is will not go to VA for additional payment if a Medicare available to all people with Medicare, while VA prescrip- Part D plan fills and makes payment for that same tion drug coverage is available to all veterans who are prescription.

Poor birth outcomes in rural United States Rural Health Trifecta planned in Texas The WWAMI Rural Health Research Center at the Partnering the Office of Rural Community Affairs University of Washington has new research showing that (of the Texas State Office of Rural Health), Texas Rural while progress has been made, rural/urban gaps in birth Health Association and Texas Hospital Association, the outcomes remain high. Those outcomes include rates of Rural Health Trifecta: Collaborating to Make a Difference low birth weight, poor outcomes and inadequate will be Aug. 5 through 7 at the Hyatt Regency Austin. prenatal care and were compared from 1985-1997 using The meeting is also co-sponsored by the Texas RURAL ROADS, SUMMER 2008 data from the Linked Birth-Death Data Set. Organization of Rural and Community Hospitals. Overall, the study found that rural residents and The Rural Health Trifecta will provide one event for residents living below poverty level have independent rural hospitals, health professionals and critical access risk factors for inadequate care and some adverse birth hospitals. Visit TRHA’s web site at www.texashospital- outcomes, especially post-neonatal mortality. sonline.org/trifecta for more information and to register.

36 NATIONAL RURAL HEALTH ASSOCIATION 37 The Illinois Rural Health Net (IRHN) is the creation creation the is (IRHN) Net Health Rural Illinois The point-to-point optic, fiber a provide will IRHN The the by impacted significantly is care health “Rural With a Washington State Department of Health grant grant Health of Department State Washington a With impact,” bigger a make can we that hoping are “We Connecting to health care in ruralConnecting to health Illinois - provid and rural health care of a coalition of universities from grant million $21 a receive to collaborated that ers Commission. The FCCthe Federal Communications territories and three $417 million to 42 states awarded Internet through care to rural health for improvement connectivity. communications network connecting and wireless Galena in northern Illinois to hospitals and clinics from at the southern be launched tip. IRHN will Metropolis and DeKalb in University Illinois Northern through 11 other hospitals and universities. to inability an and resources transportation of lack CEO of Mason says Harry Wolin, access specialty care,” will not only District Hospital. “This infrastructure also will it but specialists, to access improved provide health records.” permit the full utilization of electronic Eastern Washington Diabetes Network Eastern Washington grant awarded of almost $10,000, the Eastern Washington Diabetes Diabetes Washington Eastern the $10,000, almost of of awareness Network (EWDN) hopes to increase and education and strategies prevention diabetes the internal providers, strengthen network of health care and educators. researchers says Jennifer Polello, EWDN leader and health education manager for the Inland Northwest Health ServicesO.C. Olson Diabetes Education Center.

The InSRHN also received a recommendation for a recommendation The InSRHN also received have directors of board InSRHN and staff IRHA “The The Indiana Rural Health Association (IRHA) recently Health Association (IRHA) recently The Indiana Rural “Our rural partners are getting hit harder by diabetes,” Polello says. “EDWN started off as a Spokane-based network, Polello says. “EDWN started off by diabetes,” getting hit harder “Our rural partners are The growing EWDN is comprised of more than 90 individuals from a variety of local and regional organizations organizations a variety of local and regional than 90 individuals from EWDN is comprised of more The growing Indiana Rural Health Association awarded Association awarded Indiana Rural Health networkgrant to expand worked hard during the planning phase of this project during the planning phase of this project worked hard award,” grant this receiving of anticipation great with an see “We Kelso. Don director executive IRHA says into move to Indiana for opportunity unprecedented to information technology the 21st century in regard and connectivity.” received an $180,000 grant that will be used to expand expand to used be will that grant $180,000 an received Rural Health Network (InSRHN),the Indiana Statewide - of rural health organiza a formal network comprised in Indiana. tions and providers years of the over the second and third the same award the Department of Health and Human from project and Services Administration.Services Resources Health of the network’s The federal grant will fund 90 percent project. operating costs over the three-year and we quickly realized that we had a problem in our rural communities. Now they know what resources are available.” are in our rural communities. Now they know what resources that we had a problem and we quickly realized who have teamed up to pool their resources, enabling patients across the region to get the best diabetes care and and care diabetes best the get to region the across patients enabling resources, their pool to up teamed have who education. This is especially important in the rural communities. CDC has free information to help educate parents about childhood development.

Developmental Milestones Fact Sheets Waiting Room Poster Disability Fact Sheets

Autism can often be recognized at 18 months or younger. The Centers for Disease Control and Prevention (CDC) has prepared materials to help health care professionals inform and educate parents about childhood development, including the early warning signs of autism and other developmental disabilities.

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`$PPQFS.FEDPN`'SSTIV'IRXIV`2SVXL'PEWWIR&SYPIZEVH`3OPELSQE'MX]3/ National Rural Health Association Rural Health Clinic and Critical Access Hospital Conferences October 14-17 Savannah, Georgia

Don’t miss the best educational events on the calendar for critical access hospital and rural health clinic administrators, leadership and staff.

Visit www.RuralHealthWeb.org to take advantage of early registration rates.

Non-Profit U.S. Postage PAID Lebanon Junction, KY 521 East 63rd Street Permit #597 Kansas City, MO 64110 CHANGE SERVICE REQUESTED RURAL ROADS, SUMMER 2008 41