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 | Setup Instructions |
| Organizing for Achievement: Three Rural Health Network Case Studies
A Background Paper Prepared
for the February 1999
Organizing for Achievement: A primary goal of the Medicare Rural Hospital Flexibility (MRHF) Program is to encourage the development of rural health networks. While neither the legislation nor the rules implementing the program require a critical access hospital (CAH) to form or join a network, the conference report that accompanied the 1999 appropriations bill funding the MRHF Grant Program left no doubt of legislative intent: grant funds are to be used 1) to "improve information systems, quality assurance programs, and other activities" through networks, and 2) to "develop integrated networks of care." As desirable as rural health networks are under certain circumstances, they should not be considered ends in themselves. The goal should not be simply to form networks, but to use networks as tools for achieving defined objectives. Rural health networks are commonly used to reduce fragmentation of health services in a community, improve access to health services, eliminate unnecessary services, and support clinical and administrative services. The MRHF Program legislation defines networks very narrowly as simple bilateral relationships between two hospitals that focus only on referral relationships, communications, credentialing, and quality assurance. Networking possibilities for CAHs and CAH-eligible hospitals are actually much richer. Insights into these networking possibilities come from the two limited-service rural hospital programs that preceded the MRHF Program -- the Essential Access Community Hospital/Rural Primary Care Hospital (EACH/RPCH) Program and the Medical Assistance Facility (MAF) Demonstration Project. Three examples from these programs follow. A diagram of the networks for each example follows the narrative for each case study. Summary observations about the networks follow the three case studies. The networks presented here are examples only and not as models to be replicated. The unique circumstance of each community should determine the purpose, players, and scope of any networking arrangement. Webster County
Memorial Hospital Webster Springs sits beside the Elk River in the hills of east central West Virginia just outside of the Monongahela National Forest. Once tourists from Washington, D.C. and Pittsburgh traveled by rail to Webster Springs to stay at the resort by the springs. The resort economy was bolstered by steady employment in the thriving coal and timber industries. To support the health needs of its residents, Webster County (population 10,729) constructed a 95-bed hospital in 1955. Both busy and profitable, the three-story hospital on the hill prospered for a time. The good fortune of Webster Springs however, did not last. A series of assaults on the local economy conspired to increase poverty and joblessness and drive down the population as residents left Webster County in search of work: passenger rail service to Webster Springs stopped; the resort burned to the ground; the coal mines reduced production; and the timber harvest became erratic. Due in part to the lack of efficient infrastructure -- the 600 square mile county is served by only two two-lane mountain roads -- no new industries replaced those in decline and the unemployment rate soared to approximately 20 percent. The Hospital The problems of the local economy were mirrored in the hospital. By 1992, two of the three floors were closed, a cost-cutting measure reflecting the decline in patient census. Staff had been cut by 35 percent. Despite these efforts to reduce costs, the hospital had lost money for eight years in row. Were Webster County Memorial Hospital to close, the closest available hospitals were Summerville Memorial 40, miles to the south in Summerville, and St. Joseph's Hospital, 54 miles to the north in Buckhannon, both accessible only by narrow, winding, mountain roads. Weighing its options in 1993, the Webster County Memorial Hospital Board of Directors decided to convert to a rural primary care hospital (RPCH). Upon conversion, the hospital agreed to limit its inpatient bed capacity to six acute care beds. Webster County Memorial Hospital provides diagnostic radiology (including ultrasound and mammography), clinical laboratory, and 24-hour emergency room services. Although it does not have an active obstetrics service, the hospital delivers two or three babies per year in its emergency room. The medical staff of the hospital also performs some "scope" procedures. No mobile technologies serve the community. The medical staff of Webster County Memorial prior to conversion had consisted of two primary care physicians and one surgeon, all in private practice. The hospital also contracted with a regional service to provide emergency room coverage. Immediately following conversion, the medical staff consisted of two private primary care physicians and two physicians employed by the hospital. Today the hospital employs four physicians (two medical doctors and two doctors of osteopathy) and three physician assistants. There are no physicians in private practice in the county. The hospital also sponsors specialty clinics in gastroenterology (based in Clarksburg, 81 miles away), and orthopedics (based in Elkins, 62 miles away). Webster County Memorial would like to add cardiology and pediatrics to its medical specialty clinic complement. Reversing years of financial setbacks, the hospital has posted modest profits in each of the past three years. This improved financial picture, however, may be in some jeopardy due to differences between RPCHs and CAHs in the method of Medicare outpatient payment for physician services. Webster County Memorial Hospital is investigating its various payment options for physician services. The hospital offers no inpatient long-term care services. Although conversion of unused space in the hospital to skilled nursing may have made sense, West Virginia is operating under a moratorium on the expansion of nursing home beds. Nevertheless, the excess space in the hospital was put to good use as hospital leaders sought to integrate all health services in the community at the hospital, creating a source of "one-stop shopping for health care" in Webster County. The Vertical, Within-Community Network The West Virginia EACH/RPCH Program required all RPCHs to conduct a study of the financial feasibility of conversion and an assessment of the needs of the community. Financed by a federal grant, Webster County Memorial Hospital employed a consultant to help it create a strategic plan which incorporated both studies required by the state. Using the plan