All sites please stand by. Today's teleconference is about to begin. Hello and welcome to the RHCTA teleconference. At the request of the company, this call is being recorded and if you have any objections, you may disconnect at this time. All lines will remain in the listen-only mode until the question and answer session.

At this time, I would like to turn the meeting over to our leader, Mr. Craig Williamson. Sir, please go ahead.

C. Williamson

Sure. Hello, everyone and welcome to the third and final in a series of three conference calls on Rural Health Clinic Quality Improvement. My name is Craig Williamson and I'm doing a Fellowship here at the Office of Rural Health Policy.

We're going to start today's call with some news from CMS about the status of the rural health clinic regulations and after that, we're going to finish up our discussion about quality with a presentation on the Role of Health Literacy in Quality Improvement by Linda Johnston-Lloyd, who is chair of the HRSA Health Literacy Work Group. And finally, we're going to respond to several of the questions that the office has received from people and we're going to talk about funding resources that are available for RHC quality improvement. Kristine Sande, Program Manager of the Rural Assistance Center, will describe how RHC's can use RAC as a resource to identify funding sources and other information to support QAPI programs. And I'm going to talk briefly about a few other funding programs, federal and non-federal, that are available for RAC quality improvement.

The call is scheduled to last about an hour and fifteen minutes. There is some time built in if there are additional questions. And we'll be stopping along the way after sections to take questions from audience and also, there will be a final question and answer time at the end.

A recording of this call is available if you would like to listen to it again afterwards. You can dial 1(800) 262-4859 and within a few days, we'll also have a transcript up on the Office of Rural Health Policy Website.

So, with that said, I'm just going to go ahead and turn things over to David Worgo from CMS. David?

D. Worgo

I guess I have just a quick announcement to make and I suspect that some of the participants already know this. CMS has recently decided to suspend implementation of the Rural Health Clinic Rule that was published on December 24, 2003. Consequently, CMS regional offices and state surveying agencies should not disqualify clinics that no longer meet basic location requirements, i.e., rural and underserved, from the rural health clinic program. Furthermore, they should not enforce the quality assessment and performance improvement program.

We hope very soon to formally communicate this in writing to our regional offices and state surveying agencies.

B. Finerfrock

Yes. Will that be on in the federal register, then, David? This is Bill Finerfrock.

D. Worgo

To the best of my knowledge, we will not communicate this with - it appears at this point, we do not need to issue a notice in the federal register.

B. Finerfrock

Will there be a letter?

D. Worgo

Well, as I just mentioned, I think our plan is to communicate this in writing to the regional offices in the state surveying agencies.

J. Suber

This is Jackie Suber. We did announce last month at our Central Office/Regional Office Rural Health Clinics call that we have nationally every month to all our regional offices to disseminate this information down to our state surveyors. And monthly, we have discussions on this issue, which we'll be meeting again on Friday for further clarification for the regions and the states on this matter.

B. Finerfrock

What I'm - I think we need something in writing, whether it's a regional office letter or a surveyor letter that can be made available to clinics, because folks aren't going to believe it just because they've been told that by me or by a State Office of Rural Health or somebody else like that. We're going to need - … say I need something in writing. And to the extent that you do a letter to the regional offices or to a surveyor and you can make that letter public, that we can then distribute, I think would be extremely helpful.

D. Worgo

That is our plan. We realize we need to communicate this in writing.

B. Finerfrock

Will that letter be available?

J. Suber

If the letter is a Survey and Cert letter, those letters are available on the CMS/Medicare Website.

B. Finerfrock

Okay. And can we get a link to that at some point? Or where do we find that?

J. Suber

Well, I'm not definitely sure if it's going to be a letter coming from Survey and Cert or from CMM. But if it does come from Survey and Cert, we'll give that link to Craig's office so he can put it up on the Website.

B. Finerfrock

Great.

C. Williamson

And Jacqueline and David, to the best of your knowledge, sort of, how is CMS expecting or planning to proceed from here after the regulation is withdrawn? When can clinics expect to see further action on revising and putting out additional reg if that's what the intention is to do?

D. Worgo

Well, let me see if I can explain where we're at at this point. Some members of Congress have questioned whether the final REC rule is in compliance with the MMA, specifically Section 902, which requires CMS to issue regs or publish regs in a timely manner, within three years. As I understand, we have suspended implementation of this rule to give CMS and our general counsel additional time to review and evaluate those concerns.

If CMS concludes that we need to reissue this final rule, I suspect we will reissue it as a Notice of Proposed Rulemaking and that rule may contain additional updates and changes. In other words, it may go beyond just reissuing the final RHC rule that was published on December 24th.

C. Williamson

Okay, thank you very much, David.

D. Worgo

Okay.

B. Finerfrock

Sorry, Dave. What you just said is a little different than what I think the impression that at least has been out there, which is, you're saying that this is a suspension in order to review whether the rule was in compliance with the statutory provisions of the Medicare Reform legislation. And that a decision with respect to compliance with that had not been made and one possible action would just simply be a lifting of the suspension and the immediate implementation of what was issued on December 24th?

D. Worgo

I guess what we're saying, Bill, is that we are evaluating these concerns and if we conclude that we're in violation of this new provision in the MMA, the likely outcome will be to reissue the final rule. But let me see if I can add to that.

