Table of Contents

Regional Commissions Meeting

Executive Summary

Summary Report

Appendix One - Conclusions and Recommendations

Executive Summary -- Regional Commissions Meeting
July 27-28, 2006

In two days of focused discussions and presentations, leadership of the Federal Regional Commissions met to describe their current health initiatives and find areas of shared interest and possibilities for continued, coordinated action. The Department of Health and Human Services, Health Resources and Services Administration (HRSA), Office of Rural Health Policy (ORHP) sponsored the July meeting. The Delta Regional Authority (DRA), Appalachian Regional Commission (ARC), Denali Commission, and US-Mexico Border Health Commission (USMBHC) provided an overview of the health challenges faced by the populations they serve and strategies they have developed for meeting the health needs of these underserved populations.

Dr. Betty Duke, Administrator of HRSA and Dr. Marcia Brand, HRSA Associated Administrator for rural health, provided a framework for the meeting's outcomes. The objectives of the meeting were to continue the health-focused dialogue (which formally began in 2003) between the Federal Commissions and HRSA and to promote partnerships between HRSA and the Commissions. Dr. Duke described HRSA's increased presence in underserved areas and pledged to continue to expand access to oral and mental health, health centers, and the National Health Service Corps.

Utilizing poverty as a common proxy, leadership of each Federal Commission presented an overview of specific initiatives underway to address the health problems unique to their communities. From a media-focused diabetes prevention effort in the Delta to the ARC's community-oriented substance abuse conference, the Commissions related successful strategies and how these might be translated across geographic lines. The Denali Commission provided a framework for detailed, strategic planning and the US-Mexico Border Commission described its use of research and telemedicine to address the unique challenges of health along the Border. Additionally, experts from several health-related areas provided detailed information on such pertinent issues as the J-1 Visa program, provider performance management, and regional diabetes care.

At the end of the two days of discussions, participants examined cross-cutting problems and developed shared strategies to combat shared or similar challenges. The relationship between health care and economic development was stressed as a means of increasing access to health care while at the same time increasing economic opportunity in rural communities.

The Commissions sought to continue the discussions and suggested the creation of a commission exchange to promote continued dialogue and communication. Other possible outcomes included a joint research initiative between the Commissions and HRSA on promoting healthy living for children, the development of core measures for Federal grants accountability standards for the Commissions, and increased information about coordinating health information technology. The J-1 Visa program was also cited as a method for increasing provider access, and its continuation was promoted.

In all, the meeting was marked by an excitement about the possibility of future collaborative efforts. The Federal Commissions found willing partners with HRSA and ORHP in their joint mission of expanding access to health care in underserved communities. Through collaboration and cooperation, the meeting's participants have pledged to continue to work together for increased quality health care throughout the economically challenged areas they represent.

Regional Commissions Meeting
July 27-28, 2006

The Department of Health and Human Services, Health Resources and Services Administration (HRSA), Office of Rural Health Policy (ORHP) hosted a recent two-day meeting to facilitate discussion of the Federal Regional Commissions' health initiatives. The Appalachian Regional Commission (ARC), the Delta Regional Authority (DRA), the Denali Commission and the U.S.-Mexico Border Health Commission (USMBHC) met to discuss common health and social service issues and to share their specific strategies for improving access to quality health care in their regions. Last convened in conjunction with the ORHP All Programs Meeting of 2003, this meeting was a smaller, more focused gathering of the Regional Commissions to assess progress and articulate new strategies.

Dr. Marcia Brand, Associated Administrator for rural health at HRSA, welcomed the meeting's attendees with a statement of the conference objectives and proposed outcomes. In these two days, HRSA and ORHP planned to facilitate a health-focused dialogue in order to better understand how HRSA could best collaborate with the Regional Commissions to address the health needs of the communities they serve. Through the discussions and presentations, the Regional Commissions planned to identify priority areas for coordinated efforts with HRSA. The conference also aimed to improve collaboration among the Commissions through sharing best practices and useful products. By the meeting's end, HRSA and the Regional Commissions planned to have developed a strategic plan for partnering to address access to care priorities and planned to discuss ways different regions could work together to solve shared problems.

