The National Advisory Committee
on Rural Health and Human Services
U.S. Department of Health and Human Services
Office of Rural Health Policy
National Advisory Committee on Rural Health
and Human Services
Health Resources and Services Administration National Advisory Committee Fort Collins, Colorado Meeting Summary The 56th meeting of the National Advisory Committee on Rural Health and
Human Services was held on June 10-12, 2007 in Fort Collins, Colorado. Sunday, June 10, 2007 Governor David Beasley, Chairman, convened the meeting at 1:00 p.m. on
Sunday. He began the meeting by extending appreciation to the staff from
the Colorado State Office of Rural Health for helping to organize the
meeting. Mr. Tom Morris from the Federal Office of Rural Health Policy introduced
several new members of the staff and announced that Mr. Thomas Pack and
Ms. Andrea Halverson would be leaving soon. The Committee members present at the meeting were: Susan Birch, RN, MBA;
Paul Craig, Ph.D., A.B.P.P.; Bessie Freeman-Watson; Joseph Gallegos; Sharon
Hansen; Julia Hayes; David Hewett; Thomas Hoyer, Jr., M.B.A.; Lenard Kaye,
D.S.W.; Clint MacKinney, M.D., M.S.; Arlene Jackson Montgomery, Ph.D.;
Michael Meit, M.P.H.; Karen Perdue; Ron Nelson, P.A.; Sister Janice Otis;
Larry K. Otis; Patti Patterson, M.D.; Tom Ricketts, Ph.D.; Heather Reed;
and Tim Size. Present from the Office of Rural Health Policy were: Tom
Morris, M.P.H.; Nina Meigs; Judy Herbstman; Thomas Pack; Michele Pray
Gibson; Carrie Cochran; Jennifer Chang; and Erica Molliver. SETTING THE CONTEXT FOR RURAL COLORADO Mr.Weskott presented information about the Colorado State Demographic
Office and its responsibilities for forecasting population and economic
changes in the State. He identified and described demographic characteristics
of the three major economic areas of the State. These are the Metro Front
Range, the Western Slope and Central Mountains, and the Eastern Plains
and San Luis Valley. He described the major industries in each area and
their different needs and issues related to the labor force. He then highlighted
demographic data on the aging of the population in Colorado and presented
a forecast that by the year 2030 every five-year age group over age 65
will have nearly tripled compared to the year 2000. He talked about the
huge growth of retirees coming to the State and presented data to compare
the aging Colorado population with the U.S. population as a whole. He
concluded by saying that the Metropolitan Front Range and scenic areas
of the Western Slope will continue to grow, and that the struggling agricultural
regions of the eastern part of the State will also capture some of the
increase in the number of retirees coming to the State. Governor Beasley asked about the tax and economic implications of population
decline in some eastern parts of the State coupled with growth in the
west. Mr. Weskott acknowledged the difficult challenges to both economic
sectors, highlighting that housing for seniors in the east will be a significant
problem. Mr. Hoyer asked whether the State would produce sufficient health workers
to serve its growing population. Mr. Weskott responded that Colorado has
a good community college system that is meeting some of the needs currently
and is well positioned to meet additional demands in the future. Mr. Hewett asked about the water supply needed for population growth.
The speaker replied that the State has plenty of water, but there is a
poor distribution system for eastern parts of the State. Peggy Godfrey recited a few selections of her poetry to evoke the moods
and values of rural Colorado. HEALTH PANEL Dr. Wallace spoke about health care access, systems integration, and
community partnerships in northern Colorado. The service areas of Weld
and Larimer Counties are facing a perfect storm in terms of population
growth, high percentages of the population under 200 percent of the federal
poverty line, and large numbers of uninsured. The mission of the Colorado
Health Alliance is to ensure that all underserved residents have access
to care through an integrated service delivery system. The Alliance is
comprised of public and private health and human services providers in
the two counties. The Alliance strives to develop collaborative systems
of care, workforce development strategies, and programs for improved quality
of care. The group has made recommendations to reform privacy barriers
to integrated care, eliminate funding silos, develop national health care
workforce strategic plans, and to assist rural communities in developing
the capacity to train, recruit, and retain a competent workforce. Dr. Westfall began his presentation with a brief description of all 64
counties in Colorado. Twenty-nine are considered rural and 23 others are
considered frontier. There are 12 urban counties. Fifty counties are entirely
or partially designated as Primary Care Health Professional Shortage Areas.