The decision to reissue, it will be made - there's several layers. You have CMS, you have the Department, you have OMB and all I can tell you at this point is that at the CMS level, we're evaluating this issue and there is a possibility we're going to reissue. But there's no guarantee that as it works its way up the process up to the Department of LNB, I cannot guarantee that it will be reissued. I guess that's what I'm saying.

C. Williamson

Well, David and Jacqueline, thank you very much for coming on and making the announcement and letting people know what the status with this.

I think we're going to go ahead and move on with the agenda. And I mean, just sort of emphasize that no matter what happens, RACs are still going to have some form of quality required. It may not be identical to the QAPI requirement that came out now, we'll just have to wait and see what that is. But we'd like to go ahead and sort of finish up this series of calls and fill in a little bit of gaps of what our discussion about RAC quality has been so far.

So I'm going to go ahead and turn things over to Linda Johnston-Lloyd to talk a little bit about health literacy and its role in quality improvement, and we're going to move on and then talk for a while about some funding sources that RACs have to do quality improvement activities.

D. Worgo

Craig, do you mind if I make one more -

C. Williamson

Sure. Go right ahead.

D. Worgo

If, under the scenario where we do reissue the final rule as a Notice of Proposed Rulemaking, I suspect that the intent of reissuing that rule is to open up these final provisions for additional comments, public comments. And our intent will be to allow the public, the RHC industry to comment on issues that they were not given an opportunity to comment on such as any new policies that were established in that final rule. And the point I'm trying to make is that the basic provisions and the basic requirements under the BBA and under this final rule, if we do reissue, will not be going away.

It sounded, by your description and your segue into this next topic, it sounded like you were implying that some of these requirements were going to go away.

C. Williamson

No. That's an excellent point, David. Thank you for filling in. The quality requirement is part of the BBA and RHCs are still going to have to have a quality improvement program of some kind. And you bring up a great point that RACs may have an opportunity now to give CMS a little more comment and input onto what the form of the regulations should be. So, thank you for filling us in on that.

David, Jacqueline, do you guys have any final comments before we hand things over to Linda?

J. Suber

Actually, Craig, I do have one final comment. I did want to remind all the rural health clinics that Phase 1 of the BBA requirements - there were two specific provisions that required implementation that was not contingent upon the regulations and we have had some gray areas, some cloudiness with understanding of that and I want to make sure that everyone understands that even though this regulation is suspended, if it's withdrawn, that the two provisions of the refinements of shortest area requirements and the mid-level staffing waivers, specifically with the refinement of shortage area, it was implemented in January 1, 1998, that only participating rural health clinics in outdated shortage areas will continue to be grandfathered and protected from certification. New applicants for rural health clinic status must be in a current, shortage designation that is a HPSA, MUA or government designation, in order to come into the program.

The second provision was the provision for staffing waiver for mid-level providers. Only participating rural health clinics can request a waiver. The new applicants cannot come on board the program requesting a waiver for mid-level provider.

C. Williamson

Okay, thank you, Jacqueline. That was also a very important point. Alright. Well, let's go ahead and there will also be a time for open questions at the end of the call. So if listeners have additional questions, hold off on those until we get through these presentations and there will be some open time for question and answer.

Linda, why don't you go ahead and take things away, then?

L. Johnston-Lloyd

Thank you. Good afternoon to everybody. I wanted to start by giving you some history on where health literacy has come in the departments since the fall of 2002.

We have, here at HRSA, in the fall of '02, we took the lead - well, actually, I was asked to take the lead on the Healthy People 2010 Objective on Health Literacy, so we started working internally to create an awareness of the topic here in HRSA. And then in January of '03, we had officially established a workgroup, which was representative and is still representative of the offices and bureaus across the agency.

In April of 2003, about a year ago, the IOM began their study on Health Literacy, the yearlong study. In September 2003, the secretary came out with a statement that said, "The health of our country depends on how people can understand basic health information to live their lives in a healthy way."

So Secretary Thompson has now continued to emphasize health literacy and had recently included it in his annual conference, Steps to a Healthier U.S. And at that conference, there was a blueprint for action release and within that document there are action steps for health literacy.

So in a little more than a year, we've come a long way. I believe that we're at the tipping point now where we're going to hear health literacy mentioned everywhere we go, in every newspaper and it should become just part of our daily life.

And you all are in a position to really help us with this, because you reach out to the rural areas of … who are not always on the low end of health literacy, but certainly have a need for letting us know what is important to them and how we can help them and how we can make it easier for them to access care. And that's what I want to start to talk to you about today.

You have the slides and basically, my job here has been to really look at how we can link health literacy to quality. And there's no doubt in my mind or anybody else's mind that it's not an important component of quality of health care and of the mission of HRSA, of which you are all a part of.

There's several definitions for quality health care and I've highlighted the ones that I think really make a case for its link to health literacy. And if you look at the IOM study, the IOM definition, where they talk about providing health services for individuals and populations in a quality manner increases the likelihood of desired health outcomes. And that's what we're talking about. If we're working with people with limited literacy, how can we make sure that they have the outcomes that we'd like to see? How can we make sure that we avoid medical errors and that we continue to provide quality care?