as a blueprint, hospital leaders embarked on a process of health service integration that continues to this day. The first step in the process was to stabilize the medical staff. Following the financial incentives of the EACH program which allowed for cost-based payment for the professional as well as the technical component of outpatient services, the hospital hired two physicians to provide ambulatory care services using clinic space remodeled for them in the hospital. Webster County Memorial also successfully acquired the practices of the two private practice physicians in the community and hired three full-time equivalent physician assistants. The entire medical staff now provides services from the hospital-based clinic. Clinic services are available Monday through Friday until 9 p.m., and the medical staff rotates call in the emergency room, eliminating the need for the contract service. Prior to 1996, ambulance service in the county was provided by a private, for-profit firm. In that year, Webster County purchased the ambulance service and turned over the governance and operation of the service to the hospital. The county continues to provide the ambulance service with an annual subsidy of $65,000. The hospital maintains two full-time crews to staff its two ambulance substations. One ambulance is located in Webster Springs and the other is in a substation in Diana, a community nine miles to the north. Both ambulances are dispatched centrally. Noting that no home health provider existed in the county, the community needs assessment identified a need for home health services. Following the plan, Webster County Memorial Hospital obtained a Certificate of Need to operate a home health agency housed in the hospital. The hospital also became the "landlord" for other health services in the community. Recognizing that proximity is an important step in fostering greater levels of collaboration and as a means of promoting its concept of "one-stop shopping," the hospital, in 1993, offered the Webster County Health Department rent-free space in the hospital. The health department is governed by its own board and maintains a range of direct medical services including adult and child health services, immunizations, and health screenings. After it moved into the hospital, the health department and the hospital began to collaborate on some activities (such as the mobile van described below) and are alert for future collaborative opportunities. A willingness to collaborate notwithstanding, several barriers stand in the way of greater collaboration. The hospital would like to subsume many of the direct care services of the health department as a means of both reducing duplication of services within the community and positioning the hospital for managed care (i.e., controlling health promotion and disease prevention programs in the county). Unfortunately, in a time of diminishing funds, the health department views its direct care services as a means of subsidizing its core public health functions and, understandably, is reluctant to give them up. Approached in 1997 by a pharmacist to rent space within the hospital, the hospital also became landlord to a retail pharmacy. Operating under the name Highland Pharmacy, the pharmacy fills prescriptions and offers a variety of over-the-counter drugs and health care supplies as well as offering a small selection of sundries. The pharmacy is open evening hours. Highland Pharmacy is not the only retail pharmacy in Webster Springs. A pharmacy chain also operates a store in the community. The administrator of the hospital observed that prices at the chain pharmacy have dropped since the competing pharmacy was opened in the hospital. Two community social service agencies also make their home in the hospital, the Family Resource Network (FRN) and Women's Aid in Crisis. The Webster County Family Resource Network is a loose-knit confederation of social service agencies, health care providers, and the faith community funded by the West Virginia Families First Project (under an agreement with the Governor's Cabinet on Children and Families and the West Virginia Department of Health and Human Resources). Its purpose is to serve as a clearinghouse for families in need of services and as a catalyst for the production of new services to the community. The administrator of Webster County Memorial sits on the board of directors of FRN and credits FRN with reducing duplication of services and improving communication among health and social service providers in the county. One FRN project was the creation of a food bank. The food bank was initially located in and managed by the hospital. The success of the food bank necessitated its moving out of the hospital to larger quarters. The proximity of health care providers and social services agencies like the health department and FRN have provided opportunities for collaboration. Using money from a Small Cities Block Grant, the hospital, the health department, the Senior Citizens' Center, and Richwood Area Community Hospital (a small hospital in the adjacent county) collaborated on the establishment of a mobile clinic to serve isolated portions of Webster County. The mobile clinic is staffed by a physician assistant or nurse practitioner, a health department nurse, a social worker, and a senior citizen liaison. The enterprise is operated by an interagency management team. The partners have established a common clinic chart that is used by both the mobile van and the hospital. The mobile clinic is governed by many of the same quality assurance and operating policies and procedures used by the hospital-based clinic. The hospital also collaborated with the FRN and the school district in a joint venture to create a wellness center. Based on a desire for a "health club" identified in the community needs assessment, the hospital began to plan for a wellness center. The FRN and the school district were induced to participate in the venture, in part because the wellness center could be viewed as a place of family recreation in a community with few recreational outlets. In addition to exercise equipment and classes, the wellness center also provides training in CPR, nutrition, weight loss, smoking cessation, and other health-related topics. The wellness center is not located in the hospital. The Horizontal, Cross-Community Network As an RPCH, Webster County Memorial was required under the terms of the West Virginia EACH Program to designate an EACH, a full-service hospital that contracts with an RPCH for patient referral and transfer, to develop and use communication systems, and to provide emergency and non-emergency transportation. Webster County Memorial selected United Hospital Center in Clarksburg, West Virginia, to