Twenty-one do not have an acute care hospital and every rural county has
job openings for a wide range of health care professionals. Dr Westfall
provided data on mortality rates in the High Plains of Colorado and reviewed
significant demographic and economic indicators for rural Colorado. He
noted that rural residents are more likely to live in poverty, more likely
to describe their overall health status as fair or poor compared to their
urban counterparts, and more likely to lack health insurance. Geographic
barriers to health care and the lack of public transportation are important
issues in rural areas of the State. The Hispanic and indigent patient
pool is putting immense pressure on rural health care providers. He also
spoke about the acute shortages of mental health and dental health providers
in rural areas. Other barriers to health care are inexperienced rural
hospital boards, rural hospital administrator turnover, town rivalries,
unrealistic residency requirements for family physicians, adverse weather
conditions, water shortages, and poor communications capabilities. Dr.
Westfall discussed rural solutions involving hospital board development,
incentives for rural hospital administrators, collaborative outreach grants,
and changes in physician residency requirements. He also recommended the
need to provide incentives for specialists who will train rural physicians
and residents, and the need for resources to help current rural practices
to provide a similar scope of services as Federally Qualified Health Centers. Mr. Nelson commented on the importance of pharmacists in an integrated
system of care. Dr. Wallace agreed that pharmacists have to be part of
an integrated system and cited some examples from his own community. Dr. MacKinney asked about incentives for members of collaborative ventures
to pool their funds. Dr. Wallace responded that pooling is often possible
within existing guidelines for resource use, but he also said that new
incentives are needed to encourage collaboration and integration of services. Mr. Otis asked about the status of rural providers. Dr. Wallace spoke
about training programs that are meeting some rural needs, but there is
a declining interest in family medicine that will continue to hurt rural
areas. He talked about the fact that training for family residents often
takes place in settings where there are large numbers of uninsured and
no compensation to the site for providing the training experience. HUMAN SERVICES PANEL Ms. Brewster-Willeke spoke about the Rural Communities Resource Center
in Yuma, Colorado. The Center was founded by a group of women who were
interested in exploring alternatives to the standard method of childbirth
delivery. As a result of their positive experience in working together,
the founders began to think about how their experience could be a model
for community collaboration on a wider range of issues. They organized
a workshop called “Family Life in the Eighties” in Yuma where
everyone who provided a community service was invited. At the end of the
conference it was agree that there was a need for one place where people
could go to connect with the services already available in the area. She
described the current areas of focus for the Center that include: 1) Advocacy
and support on homeless issues and support for parents and their families;
2) Domestic Abuse Prevention and Intervention; 3) Early Childhood education;
4) Economic and Social Justice; 5) Family and Community Health and Safety;
6) Youth programs; and 7) Community capacity and systems building. The
Center has forged essential partnerships and collaboration with organizations,
agencies, and individuals to bring needed programs and services to the
area. Ms. Mulch spoke from the perspective of a Public Health Nurse in describing
her experiences in directing the Kit Carson County Health and Human Services
agency. She described her relationships with the County Board of Health,
the County Board of Human Services, and both State and Federal programs
administered by her organization. The organization is extensively involved
with all aspects of public health, including family planning, school health,
immunizations, emergency preparedness and chronic disease prevention.