Another definition is from a later IOM study, which was, Crossing the Quality Chasms and that is "good quality means providing patients with appropriate services in a technically competent manner." But more importantly, it goes on to say, "with good communication, shared decision-making and cultural sensitivity" which is really one of the key points of health literacy; making sure that we value the patient's gender, ethnicity, and their culture and are cognizant of their needs.

In that same definition, the Institute of Medicine described components of quality health care meaning, "safe, effective, patient-centered, timely, efficient, and equitable." And if we're working with people of limited literacy, we really need to look at those components and see how we can work with them more successfully to make sure that we are providing patient-centered care and that it is effective and equitable.

Sometimes physicians feel like they're hanging on a cliff, or maybe the patient's feel like they're hanging on a cliff and there's an actual group in Australia called the Royal Flying Navy and I used one of their cartoons, which is actually a cartoon that is featured in some of the Australian newspapers on a regular basis. But these doctors fly out to the outback area to provide health care. But I think oftentimes the patients and health care professionals become frustrated and they may feel like they're hanging off the cliff, and where do I go from here and how can I help that person, or what do I ask the doctor?

The really simple definition for quality health care that AHRQ, the Agency for Heathcare, Research and Quality used in one of their publications is, "Doing the right thing at the right time in a right way for the right person." And that, really, is looking at the patient and the person and all aspects of that person. Not just whether they can read, but what their culture is, what their values might be. Do you have the ability to hear what they're saying, etc.?

And then that brings us to if we think about the concept of quality, and then as I continue, just try and go back to the concept of quality and see how this makes sense to you and I'm sure you'll be thinking that hey, I'm doing some of this work already. And if you are, I'd like you to let us know so we can post it on the Health Literacy Website. We'd really like to come up with some demonstration projects that we can, in the future or maybe even now, we know that they work, we have evaluations on them and that we can put them out as model programs for Health Literacy and quality.

The whole definition of literacy came from the Department of Education and when they began to do their national assessment of adult literacy, they used a definition, which was the ability to use printed and written information to function in society. And from that definition, they started to look at how people function in the job, so they gave them an assessment test in '91. And from that assessment tests, the data showed that about 90 million Americans tested at the lowest two levels. That means that if you were to give them a map to find a bus stop, they couldn't locate it. They couldn't determine how to navigate a hospital. They would have problems reading their medication directions.

And when they assessed that there were 90 million Americans that were functioning on those lower two levels, we started to think about how these people were relating to health information. And remember that, this is a written assessment, in other words, people have to be able to read to take this. So that does leave out a certain percent of the population, they have to be able to at least read English in a fairly moderate, in the mid-level English reading.

So what happened was this. As they got ready to begin the next assessment, which was in 2003, the Department of Health and Human Services worked closely with the Department of Education to include some health literacy, health-related items in this instrument and we should have that data out about 2005. And that will give us a baseline to see exactly what types of problems do these people have.

Generally, when they're given the assessment test, they have to locate a piece of information, let's say, in a newspaper paragraph. That's one example of what they have to do. There's some mathematic skills; basic subtraction and addition that they do, etc. So this will give us some sense about what are some of the issues out there and the problems that people have.

But also, I wanted to make sure that people understand that it's not just people who test low on these assessment tests who have limited health literacy. There are many people with Ph.D.'s, highly educated who really have limited health literacy. Just like many of us have limited financial literacy. And today, we're hearing about all types of literacy as far as the subject matter goes.

So, with the national assessment of adult literacy, the folks who are preparing Healthy People 2010 said, "You know, maybe it's time that we look at health literacy." And so that's when the Communications Chapter in Healthy People 2010 evolved and the definition that you see there on slide 18 is a consensus definition, which is used by the Department and most other organizations use this definition. You may see some deviations from it.

Our definition reads, "The degree to which individuals have the capacity to obtain process and understand basic information and services needed to make appropriate health decisions."

One definition I recently read said, "The degree to which individuals have the capacity to read, process and understand." I want to make it clear that it's more than reading. People obtain information in many, many different ways, as you know. So, it's much more than reading. It involves listening skills. In fact, one of the key points I recently heard a physician who's done much research in the area of health literacy make is she said, "What I found is most helpful and meaningful to the people I serve is that I have the ability to listen to them."

And that relates to a companion objective that's in that chapter, Objective 11.4 is improve patient-provider communication. So those two are really intertwined as far as being successful working with limited literacy people.

The IOM just came out with a report on slide 19, and I have that - just a little quote from there. "What they're saying to our country is that we need programs to reduce the negative effects of limited health literacy. And that it should be a concerted effort by education, health care systems, public health and the media." And you might find that real interesting to scan. You have a link to that on your list of resources that I've provided for you.

Another report that has information on health literacy is the IOM report on Transforming Health Care Quality, which came out in 2002. They've identified 20 areas for national action. Self-management and health literacy is one of those 20 areas; it's one of the two cross-cutting areas cited in that report. If people aren't health literate, they're going to have problems managing their own health and complying with their health directions.

If we go on to Healthy People 2010, I just want to make a comment that the objective reads, "Improve the health literacy of persons with inadequate or marginal literacy skills." And you might think that that is focusing on just low-literate people, and it is. But what we want people to begin to realize is that the data we'll be collecting will be on that objective, but we want it to reach all areas; all people that are maybe don't test low, but you might suspect need some help.