After welcome's to the Regional Commission representatives, Dr. Brand introduced the current and longest-serving HRSA administrator, Dr. Elizabeth Duke. Dr. Duke offered an inspiring message of service and commitment to HRSA's mission of providing health care to the underserved. "Dream big dreams," she instructed, "and improve the lives and communities of those most in need."

Describing HRSA's mission to increase access, Dr. Duke related several programs underway within the Administration. In 2002 President Bush announced the Health Center Growth Initiative, and since then HRSA has expanded services through 900 additional health centers that provide primary and preventive care to all, regardless of their ability to pay. In a plan to eliminate health disparities under this initiative, the President has also asked Congress to support a new $52 million initiative that would pay for 80 new access points in high poverty counties.

Dr. Duke also reiterated her strong commitment to finding creative health care access solutions. During her tenure at HRSA, she has overseen an expansion of the National Health Service Corps from 2300 to 4600 participants. This loan repayment program for qualified health service professionals willing to serve in areas of need has benefited many of the populations served by the Regional Commissions. HRSA has also focused on increasing access to oral and mental health care, issues of critical need for many rural and underserved areas. Dr. Duke ended her inspiring address with a message to the commissioners, "If your heart and soul is in idea and people are with you, you can make a difference."

The Delta Regional Commission -
Health Care Development as a Tool for Economic Improvement

Overview of the Commission:
Pete Johnson, Federal Chairperson of the Delta Regional Authority (DRA), provided the first of the Regional Commission presentations. Formed four years ago, the DRA serves 240 counties and parishes in eight States, including 21 counties in Alabama.

Challenges:
Beginning with a history of the region, Johnson discussed the economic highs and lows of this Mississippi River basin. Using the rich resources of the river and logging industry, the early settlers profited from the Delta's fertile farmlands and abundant trees. By 1860, the Delta was one of the wealthiest regions in the United States, but this once very prosperous area has since suffered and fallen into economic decline. A timeline of hardships beginning with infrastructure damage sustained during the Civil War and continuing to the recent brutality of Hurricane Katrina has resulted in the Delta Region becoming today one of the most impoverished regions in the United States. Seventy to eighty percent of its residents live in persistent poverty, and the region claims high levels of unemployment alongside low growth and low educational attainment.

Strategies for Success:
In looking for ways to recover from the economic hardships and reclaim its history of prosperity, the Delta Region has reaffirmed that the health care industry is an essential component of its economic growth and recovery. Health care development has become a cornerstone of the Delta initiative, with gains in education, transportation, housing, and access to affordable capital and housing all stemming from healthcare development. Because of its relative newness, the DRA is focusing its funding on strategic planning and workforce solutions while still seeking to fully discover the best avenues for improving the healthcare of citizens in the Delta Region.

To that end the Healthy Delta Program (HDP) has focused extensively on diabetes prevention and treatment, approaching the problem of diabetes from a community perspective and attempting to reach larger numbers of people than ever before. In an innovative approach to disease treatment and prevention, the Program uses extensive media coverage to inform people about the dangers of diabetes and the economic impact of this disease. The Governors of each of the eight Delta States have appeared on television to make people aware of the disease and how and where they can receive treatment. Program facilitators drive people to call centers to sign up for the Program and then track improvement using follow-up calls 90 days after each visit. In an innovative approach to health care promotion, the Program also uses churches and faith-based organizations to specifically target diverse demographics, including African American females over age 45 (those at greatest risk for diabetes).

The DRA believes that improving access to quality health care requires targeting limited resources. It hopes that its role as planning and coordinating agency for improved health care resources can help the Delta return to being one of the most prosperous regions in the U.S.

The Denali Commission -
An Emphasis on Strategic Planning To Get Results

Overview of the Commission:
With an emphasis on Alaska's great size and inherent geographic challenges, Krag Johnsen, Chief Operating Officer of the Denali Commission, spoke about the organization's goal to improve and expand the healthcare infrastructure of Alaska. Sponsored by Senator Ted Stevens (AK), the Denali Commission Act of 1998 requires that the Commission focus fifty to sixty percent of its work on power generation needs. However, it also heavily emphasizes increased access to social service facilities and provides training for local residents in the health care field. The Denali Commission partners with Tribal, Federal State, and local governments to improve the effectiveness and efficiency of its health-based services. It also seeks to develop a well-trained labor force employed in a diversified and sustainable economy, which will help to build and ensure the operation and maintenance of Alaska's basic infrastructure

In all of its work, the Denali Commission emphasizes sustainability. To that end it focuses on investment, cost containment, open door policies, private enterprise, and community planning. Since its first Congressional appropriation in 1999, the Commission's funding has steadily grown, and it now partners with Federal agencies to maximize funding sources, while improving the health of Alaskan people.

