Rural Forward NC Joins Effort to Support Those Still Recovering from Hurricane Matthew

Photo from North Carolina National Guard

On the morning of October 8th, 2016, disaster struck North Carolina when Hurricane Matthew hit the eastern coast. Bringing record breaking rain and flooding, roads quickly became washed out, rivers overflowed, and entire towns were left submerged underwater. Residents of over 50 counties were ordered to evacuate, and many who couldn’t get out had to be rescued from their homes.

While skies have since cleared and the devastating storm has passed, for many living in eastern parts of NC, the recovery is still not over. Hundreds of families who were forced to leave their homes behind are still living in a state of limbo.

Since the storm, federal, state, and local officials have made efforts to connect those impacted by the hurricane with necessary resources. Disaster recovery centers quickly opened and the Federal Emergency Management Agency (FEMA) has provided over $100 million in funding to the state. However, as time continues to pass, the needs of many residents who were hit the hardest by the storm—communities of lower wealth, communities of color, and rural communities — have been overlooked.

Recognizing this as a huge problem, several statewide groups, including The Foundation for Health Leadership and Innovation’s Rural Forward NC program, developed an advocacy group to ensure this population doesn’t fall through the cracks. The group initially included a wide range of organizations invested in various aspects of the relief, particularly philanthropy, housing, rural, policy, and legal specialists.  They currently meet every two weeks to raise issues, share resources, and address policy concerns. Their overall mission is to ensure each affected community has a voice within the recovery efforts and that resources are allocated fairly to all.

“We realized that as decisions were being made, local voices were not at the table, and that was a concern” says Calvin. “That’s why we came together. We wanted to create a mechanism where those who were most affected could be heard, and we knew we had connections to the decision makers who could help make that happen.”

The group got organized around its mission, core constituency, and strategies with facilitation support from Rural Forward NC.  The NC Justice Center, NC Association of Community Development Corporations, and the NC Rural Center have led policy and resource efforts around the recovery effort, including the “Community Allies” session in early March to connect over 90 community leaders with relevant state resource leaders.

The group also expanded within the past two months to include two key sets of leaders:  state government officials from the NC Department of Emergency Management who are leading the recovery effort, in addition to local grassroots leaders who are themselves survivors of Hurricane Matthew.  The addition of these leaders are key strategies for accomplishing the mission of this group, providing local voice to the statewide process and state government answers to local recovery questions.

The Hurricane Matthew Recovery Inclusion Support Effort has so far met twice per month over the last five months, and one of the biggest issues being raised is housing. After the storm, more than 18,000 people were displaced from their homes, and many of them are still living in motels. While FEMA has offered homeowners some options for repairs, the floods destroyed most of the land, leaving few places to rebuild. Additionally, if multiple people lived in a family home, services might  only be provided to the person who owned the house. Options for renters are even less promising. Rental property was already scarce before the storm, so finding a new place is almost impossible. While FEMA has continued to extend the deadline for temporary housing funds, this group is hoping to help develop long term and immediate solutions for when people eventually need to move out of motels.

They are also working to bridge the gap in communication between the people on the ground and those at the state level. Many residents are either not getting the information they need or are being told different things from different people in places of authority. County departments are not always on the same page, and people are often sent back and forth just to find out how to get benefits and support. Given that many people have also lost their cars, traveling this much is not easy. That’s why this group is stressing the importance of a consistent message from the North Carolina Department of Social Services and is working to make sure they are consistently training workers on what to say.

There is also a concern with compensating people in these communities for what they have already done and for the resources they have already depleted to help people. Because funding can take a while to kick in, local governments and organizations have been using their own resources and have been working to help their own communities set up shelters, providing food, etc. Whether or not they get reimbursed for these resources is typically up in the air, so this group is ensuring these types of questions are getting raised.

Lastly, the group also hopes that this recent disaster will prompt preparation for the next emergency now. Seeing the damage both Hurricane Matthew and Hurricane Floyd caused to North Carolina makes it clear that long term structures that we can put into place now are necessary. Luckily, many survivors of Hurricane Matthew were on the front-line to help, breaking into neighbors homes to get them out safely, but there needs to be a better, more organized way. “One of the main things we can do is help set up neighborhood collaboratives and coordinate communication structures for future emergencies,” says Calvin. “These types of programs and initiatives will help us to be more pro-active and better prepared if another disaster hits.”