I don't have too much time left, but let me just point out some of the other highlights that I have. You have the slides so you can go through them.

If you talk about the written word, then think about Webster's definition of language, because here at HRSA we've been calling it the language of health. Promote health literacy. If you look at the definition of the term language, it's more than words. It's how we say them, it's how we write them, of course, but it could be signs, it could be ideas, it could be feelings, it could be sounds and marks that you use. Simple signs that people don't have to read. So you can do something very simple to make a difference and that could be a health literacy component of your quality work. And maybe if you did something each month in the area of literacy, you might find yourself making a difference.

We do know that people with limited literacy skills use the ER more often. They present later in disease, they're more likely to have overall health problems. They're more likely to not comply with their treatments; they may not understand their treatments and they're less likely to come in for screenings. We know that some of the major populations that low health literacy is found in are the elderly, those living in poverty, people who may not speak English. We also know from research that if you address health literacy, it improves your access for information and to care, your ability to provide informed consent.

There's one example of a woman who was embarrassed that she did not read and so she signed her informed consent. She ended up having a hysterectomy, had no idea she'd had it. She didn't know what she had had. She was embarrassed to say she could not read. So, problems like that are still happening and we need to really work hard to help reduce those problems.

You can go to our Website and you can see what some of our program areas are doing. There are some Rural Health programs listed there, however, yours may not be there. And within Rural Health, we have a member of our HRSA workgroup, Lily Simintana and you can let her know or you can e-mail me and my e-mail address is on the first slide, because we would love to hear from you and we would love to be able to support you in some of your efforts.

The list of resources I gave you is pretty extensive. I want to highlight just one or two that I think are very good. The Hardway School of Public Health Department has a short video up there and they have some excellent ideas for health literacy programming. And that's very good. The National Library of Medicine has a bibliography on their site. The Institute of Medicine, of course, and there are direct links on those resources so you can link to them and see what ones you might want to use.

People are always asking for tools. The Partnership for Clear Health Communication has an Ask Me Three program and they're asking you to focus on getting your patients to ask you three questions. What is my problem? What should I do? And how do I do it? If you go to the Website, they have a kit there, too. You might be interested in that.

The AMA has a kit out that's excellent. It's called, Helping Your Patients Understand. They also have grants for health literacy programs. And the, I believe Pfizer has some grants, too, also.

The National Institute for Literacy is excellent. They have a special health and literacy collection. And one that I really like is the State Official's Guide to Health Literacy. And they have a tool kit with fact sheets and ideas for programs and they have a CD ROM that shows patients and the problems that they've faced. In other words, one person was taking so many medications, they couldn't remember when to take them, so the provider taped each pill to a card and in simple language wrote when they should take it. So it was color-coded by the pills, and in simple instructions like, "Once at lunchtime." And many, many mistakes happen with prescriptions. Many, many mistakes with people.

There was recently an article about a woman who was - her baby had an ear infection so she was given drops. And she didn't know she should put the drops in the ear, so she gave them to her by mouth. And those things happen, because it's just not clear and people don't take the time to ask the patients, to say, "Can you read? Do you understand?"

And as I said, I think the one key that one of the physicians recently mentioned is to listen to your patients. If you take an egg timer for two minutes, if you just give the patients two minutes when they come in to listen to everything they have to say. And it's not only the physician; it's when they walk into the clinic. Or when the first person that meets them. So, if I had more time, I could give you many more hints, but I'd like to give you a chance to ask questions.

C. Williamson

Forrest Calico is here and I think he had a comment that he wanted to make.

F. Calico

Hi, folks. Thanks, Craig. I just wanted to just thank Linda for addressing what is really a huge problem nationwide. This certainly isn't rural-specific. But, you know, earlier in our conversations, we talked about patient-centeredness as being one component of high-quality care, one of the six aims that sort of defines quality.

In my mind, patient-centeredness certainly requires culturally appropriate care giving on our part, but it also requires what Linda's been talking about, that we help our patients to grasp and comprehend the things that they need to know about their health and that's what health literacy is all about. So to me, combining culturally appropriate care giving with health literacy enables us to engage in therapeutic communication, which is one of the most important components of the healing art.

So I just wanted to mention that. I think that clearly projects to enhance the communication between caregivers and rural health clinics and your patients will clearly improve quality; that that link is absolutely indisputable and unquestionable and would make some great performance improvement projects (background noise).

C. Williamson

Well, thank you very much as always, Forrest, for your input and your words. At this time, let's open things up, Operator, and see if there are a few questions for either Linda or Forrest relevant to health literacy.

Coordinator

Thank you. One moment, please. Our first question comes from Jill Doyle.

J. Doyle

Good morning. I'm just wondering where we can find some of Linda's brochures for some of the patient literacy programs?

C. Williamson

Great question, Jill. All of that stuff is up on the Office of the Rural Health Policy Website along with all of the other materials and resources that will be discussed on this call. If you haven't been there, the Website for that is http://ruralhealth.hrsa.gov. So if you just type in ruralhealth.hrsa.gov into your browser, it will come up and click on the link for Technical Assistance for rural health clinics on Quality Improvement. And if you don't have access to the Internet, go ahead and give us a call here at the office, (301) 443-0835 and we can see about printing that stuff up ourselves and faxing it to you or finding some way to get you those materials.