Challenges:
Alaska faces unique challenges due to its geography and size. Poverty, isolation, and transportation needs, among other difficulties, continue to plague the State and its residents. Nelson Angapak, CEO of the Alaska Federation of Natives (AFN), related his personal story of how his home community had unemployment rates of 60 to 80 percent and very limited access to health care. In this region, which is the size of the State of Washington, there is only one hospital, accessible only by air. These geographic challenges require coordinated resources, and the Denali Commission has a core structure meant to work between agencies to coordinate activities and find solutions to the needs of each community. Most funding goes to critical core infrastructure, basic reliable energy, housing, job training, and economic development

Strategies for Success:
To describe the Commission's specific health agenda, Denali Daniels shared her work with Denali health organizations. She noted facility development, especially the development of primary care clinics, as a priority. Social service provisions including behavioral health, elder housing, and domestic violence shelters are also top priorities for the Denali Commission.

The Denali Commission has adopted a policy of investment in the detailed planning of health facilities. To be developed, the facilities must first have an approved business plan and then have a clearly outlined plan for site control issues, including plans for construction and equipment. In developing their budgets, she reminds grantees to be aware of the statutory cost share match requirement and the potential for huge travel costs.

From careful planning and thorough assessments, the Denali Commission can boast of numerous accomplishments. Its strategic planning has already led to the creation of 282 primary care clinics, with 37 projects in construction, 74 in planning or design, and 101 approved but yet to engage. With an exit strategy at 40 million dollars per year, the Denali Commission's plan is to complete all of the clinics by 2012. Their improved methods have allowed them to increase access, improve provider efficiency, and create better road systems. They have learned to utilize cost share, match the appropriate facility size to the service delivery model, and plan for organizational capacity. The Commission has also increased the number of community health aides in the State and improved technical assistance and pre-development.

US-Mexico Border Commission - Using Technology and Community Partnerships to Overcome Obstacles to Access

Overview:
Four US-Mexico Border Commission (USMBHC) representatives offered their perspectives on its valuable work-- Mary Lou Valdez, Secretarial Delegate, U.S. Section and Deputy Director for Policy, Office of Global Health Affairs, U.S. Department of Health and Human Services; Héctor Xavier Martinez Sánchez, Executive Secretary, Mexico Section; and Dr. Larry Kline and Emma Torres, Members, U.S. Section.

The Commission brings together two sovereign countries, in a composition of ten Border States (six Mexican States, four US States), two sections, and twelve individual Commission members. It was created in July 2000 by an agreement signed by the U.S. Secretary of Health and Human Services (HHS) and the Secretary of Health of Mexico. In 2004, the President signed an Executive Order to designate the Commission as a Public International Organization. The USMBHC receives no direct Federal line of funding. Instead, it resides as part of the Office of the Secretary of Health and Human Services (HHS) and works with HHS to provide needed resources to the U.S.-Mexican Border region.

The USMBHC's goals are to provide international leadership to optimize the health and quality of life along the US-Mexico border. It seeks to institutionalize a domestic focus on border health from a perspective that is uniquely of the Border, not American or Mexican. To create an effective venue for bi-national discussion and address long term key public health issues, the U.S.-Mexican Border Health Commission emphasizes sharing and collaboration so that each side can provide successful strategies and find common solutions to common problems.

Challenges:
The challenges of access, poverty, lack of providers, and language and cultural barriers, represent huge obstacles to public health needs in the area. If the US- Mexico Border were a separate state it would rank first in the number of children living in poverty and second in tuberculosis prevalence. It is the most crowded border in the world, with over a million people crossing its line each day in either direction, making its needs even more pressing by the sheer number of people seeking access in an area with little critical infrastructure.