 

The table below from the CDC illustrates what we hear all the time on the news and in our communities: drug overdose deaths are on the rise. It’s both heartbreaking and shocking! Since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids. Escape from chronic pain, caused by a myriad of physical ailments, often initiates the journey to overuse and addiction.

CDC Death by Overdose line chart

Rather than focusing on the enormous and incredibly complicated routes to opioid addiction, this newsletter will take this opportunity to shine a light on some of the people, communities and projects that are working to make a difference. Once again, our mantra at the Foundation, “it’s a whole-person, whole-community thing,” holds true. Solving this issue is not possible by a single person or a single agency/institution; it’s about how we all can work together.

Rural communities are particularly vulnerable to this issue for a variety of reasons. Access to care, access to pain management, and the number of heavy labor occupations inherent in the economy of these communities have all been linked as reasons for increased opioid use. Research has also shown that prescription drug use in some rural areas is an embedded part of the culture, as they are often prescribed them to maintain a steady workflow in heavy labor occupations.

The Foundation houses The NC Rural Health Leadership Alliance, a group that works closely with the National Rural Health Association (NRHA) on a variety of issues. In February, NRHA provided testimony to the United States Senate Committee on the Judiciary regarding mental health and substance abuse issues in rural America. The following is a summary of the comments and recommendations from NRHA:

  • Rural Americans in need of substance abuse treatment services and behavioral health care will find that access to care can be limited.
  • Even with rural telemedicine services improving access to mental health care, 60 percent of rural Americans live in a mental health professional shortage area.
  • Rural Americans are forced to travel significant distances for care, especially specialty services such as mental health services and pain management.
  • With rural hospital closures, rural Americans are farther away from emergency care, as well as options for the ongoing treatment that is essential for successfully treating substance abuse.
  • The differences between rural and urban settings, culture and resource availability means the solution for rural America must be uniquely tailored to this population.
  • Treatment programs must be available locally and should be tailored to the unique needs and characteristics of rural Americans. Treatment programs must be able to leverage the health care providers in the community while using tele-health and other resources to bring new providers into the community.
  • The implementation of models to engage rural communities in addressing opioid issues must be supported. Broad community coalitions, including schools, law enforcement and medical providers need to be a part of the rural solution.
  • Evidence-based prevention programs tailored to the needs of rural communities must be identified and developed.
  • Implementation of harm reduction strategies must increase. Harm reduction is an essential part of dealing with the existing problem and will require training of both law enforcement and first responders. It will also require administering interventions known to reduce the harm of drug use including needle exchange and naloxone.
  • Use of evidence-based prescribing guidelines need to be promoted. Pain management is an important component of health care. However, measurement of hospital and physician quality must balance the need to address patient’s legitimate pain with the need to avoid misuse and diversion of pain medications.
  • State prescription drug monitoring programs (PDMPs) must be strengthened.
  • Use of substance abuse treatment as an alternative to incarceration for opioid users must expand. Those facing substance abuse or mental health crisis may wait years before seeking treatment from a professional, especially in rural America where the stigma discourages people from seeking treatment and views addiction as moral failure.

For the complete testimony from NRHA to the U.S. Senate Committee on the Judiciary, visit: http://connect.nrharural.org/blogs/erin-mahn/2016/02/22/nrha-submits-testimony-on

An enormous thank you to all the people engaged in this work every day. At the end of the day, success comes from the work done by communities, their citizens and the people who need their help.

-Maggie Sauer

CEO & President

NC Rural Counts Logo

Through a series of regional briefings held this month, the NC Rural Economic Development Center (Rural Center), a partner of the Foundation, released its rural advocacy agenda titled “Rural Counts: 10 Strategies for Rural North Carolina’s Future”.

The agenda promotes “stabilizing and transforming rural health” as an essential strategy for providing rural communities with a foundation for success. Regarding this strategy, the Rural Center specifically advocates to “strengthen local, state, and federal efforts to reduce opioid and methamphetamine drug addiction” recognizing addiction and substance abuse as a national crisis and supporting programs from various sectors and government levels designed to address this issue.

Learn more about the Rural Center’s recommendations regarding rural health and its comprehensive strategies for realizing the “economic potential for our rural communities and citizens” from the #RuralCounts download center on the Rural Center’s homepage: http://www.ncruralcenter.org/

Opioid pill bottle tipped overFor years, the country’s opioid crisis has quietly escalated. From 1999 to 2012, deaths from common opioid medications increased by 400 percent. Additionally, accidental drug overdose is currently the leading cause of injury-related death in the country for people between the ages of 35 and 54.