J. Doyle

Thank you.

L. Johnston-Lloyd

You also could, after the next month is up, check the Quality Website. We have a health literacy page on that site and that's hrsa.gov/quality. And on our front page, there's a link to health literacy.

J. Doyle

Okay, thank you.

L. Johnston-Lloyd

You're welcome.

Coordinator

Thank you. Our next question comes from Tidy Langford.

T. Langford

Yes, my question was the same about the Website and I didn't get - what was the, after rural health, what were the letters?

C. Williamson

It's dot hrsa. So, ruralhealth.hrsa then .gov for dot government.

T. Langford

Thank you very much.

C. Williamson

No problem.

Coordinator

Thank you. We have no further questions at this time.

C. Williamson

Alright. Well, thank you for your questions, everyone. And let's just go ahead and turn things over to Kristine Sande, then, from the Rural Assistance Center, which is a wonderful resource that you should all know about for getting all kinds of rural health care information. So, Christine, why don't you take things away?

K. Sande

Okay. Just a little bit of background information for those of you who may not be familiar with the Rural Assistance Center. The Rural Assistance Center, which you might also hear referred to the R-A-C or RAC, it was a product of the Department of Health and Human Services Rural Initiative and was established in December of 2002. It's intended to be a rural health and human services information portal.

What we do is we help rural communities to access the full range of available programs, funding and research, which will allow them to provide quality health and human services to people in their rural areas. In order to do this, we gather and streamline information from many sources and try to provide easy access to that information.

The Rural Assistance Center is a collaboration of several different organizations; the lead partner is the Center for Rural Health, located at the University of North Dakota School of Medicine and Health Sciences. We also work with the Rural Policy Research Institute at the University of Missouri Columbia and the University of Nebraska Medical Center as well as the Welfare Information Network in Washington D.C. And we're funded through HRSA's Office of Rural Health Policy.

RAC users can be anyone who is looking to maintain or improve the access, quality and financial viability of rural health and human services delivery systems. Some of the services that we provide are Websites, lists or postings, as well as customized assistance. The RAC Website is available at www.raconline.org. That link is also available off of the Office of Rural Health Policy Website on their Links page, if you didn't catch the link.

We try to make all of our information accessible via the Web as much as possible just for ease of people trying to access that information. Features on the Website that can be of assistance to grant seekers are funding opportunities, recent news, information guides and our rural documents index.

The funding section of the RAC Website allows users to access funding announcements and summaries of funding opportunities sponsored by federal and state governments as well as private foundations. This includes both limited time and ongoing funding opportunities.

Summaries of funding opportunities that you might find on the RAC Website will include things like the program Website, the sponsor of the program, the purpose of the program, eligibility requirements, the geographic coverage, amount of funding available, details about the application process and contact information.

When you get to the Website, you can browse these funding opportunities either by the sponsoring agency or organization such as the Office for Rural Health Policy, the Department of Agriculture, the Robert Wood Johnson Foundation, etc. Or also, we have a set of preselected topics or categories such as community development, emergency services, and health research by which you can browse. In addition, news items related to these funding opportunities can be browsed by deadline date or announcement date.

You can search funding opportunities as well, which a lot of people like to do to find targeted funding opportunities and things you can search by include the topic of your choice, the sponsoring organization. You can search for only entries flagged as health-related or human services related. You can search for only entries that are rural-specific or by active programs only or you could also include inactive programs.

The reason you might want to include the inactive programs is so that you can identify programs that might not be currently accepting applications, but may be offered in the future. And if you find those, there's generally a contact person listed on those opportunities that you might want to give a call and see if they think those opportunities will be offered again in the future.

And when you're searching, you can use only one of these search criteria that I've mentioned to do a broad search, or you can use the criteria in combination to do a more targeted search.

We do have a Funding Tips page that can be accessed from any page within the Funding section of the Website and I would really recommend that new users of this section of our Website browse that Funding Tips page to learn how they can make the optimal use of the RAC site to help with their funding needs. Most of the information that I'm covering today is included on that page, so some good information there.

The Recent News section of our site might also be of interest to you. RAC staff does do a daily search for news and announcements that might be of interest to anyone concerned with rural health and human services, such as Federal Register notices that could affect rural stakeholders are posted to the RAC site. These include funding announcements, proposed and final rules concerning regulations, as well as notices regarding meetings, government information collection and other miscellaneous items.

Also, on the Recent News section, you'll find press releases from HHS and other federal agencies announcing studies, grant awards, new programs that are available, new resources, comments from the Secretary and other types of press releases. You'll also find press releases from other organizations as well as media coverage of rural health and human services issues such as articles from newspapers, press releases from foundations or organizations.

The Information Guide section of our Website is something that we're continually working on improving the information found there. The Information Guides are pages that provide information including links and resources available on a variety of rural health and human services topics. Among those topics are a broad grant and funding guide, as well as detailed guides on some key funding topics. The grants in the funding resources guide show many links to resources available on the RAC site, as well as elsewhere on the Internet. And from that Guide, a user can enter the more detailed funding guides.

