Healthier Rural West Panel Abstracts

This panel provides an overview of strategic, operational, and collaborative activities used to develop the Utah Alliance for the Determinants of Health – a population- and place-based collective impact approach led by Intermountain Healthcare in partnership with local private and public sector stakeholders to address the social determinants of health and promote health equity.

The Alliance convenes community partners to screen for social needs, to assist in navigating to resources, and to align on shared vision, goals, policies, work processes, funding, data, and knowledge. The Alliance enjoys broad membership from healthcare and social service sectors – including health systems, behavioral health, and community-based organizations – who jointly address social determinants and healthcare needs for patients and communities.

Panelists:
Mikelle Moore, MBA, MHSA (panel leader)
SVP Community Health, Intermountain Healthcare

Ali Martinez and Brian Bennion
County Representatives (Weber County, Utah)

Amber Rich and Lori Wright
County Representative (Washington County, Utah)

Why is planning and policy in rural communities important in creating healthy, equitable and resilient communities? Often people talk about the importance of healthy communities, using metrics such as access to green space, parks, trails, healthy homes, and food.

Evidence supports that a person’s health and well-being is directly related to where they live, work, and play. In fact, designing healthy, equitable, resilient, and economically vibrant places has nine elements:

• Land Use
• Circulation (e.g. infrastructure including transportation)
• Housing
• Conservation
• Open Space
• Noise
• Safety
• Environmental Justice
• Air Quality

To make improvements through policy and environmental changes, engaging community leaders from multiple sectors is vital. Rural communities are in a unique position to convene stakeholders around specific issues and needs identified for that community. What steps should you start with? Who should you work with? How do you take an idea and make it a reality? The need for healthy, equitable, sustainable, and vibrant communities is more important than ever.

This panel will feature successful implementations, coupled with the identification and engagement of non-traditional leaders and members of the community to effectively organize to address local health needs and priorities. Data to prioritize decisions and measure success will be discussed.

Panelists:
Evon Holladay, MBA (panel leader)
COO, A Healthier We

Elizabeth Baca, MD
Deputy Director, Governor’s Office of Planning and Research, California

Locke Ettinger, PT, PhD
Vice Chair, Get Healthy Utah

Jordan Mathis
Health Officer, Utah Health Department, TriCounty Region

Telehealth can be an important contributor to overcoming health disparities. Telemedicine – which bridges the gap between provider and patient directly – can be very powerful, particularly in emergencies. Using Intermountain Health’s programs as examples, Dr. Beninati will describe the opportunities and challenges to overcoming access barriers.

Another mode of telehealth, telementoring, can address one significant driver of disparities in health care access: the gap in knowledge transfer. Over time, telementoring can build capacity in underserved areas. Dr. Bogler will briefly introduce Project ECHO, which is a low-cost, high-impact model that creates learning communities that effectively transfer knowledge and build capacity for managing dynamical, complex diseases in rural areas. In ECHO learning communities, multidisciplinary expert teams are linked with multiple primary care providers for case-based learning and ongoing telementoring in a hub-and-spoke network, enabling rural providers to expand the care delivery in their own communities. Delivery of such care results in reduction of referrals to urban healthcare facilities and enhances the quality and timeliness of those referrals that are unavoidable.

Dr. Box will discuss how knowledge transfer via telementoring results in earlier adoption of innovations in best practices and allows providers at all levels to practice at the highest level of their licensure. Benefits not only relate to better patient care, but also engender an improved sense of accomplishment and provider job satisfaction – very likely enhancing provider retention in rural, frontier, and other underserved environments.

Dr. Jones will describe a prime example of telementoring: the impact ECHO-HCV has had in the small, rural community of Newport, WA where access to Hepatitis C treatment has increased exponentially over the last 5 years.

Telementoring is not yet systematically integrated into health care in the US, but the ECHO Act has prompted analysis of ECHO by the federal government with a report to Congress in 2019, and policy pathways have been explored that could lead to sustainability.

Panelists:
Oliver Bogler, PhD, (panel leader)
Chief Operating Officer, Project ECHO (Extension for Community Healthcare Outcomes) Institute, University of New Mexico

Bill Beninati, MD
Critical Care, Intermountain LDS Hospital, Senior Medical Director for Intermountain Connect (virtual hospital), Medical Director, Intermountain Life Flight

Terry Box, MD
Medical Director, Project ECHO, Associate Professor (Clinical) of Medicine, University of Utah

Getting Organized: Hope and Opportunities for Rural Health Systems
Rural hospitals are a lynchpin for the sustainable delivery of health and health care. They are developing self-organizing models that are novel, hopeful, and flexible in meeting changing market demands and the unique needs of rural and frontier patients. Irrespective of the model used, hospital boards must engage in strategic planning processes to assess pros and cons, and model risk. Because failure means less access and worse outcomes, success is critical. While the stakes are high, so are the opportunities. Panelists and audience members from a range of stakeholder groups will discuss the cultures, functions, and contexts of rural health systems.

Join us as we embrace the language of optimism to explore answers to one of the most pressing questions for rural communities: How do we organize community resources to ensure the health of the population?

Panelists:
Steven J. Summer, FACHE (panel leader)
President and Chief Executive Officer, Colorado Hospital Association

Robert (Rob) W. Allen, FACHE
Senior Vice President and Chief Operating Officer, Intermountain Healthcare

Ed Clark, MD
AVP of Clinical Affairs, President of the University of Utah Medical Group and Professor, Department of Pediatrics of the University of Utah

Margo Karsten
CEO, Banner Fort Collins Medical Center, McKee Medical Center, and North Colorado

Eighty-five rural US hospitals closed between January 2010 and July 2018. In addition to rising costs of care and decreased reimbursements, rural care settings also struggle to recruit and retain high-quality clinicians and staff, implement electronic health records, and keep up with ongoing regulatory changes.

Staying viable requires new thinking and new ways of doing business.

The Utah Rural Independent Hospital Network, (‘Rural 9 Network’), was established in 2013 and includes the nine rural independent hospitals in Utah. These hospitals serve the seven counties in which they are located, as well as four adjacent counties without hospitals. The network is organized as an official business entity, with elected officers and monthly dues.