It is also involved with food safety, septic systems, land use issues,
animal odor control, and consumer protection. In the human services area,
they are working on eligibility for food stamps and Medicaid, child welfare,
child support, and child care. Ms. Mulch provided insights and experiences
on a generalist model of service integration that has a particular relevance
to frontier communities. She and her employees wear many different hats
and are required to have knowledge of a broad spectrum of health and humans
services programs. She emphasized the importance of consistency in communication
at all levels and the need for real dialogue in the community. She also
talked about the importance of cultural values and norms in working within
the community. She said that the Committee should take from her experiences
the lessons that integrated programs are critical and that committed individuals
can make a huge difference in their communities. Mr. Meit asked about the impact of stove-pipe funding on rural service
providers. Ms Mulch responded that flexibility is limited in frontier
areas where federal resources are scarce and tax revenues may fluctuate
wildly from year-to-year. She advocated strongly for more flexibility
in the use of federal funds. She also stressed the importance of accountability
in a small community. Dr. Kaye asked how the speakers would use additional funds if they were
available. Ms. Mulch replied that her priorities would be pre-natal care
and chronic disease prevention. Ms. Brewster-Willeke said that her organization
needs general operating funds that would allow greater flexibility in
meeting local needs. PUBLIC COMMENT There were two responses to the Chairman’s call for public comments. Ms. Diane Miller from Steamboat Springs, Colorado spoke about the influx
of immigrant groups and their need for services. She expressed the concern
that there are no incentives for serving this growing population. She
also called attention to the needs of the uninsured in Colorado. Dr. Jack Berry, a family physician, asked the Committee to please consider
the factors of time and distance in the American West that require physicians
to have a broader range of competencies and skills. Monday, June 11, 2007 The meeting was convened at 8:00 a.m. for a briefing on the site visits
that were scheduled for the day. The Committee departed for site visits
at 8:45 a.m. The Health/Integration Subcommittees participated in a site visit to
the East Morgan County Hospital in Brush, Colorado. There were presentations
by: 1) Larry Leaming, Administrator, East Morgan County Hospital; 2) Dr.
Marc Ringel, former National Health Service Corps physician; 3) Scott
Harold, Director of Support Services, Washington County, Colorado, and
4) Dr. Tillman Farley, Medical Services Director, Salud Family Health
Centers.. The Human Services/Integration Subcommittees visited the Northeast Area
Agency on Aging where there were presentations by: 1) Jackie Reynolds,
Executive Director, Rural Solutions; 2) Fred Crawford, Director, Logan
County Department of Social Services; and 3) Margaret Long, Program Manager,
Larimer County Office on Aging. Following the site visits, the Committee returned to Fort Collins for
a review of the schedule for Tuesday. The meeting was adjourned until Tuesday morning. Tuesday, June 12, 2007 Governor Beasley convened the meeting at 8:30 a.m. and asked Larry Otis
to provide a brief overview of Toyota operations in Northwest Mississippi.
The Committee will receive a formal presentation from Toyota at its next
meeting. Mr. Otis said that Toyota is heavily invested in health care for its
employees and suppliers. The plant to be opened in Mississippi will have
a primary care clinic on site and referral arrangements with local health
care providers. A pharmacy will also be on site. The Company has disease
management programs, integrated disability management programs, and other
health care options for its employees. Mr. Otis said that the Company
achieves significant cost savings through its proactive approach to health
care for employees. Mr. Size commented that the Toyota presentation at the September meeting
in Madison, Wisconsin will attract great interest. He also said that there
is a provider pushback on the Toyota model and it will be healthy to have
a discussion in Madison. Dr. MacKinney commented that Toyota has an appropriate emphasis on quality
and efficiency, but there is a concern about the lack of choice for employees.
SUBCOMMITTEE REPORTS Health Subcommittee: Mr. Hoyer reported for the Health Subcommittee.
He said that the main message of the Subcommittee report ought to be that
there are two key things to do: 1) work harder to coordinate services,
and 2) provide a warning that the success of the current system is the
result of twenty years of patchwork exceptions where the system does not
work efficiently. Efforts at health care reform need to acknowledge this
from the beginning. He asked the Subcommittee members to send him their
thoughts on the annual report over the next few weeks. Dr. Patterson commented that the current system is based upon urban models
and this is the time for boldness in the report. Other members reinforced
her comments, emphasizing that we cannot solve rural issues without fixing
the system as a whole. Ms. Birch urged the Committee think futuristically about home and community-based
health care services and to be careful not to focus primarily on hospital
care. Mr. Size cautioned that the Committee should be careful when looking
at hospital issues. Hospitals have become so diverse the word itself can
often be meaningless. Mr. Meit advocated for a broad community health perspective in the deliberations
of the Committee. Mr. Morris noted that much of the conversation taking place in the Health
Subcommittee would also fit with the chapter on integration. The report
section on health care services to be drafted by the Health Subcommittee
will need to be carefully coordinated with the section on integration.
