Brandy Bynum Dawson, Rural Health Policy Fellow, Presents to NHRA
Brandy Bynum Dawson, Associate Director for Rural Forward NC, was selected last year as one of 16 Rural Health Policy Fellows to participate in a year-long, intensive program aimed at developing leaders who can articulate a clear and compelling vision for rural America. As her time in the program comes to an end, she recently presented her policy paper, entitled Rural Community Violence, an Untold Public Health Epidemic to the National Rural Health Association at the Rural Health Policy Institute.
You can view her presentation below:
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.
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.
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!
It takes a cooperative and effective workforce to accomplish value-based, quality-driven care. Ron Gaskins, executive director of Access East, is an alumni of the Jim Bernstein Fellows program. Gaskins is leveraging healthcare communities in the direction of team-based care.
Access East is a nonprofit located in Greenville, NC, whose mission is to improve the health status of the underserved and indigent in eastern North Carolina through enhancing access to quality health care and implementing and coordinating healthcare delivery models. Access East is part of Community Care of North Carolina, a care network that’s evolved over 25 years, with support from the NCFAHP.
“We provide wrap around services for high-risk Medicaid patients with an interdisciplinary team focus,” said Gaskins, “We deploy care managers to the home in a timely fashion in order to keep patients out of the hospital.”
The interdisciplinary team at Access East and their partners collaborate with primary care providers in an ambulatory setting to proactively engage and manage chronically ill patients before their conditions become severe enough to merit care in higher-cost, more acute settings such as the emergency room. Access East uses a vast network of professionals (e.g., registered nurses, social workers, pharmacy technicians, pharmacists, patient advocates, health coaches, etc.) to support its initiatives, which encompass transitional care, medication management, pediatrics, chronic pain, palliative care, and behavioral health integration. The goal is to navigate patients to the right level of care.
“Workforce development is key,” said Gaskins. “As value-based reimbursement becomes more and more prevalent, the right prescription of team-based care will be vital in effectively managing populations.” Access East has built a workforce infrastructure to ensure the transition to proactive and coordinated care. “This infrastructure requires a holistic framework around workforce diversity that taps into the many different backgrounds and experiences that professionals can bring to the job,” Gaskins added.
The constant need for more healthcare professionals looms in the background of every conversation on rural health. “More primary care physicians are needed, of course,” said Gaskins, “but to meet the demands in care that the coming decades will bring with baby boomers retiring and medicine extending lives longer will require using mid-level providers (i.e., nurse practitioners and physician assistants) to fill in the gaps. Moreover, connecting support staff such as nurses, social workers, and community health coaches with direct providers, we will begin creating team-based care models that can further assist in engaging patients and improving health outcomes.”
Gaskins gives the example of boosting the role of pharmacists in the coordination of value-based care. “The data tells us that Medicaid patients on average visit their primary-care provider two to four times a year, while they see their community pharmacy close to 20 times a year,” said Gaskins. “With this frequency of exposure to the patient, it makes perfect sense to engage the pharmacist out in the community more on chronic disease management.”
To accomplish this, Access East is partnering with Community Care of North Carolina on a project called Community Pharmacy Enhanced Services Network (CPESN) that financially rewards community pharmacists for conducting on-site education around medication management when people pick up their prescription, and reporting any important information back to the patients care manager and primary care provider. “We see the potential of expanding the medical home to more of a medical neighborhood mentality that encourages the cross-pollination of professional disciplines throughout the community,” Gaskins said. What’s needed to empower a workforce that drives value-based care? “Strong community connections, solid care coordination, and holistic, interdisciplinary teams,” he said. “We’re piloting projects to see what works.”
The Foundation is excited to announce Ron Gaskins, Bernstein Class of 2011—2013, as the first Distinguished Fellows Award Recipient. Ron will receive this award at the 10th Annual Jim Bernstein Health Leadership Dinner on October 8th, 2015.
Rural 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.”
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”;
Invest in small businesses and entrepreneurship to grow local and regional industries.
Increase support for quality child care and education (birth through age 8) and parenting support to improve school readiness.
Work within the formal and informal education system to support healthy eating and active living.
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.
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.
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.
No day is the same for Calvin Allen and Brandy Bynum, the dynamic forces behind Rural Forward NC, NCFAHP’s newest program. They could be, and often are, at a county commissioner’s meeting in Halifax County, attending a training in Winston-Salem, and making a stop at the office in Cary to hop on a few conference calls, all within a 36-hour period.