The Network’s goals are: 1) reduced isolation; 2) a better negotiating position for purchasing services and products; and 3) a forum to network, share best practices, and participate in joint educational opportunities. Manager subgroups are organized for face-to-face meetings and networking; subgroups include CEOs, CFOs, CNOs, Business Operations Managers/Health Information Managers, Quality Coordinators, Risk Managers, HR Managers, and Pharmacists.

Successful initiatives of the network include: 1) collaborating with larger systems in the state to provide high quality, low cost services, such as: ICD-10 preparation (Steward Healthcare), hands-on nurse training (University of Utah), annual rural hospital conference (Intermountain Healthcare), leadership development workshops (University of Utah), and revenue cycle and regulatory compliance training (Intermountain Healthcare); and 2) providing resources to hospitals struggling with operational and financial issues.

Panelists:
Greg Rosenvall (panel leader)
Rural Hospital Improvement Director, Utah Hospital Association, and Rural 9 Network Director

Clayton Holt
CEO, San Juan Hospital (Rural 9 Member Hospital)

Allen Barry
Governing Board Chairman, San Juan Hospital

Montana currently suffers the country’s highest suicide rate. One out of 10 Montana high school students attempt suicide, and 78% of Montana suicides are men.
This panel focuses on our experience of testing and implementing two innovative treatment approaches that fit the needs of – and with an emphasis on – rural Montanans.

Youth Aware of Mental health (YAM) is a culturally sensitive, universal, innovative program driven by youth (9th grade) that has been adapted and is currently undergoing a three-year pilot in a wide range of Montana high schools. Significant results include a 79% increase in students reporting that they would seek help from school staff for assistance with depression, and a 49% increase for those seeking assistance with suicidal feelings.

A complementary treatment is Thrive for Montana, adapted from Thrive Inc. It is a computer based training (CBT) program that is a low cost, confidential, and easily accessible internet program for those 18 and older who have anxiety and depression-like symptoms and/or depression. The first randomized controlled trial (RCT) showed significant improvement in self-reported depression and anxiety symptoms, and in work and social adjustment and resilience. There was mean improvement regardless of symptom severity. A second RCT is now underway, aiming to involve 1,000 Montanans.

Panelists:
Bill Bryan, PhD (panel leader)
Co-Founder and Program Manager, One Montana

Sandra Bailey, PhD
Professor and Family and Human Development Specialist, MSU Extension

Mark Schure, PhD
Assistant Professor of Community Health, MSU

Julie Riley
Montana Extension Agent, Powder River County (Broadus, MT)

Jane Wolery
Montana Extension Agent, Teton County (Choteau, MT)

Rural workforce models that have proven to be successful include getting the right people into the training pipeline, providing training that reinforces rather than discourages employee interest in the rural sector, and attending to the core business of rural health: accessible, cost-effective primary care.

In this session, we will focus on successful models for training, recruiting, and maintaining the workers who are essential to creating a viable and resilient rural healthcare workforce. Rural healthcare workforces can be particularly vulnerable, and are subject to disruption when any of the small number of individuals in a particular category is absent. Generalism and cohesion are keys to rural viability and resilience, particularly in the nursing and physician workforce domains.

Panelists:
Mark E. Deutchman, MD (panel leader)
Professor of Family Medicine, Associate Dean of Rural Health, University of Colorado School of Medicine

Linda Edelman, RN, PhD
Chair, Division of Health Systems and Community Based Care, University of Utah College of Nursing

Matt Probst, PA-C
Medical Director and Chief Quality Officer, El Centro

Traditional methods of planning and allocating resources for support and growth of our nation’s primary care workforce are based on simple clinician to population ratios. These ratios do not describe how efficient a healthcare workforce is, or what the needs of a given population are for primary care-provided services. There is a need for more refined estimates that take advantage of the sea of available data in new ways, leveraging available modern technology to improve information and provide insights into how to best allocate resources centered around the healthcare needs of the population. Calls for developing new models to deliver team-based care come from every medical profession. Finally, policy makers are looking for new, more data informed methods of making resource allocation decisions for health workforce development.

The Utah Area Health Education Centers Program, the Utah Medical Education Council, and IBM Health Corps (a philanthropic effort of IBM Corporate Citizenship) have created an interactive web-based tool to model primary care workforce needs by age, gender, geography, and profession type in comparison to primary care workforce supply by the same categories within the State of Utah.

The model incorporates expectations of a transformed inter-professional team practice environment that responds to population health needs. It is based on population demographics, prevalence of common chronic conditions, and need for acute and preventive services. The model receives data about evidence-based services for each category of care, along with estimates of clinician time to deliver each service, and assigns services to different clinical team members. The model then calculates total time per clinician type, and uses this to estimate clinician full-time equivalents (FTEs) that would meet the service needs for the population. The model allows end-users to vary assumptions about a number of factors, including delivery system and payment design, available providers/services by location (e.g., rural vs. urban), suitability of services by profession, and cost of clinicians. It also incorporates time required for care separately from direct face-to-face encounters, including documentation, population management, and team collaboration.

The model also permits different projections assuming a ‘clean slate’ ideal design of clinician staffing, an option for optimization of added workforce assuming starting with current supply, and maximizing efficiency assuming no change in workforce composition.

Future work on this model intends to validate the model with available data as well as further develop data inputs around identified key driving factors using research projects. Some key factors that further research is needed in are, how do things like the social determinants of health effect population health needs, which professionals are most suitable to provide specific services in different care delivery settings or under different payment models and where is there a lack of developed guidelines for what care should be given for different conditions being experienced in the population such as mental health disorders. Attempting to model solutions to complex questions like these requires cross-sector collaboration across many disciplines, from healthcare to public policy to technology, in order to fully understand the problem and create acceptable solutions.

Panelists:
Clark Ruttinger
Director of Workforce Research and Director of Utah’s Nursing Workforce Information Center for the Utah Medical Education Council

Michael K. Magill, MD
Director, Utah Area Health Education Centers (Utah AHEC)

Utilizing Cross Sector Collaboration to Build Well-Being

Cross-sector collaboration among health, healthcare, universities, and communities offers an essential opportunity to improve population health, reduce spending, and develop a wide spectrum of actions that address both social determinants of health and the needs of individual, rural communities. This panel will highlight several collaborations currently helping New Mexico that are showing a return on investment and improvements to health and wellbeing.