Several other funding information guides that are available in a more detailed format include capital funding, grant writing, and scholarships and loan repayment for health professionals. Included on the detailed guides, you'll find things like Frequently Asked Questions, tools, funding opportunities, relevant documents and regulations, journals, organizations, terms and acronyms, and contacts.

But the Information Guide topics are not just limited to funding. Other information guides that are available that might be of particular interest to this group include the Rural Health Clinic Guide and our Health Care Quality Guide. And these and other information guides and the RAC document search can help users identify resources such as maps and statistics that can assist them in writing strong grant applications.

I just mentioned our documents database, so I'll talk about that a little bit. The RAC site includes a searchable document database, which now has over 2300 entries related to rural health and human services. Types of documents that you might find in the database include Rural Health Research Center reports, State Rural Health Association and SORE newsletters, federal and state government publications, and foundation reports and briefs. The document database can be searched to find documents that can provide background information and statistics. The Document Search Tip page is available that can assist you in using that document search to its fullest and I would recommend checking that out before you try to use the document search. I think it's helpful for most users.

Another thing that we offer is our list/serve postings. These postings help our users keep abreast of current happenings and these list/serve postings have things on them such as new funding opportunities, recent news articles, new documents and upcoming events. We have a rural health list/serve posting that goes out every two weeks and our rural human services posting that goes out once a month. And you can sign up for both of those list/serves on the RAC Website. And really, those list/serve postings are the things that we get the most feedback from our users about as far as being really a useful resource, so I would encourage you to sign up for those.

Another thing that the Rural Assistance Center provides is customized assistance. This is particularly useful to people who don't have Internet access or people who might have questions that they can't find the answers for on the Internet anywhere, and you can give our information specialists a call and they can try to help you hunt down answers.

Some of the types of information or assistance that the information specialists can provide is that they can perform detailed searches for funding opportunities using many resources including our RAC funding database, government Websites, the foundation directory, which can identify foundations who might fund certain types of projects in certain areas. They can also point callers to appropriate government contacts for various programs, funding and otherwise.

The information specialists can also find print and electronic documents as well as statistics, data sources, and maps that are useful to grant writers. They can also identify experts, organizations and colleagues who might be able to assist you in your grant writing efforts or otherwise help you find information.

The information specialists are all Masters-trained librarians so they're really good at trying to track down that information. We do ask that when you call, you give us adequate information about exactly what your question is. If you're looking for funding opportunities, it's really important that you tell us things like the topic of your program, if you're doing a QI program; are you looking at patient education for diabetes or other chronic diseases, or information technology or smoking cessation, because that really helps us find targeted information and funding opportunities. Whereas if you just tell us that you want information on quality improvement, we probably won't find as many opportunities for you, or they may not apply to what you really want to do.

Also helpful to know is the location of your facility; including city, county and state. That helps us search for some of the opportunities that may be more regional in nature. Also, it's helpful for us to know if your status as a not-for-profit or a for profit organization just because that may affect your eligibility for certain programs.

So that's a brief rundown of what the Rural Assistance Center can do for you. Again, the RAC Website is www.raconline.org. Customized assistance is available Monday through Friday, 8:00 a.m. to 5:00 p.m. and that's Central time. And so I would encourage all of you to use these resources.

If there are any questions, I'd be happy to answer.

Coordinator

Thank you. One moment please. We have no questions at this time.

C. Williamson

Okay. Well, thank you very much, Christine. I just encourage all of you out there, if you haven't checked out Rural Assistance Center before, go online. There is a whole host of information that's updated very regularly. It's a very wonderful resource for rural providers.

I'm just going to go through and talk very briefly about some other grant opportunities, both federal and non-federal, that are out there for rural health clinics to apply to that could garner some funding for a quality improvement project. And a lot of these I actually found by asking the Rural Assistance Center to go through and do a search for what rural health clinics were eligible for. So, that's sort of a real-time example of what RAC can do for you.

There's a set of slides that are up on our Website at ruralhealth.hrsa.gov that list about six different grant programs that we were able to find that RHCs may find relevant to them. These include grants from the National Library of Medicine for Information Systems; the Agency for Health Care, Research and Quality's Demonstrating the Value of Health Information Technology grants; Rural Health Outreach and Network Development grants that are sponsored by the Office of Rural Health Policy; and some grants from private foundations including the Quality Health Foundation, Robert Wood Johnson and The Commonwealth Fund. So, I'm just going to go through these real briefly and if you want more detailed information, I'm going to provide a link to their Website and also a contact person and phone number … available for you for those of you who may have limited Internet access out there.

So the first program is the National Library of Medicine sponsored Information System grants and one of their priorities are these grants can be used to deliver information resources and services to underserved rural populations. And so the way that that can be useful for RACs is some of their grantees include consortiums of health centers in rural southern Illinois and rural western Pennsylvania that have received funding for high-speed Internet access and information sharing between clinics, which the Internet can be a wonderful resource, both for you to offer information to your patients and for you yourself to find information about quality improvement ideas and best practices and all of those. So, this program can provide funding for that.