Human Services Subcommittee: Mr. Otis reported for the Human Services
Subcommittee. He said that the site visits had been very interesting and
that one of the key lessons was the ability of the agencies to pull together
funding from multiple sources to pay for transportation and other services.
Speakers at the site visit provided comments and examples on the complexity
and abundance of rules and regulations affecting their operations. They
also talked about the problem of labor shortages and were keenly aware
of the need for collaboration. The Subcommittee is leaning toward recommending
some demonstration activities that the Department could support to address
these issues. Ms. Hansen said that building leadership capacity in rural communities
is essential and can provide the means for taking full advantage of the
volunteer spirit in communities. Mr. Otis commented on the problem that federal and state agencies do
not share information about their clients that would be helpful in building
more collaborative service systems. Mr. Morris noted that human service issues are confusing because providers
are subject to both State and Federal regulations and it is hard to pinpoint
the source of some problems. He asked the Subcommittee to address this
issue in its annual report. Ms. Freeman-Watson said that the Committee needs to become familiar with
workforce issues related to human service programs. Integration Subcommittee: Dr. Ricketts reported for the Integration Subcommittee.
He noted that the Committee’s 2005 report had conceptualized the
issues but it requires clearer models of the problems. We need to extend
this conceptualization to give a clearer explanation of what we mean by
integration. The Subcommittee is challenged to come up with the proper
tactics for change. It needs to think about what a healthy community would
look like and how to address the needs of communities that do not yet
have the competence to cope with their own problems. Part of the problem
is that there is a tension in the relationship of the federal government
and its state and local partners: Governments at all levels need to be
better listeners. There is a need to build human assets and capital so
that people can be transforming and entrepreneurial in addressing the
needs of their communities. The huge investment in volunteerism must be
recognized and leveraged in finding integrated approaches for community
services. Ms. Perdue urged that the Committee keep in mind the sustainability of
demonstration projects for integrated services. You can have a great demonstration
that falls apart if there is not proper planning from the outset. She
also urged that the Subcommittee report underscore the positive aspects
of rural settings where people who are place-committed are tremendous
assets in the community. Mr. Meit commented that we should not undersell proven solutions by suggesting
demonstration projects that may not work as well. Mr. Otis said that communities that seem incapable of helping themselves
must not be ignored because there is always latent ability within a community
that can emerge with leadership training. Dr. Ricketts said that communities can build on the success of their
neighbors and we have to find ways that allow neighbors to help each other.
Mr. Gallegos stressed the need for leadership training to help communities
address their problems, emphasizing that this is just as important as
eliminating funding barriers to integrated services delivery. REPORT ON SEPTEMBER MEETING Mr. Size reported on plans for the September meeting to be held in Madison,
Wisconsin. The meeting location will be across from the State Capitol
Building. A large block of time will be allocated for the work of the
Subcommittees. There will be a presentation from Toyota, a discussion
of welfare reform, and presentations on some innovative programs in Wisconsin.
Mr. Size asked for suggestions from the human services members on the
kinds of people they would like to hear from at the meeting. Ms. Birch suggested hearing from vulnerable members of the population.
Mr. Size replied that the Committee could hear about the Hispanic community
in Wisconsin. Ms. Perdue suggested that the Committee hear from a Native American population
in the State. PUBLIC COMMENTS There were no public comments and the meeting was adjourned.
Office of Rural Health Policy
on Rural Health and Human Services
June 10-12, 2007
Jim Weskott, Senior Demographer, Colorado State Demographic Office
Peggy Godfrey, Cowboy Poet
Dr. Mark Wallace, North Colorado Health Alliance
Dr. Jack Westfall, Associate Dean for Rural Health, Colorado University
School of Medicine
Patricia Brewster-Willeke, Co-Director, Rural Communities Resource Center
Kindra Mulch, Acting Executive Director, Colorado State Office of Rural
Health