Social determinants play a far larger role in health than the healthcare system. The University of New Mexico (UNM) has built three programs to address adverse social determinants of health and consequent health disparities, particularly in rural NM. These programs link to all sectors in the community and are replicable in other states and universities.

The Health Extension Rural Officers (HEROs) program adapts the approach of the agricultural Cooperative Extension Service to the health system, focusing on policy and systemic disparities and adverse social determinants in their regions, and linking community health priorities to health science center resources in all mission areas – clinical service, education, research, and health policy.

Community health workers (CHWs) are incorporated into clinical settings where patients’ adverse social determinants are assessed and addressed. State Medicaid, realizing a 4:1 ROI by deploying CHWs to help manage high resource utilizing patients, now mandates all Managed Care Organizations employ CHWs.
Finally, UNM’s approach to reducing health disparities and adverse social determinants has expanded beyond the Health Sciences Center to tap into the resources of the entire campus, including the College of Education, Law School, School of Engineering, Business College, and School of Architecture and Planning – all of which play a complementary role in a broader definition of health.

Panelists:
Phil Polakoff, MD (panel leader)

Lynn Gallagher, JD
Former Cabinet Secretary of Health, State of New Mexico

Arthur Kaufman, MD
Vice Chancellor, New Mexico School of Medicine

Every month, 52 Utah adults die as a result of drug poisoning, 77.6% of which involve opioids. The Centers for Disease Control and Prevention identified 220 counties as the top 5% of counties at risk of outbreaks of HIV and Hepatitis C, as a direct result of the opioid epidemic. Three rural Utah counties were included on the list: Carbon County (84th), Beaver County (114th), and Emery County (186th). Counties were identified based on risk factors of drug-overdose deaths, prescription opioid sales, income, mental health services, insurance coverage, urgent care facilities, transportation statistics, population density, non-Hispanic ethnicity, unemployment, poverty, and buprenorphine prescribing potential by waiver. The major objective of the Utah Rural Opioid Consortium planning grant is to build a multi sectoral, multidisciplinary consortium to address opioid prevention, treatment, and recovery in these counties and reduce Opioid Use Disorder morbidity and mortality.

Panelists represent four Western states that received planning grants of $200,000 each for combating opioid use disorder. The grant was awarded in September 2018 as part of a series of grants from the Federal Office of Rural Health Policy within the Health Resources and Services Administration (HRSA), aimed at combating the opioid crisis. Idaho, Colorado, Montana, and Utah will be represented in this discussion.

Each rural area has created a consortium of local members that are evaluating and designing ways to combat the issue, especially as it manifests itself in frontier and rural counties. Each consortium will conduct needs assessments and develop strategies that can provide direction for future efforts. The goal of the groups will be to work together in order to avoid duplication of services, maximizing the assets already in place in rural communities, as well as to utilize the individual strengths of the consortium members to improve the care available to those with an opioid use disorder. Through the establishment of these consortia, rural communities will be better able to plan for the future, identifying existing gaps in rural health coverage to better allocate future funds for fighting the opioid crisis in more effective ways.

Panelists:
Rita Osborn (panel leader)
Executive Director, Utah Center for Rural Health, Southern Utah University

Tara Fouts
Central District Health Department (CDHD), Idaho

Tracey Wall, PA-C
Memorial Regional Health Care, Craig, CO

Michele Stanton, BS, LAC
Lead Care Coordinator, Behavioral Health – HRSA, Central Montana Medical Center, Montana

The periodic impacts of wildfire have always been a part of living in the rural west. Unchecked flames threaten human life and property, persistent smoke exacerbates respiratory problems and stanches tourism, and burned watersheds can impact water security for agriculture and communities. Despite these downsides, fire is also an essential ecological process, critical to sustaining resilient forests and functioning watersheds.

We bring together a panel of conservationists and land managers who are working across sectors to plan for and mitigate the impacts of damaging wildfires. From the scale of a single rural community, to multi-state partnerships that span municipalities, tribes, irrigators, and corporate partners, innovative approaches are emerging that demonstrate how we can live more safely with wildfire in the rural west.

Panelists:
Nick Goulette
Executive Director, Watershed Research & Training Center

Alexander “Zander” Evans PhD
Executive Director, Forest Stewards Guild

Jennifer Hansen
Wildfire Risk Reduction Coordinator, Utah Division of Forestry, Fire & State Lands

Bastrop County Cares (BCC) has grown from a nearly defunct collaboration between a handful of churches into a vibrant countywide intermediary organization with more than 300 active coalition members in just over 16 months.

During that time, BCC has brought more than $2.1 million in funding into Bastrop County to address a wide range of issues that no one organization can solve on its own, including early childhood development, workforce housing, food & nutrition, parks & recreation, veteransissues, mental health, human trafficking, and physical/emotional neglect.

Creating diverse coalitions that inclusively and collaboratively utilize proven systems change models like Collective Impact, Results-Based Accountability, and SAMHSA-based programming has attracted not only robust funding, but also established and emerging leaders from all corners of our highly rural county.

Our coalition members are direct service providers, judges, mayors, and school district superintendents, but also grocery store employees, daycare workers, cooks, stay-at-home parents, and retirees from all across the public and private sectors.

The vision that revived and revamped Bastrop County Cares was born through a collective realization from a handful of local citizens. Those engaged community members saw the explosive growth impacting the Central Texas region moving east into Bastrop County, and knew our county’s infrastructure – particularly in the healthcare and social service sectors – was unprepared.

A grassroots study around workforce housing became BCC’s first coalition work, and grant funding through the Texas Home Visiting Program allowed for the hiring of two full-time staff members to accelerate implementation of outcome-based models around early childhood development. With funding in place and a coalition model proven successful on the local level, our organization grew rapidly to now include nearly a dozen collaborations focused on improving the social determinants of health for all local residents of Bastrop County, Texas.

