Rural health breakfast Strong States, Strong Nation Rural health breakfast October 14, 2017 Sioux Falls, South Dakota

What’s Covered Today Rural health landscape State strategies to address challenges: Telehealth Rural Facilities Community Paramedicine Peer Support Specialists Discussion

Rural Health Overview 77 percent of rural counties are Health Professional Shortage Areas (HPSAs) Since 2010, 82 rural hospitals have closed Rural population older, sicker and poorer Death rate higher in rural areas than urban federal designations that indicate health care provider shortages and may be geographic, population or facility-based Only 11 percent of physicians practice in rural America despite the fact that nearly one-fifth of the population lives in these areas. According to the U. S. Department of Health & Human Services, over 8,400 additional primary care providers are needed in rural America alone. Rate of growth for seniors living in rural areas has tripled since the 1990s, higher incidence of chronic illnesses in rural areas and 18% of rural residents living in poverty compared in 16% for urban counterparts A higher percentage on Medicaid A recent study (just released this year) found that rural residents are more likely to die from the 5 leading causes of death, than their rural counterparts. Many of which are preventable Life expectancy is 2 years less for rural residents Drug overdose death rate 45% higher in rural areas than metro.

Telehealth “The use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration” (HRSA) Primary, acute and specialty care Chronic disease management, home health and long-term care Oral health care Behavioral health care Four modalities: Live video, Store and Forward, Remote Patient Monitoring, mHealth

Telehealth 150+ bills/year Key policy issues: Reimbursement Licensure Practice standards

Rural Facilities Rural hospital: any short-term, general acute, non-federal hospital that is not located in a metropolitan county; or is a Critical Access Hospital. Critical access hospital: designation given to rural hospitals (by CMS) that meet certain criteria, such as having 25 or fewer acute care inpatient beds, being located more than 35 miles from another hospital, and receive cost-based reimbursement. Federally Qualified Health Centers (FQHCs): outpatient clinics that qualify for specific reimbursement systems under Medicare and Medicaid. Must meet certain criteria such as serving an underserved area or population, offering a sliding fee scale, and providing comprehensive services. Rural health clinics: clinics located rural areas. Provide primary care services using a team approach of physicians, nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNM). Must be staffed at least 50% of the time with a NP, PA, or CNM. Receive enhanced reimbursement rates for providing Medicaid and Medicare services. Free-standing emergency departments: facilities that receive individuals for emergency care. Can be independent of a hospital system or be run by a hospital but is structurally separate and distinct from the hospital. They are often under staffed and under funded As I mentioned earlier, 82 rural hospitals have closed since 2010 When a rural hospital closes, not only does community lose a critical access point, but that also represents a major job loss in the community Indian Health Service (IHS) and tribally-operated facilities: managed directly by IHS, tribes or tribal organizations under contract or compact with the IHS. Located mostly on or near reservations.

Rural Facilities Strategies: Coordination between rural hospitals and other facilities, e.g., rural health centers or IHS providers Repurpose: urgent care, skilled nursing, outpatient care, emergency care, acute rehab, primary care Accountable Care Organizations and other partnerships, e.g., frontier health system model Telehealth Mergers with larger health systems Value-based payments, e.g., global budgets for rural hospitals Coordinated care- For example, GA’s legislature formed a rural hospital stabilization committee, which recommended the ‘hub and spoke model’ in one of their reports It designates a rural hospital as a hub and other points of care as the spokes (e.g., FQHCs, school health centers, IHS clinics) and works with these other points of care to ensure patients are receiving care in the most appropriate setting and minimizes over utilization of Er’s 2) Value based payments- aims to pay for value of care over volume of services and incentivizes quality care example: PA’s rural hospitals were recently approved to test a new payment model, w/ $25 million from CMS 3) ACO-groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. 4) Telehealth- connect people in rural areas with specialist, and provide emergency care to people in remote locations

Community Paramedicine Community Paramedics are trained to provide non- emergency services to patients in their homes or other community- based settings Perform an expanded role within their scope of practice Aim to connect high-risk and underserved patients (e.g., frequent emergency dept. utilizers) with primary care services

Community Paramedicine Services may include: Assessment (e.g., blood pressure screening and monitoring) Treatment/Intervention (e.g., providing wound care) Referrals (e.g., mental health and substance use disorder referrals) Prevention and Public Health (e.g., immunizations) Many programs implemented as pilot programs Reimbursement challenges

Peer Support Specialists Services delivered by a person with similar life experiences and previous behavioral health challenges Support groups, peer recovery education, and peer-run services such as mentoring and case management May be able to better connect with patients and help them obtain treatment, social support and housing Optional certification programs Increasingly, Medicaid and public mental health systems will pay for peer support services

Table Discussion What are the biggest challenges in your state related to rural health? What has been successful in your state? What ideas have you heard today that you are interested in bringing back to your state?