Strategies for Success:
The Commission combats these and other health disparities by facilitating study and research, raising awareness, and developing partnerships for action. Their innovative research focus has led to the proposed Border Telemedicine Initiative led by the Mexican State of Nuevo Leon. Using technology to reduce modifiable risk factors associated with diabetes and cardiovascular disease, telemedicine provides improved health services and increases access for populations most in need and most difficult to reach. Technological infrastructure can be an issue, and using top technology like satellites is expensive; however, relative to other provider methods, this project is more cost effective and more sustainable. With different languages needs and other challenges, this could be one of the best tools to serve the unique needs of the Border.

Other Border initiatives have sought to increase health literacy through community-based approaches. Healthy Border 2010 promotes healthy lifestyles on the Border by proposing benchmarks for health outcomes through the promotion of 20 health indicators in 11 focus areas. Border Bi-national Health Week takes place on both sides of the border. The 3rd Annual Border Binational Health Week 2006 will be celebrated from October 9-13th with a focus on the goal of "promoting sustainable partnerships to address border health problems." Another program, Ventanillas de Salud (Health Windows), is working to establish public information stations within the Mexican consulates on the border to help direct at-risk populations to appropriate health services. Partnerships between border agencies and community organizations are also important for lessening health disparities. For example, the Pfizer Alliance for a Healthy Border, a public-private partnership, seeks to reduce modifiable risk factors associated with diabetes and cardiovascular disease, and the Centers for Disease Control and Prevention has partnered with the Pan American Health Organization to promote immunizations along the Border through the annual National Infant Immunization Week/ Vaccination Week of the Americas during the month of April.

Appalachian Regional Commission -Providing Community-Based Solutions to Community-Articulated Needs

Overview of the Commission:
In 1965, Congress created the Appalachian Regional Commission (ARC) as a Federal-State partnership in an effort to increase job opportunities and per capita income in Appalachia to help the region reach parity with the rest of the U. S. Henry King, Director of Program Operations for the Commission, explained its current programs, which focus on infrastructure, education, and health demonstration projects and serve more than 22 million people, almost half of whom live in rural areas. The ARC strives to promote civic entrepreneurship, believing that if the problem is in the community, the solution must then come from the community. This belief necessitates sensitivity in listening to the needs communities themselves voice.

Challenges:
Appalachia faces long-standing economic and health care challenges. Access to health care is extremely limited, particularly in distressed counties, with few dentists per capita, limited access to obstetrics, and limited availability of mental health and substance abuse treatment services. The economic status of ARC counties reflects need for more investment and growth. Of the 410 Appalachian counties, 77 are considered distressed, with per capita income two-thirds or less of the national rate, and poverty and unemployment rates at 150 percent of the national rate. Another challenge stems from the ARC's limited role in health promotion due to changes in its Federal Authority. There is no requirement for how States spend their allocated funds, and a majority of States choose not to spend their ARC money on health care.

Strategies for Success:
Today the ARC is taking a more active role in health and is tasked to increase national understanding of the health care problems unique to the region. Their health program is not project specific, but a forum for exchanging ideas and information to develop and promote solutions to regional health care problems. The ARC's public health initiatives have been aided by its Health Policy Advisory Council's research and analysis efforts. The Health Policy Advisory Council recommended that ARC fund studies of the financial viability of health care institutions in the region and the economic development role of health care services. Ongoing studies of substance abuse and hospital closures have provided insights into long-standing health disparities in Appalachia.

The health care goals of the ARC are closely linked to economic development. The Commission seeks to enhance entrepreneurial activity in the region, and has tapped into the human resources of Appalachia in order to foster civic entrepreneurship and enhance educational opportunities. A healthy workforce is a productive workforce, and the ARC seeks to promote health through wellness and prevention efforts. Providing access to health care professionals is a top priority, but it is difficult to attract health professionals to the area. Telemedicine is one solution to the provider gap, as is a particularly robust J-1 Visa Program, described in more detail below. This program fills the gap by offering services in the areas of primary care, family practice, pediatrics, obstetrics, internal medicine, and psychiatry.

To remain sensitive to the needs of the communities themselves, the ARC strives to foster a cohesive focus among its States, and allow for partnerships to grow based these articulated needs. The ARC has worked with the Centers for Disease Control to develop prevention and control strategies for diabetes and cervical cancer in the area, and an ARC-ORHP mental health and substance abuse conference allowed local organizations to collaborate and develop community-based solutions. Participants from 26 communities were granted $3000 to develop comprehensive plans to address their individual substance abuse problems. This program allowed partnerships and local initiatives, two methods of health care promotion foundational to the Appalachian Regional Commission.

