Power in Collaboration: Rural Forward works with Communities to Uncover “Boundary-Spanners”

power-in-collaborationRural communities are characterized by community strength and expertise on their unique needs. Rural Forward NC (RFNC) taps into that strength by bringing together rural health leaders and in some cases, highlighting leadership and unidentified community assets.  The program, funded by Kate B Reynolds Charitable Trust and their Healthy Places NC initiative, supports counties in central and eastern North Carolina participating in the Initiative.  Most importantly the team works with the community to expose opportunities for collaboration and leveraging community assets.  Community organizations are critical to the identification of workforce “boundary spanners”, individuals and organizations that provide critical connections to healthcare.  These organizations can be the link between traditional healthcare setting and community self-care.

Lack of transportation, few physicians, and minimal employment opportunities make it hard for rural residents to maintain their health. Calvin Allen, Director of RFNC says, “Despite these challenges, small towns have a unique asset to build upon. People in rural communities often know each other and have established networks.” Value-based care and the opportunity for community-based workers to actively participate in the health of their community recognizes the unique knowledge and influence they contribute, something the traditional healthcare system needs to successfully improve population health.

Currently, Rural Forward NC is working in Halifax County with leaders creating a community health home.  The work is part of the Blue Cross and Blue Shield NC Foundation’s Community Health Home initiative.   Sharing data across department lines is one of the tactics that leaders in Halifax County are using to address the health of their populations, identify unmet need and create opportunities for the broader community to collaborate

During a three-hour meeting in the Halifax Regional Medical Center facilitated by the RFNC team in June, health professionals met to hash out ideas on how to get Halifax County healthier.  Representatives from the community health center, public health department and hospital attended the meeting, as well as primary care physicians. They discussed further coordination to prevent the replication of services, the idea of a mobile care unit to reach frequent or repeat EMS callers, and a new data-sharing tool that the coalition has developed.

Data-sharing is an extremely useful way for communities to work together. “When you develop an intervention, data can tell you where the greatest need is, and where the greatest potentials are,” says Allen.  “The Halifax County team discovered a family with multiple visits to the health clinic and the emergency room for respiration problems, but had no idea until they combined data that one of the parents was a smoker.” Information sharing across departments changes the intervention from treating symptoms to addressing the root cause in the household. This innovation helps departments streamline their efforts so that services aren’t replicated, which makes greater economic sense, and more importantly, patients aren’t receiving disjointed care.

Despite the benefits, sharing data like this can be very touchy. ” A level of trust has to be established to cross long-held boundaries,” says Allen.  “Our local colleagues are doing an amazing job of respecting privacy and also pooling data across department lines. Fortunately, communities like Halifax County have come a long way in establishing that trust.”

In a health climate that is slowly shifting to value-based care, rural communities, especially the health care workforce, need to work even harder to collaborate around the health of the population as a whole. “It takes creative ideas, development, good case-management, and co-operation,” says Allen, “We are seeing the value of crossing department lines when health leaders look beyond their departments and take a collective view of their community.”

integrated-careMost healthcare providers agree that mental health affects physical health and vice versa. However, integrating the two is not easy.  Providers aren’t trained to address both the mind and the body in one setting. As we transition towards value-based reimbursement, there’s a greater incentive to improve quality for patients. The Center of Excellence for Integrated Care (COE) is an example of a creative approach to improving patient outcomes.

The imminent changes to our healthcare system will result in a workforce that operates differently—and that’s where COE steps in. Housed in the NCFAHP, this small team provides the tools and training for integrating mental and physical health. “And we have our eyes on oral health specialists and pharmacists too.” says Associate Director Christine Borst.

The COE team works in a broad range of settings, and not just traditional healthcare sites. “North Carolina is one of the most diverse states in the nation when it comes to putting teams together to meet the patient where they seek services,” says Director Cathy Hudgins, “This can be a school-based clinic, a mental health or substance abuse clinic, homeless shelters, migrant worker camps and church basements.”

COE breaks down the cultural and educational barriers between health sectors. This type of workforce development, dubbed cross-training, is crucial to better patient outcomes. “It’s been exciting to work with universities,” said Borst, “Conducting trainings early on is really helpful for developing that multidisciplinary lens.”

In a healthcare practice with established workflows, cross-training requires a colossal team effort. “We work with everyone in the office, from the front desk ‘eyes and ears’ of the clinic, to the physicians and therapists in the back,” said Borst, “Regardless of what kind of specialist you are, it’s essential to work together as a team and develop a mindset of integration.”

Every care site is different. Some have a behavioral health therapist in-house; others have close connections to one. Some have no partnerships or experience with behavioral health. Borst gave the example of smoking cessation or diabetes diagnosis. “These issues really require a behavioral health intervention,” she said, “And not every clinic has the resources to provide that.” Tailoring training to meet the needs of a care setting is part of COE’s work. Every practice and every community has its assets, and COE works to create partnerships around those assets.