Our coalition work and unique approach to collective impact attracted the attention of several like-minded organizations in Central Texas that have brought both funding and expertise to our initiatives. Our organization was awarded a Hogg Foundation for Mental Health grant in July that allowed for the hiring of a third full-time employee, and has opened doors to robust conversations about coalition work and project alignment with both foundation leadership and a “learning team” comprised of experts in community psychology and working with marginalized communities.

Partnerships with regional foundations have expanded our capacity and the scope of our vision, while forward-thinking organizations like Texas A&M Agrilife Extension and Rotary International have challenged us to keep thinking creatively by approaching us with “outside-the-box” ideas to leverage shared resources.

These nascent partnerships, currently in their initial phases, could create replicable models for collective impact through collaborations led by known and trusted organizations that operate in all 254 counties in Texas.

Panelists:
Jennie Birkholz (panel leader)
Principal, Breakwater Light, Central Texas

Debbie Bresette
Executive Director, Bastrop County Cares, Bastrop County, TX

Hillary Lon
Extension Service Family and Community Health Educator, Texas A&M, Agrilife

Krystal Grimes
Resilience Director – Bastrop County Cares, Bastrop County, TX

Health is often intertwined with interpersonal relationships, genetic traits, access to resources, health history, and personal health beliefs. Action toward healthier rural communities often requires a multi-disciplinary approach – between public and private partnerships – to truly inspire individuals to engage in health-promoting behaviors.

In discussing a fundamental shift in how communities and policies engage individuals, this panel discussion will provide evidence-based solutions to provide resources to rural west communities. Touching on multimodal innovative solutions – including web-based deliveries, mobile apps, Connect Care, and telehealth – we’ll address how whole personal wellness can be delivered in differing mediums.

Panelists:
Trevor Smith, PhD (panel leader)
Executive Director of Health Promotion and Wellness, Intermountain Healthcare

Tim Butler
Select Health/ Hero Health Promotion

Cherie Pettitt, PhD
Associate Professor, Health Promotion & Wellness Track Director, Rocky Mountain University of Health Professionals
Kelly H Woodward, DO, MPH – Medical Director, Park City LiVe Well Center

This session focuses on the Community Outreach & Patient Empowerment (COPE) experience of building community-based partnerships and collaborative clinic-community linkages to improve health outcomes for individuals on Navajo Nation. COPE, founded in 2009, began as a collaboration among the Navajo Nation Department of Health (NNDOH) Community Health Representative (CHR) Program, Boston-based collaborators – Brigham & Women’s Hospital/Partners in Health, and Navajo Area Indian Health Services (NAIHS). COPE’s vision is to eliminate health disparities and improve the wellbeing of American Indians and Alaska Natives. COPE believes that the power to overturn longstanding historical health disparities inherently lies in the community itself. COPE strives to promote healthy, prosperous, and empowered Native communities through three collaborative approaches: robust, community-based outreach; local capacity building and system-level partnerships; and increasing access to healthy foods.

The panelists will share their experience starting the COPE program. Working closely with the Navajo CHR Program and health facilities on Navajo Nation, COPE also started community advisory panels and clinical advisory groups. Receiving stakeholder feedback on their priorities, COPE worked collaboratively – leveraging community strengths and resources – to meet identified gaps and needs. Resulting initiatives include: facilitating trainings, developing culturally appropriate evidence-based education materials, and using unique approaches to foster coordination between CHRs working in the community and clinic-based staff to better serve patients with uncontrolled chronic conditions. As a result of this collaboration, patients working with CHRs experienced improved health outcomes including improved health utilization and clinical indicators, while the program strengthened clinic-community linkages.

The COPE Program continues to use community-based approaches to expand its programming in close collaboration with local stakeholders including NAIHS and NNDOH. These programs include increasing access to healthy foods, working with young families, building local capacity through Community Health Worker (CHW) Certification, as well as programming to address cancer disparities on Navajo Nation via the use of new/tailored technology.

Panelists:
Hannah Sehn, MMSc (panel leader)
Co-Founder and Program Manager, COPE Program

Geraldine Yazzie
Senior Community Health Worker, Navajo Nation CHR/Outreach Program

Olivia Muskett
Community Outreach Manager, COPE Program; former Navajo Nation CHR
TBD – CHR Program, Navajo Nation CHR/Outreach Program

The Oregon Healthiest State initiative, with leadership funding from Cambia Health Foundation, has begun to improve health trends one rural community at a time, starting in Klamath Falls, and now in Grants Pass, The Dalles, and the Umpqua region. The model is using cross-sector, community-based partnerships and initiatives such as Blue Zones, Health & Outdoors, and Financially Fit Oregon to bring systems together in helping Oregonians achieve greater well-being. Schools, businesses, civic groups, local governments, and community members are coming together to make healthy choices easier for everyone in the community. This session will highlight key components of the model, as well as work taking place in one of the communities.

Panelists:
Kathleen Pitcher Tobey, MA
Director of Foundation Operations, Cambia Health Foundation

Sarah Foster, MPH, MPA
Executive Director, Oregon Healthiest State Initiative

The changing economics and dynamics of healthcare necessitate new models of patient care and delivery. Hospital focused, fee-for-service models will need to be replaced with a patient-centered, value-added delivery model that also incorporates social determinants of health, including adequate housing, nutritious food, transportation, and the availability of jobs. As healthcare dynamics change, it is important that those in rural markets – including lower income individuals – are able to participate. Partnerships with local housing providers, local governments, transportation authorities, educational institutions, and primary care providers will be keys to success.

Panelists:
Phil Polakoff, MD (panel leader)

Bob Taylor
Executive Director, Morgan Stanley | Community Development Finance

Heather Brace, MS
VP and Chief People Officer, Intermountain Healthcare

This panel will address ways of reducing costs, improving the viability of rural hospitals, and improving the quality of care through participation in an innovative Accountable Care Organization (ACO) model. National data from the experience of Caravan Health in implementing a Population Health Nurse model will be presented. Caravan Health is an ACO convener currently supporting 17 accountable care organizations in more than 250 health systems across the country, and nearly 500,000 attributed lives. The Six Imperatives for ACO success will be highlighted and include: (1) ease physician burden by empowering population health nurses; (2) rigorously and transparently track performance; (3) enhance primary care; (4) leverage big data; (5) engage all levels of the organization; and (6) collaborate to form ACOs with more than 100,000 lives.