Rural Forward NC is an initiative launched out of Healthy Places North Carolina, (HPNC), a statewide initiative led by the Kate B. Reynolds Charitable Trust. The Trust has committed to a 10-year, 100-million-dollar investment in 10-15 Tier 1 counties in North Carolina. Tier 1 counties are the poorest counties in the state, as designated each year by the NC Department of Commerce. The 10 years of funding for HPNC is exciting and shows the Trust’s commitment to “being in it for the long haul,” supporting counties in multiple ways. Unlike a lot of other grant programs where funds are distributed and the grant facilitators step back, Healthy Places North Carolina, now in its 3rd year, is using partnerships to implement and support the initiative all over the state. Program officers at the Kate B. Reynolds Charitable Trust work with community partners to build relationships and networks, and manage the implementation of HPNC initiatives.
Rural Forward NC (RFNC) is a program of the NC Foundation for Advanced Health Programs (NCFAHP), which incubates and supports initiatives that focus on community-centered care.
Calvin Allen is the Director and Brandy Bynum is the Associate Director of the Rural Forward NC. The two work in tandem, going into communities where the need is and sending whichever of the two has most expertise and/or time available. But they work as a close-knit team, and together they are helping communities move forward to change for the better and improve health outcomes for their residents.
Rural Forward NC works in designated Tier 1 counties – right now Halifax and Rockingham – to make the efforts of local leaders stronger so that they can make real change in communities. RFNC does not dictate what changes should be made, but supports with the purpose of training and facilitating change. The first step to this, Calvin and Brandy say, is to help communities become aware of their issues, prioritize the issues, and decide on what changes are needed. Training, facilitation, resource management, and policy analysis are all central to what Rural Forward NC provides.
“Part of our job is to ask the questions – and to do it as diplomatically as possible,” Calvin says. He and Brandy often have their own feelings about what may work and the value of some things over others when attending meetings with a community group or in a one-on-one conversation. “But, that’s not our place,” Calvin says. “It’s to help bring voices out, and to provide exploration, and to challenge gently, so that the strongest ideas come out and are explored.” Both Calvin and Brandy agree that the best ideas often are within the community already; they just need to be heard.
Both Calvin and Brandy share a background on youth issues, and a big part of their work at Rural Forward NC focuses on the youth voice as well. In a lot of rural communities, young people go off to college and never come back. Brandy says that their team wants youth to go out and then come back, eager to re-invest in their communities. “But, if we’re not listening to them now, why would they want to do that?” she says. “Rural Forward has been working with organizations that work to bring young people into conversations about issues – like improving access to recreational facilities and programs – that young people can and should be a part of.”
One example of a specific intervention RFNC has been a part of is around child health in Halifax County, where the childhood obesity rate was 34% in 2012. The team kept hearing that the central “place” in this issue was schools, where kids spend most of their time. Brandy contacted experts and spent months studying and asking questions about the schools’ perspective on the issue. The team then brought together school administrators, parent involvement coordinators, school nutrition, and community voices to talk about the barriers and strengths to addressing childhood obesities in the schools.
After months of conversations, 3 program examples were presented and the Coordinated Approach to Child Health (CATCH), an in-school/at-home model, was adopted. CATCH utilizes tools from visual aids of healthy eating in cafeterias, to incorporating conversations about health foods in math and English classes, to materials for kids to share with their families and implement in their own homes.
This is just one of many interventions in which Rural Forward NC has played a role during the past 3 months. They’ve also worked with helping coach community leaders, facilitating various funding opportunities, and supporting the creation of a comprehensive parks and recreation plan to improve access to programs and facilities, among many, many other projects.
Calvin and Brandy hope to take their work in policy, training, facilitating and convening, and go even a step further. They want to be able to look at what happens in different counties, seeing what the connections are, and figuring out if there is a strategy that could be useful for multiple places in a community-driven approach. They recognize that broader strategies can be effective and can save time and money, but they also emphasize the importance of recognizing that every county and every community is different, and sometimes there is no “one-size-fits-all” solution.
Though Rural Forward NC is primarily focused on health issues and outcomes, they also have the flexibility to work on issues that are one step beyond health, but that have a clear impact on health. The HPNC team recognized that, if people are healthier but don’t have jobs, or there’s a gang issue, or an overall lack of opportunities, the chances for sustainable health improvements will diminish. Brandy is quick to share her expertise and passion for juvenile justice and improving education in order to keep kids out of the juvenile and adult criminal justice systems. Calvin has years of experience in community economic development, specifically rural economic development, and is passionate about finding out how and why communities grow or don’t grow.