The biggest hurdle for integrating care is payment reform. “Everyone wants to know how to pay for it,” said Borst. COE provides some direction on navigating the billing process, but it will take policy reform to dictate how behavioral health integration will be properly reimbursed.

Effective workforce training to integrate the siloes of care is an important step towards fully implementing value-based care. “There’s a method to our madness,” Borst said, “Laying a strong foundation for a multidisciplinary approach is the first step.”

2 Trees in WinterEvery year the North Carolina Foundation of Advanced Health Programs hosts a premiere event that brings together health leaders from all over the state of North Carolina for an evening of dining and networking.  Up to 300 health professionals attend this event that honors the work of Jim Bernstein and supports the Jim Bernstein Health Leadership Fellows program.

This year’s event will feature Jonathan Oberlander as the keynote speaker, and Tom Bacon as the recipient of the 2014 Career Achievement Award.

Please join us for this exciting event, which includes a reception and dinner/lecture at the Friday Center in Chapel Hill, NC on the evening of October 9th, 2014.

Most students in North Carolina have just started another year of school, another year of learning with teachers, friends, homeroom, and physical education classes.

For students in rural areas, good healthcare is not always easy to access.  Many parents work full-time, and it can take up to an hour (or, in some places, longer) to get to the nearest hospital or doctor’s office.  This often makes finding the time to take your kids to the doctor, for a routine check-up or a seemingly small health issue, so difficult for parents that many don’t do it.  Consequently, many students don’t receive medical attention they might need.

That’s why school-based telemedicine programs – where students have videoconference appointments from right inside their school building with doctors who are in other locations – are spreading across the country and showing successful outcomes.  One such program is right here in the western part of North Carolina.

MY Health-e-Schools is a program started in 2011 by Dr. Steve North, a family physician who saw the need for better healthcare access for students in Mitchell and Yancey counties in western North Carolina.

Amiria w/CartHow does a telemedicine program like MY Health-e-Schools work? At the beginning of each year parents can sign consent forms enrolling students in MY Health-e-Schools, which allows students to be seen during the school day by remotely located nurse practitioners or physicians.  Parents or teachers can refer students, or the students themselves can make an appointment to be seen for anything from a cold to potential symptoms of ADHD.

Many things can be done at that appointment, which is conducted via high-definition videoconferencing using specially equipped stethoscopes and cameras.  This allows a centrally located health-care provider to examine students at multiple schools without traveling, and therefore allowing more students to be seen across a large area.  When more complex processes like lab work or further tests are needed, the provider refers the student to the closest hospital or specialist.

MY Health-e-Schools providers can address issues ranging from the common earache, stomachache or cold, to chronic disease management, medication management, check-ups, sports physicals, adolescent medicine, and even telepsychology and tele-behavioral health.

North first became interested in school-based health systems while working for Teach For America in Edgecombe county before attending medical school at UNC-Chapel Hill.  Steve then moved to Rochester, NY for his residency and a fellowship in adolescent medicine, during which time he learned from the school-based health centers there.

North relocated back to North Carolina in 2006, and in 2007 became a Bernstein Fellow. During this time, he continued researching and seeking to better understand telemedicine systems and began developing the idea of a school-based telemedicine program in western North Carolina.  He received initial grant funding from the Kate B. Reynolds Foundation and the Community Foundation of Western NC, and several other sources that matched funds in the following years.

With these funds, a pilot program was begun in 2011, serving three schools in Mitchell and Yancey counties. By the second year, the program was expanded to 10 schools in the two counties and, by the third year, to 14 schools, which meant that all the schools in the two counties without their own health center had access to a primary care provider through MY Health-e-Schools.

This year MY Health-e-Schools is expanding into schools in McDowell County, and the program now allows over 8,000 students in 21 schools in the three counties to have access to trained medical providers during the school day without leaving their school building.

MY Health-e-Schools also recently received the 2014 American Telemedicine Association’s President’s Award for Health Delivery Quality and Innovation, showing that, even in only its 4th year of operation, the program is still growing and has the opportunity ahead to better health-care access for rural communities in North Carolina.

Health e-SchoolIn the meantime, MY Health-e-Schools is working to improve health care in the community, one student at a time.  North talks about the program’s impact with stories, including one of an eight-year-old student with high blood pressure who was seen at an appointment through the program.  During the appointment the provider referred him to his primary care physician and to get labs done, during which time they discovered that the student had post-streptococcal glomerulonephritis (GN), a kidney disorder that can occur after a routine strep infection.  Without the initial appointment with the MY Health-e-Schools provider, the disorder might have gone undetected for much longer and become much more severe.

North attributes the success of MY Health-e-Schools to being able to do a lot without a lot of resources, with tremendous community support.

MY Health-e-Schools is now the largest program part of North’s nonprofit organization, the Center for Rural Health Innovation.  For more information on MY Health-e-Schools, visit their website.

Special Note: The N.C. Foundation for Advanced Health Programs is pleased to announce Dr. Steve North will be joining its Board of Directors in 2015.