The experiences of Margaret Mary Hospital in Batesville, IN will be reviewed from the hospital CEO perspective. The CEO will describe how participating in a collaborative ACO with shared governance has enabled his Critical Access Hospital to move away from fee-for-service, and towards value-based care and providing better patient care at lower costs to patients.
The physician perspective in adopting accountable care and population health strategies will also be presented. Transformational leadership strategies for physicians will be reviewed and tips to help physicians adopt value-based strategies and team-based care models will be highlighted.

Attendees will review next steps to be ready for opportunities to mitigate risk in the Medicare Shared Savings Program Pathways to Success Program though participation in collaborative ACOs. The Pathways to Success Program final rule will be highlighted, along with program requirements and timeframes.

Panelists:

Stephen Shortell (panel leader)
PhD, MBA, MPH, Blue Cross of California Distinguished Professor of Health Policy and Management, University of California, Berkeley

Lynn Barr, MPH
Chief Executive Officer and Founder, Caravan Health

Tim Putnam, DHA, MBA, FACHE
President and CEO of Margaret Mary Health, Chair of the National Rural Accountable Care Consortium, and President of the National Rural Health Association

John Findley, MD
Medical Director for ACO Programs, Caravan Health

Person-centered care is a way of thinking and doing things that sees the people using health and social services as equal partners in planning, developing, and monitoring care to make sure it meets their needs.

Person-centered care is especially important when caring for the elderly or those with dementia disease, such as Alzheimer’s, Parkinson’s, or other impairments. This panel identifies solutions being used today to transition care centers from task-based to person-centered care, across three domains:

1. Policy: Colorado state regulations were enacted for Assisted Living Communities in April 2018. These are the first updated and comprehensive regulations in 34 years requiring better levels of care. These regulations were approved on April of 2018 and are being rolled out statewide over the next 18 months. Person-centered care is now a required cornerstone of each individual’s care plan. To achieve this transition from task-based to person-centered care, ‘the assisted living residence shall provide each staff member with a minimum of eight hours of training and education’. This requirement is further stipulated to comprise part of new staff orientation.
2. Caregiver Training: in addition to required training for professional caregivers, it is critical to provide resources for the many family and friends that provide care. Summit Resilience Training provides practical, hands-on training in proven strategies and techniques for effective communication skills and living with resilience.
3. Care Community Model: Continuum Inc. uses person-centered care in one urban and three rural community living centers. Their memory care residents maintain three gardens, lead activities, go on weekly outings for dinner, movies, the zoo, walks, and more. They have no locked doors, and residents can walk outside at their leisure, secured by a perimeter fence. Costs of care are lower than in traditional nursing homes, with a focus on engagement rather than activities, and thriving rather than mere palliation.

Panelists:
Jill Lorentz (panel leader)
President and Owner, Summit Resilience Training

Stacie Naslund
Director of Spring Ridge Memory Care, A Continuum, Inc Facility

Dee Reda
Community Services Section Manager, Colorado Department of Public Health and Environment (CDPHE), Health Facilities & Emergency Medical Services Division

Outcomes for oral, behavioral, and medical health care closely correlate, yet the data for each is strictly siloed. Electronic Health Records (EHRs) are perfect for combining this data into one place; unfortunately, a variety of regulatory and structural challenges prevent much of this functionality from being fully realized. A further complication is the insurance system. It has evolved to place oral, behavioral health, and medical care into separate buckets, limiting how patient information is combined. Laws like Code of Federal Regulations (CFR) Title 42 Part 2 impede sharing substance abuse and mental health information, even within a system’s own EHR, much less with other health systems. Oral health providers and medical providers have traditionally built systems in parallel, rather than together, so that EHRs designed for each type of medical practice do not share information easily. Oral health modules are only now being integrated into major EHR systems. While some regions have opted to implement Health Information Exchanges (HIEs) in place of integrating EHRs, the issue of regulation and having information from oral, behavioral, and medical care remain a gap in the ability of clinicians to have a comprehensive viewpoint.

The issue of fragmented health information is even more complex for rural patients, who often travel great distances and interact with multiple health systems. This panel explores the benefits of an integrated EHR from the perspective of patients and clinicians. In particular, we will explore the benefits for patients living in rural areas where coordination of care is even more difficult. We will discuss why and how combined data contribute to overall patient health, some of the practical challenges to achieving ‘integration’, and how University of Utah Health is partnering with local providers to address these challenges.

Panelists:
Howard Weeks, MD
Associate CMIO, University of Utah Health

Michelle Goldberg, MD
Medical Director, 4th Street Clinic

Wyatt R. Hume, DDS, PhD
Dean, School of Dentistry, Associate Vice President for Academic Affairs and Education, University of Utah

Brian Watts, JD
Chief Compliance Officer, University of Utah Health

Rural Eastern Washington has some of the lowest health indicators in the state, including provider shortages in all rural counties, diagnoses of mental illness higher than the state average, a severe lack of affordable housing, and a youth suicide rate that has more than doubled in the last five years. In 2017, Washington State was awarded a $1.3 billion Section 1115 Medicaid Waiver to transform the Medicaid delivery system through an innovative community-based approach. This panel focuses on our experience building multi-sector community partnerships in the rural counties of Eastern Washington. The work of Better Health Together and Medicaid Transformation seeks to connect the health care delivery system with crucial social determinants of health and community resources.  

Panelists:
Hadley Morrow (panel leader)
Director of Engagement, Better Health Together, Spokane, WA

Jenny Smith, MA
Marketing and Foundation Director, Newport (WA) Hospital and Health Services

Ed Dzedzy
Public Health Director, Lincoln County (WA)

There are over 50 million Latinos living in the US, with the largest concentrations in the Southwestern states. During the past three decades, the Latino population in rural areas grew at the fastest rate of any racial or ethnic group. Many small communities in the rural West are over 80 percent Latino.

These communities provide labor to regional agriculture and service industries but are often ‘invisible’ to urban majority populations. Many health-related disparities exist for these rural Latinos compared to urban Latino and non-Latino populations.