North Carolina is no exception. In 2014, more people in North Carolina died from drug overdoses than car accidents.

Some blame decades of overprescribing opioids for the epidemic. Others blame law enforcement for not controlling the influx of cheap heroin.  But according to community health advocate Anne Thomas, the “blame game” isn’t helpful. “Everyone is part of the problem. And everyone is part of the solution.”

Anne Thomas Portrait

Anne Thomas
Consultant for Chronic Pain Initiative and Project Lazarus

Anne Thomas is the current Chair of the Foundation’s Board of Directors and a consultant for the Chronic Pain Initiative and Project Lazarus. She supports communities in over 30 North Carolina counties who are building capacity to address the opioid epidemic and manage chronic pain effectively.

“Communities are best poised to solve their community health problems because they know their resources, they know their own culture,” said Thomas. “They know what things are possible, where there’s support, and where there’s resistance.”

The Chronic Pain Initiative and Project Lazarus is a two-year project funded by the Kate B. Reynolds Charitable Trust.  The Foundation partners with the NC Office of Rural Health and Community Care of North Carolina to administer this statewide collaborative around opioid prescription management.

Project Lazarus is based on a successful model developed in Wilkes County aimed at preventing overdoses and meeting the needs of those living with chronic pain. The model includes the use of toolkits for clinical and community training. The toolkits are a range of guidelines for community action, education and for assessing pain and prescribing medication safely.

Thomas’s work is with community engagement. She provides technical assistance to help communities create and maintain local coalitions. She assists them with developing locally identified needs and locally tailored drug overdose prevention programs and connects them with state and national resources. This work includes identifying stakeholders who need to be at the table, leveraging resources or providing educational materials to boost awareness. “Many times they have the resources right there in their community, it’s just helping them explore and navigate them,” said Thomas.

One of the premises of the project is that change is possible with community engagement. Thomas says this means engaging with traditional and nontraditional partners. “We try to bring everyone together and engage the entire community,” said Thomas.  Many coalitions are made up of parents, school systems, law enforcement, public health, businesses, churches, pharmacists and the medical community.

Map of North Carolina with Seven Counties highlighted in top right corner

Thomas said that regional alliances can have a big impact. A cluster of seven counties in the northeastern part of the state have a coalition called the Albemarle Region Project Lazarus Coalition. The coalition includes Currituck, Camden, Pasquotank, Perquimans, Gates, Chowan and Bertie counties. Because of their shared resources, the alliance distributed effective messaging around safe opioid medication use and disposal.

They also organized drop boxes for unused prescription medication and purchased two incinerators for disposing them. They organized training in naloxone—a drug that reverses opioid overdoses—for emergency first responders.  The alliance has partnerships with the school system to train school resource officers and school staff in providing prevention education. They work with community colleges to provide addiction education in the health curriculum as well as with law enforcement and the public health department.

“Rural communities have scarce resources,” said Thomas.  “So creating economies of scale and scope by sharing resources and getting more people at the table is really effective.”

Thomas says communities can accomplish a lot by setting goals, assigning roles and developing strategy. “People don’t want to come to the table to just talk about something,” she said. “They’d rather be doing something. And when the doing starts to happen, people get involved.”

To learn more about the Chronic Pain Initiative and the Project Lazarus model, visit:
https://www.communitycarenc.org/population-management/chronic-pain-project/

For more information on North Carolina’s opioid epidemic, read “Policy for the Use of Opiates for the Treatment of Pain”.

The Center of Excellence for Integrated Care (COE) is a program of the Foundation that works with health providers across the state to integrate primary care and behavioral health services. COE’s model of integrated care is well-suited for substance abuse issues, which can harm both the mental and physical well-being of a patient. COE Director Cathy Hudgins says that “integrated care provides those struggling with addiction an opportunity to be treated as a whole person.”

The COE helps organizations develop their ability to provide integrated health care. One of their longstanding partners is Family Service of the Piedmont (FSP) in Guilford County.

Anthony Steele Portrait The primary care provider for FSP is Anthony Steele. Steele is a nurse practitioner with a certificate in family medicine and psychiatry. He has spent 16 years serving individuals with addiction. He says he’s a “one-stop-shop” for patients because he has the training to address their physical and mental health in one setting. In the time that the COE has been working with FSP, Steele has assisted in building exemplary integrated care services.

We asked Steele a few questions to understand how he uses the integrated care model to help patients suffering from addiction.