be its EACH. The relationship between the hospitals was formalized in two documents, a network affiliation agreement and a patient transfer agreement. These agreements only hint at the richness of the connection between the two hospitals. According to the Webster County Memorial administrator, the EACH relationship with United Hospital Center was "more valuable [to Webster County Memorial] than [the enhanced] reimbursement." In the first two years following conversion to RPCH status, Webster County Memorial had a management contract with United. In addition to placing a qualified administrator in Webster County Memorial, United helped recruit new physicians for the hospital-based clinics. United provided a variety of technical services to Webster County Memorial at no charge. It provided advice and training in quality assurance and peer review, patient billing, policy and procedure development, and biomedical engineering. It made available its legal staff to help review contract and structure issues related to the conversion. To help in the remodeling of the facility, United taught Webster County Memorial staff how to obtain and evaluate bids from contractors. United also made recycled equipment available to Webster County Memorial. United is also the retrieval site of Webster County Memorial's teleradiology service. As important as the relationship between Webster County Memorial and United is, it is not an exclusive relationship. Webster County Memorial also has referral relationships with other West Virginia hospitals. Which hospital a patient is referred to depends on the condition of the patient and, increasingly, the dictates of the patient's health care plan. Other Networks United and West Virginia University Hospitals have recently joined to form Health Partners, Inc., a managed care and direct care contracting entity composed of hospitals and their medical staffs. Through its link to United, Webster County Memorial and its employed physicians and mid-level practitioners are members of Health Partners, Inc. Health Partners, Inc., is in the process of developing a credentialing program to be used by all participating medical providers. Linking itself to a major player in the West Virginia provider market is strategically advantageous for Webster County Memorial. Health Partners, Inc., has not only the expertise to negotiate acceptable managed care contracts for its members, it has the clout to bring managed care companies to the table. Webster County Memorial's participation in Health Partners, Inc., is not purely an academic positioning exercise, because West Virginia is moving quickly into managed care. For example, the Public Employees Insurance Association (PEIA) in West Virginia provides health insurance coverage to all state employees, county employees, and school district employees. These three public entities are major sources of employment in rural areas, especially in areas where unemployment is high. PEIA is attempting to move to managed care throughout the state in the near future. Webster County Memorial will be able to contract with PEIA on the same basis as its much larger partners in Health Partners, Inc. Conclusion Webster County Memorial Hospital has, over the past five years, made steady progress toward its goal of creating "one-stop shopping" for medical services in Webster Springs. Many of the steps in achieving the goal were outlined in the strategic plan (community needs assessment) conducted prior to conversion to RPCH status. Despite the importance of this blueprint, the needs assessment merely provided hospital leaders with a detailed vision of what an integrated health system in Webster County could be. It was the job of hospital leaders to make the vision a reality. In the process of making the vision real, hospital leaders understood that it was not necessary to do everything at once nor was it necessary for the hospital to own all services. They added services and providers to the orbit of the hospital incrementally. In some cases, services were added following lengthy planning; in other cases, opportunities presented themselves to the hospital upon which leaders quickly capitalized. Some of the services the hospital owns and operates; some services are tied to the hospital through contracts; and other services are merely housed in the hospital. In every case, however, Webster County Memorial made incremental progress toward its goal of creating an integrated delivery system. Although community leadership is perhaps the key determinant in the success of Webster County Memorial's networking activities, the hospital's administrator also credits the roles played by grants, consultants, and the state Office of Rural Health Policy. At critical points in the development of the network, Webster County Memorial relied on grants. It used EACH program grants to begin the process and Small Cities Grants to purchase the mobile clinic and install T-1 lines for telemedicine linkages with United Hospital Center. Consultants were instrumental in the early portion of network development. The hospital would not have sought RPCH status if the financial feasibility study conducted by consultants had not shown that the hospital's financial status would improve by conversion. Through the needs assessment, the consultants provided hospital leaders with a glimpse of their possible future. And finally, the West Virginia Office of Rural Health Policy provided technical assistance and support to Webster County Memorial at every stage of development. The Networks of Webster County Memorial Hospital
Culbertson, Montana Located in Culbertson, Montana, Roosevelt Memorial Medical Center serves the approximately 1,500 residents of a 500 square mile area of northeast Montana. Twenty-three miles from the North Dakota border, where the Yellowstone River meets the Wide Missouri, Culbertson is 37 miles from Sidney, Montana (population 5,217), 43 miles from Williston, North Dakota (population 13,131), and 300 miles from Billings, Montana (population 81,151), its tertiary referral center. The closest community to Culbertson with more than 20,000 residents is Regina, Saskatchewan, 164 miles to the north. A town of 900 residents, Culbertson is surrounded by farms and ranches that specialize in growing wheat and sugar beets and in raising cattle and sheep. The town is located in the eastern portion of Roosevelt County, approximately five miles from Big Muddy River, the eastern border of the Fort Peck Indian Reservation. The Missouri River forms the southern border of Roosevelt County. The county is almost 90 miles wide and the river is spanned by only three bridges. Not only is Culbertson physically isolated, but its isolation is exacerbated by weather. The winters in