This session will briefly describe the changing demographics of rural Latinos, and will then focus on approaches that have been developed to address the disparities in health care and public health-related services for this population. Academic-initiated programs by the Health Initiative of the Americas (HIA) for support and education to better handle mental and other health issues will be described. These programs include the use of lay community workers (promotores), a Binational Health Week, and Latin American Consulate-based services (ventanillas de salud).

We will also present multiple programs by a non-profit organization, Migrant Clinicians Network (MCN), dedicated to creating practical solutions at the intersection of poverty, migration, and health. These include case management, technical assistance, and professional development to clinicians in Federally Qualified Health Centers (FQHCs) and other delivery sites, with the ultimate purpose of providing quality health care that increases access and reduces disparities for migrant farmworkers and other mobile underserved populations. Finally, we will describe workplace-based programs of a large grower, Reiter Affiliated Companies (RAC), including a chronic disease prevention program to enhance their private health care clinics, and the Harvesting Wellbeing Program, which educates, engages, and inspires employees and their families to be agents of change for a healthier community.

Panelists:
Marc Schenker, MD (panel leader)
Distinguished Professor Emeritus of Public Health Sciences and Medicine, UC Davis School of Medicine
Xóchitl Castañeda – Director, Health Initiative of the Americas

Deliana Garcia
Director, International Projects and Emerging Issues, Migrant Clinician’s Network

Yissel Barajas
VP, HR, Reiter Affiliated Companies (RAC)

‘Health Without Borders’ will inform participants about how they can leverage resources available through their State Office of Rural Health, and provide case studies from Utah and North Dakota about how individual communities have benefitted from working with their state office to tackle challenging rural health issues.

Each State Office of Rural Health has the following three main objectives: to collect and disseminate information on rural health care issues and researching findings relating to rural health care; to coordinate the activities carried out in the state that relate to rural health care, including providing coordination for the purpose of avoiding redundancy; and to provide technical assistance to public and nonprofit private entities regarding rural health and participation in federal and state programs.

State Offices of Rural Health assist rural communities and organizations with a broad range of topics, including recruitment and retention, needs assessments, shortage designations, Rural Health Clinics, access to care, creating health care networks, grant writing, quality improvement, and understanding value-based care and reimbursement models (among other things).

Panelists:
Matt McCullough (panel leader)
Director, Office of Primary Care and Rural Health, Utah Department of Health

Lynette Dickson, MS, RD, LRD
Associate Director, Community Outreach and Engagement, Center for Rural Health (CRH), University of North Dakota School of Medicine & Health Sciences

In 2017, police officers spent 21% of their time responding to or transporting people with mental illness, according to preliminary data from a survey of 355 U.S. law enforcement agencies by the Treatment Advocacy Center. The volume of mental health-related calls to police dispatchers has bred the need to think creatively about resource allocation in departments. Further, changes in the political climate are driving new ways of looking at recruiting and officer training.

This panel will discuss strategies that have been implemented by departments to respond to these new concerns. The panel looks at the partnerships formed with local nonprofits and hospital administrators that have addressed critical resource allocation questions and delivered improved solutions to these communities. Also addressed will be the evolution of the skill set required for new recruits, and training efforts to address gaps where they emerge.

Panelists:
Phil Polakoff, MD (panel leader)

Jim Lorentz
Division Chief, Patrol Operations, Wheat Ridge, CO Police Dept.

Chris Skinner
Chief of Police, Eugene, OR

Firearm access is a major driver of the rural west’s disproportionately high suicide rate. Putting time and distance between a person with a suicidal impulse and a highly lethal method is one of a limited number of empirically based, high-impact suicide prevention strategies.

In Utah, gun owners and advocates are committed to working with health professionals to advance new safety and social norms aimed at reducing access to lethal means for at-risk individuals. This panel will describe this highly productive, data-driven collaboration; panelists will also report on the results of a 2018 Utah firearm and suicide study funded by the Utah State Legislature and completed by researchers with the Harvard T.H. Chan School of Public Health.

Panelists:
Morissa Sobelson, DrPH (panel leader)
Community Health Program Director, Intermountain Healthcare

Kimberly Myers, MSW
Administrator for Suicide Prevention and Crisis Services, Utah Department of Human Services, Division of Substance Abuse and Mental Health

Winton Aposhian
Chairman, Utah Shooting Sports Council

The past several decades have seen a dietary transition to foods higher in refined sugars, refined fats, oils, and meats. In this time, we have experienced growing rates of diet-related illnesses such as obesity, diabetes, hypertension, heart disease, and a variety of cancers. Coinciding with this dietary shift, we have seen increased environmental and economic pressures. Two-thirds of the Western United States is suffering from drought, and precipitation is expected to decline 20-25% by 2100 while population continues to rise. Additionally, more than 20% of American children live in food-insecure homes.

School and hospital institutions that offer high quality, nutrient-dense foods to meet health needs and eater satisfaction offer a solution to improving human well-being, economic conditions, and community vitality. Kitchen efficiencies and waste reduction (making the right amount of food that people want to eat and serving the right portions) form the foundation for purchasing more expensive foods. This panel is leading the way to connect people, planet, community, and economy. As a result, sick and economically disadvantaged people are eating healthy foods that contribute to their well-being. The staff come to work inspired and produce inspiring results. The community becomes more resilient and resistant to environmental disasters with a stronger local food system. The economy strengthens as jobs are created.

Panelists:
Greg Christian (panel leader)
Chef and owner, Beyond Green Sustainable Food Partners

Judy Donovan
Regional Director of Marketing & Strategic Planning, Kona Community & Kohala Hospitals, Island of Hawaii

Andrea Moore
Assistant Principal, Mililani High School, Honolulu, Hawaii

Utah is the 12th largest state in the US, encompassing over 82,000 square miles. While there are many more rural than urban counties in Utah, rural counties make up less than 10 percent of Utah’s population. People living in rural counties face demographic challenges that are different from their counterparts in urban areas. For example, in Utah, rural counties have a higher poverty rate, higher unemployment rate, a less educated workforce, and a higher percentage of elderly adults compared to urban counties. Rural communities want to protect their vulnerable populations and identify strategies that address their unique situations.