Plenary Discussions

J-1 Visa and Conrad 30 Programs
The J-1 Visa Waiver program and health care workforce issues were the topic of the first panel discussion. R.L. Condra, Washington, DC representative and manager of the Delta Regional Authority's J-1 Visa program and Connie Berry, Director of the Texas Primary Care Office, shared their respective views on these topics. As illustrated by the Appalachian Regional Commission's presentation, the J-1 Program operates by allowing underserved communities to request waivers to allow foreign medical students the chance to waive their three-year home residency requirement for an agreement to practice within medically underserved, rural communities. Because of the Conrad 30 program, a legislative initiative due for reauthorization in 2006, each State is allowed up to 30 J-1 visas. Urban centers also can receive waivers, but they must follow a more complex application process.

The J-1 program accounts for over 50 physicians in the Delta region, and the program pays for itself through a $3000 application fee by the institution recruiting the physician. Concerns that it may take jobs away from American physicians have been allayed by ensuring the positions were advertised extensively to domestic physicians first. J-1 applicants must agree to a three year commitment to work 40 hours per week, practice within the Delta counties, and take Medicaid and indigent patients. The DRA hopes to process and accept 25 applications per year. So far, zero applications have been denied by the Department of State, the responsible entity for J-1 Visa applications. The future of the program centers upon marketing the uniqueness of the Delta to potential J-1 Visa doctors. Using brochures, J-1 Visa conferences, travel and presentations, and meetings with health officials and medical schools in the region, the DRA hopes to promote and expand the J-1 Program.

Connie Barry followed with a less optimistic view of the future success of the J-1 Visa program. The program has grown steadily since its inception in 1948, but a final rule adopted in 1995 now allows residents to enter on the H1-B visa instead. The H1-B program also waives the foreign residency requirement, but it does not require any service in rural or underserved communities. Since the H1-B visa's inception, the number of J-1 Visa applications has dropped by 56 percent, from 11,026 in 1995 to 6,150 in 2004; the number of year-one participants has dropped to just 680. According to Berry, if the numbers continue to drop by 100 each year, there could be no J-1 Visa-placed doctors serving in these communities in the next five years. Requiring an MSA service obligation for the H-1B Visa may be a solution to this growing problem.

Provider Performance Improvement and Sustainability
Christy Crosser of Mountain States Group and Michael Beachler, Director of the Rural Health Policy Center, at the Penn State College of Medicine led the second panel, focusing upon performance improvement and sustainability of rural health care facilities. Helping rural health care providers improve performance is the key to sustainability. Current legislation calls for greater attention on sustainability, and providers who learn to do well in this environment will keep their facilities viable.

Availability of health services is a key economic driver in poor rural communities, and financial performance is the solution to keeping hospitals open. Beachler provided an overview of Practice Management Technical Assistance (PMTA), a service designed to help providers improve their operational and financial performance. Consumers are increasingly demanding that providers make improvements, and PMTA is an organizational effort to improve the operational and financial efficiency of rural safety net providers. It is relevant to community health centers, private physicians, certified rural health clinics, small hospitals, and not-for-profit organizations.

The effectiveness of PMTA has already been demonstrated. In Louisiana the Bureau of Primary Care and Rural Health has practiced management services since fall 2002. After Hurricanes Katrina and Rita, the State provided continued funding for staff and played a key strategic role in helping rebuild Louisiana's primary and secondary care structure. The Mississippi Hospital Association also started Practice Managed Technical Assistance in the fall of 2000. Now it has grown to nearly three full-time professionals whose primary, but not exclusive, focus is on hospitals. Facilities receive considerable funding support from the host agency and cover costs with any fees they collect.

Physicians are trained as clinicians, not businesspeople, but health care is both a vocation and a business. Third party reimbursement policies and requirements are constantly changing potential revenue. Loss can be significant if timely modifications are not made. Practice Management makes sense in helping to bridge the management gap and bring better services to people. Sponsoring host agencies have embraced the service, which has helped increase retention and reduce turnover of primary care physicians in targeted regions. Providers could also consider charging fees to cover PMTA costs from the outset and some not for profits could charge fees, improving marketing for the service as well.