this part of the country are long and harsh, often making travel over secondary roads extremely hazardous. The Hospital Some form of institutional health care has been provided in Culbertson since the turn of the century. In 1954, the residents established Roosevelt Memorial Hospital. In 1977, they built a new, combined facility which offered 14 acute care beds and 40 long-term care beds. The hospital currently operates as Roosevelt Memorial Medical Center (RMMC), one of three hospitals in Roosevelt County. RMMC serves primarily the residents of a hospital district composed of three contiguous school districts. RMMC is a not-for-profit community hospital which receives the proceeds of a mil levy from the district. The amount of the mil levy is determined annually; it typically ranges between three and six mils (at three mils, the annual proceeds would equal approximately $70,000 in today's dollars). In 1992, following several years of poor financial performance and difficulty recruiting and retaining physicians, RMMC was licensed as a Medical Assistance Facility (MAF), a form of limited-service hospital operating in Montana as a demonstration project funded by the Health Care Financing Administration (HCFA). Licensed as an MAF, the hospital receives cost reimbursement for Medicare and Medicaid patients and can provide services to inpatients and emergency room patients with mid-level providers when physicians are not available. At the time of the conversion, the facility altered its bed capacity slightly to its current complement of 10 acute care beds, 6 swing beds, and 44 long-term care beds. At the time of conversion, RMMC decided to stop its inpatient surgery services. The hospital had halted its obstetric service several years earlier. In its current configuration, RMMC provides radiology, laboratory, physical therapy, and 24-hour emergency room service. The radiology department is linked to a hospital-based radiology group in Glasgow, Montana, by a teleradiology system. Radiologists from the group visit RMMC two times per week to conduct radiological procedures and to over-read films. Mobile ultrasound and mammography are available to RMMC on demand from the same radiology group. A pathologist from Williston, North Dakota, provides supervision, training, and services to the hospital and is present in Culbertson at least one day per month. Pharmacy services are provided by a consulting pharmacist who owns a retail pharmacy in town. The Vertical, Within-Community Network Vertical integration of health services in Culbertson began before conversion to MAF status and has continued since conversion. In 1989, Roosevelt County, which had been the only ambulance provider in the county, decided to divest itself of its ambulance services, and gave each of the three hospitals within its borders one of its ambulances. Capitalizing on this opportunity to operate its own emergency medical service, RMMC leased two additional ambulances from the Fort Peck Tribal Health Service. Relying in part on a Rural Health Transition Grant, RMMC built an ambulance shed in Culbertson to house two ambulances and located the third ambulance in Froid, Montana, 13 miles to the north, in a shed donated by the town. These funds were also used to purchase defibrillators and improve training for local EMS staff. A defibrillator was placed in each of the three ambulances and two additional defibrillators were placed in decentralized locations within the service area. Because of its remote location, RMMC relies heavily on air ambulance service to move critical patients to Billings. A city-owned airport is located approximately 100 feet from the end of hospital property. Fixed-wing air ambulances from either Glasgow or Billings evacuate patients from Culbertson to one of two referral hospitals in Billings, a trip of approximately one hour duration. In comparison, ground travel to Billings from Culbertson, in good weather, would take approximately four-and-one-half hours, Montana's liberal speed limit notwithstanding. With an 80/20 grant from the Department of Transportation, RMMC purchased a 14-passenger van to provide non-emergency transportation within the service area. The van is used to transport area residents to doctors' appointments in Culbertson and is also used to transport area residents the 43 miles to Williston or the 37 miles to Sidney to see specialists. Prior to 1990, Culbertson and the surrounding area had obtained home health services under a unique arrangement from a provider in Poplar, Montana, 33 miles west of Culbertson. The Poplar provider had obtained a Certificate of Need that allowed it to provide home health services from two locations, one in Poplar and one in Culbertson. RMMC administered the Culbertson branch of the service. Following several years of logistic and administrative problems providing home health services under this arrangement, RMMC applied for a Certificate of Need to operate its own home health agency. The RMMC home health agency has operated successfully for eight years, but this year it is beginning to feel the stress of changes in Medicare payment policy. When the hospital converted to MAF status, its only physician was in the process of moving from the community. (The decision to leave Culbertson was unrelated to the hospital's decision to convert to MAF status.) RMMC purchased the practice of the physician (accounts receivable, patient records, and office fixtures) and formed a Medicare-certified provider-based rural health clinic (RHC). During the six months it took to recruit another physician, the RHC was staffed by locum tenens physicians and a single physician assistant (PA) supported by physicians in Williston and Sidney. Today RMMC employs one full-time, board-certified general internist, one full-time PA, and one part-time PA. RHC services are provided in the MAF in seven nicely appointed treatment rooms. No other physicians or mid-level practitioners provide services within the primary service area. Due to the size of the county and the difficulty of providing public health services from a single location, RMMC contracts directly with the Montana Department of Public Health and Human Services to provide some public health services to the eastern part of the county. RMMC provides WIC and immunization services, and it has a contract with the county to provide Meals-on-Wheels to Culbertson residents. No medical specialty clinics are offered in Culbertson. Some satellite specialty clinics from Billings and Glasgow, Montana, are offered in Sidney and some medical specialists practice in Williston. Visits to specialty clinics in Sidney and Williston are arranged for patients by the staff of the RHC. Through an arrangement with Mercy Medical Center