When did you realize that you wanted to work with addiction?
I was done with inpatient healthcare. I needed to do something different. When I came in 16 years ago I knew nothing about addiction. But guess who were the best educators? My patients. They were the ones who taught me about the disease. They even taught me how to change my language when speaking to clients. I had to really adjust. Because when you’re looking at a patient and you’re calling him or her an addict, it’s one of those things that just makes them cringe. ‘No, I’m not just an addict. My name is John,’ or, ‘my name is Suzie.’

I also had to work on my perception and how I addressed individuals. I had to look at them as a patient and as a client. This is someone’s son. This is someone’s daughter. This is someone’s brother. In treatment we always want to keep people alive. Every day you see someone alive is a success. Then you work on developing tools to help them stay alive. You work on helping them build resources and you meet them where they are. Within the first month of working with addiction I became engrossed with learning about the disease process and I thought if not me, then who?

What’s encouraging about your work?
When I have a patient come in who’s been using 10 bags of heroin a day and then within a week of treatment, they are looking at me in the eye, they are taking a bath, and they are beginning to see changes in their life. When you see a pregnant mother who’s been using every drug under the sun get stabilized and she’s now able to have a normal labor and delivery.  When I see those patients, I know this is where I need to be.

How does integrated care help you serve individuals with addiction?
We look at the whole picture. We do a comprehensive assessment when people come in. We have screening tools that look at depression, anxiety, trauma, addiction history, and physical health issues. When a patient comes in, they have bared their souls to us, and it’s a judgment-free zone. It just makes sense for us to treat the mind, the body, and the soul. If a patient is struggling with opioid addiction, but also high blood pressure and diabetes, I’m not going to ignore those physical issues. I’m not going to send them to another primary care doctor that doesn’t know them or who may prescribe other medications that could get the patient into trouble. It’s important to be mindful of not causing a relapse.

If we don’t begin to address the fragmentation of care, then our opioid addicted individuals will continue to be stigmatized. We need providers that know a patient’s history, won’t judge them, and will meet me where they are. Some of these patients don’t have their basic needs being met. When you add addiction on top of that, their addiction takes precedence over food and shelter. That’s why we help clients get their cravings under control, and then we work on the other aspects of life. Let’s get you gainfully employed. Now let’s work on relationships with your family so you can be supported on that road to recovery. Instead of disconnecting the head from the body, my goal is to connect it all together.

[box type=”bio”] “If we don’t begin to address the framentation of care, then our opioid addicted individuals will continue to be stigmatized.”[/box]

How does addiction tie in with other health issues?
People who have addictions have the same chronic medical issues that anyone else has, but they might be highly elevated because they aren’t typically treated. If you look at most statistics, more than one in five adults have a co-occurring mental health and substance abuse issue. And so it just makes sense to figure out how to treat them in a collaborative perspective.

One thing I’ve noticed is that dental care is much needed and sought after. A patient who’s addicted to opioids, one of their side effects is dry mouth. If you have dry mouth you aren’t producing enough saliva, and then bacteria grows and your teeth decay. But if you’re in active addiction, you’re not going to be worrying about brushing your teeth. It’s a perfect storm for dental problems. If I have dental issues, they effect my self-esteem, and now I have self-doubt, now I’m depressed, now I’m isolated. And it continues that cycle of relapse and recovery, relapse and recovery. Oftentimes our patients are also IV drug users which opens up the risk for Hepatitis C transmission with potentially shared needles. They may not know or have any symptoms, so they keep sharing needles, snorting drugs with dollar bills and having unsafe sex.

Spilling pills out of bottle onto table

Why do you think that integrated care for opioid addiction isn’t more widely used?
Sometimes I think it’s a comfort level. Most medical programs don’t give you a lot of training in substance abuse and mental health. In primary care you maybe get one to two week’s rotation in substance abuse, and that’s it. You’re taking on the responsibility of something you really don’t know much about. And sometimes in primary care, if you don’t ask about addiction, you don’t have to deal with it. Some primary care providers do want to deal with it, but guess what? They are limited in terms of where they can refer patients. The amount of money that’s available for substance abuse treatment compared to all the other diseases is a drop in the bucket. If I’m a primary care provider and I screen for addiction, where can I get this patient into treatment? The hospital is limited and here in Guilford County we only have one in-patient detox facility, which is also limited. I think there might be 15 beds.

