Rural Health Plicy: Hw des Rural Health Overlap with Plicy and Plicy Frmulatin? NURS 586 Rural Health Prgrams and Research Nvember 1, 2016 UND Cllege f Nursing and Prfessinal Disciplines Presented by Brad Gibbens, Deputy Directr and Assistant Prfessr Established in 1980, at The University f Nrth Dakta (UND) Schl f Medicine and Health Sciences in Grand Frks, ND One f the cuntry s mst experienced state rural health ffices UND Center f Excellence in Research, Schlarship, and Creative Activity Hme t seven natinal prgrams Recipient f the UND Award fr Departmental Excellence in Research Fcus n Educating and Infrming Plicy Research and Evaluatin Wrking with Cmmunities American Indians Health Wrkfrce Hspitals and Facilities ruralhealth.und.edu 2 1
Tdays Objectives: 1. T better understand the relatinship between the rural setting and health plicy. 2. T gain insight int current rural health plicy issues. 3. T understand hw health plicy is develped. 3 Rural Health (REVIEW) Rural Health fcuses n ppulatin health Rural Health fcuses n infrastructure that impacts access t care Rural Health is nt urban health in a rural r frntier setting Rural Health can be framed as a health equity r fairness issue Rural Health can be framed as interdependent/cllabrative r cmmunity engagement Rural Health is inclusive f cmmunity sectrs Business/ecnmic Educatin Lcal/area gvernment public sectr Faith-Based Health and Human Services Rural Health exists in a larger envirnment which has an affect n rural health r the rural cmmunity, but the cmmunity can take actin (engagement) that in turn impacts the envirnment. 4 2
Significant Areas f Interest Addressed in Rural Health Plicy Reimbursement/Payment/MONEY Health Wrkfrce Health Care Quality and Perfrmance (als HIT) relatinship t health refrm Ppulatin Health significance within health refrm The Sils (Infrastructure) Hspitals (private fr-prfit, nn-prfit, specialty, rural including CAH, SCH, MDH); physicians (primary care, specialty, independent sl, small grup, larger system) ; nurses; clinics (including fr-prfit and nn-prfit, RHC, FQHC, specialty); pharmaceuticals; ral health; mental health; behaviral health; EMS (including private fr-prfit and nn-prfit, EMTs and numerus types including cmmunity paramedic); nurse practitiners; physician assistants; allied health; lng term care (nursing hmes r ther settings like independent living, basic care, assisted living); aging (including aging services, nutritin, mney fllws the persn r helping elders stay in nn-institutinalized settings); human services; Medicaid; Medicare; CHIP; veterans; Native Americans (IHS); health refrm (insurance and health system refrm); and MORE (We will discuss interest grups later). 5 6 3
Key Cncepts in Health Refrm 2 Primary Changes: Insurance and Health System Redesign Ppulatin health imprve utcmes emphasize preventin, care crdinatin, less hspital admissins/readmissins, less inapprpriate ED visits Scial determinants f health Vlume t value (changing hw we pay fr services t be less vlume and mre value quality and utcmes) Accuntable Care Organizatin (ACO) is an example (CHI-St. Alexius Primecare Select ACO 10 ND CAHs; Natinal Rural Accuntable Care Cnsrtium 5 ND CAHs) - 42% f ND CAHs are assciated with an ACO Preliminary CHNA Issues (2014-2016) 34 CHNA analyzed ut f 45 151 needs (range 2 t 9 ranked needs, mst 4-5) Issues Behaviral Health 29 ut f 34 Ability t Attract and Recruit a Prvider 20 Mental Health 18 Cst (insurance and health care) 15 Obesity/verweight 11 Child Care 10 Availability f Resurces t Help Elderly (stay in hme) 10 Jbs with Living Wages 8 Wellness (life style, fitness, exercise) 8 Ability t Recruit and Retain Yung Families 7 Husing 4 Bullying/Cyber-bullying 8 2 Pverty 2 4
Hw des the health plicy prcess wrk t advance rural health cncerns and needs r hw des rural health wrk within the prcess r use that prcess? Health Plicy The Frmal Side Executive Legislative Prcess (Cngress and the Federal Agencies) White Huse Rural Cuncil t Strengthen Rural Cmmunities Senate Rural Health Caucus histry in Nrth Dakta - 1985 Huse Rural Health Care Calitin - 1987 Senate Finance, Senate HELP, Senate Energy and Natural Resurces, Senate and Huse Indian Affairs, Senate and Huse Judiciary, Huse Ways and Means, Huse Energy and Cmmerce (Cramer), Senate and Huse Apprpriatins (Senatr Heven), Senate and Huse Budget Cmmittees (rle f Senatr Cnrad) Federal Agencies Ø US Department f Health and Human Services ü HRSA and within it Office f Rural Health Plicy- SORH, FLEX, Rural Health Grants, Rural Health Advisry Cuncil, Bureau f Primary Health Care Cmmunity Health Centers, Bureau f Health Prfessins healthcare wrkfrce issues, Bureau f Clinician Recruitment and Services Natinal Health Service Crps ü Centers fr Medicare and Medicaid Services (CMS) Medicare reimbursement and rules, CMS Innvatin Grants fr health refrm ü CDC Cmmunity Transfrmatin Grants Ø USDA Rural Develpment prgram has Cmmunity Facility lan/lan guarantee/grant prgram fr capital imprvement (Sen. Heitkamp n Ag. Cmm.) Ø USDHUD HUD 242 prgram fr capital lans t rural hspitals Ø Veterans Administratin access t care, VA hspitals, VA CBOC (cmmunity based utpatient clinics, mental health 5