Crosser described the Rural Hospital Performance Improvement (RHPI) project, which seeks to build health care capacity in the Delta Region. RHPI is a program funded by the Office of Rural Health Policy. Its main goal is to provide on-site technical assistance to eligible rural hospitals in the Delta to help them improve their financial, clinical and operational performance. It seeks to build the capacity that will provide ongoing assistance to rural hospitals, and collects and disseminates tools, including technical improvement workshops, which hospitals can use to help themselves. Its consultation services include performance improvement assessments; it helps hospitals to assess market and clinical services and identify other performance improvement opportunities that will result in increased financial stability.

To participate in the RHPI program, hospitals must undertake an application process. Eighty-four applications have been received as of July 2006, resulting in more than 40 targeted consultations. Final evaluations have shown that participants have better performance, liquidity, and profitability. RHPI works due to its quality consultants who know the health care industry in rural areas and can develop trust and through the follow-up the program provides. It has been successful enough for its implementers to recommend using it as a model for programs in other regions.

Community Health Plans for Metabolic Syndrome and Diabetes Care
"Diabetes is only a test case --a foothold for prevention. To get prevention on the road, you have to get trust and produce outcomes for people to see." Dr. Marshall Bouldin

The final plenary revolved around regional diabetes care, with perspectives from Dr. Richard Crespo, Associate Professor of Community Health at Marshall University, and Dr. Marshall Bouldin, Associate Professor of Medicine, University of Mississippi Medical Center.

Diabetes is a health care burden that accounts for 15 percent of total US health care costs and 25 percent of Medicare costs. Mississippi has the highest prevalence of diabetes and obesity in the U.S., but all of the Regional Commissions noted their concern with the disease, and all have comparatively few health care resources to help solve this relatively new epidemic. Type 2 diabetes did not exist 200 years ago, and even just in 1987, its prevalence rate was 2.8 / 100,000. However, now the disease has hit pandemic levels, with a ten-fold increase in pediatric diabetes alone. One in three children born in 2000 will develop diabetes, and one in two African American children. Diabetes is preventable, but it requires long term "sugar" control, without treatment it can cause renal failure, blindness, and symptomatic neuropathy. Metabolic syndrome, a compilation of conditions including diabetes, has abdominal obesity as its number one risk factor.

Dr. Crespo related his work with the Appalachian Diabetes Control and Translation Project, a community, State, and Federal partnership. This effort has helped county-level coalitions to organize around the problem of diabetes with help planning, implementing, and evaluating their projects. The coalitions supported work with the neediest counties in nine Appalachian States. The States received $10,000 startup grants to focus on Diabetes Today training, and training in chronic disease self-management.

Partnership is a critical component to the Diabetes Today project; it teaches health care educators to walk alongside people and communities, helping them to articulate what they want to do in a measurable form. Because of its community nature, base communities have no affiliation with granting organizations, and the States may make a number of adaptations. There are no specific objectives or plans in the application process; planning occurs after the application is accepted and the program is adapted. The grants are open ended, meaning there is no specific end date for the project. It is a one-time money allotment, but a long term relationship is expected. People learn to leverage funds by asking local agencies for contributions and have generated over $300,000 in-kind contributions.

The program has progressed into an ongoing relationship with sets of coalitions. The engagement in health education programs over the past two years has allowed coalitions to specify projects towards an increased concern for the welfare of children. Over 20,000 children have now interacted with health communications networks; more than 954 kids have received health screenings and even more have signed up for physical activity programs. Coalitions have used a social marketing campaign that includes billboards, local TV and radio, church bulletins, and grocery stores to expand and reach more individuals.

An important component of the program involves leadership development, which means helping to develop planning skills, objectives, and promoting measurable outcomes. This empowerment part of the work trains leaders to plan and facilitate skills for behavior change. Community involvement is key to sustainability, and they have learned that coalitions tend to require a minimum of five partners. For instance, the County sheriff is involved in one coalition, and even prison labor has built a community walking track.