And the Website for the National Library of Medicine is www.nlm.nih.gov. So that's nlm.nih.gov/ep. And the contact person there is Dr. Valerie Florence and her number is (301) 594-4882. And if you don't get all this, all this will be up on a transcript later or you can call in and listen or contact me after the call.

The Agency for Health Care, Research and Quality has just kicked off an initiative to study the value of health information technology. And for the 2004 fiscal year, their focus was actually on the challenges and opportunities to increase information technology in rural areas. So, they're strongly encouraging primary care research networks and networks of rural primary care providers and are providing some funding for FY04 to implement an IT program, and also study and evaluate that.

And I should mention that most of these grants I'm going to talk about, the funding, the FY04 deadline has passed, so keep a look out for next year, and the same thing with the ARC program. The applications for that closed April 22nd and winners will be announced September 30th. But I think it will be interesting to follow this program and see what some of the examples of programs are and what the evaluations of them show. And you can access information from that from the Agency for Heath Care, Research and Quality page, which is www.AHRQ.gov. And a contact person there is Eduardo Ortiz and his number is (301) 427-1585.

And a lot of you are probably already aware of Rural Health Outreach and Network Development grants that are sponsored here at HRSA in the Office of Rural Health Policy. These grant programs fund innovative ways of delivering care to rural populations. Both of them require, like a lot of other programs that we are going to talk about, a network of some providers. The Outreach program requires a network of at least three different partner organizations: rural health clinics, local public health department, hospital or schools or safe-based organizations as well. The Network Development program gives money to develop information sharing and formal networks between different provider types.

And rural health clinics in a lot of towns are very situated, because you have close partnerships with hospitals and other health providers in the community to really put together an effective network and also an outreach program. One example of a rural health clinic outreach grantee is an RAC in rural Alabama that's the lead entity of a group of between schools and some other organizations in this town to conduct wellness outreach programs for the community. And funding for an outreach product could go into supporting a quality program or a health literacy program. I see Linda nodding over there. It could be key component doing that.

So I'm just going to go through and tell you a few other private foundation grants out there that RAC found for me. There are Quality Health Foundation grants and providers in Maryland, District of Columbia, Virginia, West Virginia, Vermont, Florida, Michigan and California are eligible for these $50,000 one-year grants for improved patient care. This focuses on use of best practices to improve care, improve access to health services and improve communication of health knowledge.

Robert Wood Johnson also has a health e-technologies initiative that you might want to look into. The Website for that is www.hetinitiatitive.org. So, hetinitiative.org. And a contact person there is phone number (617) 525-6167.

And again, if you don't catch all this information I'm throwing at you, feel free to give me a call at ORHP or send me an e-mail later on.

One more program, The Commonwealth Fund has several different grants for quality improvement. These include quality improvement grants, quality of care for underserved populations, child development and preventative care, and quality of care for frail elders. I've got the Website for that is up on our Web and the phone number there is (212) 606-3800. That's (212) 606-3800.

And again, if you have questions about these, you can contact me at ORHP. The number at the office is (301) 443-0835 and my e-mail is cwilliamson@hrsa.gov. So, cwilliamson@hrsa.gov. And again, all of this information is up on our Website for you to download as well.

With that, I don't have anything else to add. What I'd like to do is go ahead and open things up and see if participants out there have any final questions for anyone who has presented today. So, Operator, can we just go ahead and open up the lines and see if there are any final questions about quality improvement stuff I have talked about or also the status of the RHC regulation as well.

So, Operator, could you go ahead and open up lines for questions.

Coordinator

Thank you. One moment please.

M Craig, while we're waiting for the calls to line up, did you want me to talk about …?

C. Williamson

Let's hold off until the end of the call and you'll have a chance to make some final comments, Bill, at the very end. … as well.

M Okay.

Coordinator

Thank you. A question comes from Mark Lynn.

M. Lynn

Yes. This is Mark Lynn from Healthcare Business Specialists in Chattanooga. My question is about the rescinding of the QAPI rules. Prior to those rules, … required to do an annual evaluation and I guess we're sort of in a quandary of do we continue to go ahead and continue doing annual evaluations like we have in the past, or, I guess, what do we need to do about annual evaluations now that you guys are suspending the regulations on quality improvement?

J. Suber

Yes, this is Jackie Suber. Clinics will go back and continue to do the annual program evaluation as they did in the past.

M. Lynn

Okay. That's what we'll do.

Coordinator

Thank you.

C. Williamson

Okay. Well, if we're waiting for some questions to queue up, Forrest, I think you had a few words that you wanted to say before the end of the call?

F. Calico

Oh, very little. My final comment is just to encourage everybody to really not be discouraged because the regulations are sort of in flux right now. But I think that by far the best and most important reasons for improving our quality and our performance is really in the interest of our patients and our own ethical standards as health care givers. So your efforts at improvement certainly have not been wasted and they need to continue, and as I think it's been made clear, also, once the current questions are resolved in some form or another, we will be continuing the requirement for quality assessment and performance improvement. And so I guess you can just think of it as a chance to be even better by the time that things become mandatory.

C. Williamson

Operator, are there any more questions queued up?

Coordinator

No questions, sir.

C. Williamson

Alright. Bill, I believe you had some final comments as well. This is Bill Finerfrock from the National Association of Rural Health Clinics.