This session will focus on new models to address injury in the most vulnerable populations – youth and the elderly. We will begin with the Utah Health Improvement Index (HII), a data-driven tool to measure determinants of health, advance health equity, and improve health outcomes in Utah. Metrics that measure and track progress of health can help set priorities and inform necessary actions to keep Utahns healthy and ensure that all have an equal opportunity to achieve their potential. The HII is a composite measure of social determinants of health by geographic area that uses a standardized score to assess the needs of geographic locations that can be used to guide targeted interventions. The first presenter will demonstrate the tool and provide a practical application of how it is used in Utah.

Children in rural areas face particular risks to their health and well-being. Children in rural areas experience chronic medical conditions – including emotional, behavioral, and developmental conditions – more often than do children in urban areas. Rural families also face challenges in gaining access to health care, including the need to travel long distances to use health services. A strength for families living in rural areas is community connectedness and a safe and supportive environment. How might we use these strengths when families with young children face stress and other adverse events that can lead to a potentially isolating or stigmatizing report to Child Protective Services (CPS)? Our second speaker will describe a new model of collaborative practice between CPS caseworkers and children’s health care providers currently being tested in Utah. The hope is that this collaboration might improve health, safety, and well-being for infants with suspected child maltreatment by creating trusted connections between an at-risk family and a family-centered medical home.

Older populations aging in rural places also experience particular risks to their health and well-being, including muscle weakness and loss of balance, which can result in injuries from a fall. As with all families in rural areas, the older population often needs to drive long distances for health care services. With resources often scarce, many rural communities are finding ways to collaborate and share ideas and funding to improve the health of their community. Recently, a rural area in Utah – Tooele – combined their health department and Area Agency on Aging under the same umbrella, making it easier to receive funding and share resources. This has been a benefit to the falls prevention programs and meeting the needs of the older individuals they serve. For example, the combined funds allowed the Health Department to expand their Tai Chi for Arthritis Program in Senior Centers. The third presenter will share the experience of including aging in all health policies to further resources in rural areas.

Panelists:
Lenora Olson, PhD (panel leader)
Professor, University of Utah Department of Pediatrics

Mike Friedrichs, MS
Epidemiologist, Bureau of Health Promotion, Utah Department of Health

Kristine Campbell, MD, MSc
Associate Professor, Division of Child Protection and Family Health, University of Utah Department of Pediatrics

Amy Bate
Health Promotion Coordinator and Public Information Officer, Tooele Country Health Department, Utah

A healthy mouth is a key part of overall health. Left unchecked, an unhealthy mouth increases the risk of serious health problems such as aspiration pneumonia, heart attack, stroke, poorly controlled diabetes, and preterm labor. Diet, daily oral care, and regular checkups with oral health professionals are a critical part of overall health care.

Historically, however, medical care and oral health care have been viewed as separate and almost unrelated health care issues. A large gap in levels of access and availability of oral health services continues to exist; integrating oral health into primary care is a viable solution. Being collaborative takes time, but in the end, it is a win for healthcare.

This panel features three proven models of integrating oral, medical, and behavioral health through integrative care programs and tele-dentistry. From the University of Utah School of Dentistry, the implementation of an integrative care program that includes nursing staff in oral health screenings and fluoride applications. This is also the first dental school in the country to have an integrated health record, allowing dental providers to see medical history and vice versa.

Community Dental Health and Virtually Connected Dentistry, a nonprofit organization, was specifically founded to address the disparities vulnerable populations face in receiving dental care. Whether people are isolated within a nursing facility or a rural community, today’s technology and acceptance of provider scope of work is a valuable asset in increasing access to professional care. Virtually Connected Dentistry works together with dental hygienists utilizing the TeleDentistry concept by being the eyes and ears of a dentist to diagnose, create a treatment plan, and facilitate dental care. By having the ability to provide intra-oral photographs and digital x-rays to a dentist, a hygienist is able to show areas of disease and trauma for diagnosis and treatment planning. This concept overcomes one of the main barriers of care – transportation – by reducing the number of appointments needed or enabling treatment planning ahead of time for dental providers to come to the people.

The Oral Health Unit and Primary Care Office at the Colorado Department of Public Health and Environment (CDPHE) prioritizes oral health promotion, disease prevention, and access to care needs in dental Healthcare Provider Shortage Area (HPSAs) throughout the state. CDPHE contracts with four rural local public health agencies to house Regional Oral Health Specialists (ROHS), covering over 20 rural and frontier counties in Colorado. These specialists are used to integrate oral health care by: training medical/dental professionals to provide preventive oral health services for young children and pregnant women; increasing bidirectional referrals between medical and dental safety net clinics, screening for and helping manage diabetes and cardiovascular disease by dental providers and screening for oral diseases by medical providers; collaborating with behavioral health partners; and implementing other public health interventions such as increasing referrals for tobacco cessation, HPV immunizations, and mental health services in dental clinics.

Panelists:
Michelle Vacha (panel leader)
Executive Director, Community Dental Health (CO)

Collaborating with Media to Improve Health in Our Communities

The rapidly changing world of community health should include collaboration with media – both traditional and digital – to reach large numbers of people and improve the overall health of the communities we serve.

This case study will show how Intermountain Healthcare has successfully collaborated with a Salt Lake City television station (KUTV Channel 2) to produce remarkable results that can be replicated in some form at other organizations.

Panelists:
Daron Cowley (panel leader)
Media Director, Intermountain Healthcare

Leslie Tillotson
KUTV Channel 2 News

US healthcare costs have consistently risen faster than the rate of economic growth, to the point where total spend is approaching twenty percent of gross domestic produce (GDP), the highest anywhere in the world. Reasons given for this disparity point to higher cost per unit of service, administrative costs, and utilization of expensive services as opposed to preventing chronic and acute diseases.

This panel examines some of the biggest challenges facing healthcare markets in the American West, including provider shortages, increasing prices and waning competition. This multidisciplinary panel of experts offers stakeholders a variety of resources to help change policy and practice to promote competition and control healthcare spending.

Topics include increasing access to nurse practitioners by changing scope of practice regulations, leveraging state purchasing power to lower healthcare spending for state employee health benefits, engaging citizen volunteers to promote bipartisan solutions, and collaborating with other states to share solutions and legislative initiatives.