in Williston, RMMC is in the process of establishing an on-site ophthalmology clinic. Rural Health Transition Grants helped fund the planning for the ophthalmology clinic and the purchase of equipment for the service. The Horizontal, Cross-Community Network Montana's administrative rules governing MAFs require that they have transfer agreements with full-service hospitals and that they assure that patients needing levels of service other than those provided by the MAF (skilled nursing and home health are cited as examples) will be appropriately referred. Services required of MAFs but not provided by them on-site (e.g., registered dietician services) must, by agreement, be provided by consultants either on-site or at other locations. These written agreements, in many cases, merely document long-standing informal cross-community relationships that have existed for many years. By one count, RMMC has 18 provider agreements that formally document its cross-community structure. Arguably the most important of these network relationships are the ones with referral hospitals. Unlike the EACH/RPCH program which attempted to focus referral of RPCH patients on a single larger hospital (the EACH), the MAF demonstration project encouraged patient transfer relationships that were more organic in nature. The referral hospital to which an RMMC patient ultimately is transferred depends on the diagnosis and preferences of the patient. RMMC has transfer agreements with local full-service hospitals in Williston and Sidney, as well as both hospitals in Billings. Mercy Medical Center in Williston provides RMMC with certain clinical services, such as clinical dietary consultation and biomedical engineering. Other Networks RMMC participates in three other networks that are of growing importance to eastern Montana hospitals. The first is the Montana Health Network, a horizontal network of some 20 hospitals formed in 1987. With the exception of Deaconess Billings Clinic (an integrated delivery system formed by the merger of Billings Deaconess Hospital and the Billings Clinic), all of the hospitals in the network are located in rural areas. The stated goals of the network are 1) to improve the quality of rural health care, and 2) to improve access so that area residents do not have to travel so far to receive needed care. The Montana Health Network offers a variety of services and products to its members. Among the services are employee benefits purchasing, marketing research, legal services, repair services, and health care personnel recruiting. Member hospitals have shared the costs of speakers and consultants and have exchanged staff to increase knowledge and expand training opportunities. RMMC participates in a self-insured health insurance program for employee benefits (six participating facilities) and a joint workers' compensation program through the network. RMMC will also purchase directors' and officers' insurance through the network when the product, currently in design, is made available. The administrator of RMMC serves on the Board of Directors and the Executive Committee of the Montana Health Network. The second network in which RMMC participates is the Eastern Montana Telemedicine Network. Established in 1994 with the assistance of grant funding, this network connects all eight members in a video network. Deaconess Billings Clinic is the hub of this system. Used primarily for educational purposes, it is also used for consultations with specialists in Billings to confirm diagnoses and the appropriateness of admissions to RMMC. The only telemedicine provider in the county, RMMC has made its facilities available to county-based mental health providers and Fort Peck Tribal Health Service providers. The telemedicine services have also been made available to community groups as well, such as the school district, National Guard, local banks, and the Girl Scouts. The third network, the Linked Provider Network, is a managed care and direct care contracting entity composed of hospitals and their medical staffs organized by Deaconess Billings Clinic. The Linked Provider Network contracts with managed care organizations on behalf of its members. Both RMMC and its employed providers participate in the network. The network is developing a common protocol for credentialing medical providers throughout the network. Although managed care patients currently are not a large segment of RMMC's patient base, participation in the Linked Provider Network positions the hospital and its medical staff to benefit in the future from the terms of managed care contracts negotiated on their behalf by a powerful partner. Conclusion The web of formal relationships that constitute RMMC's networks has evolved over a ten-year period. Conversion to MAF status was not the catalyst that drove RMMC to network, but it provided the hospital with financial stability and regulatory flexibility which allowed the hospital to continue to develop its integrative efforts within the community and to reach out beyond the community. The primary costs of network development to RMMC have been the time it has taken to create the arrangements. Grant funding from various sources has helped to defray the cost of some program development. The hospital has benefitted from Rural Health Transition Grants, Telemedicine Grants, and Department of Transportation Grants. RMMC has made sparing use of consultants: a financial feasibility study was conducted prior to MAF conversion; assistance was provided in planning for and establishing the rural health clinic; and legal assistance to create or review agreements was obtained. Support of the Board of Directors has been key to the development of RMMC's network development. Board members have consistently pursued their primary goal: to keep health services in the community. Stating their understanding that the hospital is too small to survive as a stand-alone facility, the Board has approved all steps necessary to assure survival. Deaconess Billings Clinic, the major player in four of RMMC's networks, is viewed favorably by the board members. Deaconess has been supportive and has never attempted to take control. Based upon favorable experiences to date, the board feels that networking is not a threat, [but] a life saver [for the institution]. The Networks of Roosevelt Memorial Medical Center