Health Plicy The Infrmal Side Setting the Agenda (prir t frmal plicy frmulatin and during develpment) Advcacy Ø Interest grups play significant rle ü Cntent experts knw the details prvide infrmatin (fact sheets, reprts, meetings with staff, calls frm staff) ü Represent a pint f view ü Relied upn by plicy staff develp clse wrking relatinships ü Interest grups want t be relied upn, at the table Ø Imprtant Rural Health Interest Grups ü Natinal Rural Health Assciatin (NRHA) ü Natinal Organizatin f State Offices f Rural Health (NOSORH) ü RUPRI (ther federally supprted rural health research centers) ü American Hspital Assciatin ü State Rural Health Assciatins - NDRHA ü American Medical Assciatin ü Natinal Nursing Assciatin ü American Public Health Assciatin Health Plicy The Infrmal Side Managing and influencing the agenda Cntrl the infrmatin flw resurce t staff Infrmatin frmal testimny, research, fact sheets but als behind the scene Be hnest and reliable (VERY IMPORTANT is YOUR CREDIBILITY) yur utility t staff is yur reliability and yur infrmatin If yu dn t knw say yu dn t knw but will find ut Re-setting the agenda Cntinuus invlvement with interest grups t prepare fr next rund Cntinuus invlvement with plicy staff -- preparing them, helping them t see the implicatins f plicy, determining what needs t be changed, prvide evidence and data Cmmn questins What des this mean in Nrth Dakta Is there an impact fr us 6
S Really, Hw Des Rural Health Plicy Wrk r Happen? Advcacy Interest grups determine their agenda internal prcess Interest grups smetimes frm alliances with thers share agendas, backscratching t build greater numbers Message framing what messages wrk n plicy makers, what d they like t hear, what frmat r cmmunicatin strategy wrks best Ø Research shws fr rural message framing cncepts like fairness and interdependence wrk ü ü ü ü Peple wh live in rural ND shuld have the same expectatin fr quality care as urban, have reasnable access t care - fairness Rural prviders use netwrks and cllabrate avid duplicatin, efficiency, effectiveness interdependence Rural rganizatins tend t wrk tgether, health care as part f the scial and ecnmic fabric f a cmmunity - interdependence Under ACA mvement t utcme based r pay fr perfrmance frame as merit pay t prviders Redundancy and repetitin f messages are psitive in plicy say the same thing ver and ver, try t have thers (alliance partners) say yur message S Really, Hw Des Rural Health Plicy Wrk r Happen? Rle f Research 7 Rural Health Research Centers and 3 Plicy Analysis Initiatives (UNDCRH has with partner NORC the Rural Health Refrm Plicy Research Center) http://ruralhealth.und.edu/prjects/health-refrm-plicy-research-center Ø RHRPRC fcus n: ü Hspice and end f life request frm ORHP ü Hspice family member survey ü Hspice wrkfrce ü Hspice CEO study ü Rural Health Chartbk ü Care crdinatin n frntier Medicare beneficiaries quality and cst f care ü Emergency Department variatin imprving quality/reducing csts ü Rural definitins Rural Health Research Gateway http://www.ruralhealthresearch.rg/ Ø One stp shp (lcated at CRH) fr :Research prjects, publicatins (peer reviewed, plicy briefs, fact sheets, anntated literature reviews, maps, and ther prducts 7
S Really, Hw Des Rural Health Plicy Wrk r Happen? Rle f Research NRHA Plicy Cngress Ø Abut 50 peple elected frm Cnstituency Grups abut 1/3 academic Ø CG develp issue papers primary and secndary data surces Ø PC reviews and vtes, thse adpted becme fficial NRHA dcuments, and are used by Gvernment Affairs staff in plicy dcuments Natinal Advisry Cmmittee n Rural Health and Human Services http://www.hrsa.gv/advisrycmmittees/rural/ Ø 21 members natinally recgnized rural health experts Ø Prvide recmmendatins n rural issues t Secretary f DHHS Ø Fcus n 1-4 issues per year - Review backgrund dcuments, site-visits Ø Issues reprt f recmmendatins Ø Hspice interest started here - Rural Implicatins f Changes t the Medicare