Calvin and Brandy also enjoy the chance to work as a team, and say it’s exciting to see how aligned they are on their goals, objectives, and values. They’ve also embraced their new role as part of the Foundation. “It’s a group of people that are very dedicated to community, and see the value of having all voices at the table,” Calvin says. “They see the value of true inclusion. And to have that span from the community to the governor’s mansion and beyond in terms of influence…that makes working here an amazing experience.”
Rural Forward NC is the newest part of the NCFAHP, and complements the pillars of the NCFAHP through leadership, being community centered in shaping practice, helping to drive innovation, and affecting policy. “Those underlie our values, how we do our work, as we do our work,” says Calvin.
All in all, it has been a busy first few months for Calvin and Brandy at the Rural Forward NC. The program currently has three years of funding, and when asked how they’ll know if their work is successful, Calvin answers by focusing back on the communities: “Our success is really based on the success of the counties. Are they achieving the goals that they’ve set up? Do they have a vision? Do they have strategies for achieving that vision? Are the entities in the community strong, and exhibiting leadership? Do they have strong leaders? This is how we measure success.”
And this, like the rest of their work, shows how Calvin and Brandy, while experts in their field, are putting their whole selves into training, facilitating and equipping communities, rather than dictating what they think is best.
Calvin and Brandy are undertaking a huge initiative with Rural Forward. But their passion and drive, their dozens-of-meetings-a-week schedules and their heart for seeing people and communities succeed, as well as the work they’ve already done in this short time, show that people really can change the world.
The North Carolina Institute of Medicine (NCIOM) recently published the North Carolina Rural Health Action Plan.
The Plan is a report created by the NCIOM Task Force on Rural Health, of which Maggie Sauer, President and CEO of the Foundation, was a member. The NCIOM, in collaboration with the Office of Rural Health and Community Care (ORHCC) in the North Carolina Department of Health and Human Services, the Kate B. Reynolds Charitable Trust, and other partners brought together the Task Force to develop a plan that would be both comprehensive and coordinated for rural areas throughout the state. This plan was funded through the Kate B. Reynolds Charitable Trust.
The North Carolina Rural Health Action Plan describes the unique obstacles that North Carolina faces in improving outcomes. It describes the underlying causes of health disparities in rural areas of the state, and outlines six key strategies that can be implemented at the state and local levels to address those problems and begin to close those gaps.
Jim Bernstein played a key role in creating many of the rural health centers in North Carolina, with the belief that health care is community-based. He worked to ensure that community members are the owners and drivers of their own health programs, and began the Jim and Sue Bernstein Health Leadership Scholarships.
Scholarship recipients are selected by the Jim Bernstein Health Leadership Committee, a committee made up of members of Foundation’s Board of Directors. This year the committee sought to strengthen the relationships between Foundation and the scholars and wanted to recognize the important contributions that are made to the community by scholars’ families and health centers.
To do this, Maggie Sauer, President and CEO, along with members of the Foundation’s Board of Directors, took the opportunity to visit nearly all of the scholars in their home communities. They were able to meet several parents and staff members at the rural health clinics involved in the scholarship program, and hear the stories of how this student came to be nominated for the scholarship. A member of the Board of Directors joined her on most visits to present the award, with Olson Huff, committee chair, participating in the visits in western North Carolina, and Tom Irons, chair of the Board, participating in the visits in Mt. Olive.
This year, nine individuals were awarded Jim and Sue Bernstein Health Center Scholarships to help offset the cost of their higher education. Eight of this year’s scholars are children of employees of a rural health center, and one scholar is a current employee of a center.
Celo Health Center……………………………………………Caleb Stevenson Hot Springs Health Program………………………………Travis Rice Black River Health Services………………………………..Moriah McTavish Rural Health Group – Roanoke Rapids………………….Elarnta Darden Rural Health Group – Enfield………………………………Breanna Joyner-Foreman Rural Health Group – Enfield………………………………Keanna Joyner-Foreman Mt. Olive Family Medicine Center………………………Ali Marie Eakes Mt. Olive Family Medicine Center………………………Rose Brock Benson Area Medical Center……………………………..Katherine Burnette