Lakin, Kansas A community of approximately 2,300 residents on the high plains of southwestern Kansas, Lakin is the county seat of Kearny County and lies just north of the Arkansas River. Historically, the economy of Kearny County was dominated by wheat and small grain farming, but today the economy has become increasingly diverse. In addition to crop production, the county relies on natural gas, feed lots, packing plants, and manufacturing. The place of business of some of these industries is Garden City (population 24,097), located in neighboring Finney County. The proximity of Garden City to Lakin (23 miles) assures that some residents of Lakin and greater Kearny County seek employment in Garden City. One hundred and fifty years ago, the Santa Fe Trail, a commercial route linking merchants of the burgeoning United States with newly independent Mexico, traversed Kearny County. Still a cultural crossroads, numerous residents of Kearny County today speak Spanish or German as their first language. Always the home of immigrants from Mexico, Kearny County recently has experienced an increase in immigration from Latin America, and nearby Garden City has experienced an influx of residents from Southeast Asia (Vietnam, Laos, and Cambodia). This recent tide of immigration has caused health care and social service providers of the area to develop new programs to meet the needs of culturally diverse residents of southwestern Kansas. The Hospital As the name suggests, Kearny County Hospital is owned by the county. Built in the early 1950s, the old hospital buildings were replaced in 1978 by a new hospital built on the edge of town. With its 26 licensed acute care beds, the hospital shared a campus with a 40-bed county-owned nursing home, High Plains Retirement Village. Although these two facilities remain physically separate and maintain separate boards of directors, they currently share administrative staff and some clinical staff. Kearny County Hospital is a critical access hospital, which previously had been licensed as a rural primary care hospital (RPCH) under the Kansas Essential Access Community Hospital (EACH) Program. It currently operates 15 acute care beds and is licensed to operate 25 swing beds. The decision to convert from "full-service-hospital" status to RPCH status was not made lightly. Hospital leaders harbored considerable anxiety about participating in an evolving federal program. In the second wave of hospitals in Kansas to convert to RPCH status (conversion occurred in late 1996), Kearny County Hospital became a RPCH only after evaluating the performance of other Kansas RPCHs and undergoing a financial feasibility study, which the administrator of the facility judges as being "critical" to the decision to convert. Today the hospital offers radiology, laboratory, physical therapy, and 24-hour emergency room services, in addition to acute care and long-term care in swing-beds. The hospital is also served by mobile technologies (ultrasound, mammography, osteoporosis screening, and CT) from either Garden City, Wichita, or Topeka. Dialysis services are also provided in the hospital by a service based in Wichita. The hospital recently reintroduced obstetrics and limited inpatient surgery services to the hospital. An obstetrician-gynecologist resides in Kearny County and practices part-time under an agreement with the hospital in a clinic owned by the hospital. Gynecological procedures (e.g., tubal ligations), minor orthopedic procedures (performed by an orthopedic surgeon from Garden City), and "scope" procedures are performed according to an established schedule. The services of a certified registered nurse anesthetist who resides in Lamar, Colorado (90 miles west), are provided under contract. In addition to the obstetrician-gynecologist, the active medical staff of the hospital is composed of one family practice physician and two nurse practitioners, all of whom are employees of the hospital and practice in the Family Health Center, a medical clinic connected to and owned by the hospital. One additional family practice physician is scheduled to join the medical staff in late summer 1999: however, the clinic will lose one nurse practitioner in March 1999. Due to its proximity to Garden City, there are few specialty clinics offered in Lakin. A satellite orthopedics clinic is held in Lakin, perhaps reflecting the level of competition among orthopedists in Garden City. A podiatry clinic is also offered. The Vertical, Within-Community Network The adjacency of Kearny County Hospital and High Plains Retirement Village and their common ownership by the county made vertical integration of the two facilities highly desirable, if not inevitable. Administration of the facilities was combined in 1987, which reduced costs and increased coordination between them. The nursing home has diversified its services, designating ten units as an assisted living center. The hospital and the nursing home have engaged an architect to design site and facility plans to expand and link the two facilities. Linkage of the two facilities will improve economies of operation (e.g., a single kitchen and dining service to serve both facilities) and allow for the creation of new or expanded services (e.g., enlarged special care services for nursing home residents with dementia and expanded assisted living units, including units designed for residents with dementia). The facilities are also evaluating the merger of their governing boards. In 1990, six years before converting to RPCH status, Kearny County Hospital constructed the Family Health Center, a nine-treatment-room clinic attached to the hospital. The Family Health Center was created by the community to help improve retention of physicians, and to reduce unnecessary duplication of laboratory and radiology services in the community. The entire staff of the Family Health Center is employed by the hospital. The Family Health Center provides services Monday through Friday and is open on Saturday mornings for walk-in patients. Two dentists (the only ones in the community) rent office space in the Family Health Center. Kearny County owns the ambulance service and the county commissioners provide its governance. At the time the hospital converted to RPCH status, county leaders evaluated the potential benefits of merging the county EMS service with the hospital. Sensitive to the expanded liability the hospital might face under the EACH Program (especially in circumstance when an ambulance attendant would chose to bypass the RPCH to take a patient directly to the emergency room of St. Catherine Hospital in Garden City), the hospital and the ambulance service decided to remain separate entities. This decision, however, did not mean that the two providers could not cooperate. Indeed the ambulance service and its four full-time employees are housed in the hospital. The fleet of four ambulances is decentralized with three of them located at the hospital for emergency dispatch and patient transfers and one located in Deerfield, a small community nine miles to the east of Lakin. Home health services are provided to the residents of Kearny County by a home health