Hspice Benefit (NACRHHS Plicy Brief) ü Member f Cmmittee had hspice backgrund, and pushed the issue ü ORHP after funding RHRPRC requested us t study this issue ü RHRPRC wrks with NHPCO Rural Hspice Task Frce ü Abut 5 studies in prcess S Really, Hw Des Rural Health Plicy Wrk r Happen? Rle f Research Example frm ORHP Rural Health Research Prgram Ø Office f Inspectr General (fr DHHS) reprt n CAHs very negative and nt well funded Ø ORHP relied n research frm the field (Natinal Rural Hspital Flexibility Mnitring Prject and ther research prgrams) Ø ORHP issued respnse that tk exceptin t many pints in the OIG reprt Ø Thus, research was relied n t argue pints that had plicy implicatins Ø Infrmatin shared with NRHA, Senate Rural Health Caucus, and Huse Rural Health Care Calitin Natinal Cnference f State Legislatures http://www.ncsl.rg/ Natinal Gvernr s Assciatin http://www.nga.rg/cms/hme.html Natinal Academy fr State Health Plicy http://www.nashp.rg/ 16 8
Five Key Pints n Plicy Advcacy Plicy is a cntinuus prcess Cngressinal sessins begin and end, but the prcess f frming plicy, influencing plicy, changing plicy, advcating fr plicy is nging ACA is nt the final Act in health refrm each Cngress and President will make changes (every year multiple bills just n Medicare which ges back t 1965 Imprtant t have partners, allies, calitins, alliances frge relatinships, cultivate relatinships sme shrt term, sme lng lasting Organizatins similar and even dissimilar t yur rganizatin Relatinships with plicy makers and staff Extremely imprtant t be a resurce t plicy staff Recgnize there is a relatinship between plicy frmulatin and implementatin with research and evaluatin rural paid price in early 80 s because n frmal advcacy r plicy structure Imprtant t have a legislative champin/advcate Imprtance f Having Partners Strength in numbers mre vices with same message Redundancy in plicy can actually be gd mre vices, same message An assciatin if it is the primary advcate needs it members invlved (elected fficials like real peple ) but als ther assciatins and their members) CAH administratrs n hill visits Identify the cmmnality f issues and frge alliance arund that subject may be secndary fr ther assciatin but can add t their message Hspital Assciatin and SORH rural health utreach grant funding Need t be willing t make cmprmises mre and mre imprtant Willingness t supprt partner n their issues makes it easier fr them t supprt yu n yur issues their primary is yur secndary issue, and yur primary is their secndary issue, yu gt t give t get in plitics 9
What are sme examples f successful rural health plicy? Rural Health Plicy in Actin Rural Hspital Flexibility Prgram Flex prgram Alliance f NRHA, NOSORH, AHA, SORHs, and State RHA Each state wrked with their cngressinal ffices 1 st year grant fr $200,000 went t SORHs in eligible states Flex funded at $26 millin a year Ø Grants t 45 eligible states Ø Flex Mnitring Team (RHRC research related t Flex and rural hspitals evaluatin leads t better data fr cngressinal advcacy) Flex is administered, like SORH, thrugh ORHP NRHA, NOSORH, and AHA push every year cntinued apprpriatin fr Flex CRH keeps in frnt f Cngressinal Offices 10
Rural Health Plicy in Actin Rural Health and the Affrdable Care Act Basically, every health interest grup had a stake NRHA psitin papers and fact sheets Frmed cre set f expectatins Ø Health wrkfrce Ø Prvider reimbursement Ø Prtect (and even expand) rural safety net CAH, RHC, CHC Ø Access fr rural peple financial cncerns, but als availability f prviders and financial viability rural health prviders NRHA wrked with AHA and NOSORH State level wrk with cngressinal ffices n needs and impact CRH emphasized health wrkfrce, safety net, availability f prviders, and financial viability f rural health prviders and systems The Rural Health Research Gateway prvides access t all publicatins and prjects frm seven different research centers. Visit ur website fr mre infrmatin. www.ruralhealthresearch.rg Sign up fr ur email r RSS alerts! www.ruralhealthresearch.rg/alerts Shawnda Schreder, PhD Principal Investigatr 701-777-0787 shawnda.schreder@med.und.edu Center fr Rural Health University f Nrth Dakta 501 N. Clumbia Rad Stp 9037 Grand Frks, ND 58202 22 11
Custmized inf@ruralhealthinf.rg Assistance 1-800-270-1898 Tailred Searches f Funding Surces fr Yur Prject Fundatin Directry Search 24 12
Cntact us fr mre infrmatin! 1301 Nrth Clumbia Rad, Stp 9037 Grand Frks, Nrth Dakta 58202-9037 701.777.2569 (desk fr Brad) Brad.gibbens@med.und.edu 701.777.3848 ruralhealth.und.edu 25 13