Dr. Marshall Bouldin provided reasons to be hopeful in the fight against diabetes in Mississippi, with a discussion of the Delta Diabetes Project (DDP), a program that has drawn attention from the American Diabetes Association (ADA). The DDP uses a multidisciplinary chronic disease model and non-traditional features that facilitate role changes to better utilize the State's sparse resources. Its regional system of diabetes care uses community based participatory research collaboration. Proper education and management of the program ensure that patient self-management is attained. Currently the program in Mississippi has 4500 patients. Data and outcomes drive novel applications of tele-informatics and can provide excellent quality of care.

Noting that if you solve diabetes, you can solve many other health problems, Dr Bouldin asserted that the DDP could be used as a template for other regional disease initiatives. The data shows such projects are sustainable and successful by ensuring that those who are most affected are helped the most. This is a regional concept of combating disease, and once the coalition is built, it can be used to combat any health condition. Regardless of the setting, whether facility based or a mobile program utilizing lay health workers, when people see their children and neighbors' diabetes controlled, they will want to get involved and be part of the solution.

Summary and Next Steps - Regional Collaboration and Cooperation

At the end of the two days of focused dialogue, HRSA and the Regional Commission representatives discussed strategies for partnerships and necessary next steps. A detailed outline of their proposals is attached in appendix one.

The meeting highlighted the similar missions and challenges of the Regional Commissions, and the Commissioners sought to further this productive dialogue through a communication exchange. This could be either online or through a series of continued meetings. They also discussed working together to maximize partnerships and funding sources so that more people could be helped by the services they offer.

There was a discussion about convening the health advisory panels of the Commissions for a similar exchange. Both the DRA and the ARC stressed community development with an emphasis on economic development, noting that many problems stem from pervasive poverty. The view that communities should be empowered to help themselves prevailed as a method of helping the Commissions solve common problems. Disease management models, such as the Diabetes Today program, were cited as a method of cross-regional best practices that could be shared by the Commissions. Other health issues of particular concern included oral and mental health.

All agreed that long term planning should focus on children's needs because only by keeping young people at the forefront of health promotion can long term change be sustained. Utilizing a community-based approach would allow for the Commissions' health strategies to facilitate lifestyle change at the family and community level.

Most importantly, the Regional Commissions affirmed their commitment to continuing to work together to promote health improvement in their communities. Administrative, as well as program accountability and transparency standards were stressed as a means to ensure sustainability. Seeking deliverable outcomes and statements of continued partnerships, the representatives sought to move forward on issues of shared concern. Health information technology, telemedicine, regional disease management strategies, issues of performance and sustainability-- all necessitate a collaborative approach and play an important role in the health care of rural and underserved communities. Only by working together can the problems of endemic poverty and insufficient access to quality health care be solved.

2006 Regional Commissions Meeting

Outcomes and Recommendations

1. Short Term Goals (Three to Six Months)
1. Create commission communication exchange via workgroup, list-serve, or other electronic mechanism:
1. Foster a communications network.
2. Develop a matrix of Commission issues and resources.
3. Identify foundation partners etc., to increase funding and capital development.
4. Focus Commission activities on mental and oral health.
2. Long Term Goals (One Year)
1. Convene Commissions' policy advisory or research councils:
1. Coordinate research with HRSA.
2. Focus Commission leadership on common health problems (e.g., diabetes, mental health, and oral health).
3. Ensure community input into Regional Commission planning.
4. Facilitate exchange of health information technology development.
5. Consult with HRSA to convene commissions with a conference focused on "healthy lifestyles" for children.
6. Consider inviting Mexican and international partners to commissions table.
7. Share community economic development strategies through the lens of community health workers or promotoras/es.
2. Coordinate an evaluation workgroup to develop a strategic plan:
1. Coordinate performance measurement with respect to Federal funding and Congressional earmarks, developing a core set of measures for regional commission programs.
2. Promote accountability of Commission resources through the lens of performance measurement, while maintaining a focus on outcome measures and quality controls.
3. Help to solve shared administrative challenges (e.g., PART process, grant making, and transparency).
3. Possible Secondary Activities
1. Address workforce problems:
1. Create new models of facility and workforce development (pipelines and alternate workforce solutions, i.e. community health workers).
2. Address H1-B expansion with declining numbers of J1-Visa Program applicants.
2. Educate policy makers as a group of Commissions:
   (i.e. Appalachia Caucus, Delta caucus, Border and Alaska representatives.)