B. Finerfrock

Thanks, Craig. First, I just want to echo what Forrest just said, which is that I think while the regs have been suspended, particularly as it relates to the QAPI, I think it's merely a delay in something that will eventually come to pass. And so, I think clinics should continue their preparations with the anticipation that QAPI will become a reality; exactly when that occurs is obviously CMS's timetable. But within those regulations, I think there are other provisions, particularly dealing with decertification and things of that nature, that some of those may be subject to change or significant comment. But I think as it relates to the QAPI initiative, I think it's something that I think is going to occur and folks would be well advised to at least continue with preparations for that initiative.

And as Forrest mentioned that the ultimate beneficiary of this is the patient, and so whatever you're doing that accrues to the benefit of the patients is not necessarily a bad thing.

Along those lines, there was discussion about grants and there was legislation authorizing a new grant program, it was about a year and a half ago, it was passed by Congress as part of the safety-net legislation that was adopted, and it's specifically targeted towards small providers with the intention of providing grant dollars for implementation and development of QA initiatives within those facilities. And it specifically identifies rural health clinics and critical access hospitals as the two identified providers and then authorizes the Secretary to open that up to other providers that the Secretary may deem appropriate, but specifically references rural health clinics and critical access hospitals.

Now, that program has not been appropriated as of yet. So even though it exists as an authorization, Congress has not specifically put money into that account. A couple of weeks ago, Denny Geitner, the President of the National Association of Rural Health Clinics testified before the House Appropriations Subcommittee urging them to fund this particular initiative, particularly in light of the effort at CMS to move ahead with the QAPI initiatives that these programs will cost money for clinics and to the extent that those grant dollars can be made available, it would help to either ease some of the financial burden and allow us to develop a more extensive library of resources and examples of what clinics are doing in this area to comply with the QAPI initiative.

We've asked for between $5 and $10 million to be put into that account. I can't tell you right now whether or not we'll be successful, but if we were able to get that money in there, we'd, I think, make a significant amount of money available for grants in that the expectation would be that they typical grant would be somewhere less than $50,000. So, at $5 million to $10 million, it would allow a number of grants to be funded throughout the United States.

C. Williamson

Okay. Well, Bill, thank you for your comments from the perspective of the National Association of Rural Health Clinics. And we appreciate you participating in this call.

CMS, David or Jacqueline, do you have any final things you'd like to add?

D. Worgo

No. No, we don't.

C. Williamson

Okay. Are there any more questions out there?

Coordinator

No.

B. Finerfrock

David or Jacqueline, do you guy have any sense of timing on when some of these decisions are going to get made? As Mark's question alluded to, folks are kind of in this situation of having to continue to comply with the existing requirements with the expectation that at some point, they're going to convert over to QAPI and not have to do an annual evaluation, and obviously, those decisions have financial implications for the RHC community. Can you give us any sense of what your timetable may be?

J. Suber

David's already left the room, and we really can't give you an idea. I know that the review of this is already up in the upper echelon of directors and we're just expecting a response any day now. Dave will be presenting at the National Rural Health Association Conference, I think, next Friday. He may have some more information for you at that time.

B. Finerfrock

Okay.

J. Suber

As I said earlier, I realize there are a lot of clinics that may have already merged into the QAPI program and I don't think they should have any difficulty meeting the basic program evaluations. When you look at the basic elements and you compare both programs, they both look at requiring the clinics to do a self-assessment, a review of utilization of services, their volume served, their medical records. Everything pretty much kind of mirrors except for with the QAPI program, they're looking at specific projects. But they should be able to still do a total program evaluation of their program and do an analysis of the QAPI program as a part of it.

C. Williamson

Okay. Well, thank you very much for that question, Bill, and for your answers, Jacqueline. I guess if there's no further questions that brings this call to a close. So I just want to thank everyone who has participated in these quality improvement calls for all your help. That includes everyone from CMS and Bill at National Association of Rural Health Clinics and also other folks here at ORHP as well as Linda and Christine who presented on the call today. So, thank you for taking the time out of your schedule to come in and share your resources and information with the rural health clinics.

And again, I'd just like to reiterate what Forrest and Bill have both said, that no matter what you do for quality, quality is the end outcome of providing good health care and there's few things that are more important than that.

If you guys have any questions, don't hesitate to contact our office and we will help you however we can. Again, the number is (301) 443-0835. And we will have information up and we'll continue updating more information as it comes in for the next month on quality improvement stuff.

B. Finerfrock

Craig, if I could, I just want to, on behalf of the rural health clinics community, thank the Office of Rural Health Policy for organizing these calls over the last three months. I think they've been extremely valuable to the RHC community and a very cost-effective way for individuals to get information and for that we thank you for doing that. And also, to the folks at CMS who've made themselves available for these calls and allowed folks to ask questions and get additional information. I think it's been extremely beneficial and I hope that this is something that we can try and continue to do in the future and again, just thank you and your colleagues at ORHP and CMS for taking the time and effort to put this all together.

C. Williamson

Alright. Well, thank you again, Bill, for everything. On that note, I think that's a good point to end this. So, thank you, everyone for calling in and for participating. And good luck with everything.

B. Finerfrock

Thank you.

Coordinator

Thank you for joining today's teleconference. You may disconnect at this time.