Panelists:
Jamie S. King, JD, PhD (panel leader)

Bion M. Gregory
Chair in Business Law and Professor of Law, UC Hastings College of Law

Joanne Spetz, PhD, FAAN
CSF

Dan Villa
Montana Board of Investments, former Montana State Budget Director

Carrie Butler
Policy Director, Action Utah

Every day the world is becoming more digital, but participating in this new era requires a high-speed broadband connection. While broadband has become a critical utility for industry, employment, and social engagement, according to the Federal Communications Commission (FCC), broadband is currently unavailable to roughly 25 million Americans, more than 19 million of whom live in rural communities. That’s roughly the population of New York state.

This inability to build out the last mile of the 21st century’s digital infrastructure has exacerbated the country’s growing prosperity and opportunity divides — divisions that often fall along urban and rural lines.

The Microsoft Airband Initiative is doing something about it. We will learn how Microsoft is partnering with communities, counties, and states to bridge gap and empower every person and organization on the planet to achieve more. To the Airband Initiative, this means bringing affordable broadband connectivity, but also digital solutions for schools, healthcare, agriculture, and more broadly enabling small businesses that spur economic growth and development in rural areas.

Microsoft’s goal is to help eliminate the rural broadband gap in the US, by bringing access to broadband to 3 million Americans living in rural areas by July 4, 2022. Come and learn how to get involved!

Panelists:
Evon Holladay, MBA
COO, A Healthier WE

Vincent Arribe, MEcon
Microsoft Airband Initiative

In healthcare, access matters. The availability of both primary care and specialty care consultations have an impact on the health outcomes of patients in urban and rural settings. While the ability to provide on-site specialists in rural areas is limited by time, distance, and costs, these services may be more efficiently delivered through a telehealth delivery model.

Telehealth can provide for better access, improved availability, and enhanced continuity with patients’ local primary care physicians. Intermountain Healthcare TeleHealth Services offer a wide range of acute care support as well as coordinated, outpatient visits. Intermountain TeleHealth supports local providers and hospitals while keeping patients local, in places like Anchorage, Alaska; Ely, Nevada; or Billings, Montana.

Panelists:
Chad Jasperson
Manager, Intermountain Telehealth Operations

Breein Clark
National Outreach Market Lead, Idaho & Montana

Angela Booker
Chief Nursing Officer, Teton Valley Hospital (Driggs, ID)

There is a public health demand to ensure that patients have convenient, affordable, and ready access to quality health care. What is the optimal combination of primary healthcare services that would best satisfy patient demand at a local level, and thus be more likely to improve the three pillars of patient-centered care – increased access, affordability, and better health of communities? An emerging public health model may be leveraging existing community pharmacy settings in collaboration with family physicians to deliver primary care services at the rural and neighborhood level.

Pharmacies are currently the most frequently utilized healthcare delivery locations in the United States, as 92% of people live within 1.6 miles of a pharmacy; there are 67,000 community pharmacies nationwide. A recent, large comprehensive patient-centric US-based population study modeled the demand for primary care services that could be delivered in the community pharmacy setting. A total of 9,202 adults gave valid responses to a 30-minute survey in a Discrete Choice Experiment (DCE), where they indicated which pharmacy they would prefer from competing pairs of pharmacies that varied in terms of the level of primary care services offered.

The model gave the optimal pharmacy that maximized the switch rate (the probability of adult patients changing from their current baseline pharmacy) which: offered an integrated health electronic record system, a comprehensive level of point-of-care diagnostic testing, and some level of physical examination procedures. The optimal pharmacy was then shown to 50 public and private reimbursement decision makers who were involved in an advisory or leadership role in decision-making within the organization regarding the coverage and reimbursement policies and/or protocols for various primary health care services. Two-thirds of payers were very likely or likely to reimburse for these optimal pharmacy services. This study provides empirical support from patient consumers of healthcare for the provision of convenient primary care services that consumers are willing to pay for in the community pharmacy setting, which could improve outcomes and public health.

Panelists:
Mark A. Munger, Pharm. D., FCCP, FAAC, FHFSA
Professor, Pharmacotherapy; Adjunct Professor, Internal Medicine; Fellow, Academy of Health Science Educators; Associate Dean, College Affairs, College of Pharmacy, University of Utah

David N. Sundwall, MD
Professor Emeritus of Public Health (Clinical), University of Utah School of Medicine 

Using Technology Innovations to Scale Proven Solutions

Today’s technology enables a level of connectedness like never before. The potential of this connectedness to bridge divides has clear promise for rural areas. The solutions needed to create a healthier rural West include collaborating across sectors, creating shared values, addressing inequities, and strengthening the integration of care delivery. More often than not, success requires building a face-to-face relationship – for both diagnostics and accountability – as a foundation for success. Once these relationships are in place and a model is proven successful, there is opportunity to leverage technology to increase reach, reduce cost, reduce set up time, and measure and ideally improve outcomes. In other words, technology can be used to effectively scale solutions.

This scaling process is not straightforward. Just like online shopping is not the same as a physical shopping experience, utilizing technology to improve scale requires several steps, but the promise is there and proven use cases exist. For example, digital medicine solutions can effectively standardize and scale treatments so that each patient can access as much of an intervention as is warranted, and no patient need go without for lack of access, funding, or other barriers that prevent or delay treatment. By offering immediate feedback and positive reinforcement, digital solutions have also been shown to improve an individual’s self-management and engagement in care and community.

This panel will explore how digital apps, artificial intelligence, virtual/augmented reality, social networking platforms, chatbots – among a long list of technology solutions can be leveraged to scale the proven solutions such as those presented during the summit.

Come as we explore how rural individuals and communities with access on a daily basis can change the paradigm of health and wellness from one of intermittent and acute/crisis care to condition management and health maintenance and help bring patients to a state of complete physical, mental and social well-being.

Panelists:
Beth Rogozinski (panel leader)
CEO, Signal 2 Health

Bassam T. Salem, MBA
Founder & CEO, AtlasRTX, a Mindshare Venture & Vice Chairman, Utah Tech Council

Mimi McFaul, PsyD
Deputy Director of Technology, National Mental Health Innovation Center