provider based in Garden City. To serve patients in Kearny County, the home health provider contracts with Kearny County Hospital for nursing staff, and the hospital provides the home health agency with an office and storage facilities in the hospital. In May 1996 the only retail pharmacy in Lakin closed its doors, and in June 1997 the long-time manager of the hospital pharmacy retired. The hospital successfully recruited a consulting pharmacist to provide pharmacy services to the hospital and in late 1998 induced him and his partner to open a retail pharmacy in the hospital. Located just inside the main entrance of the hospital, the retail pharmacy fills prescriptions and offers a variety of over-the-counter medicines and health products to the people of the county. In addition to providing a service to the community at large, the location of the pharmacy in the hospital expands the availability of in-house pharmacy services for patients of the hospital. The Horizontal, Cross-Community Network As an RPCH, Kearny County Hospital was required by the Kansas EACH Program to select an EACH. Kearny County Hospital selected St. Catherine Hospital in Garden City. The two hospitals formed the Southwest Kansas Rural Health Network and formalized their relationship in a series of written agreements They negotiated a network agreement, medical staff and communication protocols, a memorandum of understanding concerning medical staff credentialing, and referral and transfer protocols (which include provisions for problem resolution and quality assurance) among others. The administrator of the Kearny County Hospital views telemedicine as the heart of its extra-local networks. One of its primary telemedicine linkages is with St. Catherine Hospital in Garden City. The emergency rooms of the two facilities are linked by interactive video. Established in early 1997, the goal of the Joint Telemedicine Program was to "enhance non-emergency [emergency room] coverage for Kearny County Hospital using St. Catherine Hospital support services." The telemedicine system employs two video cameras, one wide-angle camera at the end of an emergency room and one track-mounted, high-resolution camera capable of moving up and down the length of an emergency room cart. The video equipment also connects to otoscopes and stethoscopes for aid in long-distance diagnosis. The system is used for non-emergency patients who present to the emergency room between 10 p.m. and 6 a.m. when Kearny County Hospital medical providers are on call. Protocols for the use of the system have been agreed to by both hospitals. Following an assessment of the patient, nursing personnel at Kearny County Hospital contact emergency room personnel at St. Catherine Hospital's emergency room and a telecommunications linkage is established. The emergency room physician at St. Catherine Hospital examines the patient via the video connection, confers with the Kearny County Hospital nurse, diagnoses the patient, and orders a course of treatment. All of the emergency room physicians of St. Catherine Hospital have medical staff privileges at Kearny County Hospital. Both hospitals contributed to the capital costs of the system (approximately $115,000); St. Catherine Hospital contributed approximately 70 percent of the total capital cost and Kearny County Hospital approximately 30 percent. A portion of the funds were made available through EACH Program grants. The annual operating costs (approximately $20,000) of the system are shared equally. St. Catherine Hospital also receives the teleradiology images sent by Kearny County Hospital. The hospital maintains a second telemedicine linkage. This one was established in 1992, using a Rural Health Transition Grant. Located in a non-clinical area of the hospital, it is used primarily for nursing and medical continuing education. The system links Lakin with University of Kansas Medical Centers in Wichita and Kansas City, Kansas (although the system also allows any two participants in the state-wide system to connect to each other). Through the use of this telemedicine connection, Kearny County Hospital and its physicians have been able to offer specialty clinics and obtain consultation in a number of services previously unavailable locally, including dermatology, neurology, rheumatology, child psychology, and pediatric cardiology. To the extent possible, Kearny County Hospital and St. Catherine Hospital have attempted to share supervisory and consulting positions. When supervisory positions at Kearny County Hospital become available, the hospitals evaluate whether the vacancy can be filled by expanding the job responsibilities of the person in the parallel position at St. Catherine Hospital. While it has not always been possible to share staff in this way, there have been some successes, most notably in the dietary department. Quality assurance representatives from the two facilities monitor transfer-related aspects of care and meet quarterly to review monitoring reports and recommend corrective action. The representatives discuss ongoing quality issues related to the transfer of patients between the facilities and share ideas and support the overall quality assurance activities of both facilities. Recommendations from this team of representatives are channeled through the quality assurance systems of each facility. Other Networks Kearny County Hospital is a member of the Pioneer Health Network (PHN), a horizontal network formed in 1990 of 17 hospitals that serve the approximately 150,000 residents of western Kansas. Kearny County Hospital joined PHN in 1995. PHN members engage in shared education projects, group purchasing (e.g., oxygen, biomedical engineering services), joint physician recruitment, and shared strategic planning. The network is also viewed as a forum for discussing emerging trends and "brainstorming" about health care delivery and financing issues. The network is exploring the possibility of offering itself as a middle-tier contracting entity interposed between managed care companies and member hospitals and their medical staffs. Because a sizeable number of Kearny County residents are employed by firms that purchase health care benefits from managed care organizations (e.g., the natural gas producer and a regional meat packing firm), Kearny County Hospital and the Family Health Center treat a growing number of patients who are enrolled in PPOs and HMOs. In April 1998, PHN obtained a one-year grant from the Kansas Health Foundation to conduct a cultural diversity project. Collaborating with the United Methodist American Ministries (MAM) and Garden City Community College (GCCC), PHN agreed to "identify barriers [to children's health care] and to act on solutions to remove barriers