Gail Nickerson, Director of Clinic Services, Adventist Health
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Gail Nickerson, Director of Clinic Services, Adventist Health

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  • CalSORH has mostly administered the state rural hospital grants and the J-1 Program. CDPH does licensing and certification for hospitals, clinics and skilled nursing facilities. DHCS administers the Medi-Cal program and includes the Primary and Rural Health Branch, which has had oversight over state rural grants for community clinics and health centers “licensed primary care clinics”. MRMIB oversees the Healthy Families program and a variety of grants to expand access. First 5 has funding through Prop. 10 for children ages 0-5, some of which has been spent to expand health care services to that population. RHPC is housed at OSHPD and provides a unique opportunity for rural health providers to hear and be heard by heads of state departments.
  • CMS administers the Medicare and Medicaid programs, and is the certifying entity for rural health clinics HRSA is the government agency that oversees the Public Health Service programs, including the Community Health Center programs and the National Health Service Corps. It is also the entity that designates FQHCs and FQHC-LAs. ORHP has some grant programs and provides technical assistance to critical access hospitals and rural health clinics The Department of Agriculture provides some funding for distance learning as well as food stamps for low-income individuals
  • Smiling during a job interview can usually help your chances of getting hired, but Kathy’s smile just made her job search more difficult. Each potential employer, after seeing her decayed and discolored teeth, decided not to hire her. Over the years, money was tight for Kathy’s family, and she couldn’t find a dentist who accepted Medi-Cal. As a result, her teeth showed years of neglect. She was so ashamed of the way her teeth looked she dreaded going out in public. But her life changed when she found out about a dental clinic that accepted Medi-Cal and some other programs at a local rural health clinic. When Kathy first came to the clinic she was embarrassed about the shape her teeth were in, but the staff assured her that they could give her a beautiful smile. After time and a lot of work, the staff restored each and every tooth. When it was all done, Kathy sat in the dentist chair and cried tears of joy and gratitude. It totally changed the way she looked and felt. Three weeks later Kathy came back to the clinic, but not for more dental work. She told the staff that she got a job working for the county and was already off welfare. Her smile changed her life and her attitude.


  • 1. Rural Health Safety Net and Infrastructure Presented to the California State Legislature’s Rural Caucus February 16, 2010
  • 2.
    • Rural Safety Net
    • Health Care Coverage
    • State and Federal Agencies Involved in Rural Health Care
    • Potential Impact of American Reinvestment and Recovery Act (ARRA) on Rural Health
    • Federal Health Care Reform
    • A Rural Patient Story
    • Rural Health Clinics
    • Points to Remember
  • 3.
    • California’s rural health care safety net for low income and uninsured patients includes hospitals, several types of clinics, some public health departments, and also some private providers.
    • It also includes a variety of auxiliary health care support services, such as labs, pharmacies, radiology services, home health, and medical equipment and supply providers.
    Rural Safety Net
  • 4.
    • Hospitals in rural areas include:
      • Critical access hospitals (low census, basic services)
      • Rural hospitals (often under 50 beds)
      • General acute care hospitals
    Rural Safety Net
  • 5.
    • Clinics in rural areas include:
      • Rural Health Clinics (RHC)
      • Indian Health Services (IHS)
      • Federally Qualified Health Centers (FQHC)
      • Federally Qualified Health Center Look-Alikes (FQHC-LA)
      • Community Clinics
    Rural Safety Net
  • 6.
    • Public health services in rural areas can include:
      • Immunization clinics
      • Women’s health services
      • AIDS/HIV and tuberculosis testing
    Rural Safety Net
  • 7.
    • Private providers in rural areas include:
      • Individual physicians
      • Individual nurse practitioners
      • Physician groups
      • Physician assistants are also providers in rural areas, but per California law, cannot own a medical practice on their own.
    Rural Safety Net
  • 8.
    • Statistically, rural areas have more Medicare patients and more patients on public insurance such as Medi-Cal, CHDP and Healthy Families.
    • There are also fewer insurance choices – HMOs have avoided most of the rural areas of California, or have come and gone.
    Health Care Coverage
  • 9.
    • There are many state agencies that are involved with rural health:
      • State Office of Rural Health (CalSORH)
      • California Dept of Public Health (CDPH)
      • Dept of Health Care Services (DHCS)
      • Managed Risk Medical Insurance Board (MRMIB)
      • First 5 County Commissions
      • Rural Health Policy Council (RHPC)
    State and Federal Agencies
  • 10.
    • There are also many federal agencies that are involved with rural health:
      • Centers for Medicare and Medicaid Services (CMS)
      • Health Resources and Services Administration (HRSA)
      • Federal Office of Rural Health Policy
      • U.S. Dept of Agriculture/Food Stamp Program
    State and Federal Agencies
  • 11.
    • There is money in the HITECH portion of the American Reinvestment and Recovery Act (ARRA) for hospitals and physicians who become “meaningful users” of electronic health records.
    • This funding will be available through Medicare Part B and also through Medicaid (administered by the state).
    Potential Impact of ARRA
  • 12.
    • The ARRA legislation also included funding for FQHCs’ program expansion, infrastructure and technology.
    Potential Impact of ARRA
  • 13.
    • As we know, federal health care reform has hit a snag and may not recover. The two bills that were passed in the House and Senate did include some provisions that would be helpful to rural health care providers, but not enough.
    Federal Health Care Reform
  • 14. A Rural Patient Story
  • 15.
    • Rural Health Clinics
      • Any legal medical provider in the state who qualifies for RHC status can be certified. In California, this includes:
        • Hospitals
        • Community-based organizations
        • Counties
        • Physicians
        • Nurse practitioners
    Rural Health Clinics
  • 16.
    • Rural Health Clinics (continued)
      • Because of the various types of ownership, RHCs may be licensed as departments of hospitals, as primary care clinics, or may operate under the license of the physician or nurse practitioner. Clinics that are owned by counties are exempt from licensure.
      • Regardless of licensure, every RHC must be certified by Medicare.
    Rural Health Clinics
  • 17.
    • Rural Health Clinics (continued)
      • In order to be eligible for certification, RHCs must be:
        • Located in a non-urbanized area according to the Census Bureau,
        • in an area designated as a Health Professional Shortage Area (HPSA) or Medical Underserved Area (MUA) by HRSA, and
        • have a nurse practitioner, physician assistant or certified nurse midwife available to see patients at least half of the time that the clinic is open.
    Rural Health Clinics
  • 18.
    • Rural Health Clinics (continued)
      • California RHCs are mostly owned by hospitals or private providers.
      • There are over 260 RHCs in our state – only Missouri and Texas have more.
      • 40 out of 58 counties in California have at least one RHC.
    Rural Health Clinics
  • 19.
    • The safety net in rural areas has many strands, many types of providers – hospitals, community-based organizations, public health departments, and individuals.
    • Strategies that work in urban environments do not always translate to rural.
    • Every health service in a rural area is important – collaboration rather than competition is what helps to preserve the rural safety net.
    Points to Remember