In your opinion how do we better address this epidemic?
We’ve got to do a better job with screening and treatment. You really need to meet the patient where they are. But once we screen for it, we also need funding to cover the cost of these patients who need this service. We have to stop ignoring the issue. Because it’s here, and it’s prevalent. Until we take a very hard look at this disease, we are going to continue these vicious cycles of chronic relapse and people dying on the streets. Most people look at it as a character flaw. We in the addiction world know that it’s not. This is a disease of the brain that needs to be dealt with like any other disease. You don’t tell your diabetic, ‘you’re obese so we aren’t going to treat you.’ No. You work with that patient where they are. Oftentimes with our addicted individuals, we just don’t have that same tolerance.

A flexible workforce is essential for the future of our health care system. A massive shift in the way services are reimbursed is coming. This prompts a similar shift in how we train the workforce that keeps our communities healthy. Federally funded insurance will pay providers based on the quality of care instead of the quantity. The Centers for Medicare and Medicaid is already funding pilot projects to encourage this change. These “value-based payment” projects are causing a bloom of experiments all over the country. The goal of these experiments is to provide patients with preventative and comprehensive care that is high quality and affordable.3RNet Logo and text

It’s a big challenge. But it will be easier to manage if healthcare providers learn from each other. On August 18, the NCFAHP, Practice Sights, and 3Rnet hosted the first of many webinars to begin a national conversation on the creative models in action across the country. Rural areas, because of their small size and their unique needs, are excellent places for experimentation.

The webinar is titled “New Models of Care and their Impact on Rural Workforce.” The conversation was led by Erin Fraher, PhD, an expert on health workforce research at UNC-Chapel Hill, and representatives from three states presenting on projects in their community.

3RNet Goals List

Erin Fraher set the stage for the discussion by explaining the difference between “old school” and “new school” workforce characteristics. In conventional, fee-for-service models, the healthcare workforce is trained to operate in isolated specialties instead of in coordinated teams. The “new school” workforce reaches patients in their community, rather than in a hospital or an acute care setting. This new workforce will maximize the responsibility of medical assistants, panel managers, dieticians, and health coaches. These teams will have a different work flow to accommodate new roles.

Fraher stresses that we will have to prepare and equip the 18 million members of our healthcare workforce for this change. Medical training will also need to include an emphasis on integrated care and include rotations with teams that are following a coordinated model.

The rural health centers from North Carolina, Oregon and Colorado are piloting a variety of projects in an attempt to launch value-based care. Every state is different, but all three are creatively addressing the unique needs of their community.

Chris Collins from the North Carolina Office of Rural Health & Community Care discussed the variety of loan repayment programs to attract medical workers to underserved areas, including therapists in integrated care settings. Collins also discussed the growth of telehealth services in North Carolina and the efforts to fill the gaps.

Melissa Bosworth of the Colorado Rural Health Center presented their work on creating a data bank to show the economic impact of their programs. Those programs include reducing the number of mentorship hours for nurse practitioners and introducing mediation services to improve office culture in clinics. The Colorado Rural Health Center is also pairing health IT students with rural clinics to help them transition to changing technologies.

Scott Ekblad from the Oregon Office of Rural Health highlighted the 16 coordinated care organizations across the state. Fourteen of these organizations are rural. These organizations have a “global budget,” and are given the creative power to meet needs. They have an incentive to keep Oregon citizens well using community health teams. Medical assistants, dental hygienists and community paramedics have more responsibility and are well connected to patients in a community setting.

Practice Sights and the NCFAHP will continue the conversation on the efforts of states that are moving to value-based care. Stay tuned for the next webinar!

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.”

NC Rural Health Leadership Alliance

The NCFAHP is excited to announce the formation of the North Carolina Rural Health Leadership Alliance (NCRHLA).  The Alliance is comprised of nonprofit and government leaders working in health and rural development. These rural health leaders have been meeting informally for 25 years. The original team included the following organizations and people: NC Office of Rural Health (Jim Bernstein), NC Medical Society Foundation (Harvey Estes) and NC Area Health Education Centers (Gene Mayer).  They met at least monthly to discuss how they could partner regarding the rural health needs of North Carolina.  Since 2014, the NCRHLA has grown and aligned itself to do the work as recommended by the North Carolina Institution of Medicine’s Rural Health Task Force.