to health care services." MAM, in conjunction with the Department of Anthropology at the University of Kansas, was charged with identifying cultural barriers to children's health in southwest Kansas; PHN is responsible for developing action plans for overcoming the barriers identified by MAM; and GCCC was charged with developing cultural-sensitivity training programs for the hospital and medical staffs of PHN-member institutions. Kearny County Hospital also participates with a subset of three other PHN members in a horizontal network known as the Medical Executive Staff Committee. The member hospitals of the committee are Kearny County Hospital, Hamilton County Hospital (Syracuse, Kansas), Greeley County Hospital (Tribune, Kansas), and Wichita County Hospital (Leoti, Kansas). Meeting every other month, the medical staffs of these four hospitals engage in joint peer review activities. (Kansas law requires hospitals with small medical staffs to cooperate in peer review.) The stated purpose of the committee is to comply "with risk management statutes and to evaluate and improve the quality of health care services provided within its member hospitals." The committee also engages in joint recruitment efforts. The combined active medical staffs of the four member hospitals total seven physicians and five mid-level practitioners. Finally, Kearny County Hospital has integrated the information technology of the hospital, the clinic, and the nursing home using software and support services provided by Stormont-Vail Regional Medical Center in Topeka under contract. Kearny County Hospital would prefer to participate in a regional information network with St. Catherine Hospital, but its relationship with Stormont-Vail predates St. Catherine Hospital's ability to support Kearny Hospital with information technology services. Recognizing the importance of management information for planning, marketing, and quality management, Kearny County Hospital (as a member of Pioneer Health Network) participates in the Garden City Information Technology Cooperative, an organization whose members include Garden City school districts, Garden City Community College, Finney County government, and St. Catherine Hospital. Members of the cooperative share a cadre of hardware and software technicians to support information system development. Conclusion Kearny County Hospital itself is not greatly diversified and yet it has become the lynchpin for a system of integrated health services delivery in Lakin. Primary care services were integrated with the hospital when the Family Health Center was built and the hospital employed the medical staff. The county-owned nursing home and ambulance service maintain separate governance structures, yet operationally, they have been integrated into the hospital. By providing space and staff, the hospital influences the delivery of home health services in the county without owning them. By providing space to the retail pharmacy in the hospital, Kearny County Hospital assures the availability of pharmacy services not only to itself, but to the nursing home, the primary care practice, and the entire community. The success of Kearny County Hospital at integrating these elements of care illustrates that it is not necessary to own all of the elements of an integrated delivery system to offer the residents of a service area a seamless continuum of services. The administrator of Kearny County Hospital greatly values the linkage with providers outside of the community made possible by telemedicine. He believes that telemedicine can help overcome the isolation felt by many rural physicians and nurses. Various staff members of the hospital can site specific examples of when telemedicine was used to make or conform a diagnosis. Like many rural hospitals, the environment of Kearny County Hospital is changing. Two of the major changes are the expansion of industrial workers covered by managed care agreements and the increased cultural diversity of the population. Unwilling to be simply a witness to these changes, Kearny County Hospital, through the Pioneer Health Network, is beginning to confront these forces by the creation of a managed care contracting entity and by programs that sharpen its understanding of the meaning and consequences of cultural diversity and the impact of cultural diversity on health services delivery. The Networks of Kearny County Hospital
The three cases presented here show the variety of rural health networking possibilities. The networking activities these three hospitals engage in run the gamut from local integration of health services, to telemedicine, to managed care contracting, to group purchasing. Arguably the smallest and most frail of rural hospitals -- the very hospitals the Medicare Rural Hospital Flexibility Program was designed to help -- they successfully use networks to help them manage their environments. Despite dissimilarities among the hospitals and the communities they serve, there are many similarities in their networking behavior. All three hospitals have greatly integrated services within their communities, creating "one-stop shopping" for medical services within the communities. All three employ their medical staffs, a step the administrators view as important to future integration activities. All three hospitals also participate in telemedicine networks, with two of them being linked to academic health centers. Two of the three are members of a super-PHO that contracts on their behalf with managed care organizations, and the third hospital participates in a network that is attempting to establish joint managed care contracting capability. And two of the three are linked to other small rural hospitals in a horizontal network that predates their conversion to limited-service rural hospital status. Several other observations about the networking behavior of these hospitals may be drawn:
Case study contacts: Steve Gavalchik, CEO Walter Busch, Administrator Steve Reiner, Administrator Other Rural Health Network Resources: American Hospital Association, Critical Access Hospitals, Chicago: American Hospital Association, April 1998. (Includes five case studies from the EACH and MAF Programs.) Bogue, R. and C. Hall (eds.), Health Network Innovations: How 20 Communities are Improving Their Systems Through Collaboration, Chicago: American Hospital Publishing, Inc., 1997. (Includes nine examples of rural health networks.) Moscovice, I., A. Wellever, J. Christianson, M. Casey, B. Yawn, and D. Hartley, Rural Health Networks: Concepts, Cases, and Public Policy, Minneapolis: University of Minnesota Rural Health Research Center, April 1996. (Includes six rural health network cases studies.) |
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