The present-day Alliance is now becoming an official organization with technical assistance and grants from the National Rural Health Association. The NCFAHP will serve as the administrative home for the Alliance. The health and flourishing of rural communities is of prime importance, as one-in-five North Carolinians reside in a rural area. Rural communities struggle with the challenges of economic depression, lack of health-care access, and substance-use risks. Despite these challenges, rural communities are resilient and grounded in a sense of place.  The Alliance intends to find solutions to rural challenges by harnessing the strengths of these communities and mobilizing existing rural organizations and leaders. The purpose of the Alliance is to act as a base for collaboration and partnership. The structure and size of the Alliance will continue to be flexible, and will be guided by the work of the group. For now, the Alliance has structured itself into six work groups based on the goals outlined by the “North Carolina Rural Health Action Plan”;

  1. Invest in small businesses and entrepreneurship to grow local and regional industries.
  2. Increase support for quality child care and education (birth through age 8) and parenting support to improve school readiness.
  3. Work within the formal and informal education system to support healthy eating and active living.
  4. Use primary care and public health settings to screen for and treat people with mental health and substance-abuse issues in the context of increasingly integrated primary and behavioral health care.
  5. Educate and engage people in rural communities about new and emerging health insurance options available under the Affordable Care Act and existing safety net resources.
  6. Ensure adequate incentives and other support to cultivate, recruit, and retain health professionals to rural and underserved areas of the state.

Each of these work groups is made up of members who work in related fields and can lend their expertise and resources. The work groups meet between quarterly meetings of the collective Alliance to facilitate progress in their designated work areas and to develop communication materials regarding the needs and the efforts in the work area.

Jackie_FannellRural areas are hard pressed to attract and place skilled clinicians, and loan repayment for health care education plays an important role in attracting clinicians to rural or underserved areas. When you recruit a clinician to a small rural or underserved area, and provide no community support, there is a possibility that this individual may not be happy, and ultimately will not stay once their service obligation has been met.

There has to be a partnership. There has to be support. And there has to be buy-in from the entire community so that the clinician feels welcomed as a part of that community from his or her first day on the job.

This is where the Practice Sights Retention Management System comes in.  Currently being utilized by an 11-state collaborative, each of which operates the program independently, data provides states and staff of incentive programs with information to make clinicians’ service experiences as positive and productive as possible.

Practice Sights collects data in the form of questionnaires sent to clinicians and practice administrators via email. The Cecil G. Sheps Center for Health Services Research (Sheps Center) provides expertise on data collection, analysis and dissemination. The questionnaire clinicians receive three months after the start of their service obligation asks about their background, their reasons for applying to the program (needing financial assistance and/or wanting to provide care to an underserved population or area) and their needs, values and expectations of their current position and community.  Annual and end-of-contract questionnaires will ask about their current work, whether the role is meeting their professional goals, etc.  The questionnaires will also ask them to rate their satisfaction with various aspects of their community and practices. Alumni questionnaires are sent periodically and ask clinicians if they are at the same site and, if not, to provide information about their current work.

practice-sights-graph

The rich data collected by Practice Sights allows state program administrators to identify problem areas so that they can work with site administrators to improve overall clinician retention in rural areas. The challenge, notes Jackie Fannell, Program Manager for Practice Sights, comes in getting clinicians to respond to the questionnaires, — particularly program alumni, who are no longer obligated under their contract.  Most states are now seeing over 50% response rates across the board. While this leaves room to grow, it still provides a rich set of data to help improve clinician retention.

Practice Sights plans to bring more states into the collaborative and continue to grow the program. There is no other system that collects data on clinician retention in this manner and it will become more valuable and have even greater impact moving forward and the aggregated data shows trends and reveals what is working and what is not.

Community factors have been shown to greatly impact physician retention. The findings of a 2012 report prepared for the Multi-State/NHSC Retention Collaborative by the Sheps Center calls for programs to help communities learn the important role they play in clinician retention and the things they can do to promote retention, engage community leaders and intervene early — before small problems escalate — when clinicians encounter difficulties with their communities. Efforts to build Accountable Care Communities in North Carolina and other states could be an important step in bringing communities into the health-care conversation. Including community input and participation in health care from the start could help ensure acceptance and support for new providers, rather than waiting until issues arise or only including community voices as an afterthought.

Accountable Care Communities are an important part of clinician recruitment and retention in rural areas. With Accountable Care Communities, the community is involved with all aspects of the health-care environment, and is more vested in supporting and including clinicians and their families in the community. Practice Sights, in turn, plays an important role in helping create Accountable Care Communities, with its data driving the awareness of where community and other support is lacking, as well as allowing communities to become better-equipped to receive and support new clinicians from day one.