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  • Primary care provider shortage in rural areas Primary care Providers scared to take on high costs of obstetric malpractice insurance premiums People in rural areas more likely to be uninsured than those living in urban areas
  • Including policy makers, health professionals consumers, public health professionals, and program administrators
  • Regionalization: coordination of services. E.g. obstetric services for low-risk women in rural areas and communication/coordination with tertiary facilities for transfer og high risk patients Health workers: for outreach and education

Dotson Dotson Presentation Transcript

  • VIRGINIA RURAL HEALTH SUMMIT MARCH 17, 2010 PRESENTED BY: ANJALI DOTSON, MPH REPORT PREPARED BY: ANJALI DOTSON, MPH & FATIMA SHARIF, MPH Access Council Research Compendium: Best practices in rural health
  • Barriers to rural healthcare access
    • Lack of providers/specialties (or lack of participating providers)
      • Poor workforce retention
      • High malpractice insurance rates
    • Long distances to reach providers/facilities
    • Lack of health insurance
    • Low socioeconomic status
  • Project objectives
    • Compile best practices from around U.S. to advance goals outlined in VA State Rural Health Plan
      • Focus on 4 health areas:
        • Oral health
        • Maternal and Newborn health
        • Mental and Behavioral health
        • Telemedicine and Telehealth
    • Develop a comprehensive website to disseminate rural health information to diverse audience
  • UNESCO’s definition of Best Practice
    • Be innovative
    • Make a difference
    • Be sustainable
    • Have potential for replication
    • 4 out of 4: Best Practice
    • 3 out of 4: Promising Practice
    • Source: United Nations Educational, Scientific, and Cultural Organization (UNESCO)
  • Methodology
    • Systematic literature review
      • Online search engines
      • Research databases (e.g. PubMed, Rural Assistance Center)
      • Academic/community health journals
    • 8-12 program models/practices chosen for each health area
    • Spoke with program directors, clinical professionals and public health officers when possible
  • Highlighting Best Practices
    • Oral Health
    • Maternal and Newborn Health
    • Mental and Behavioral Health
    • Telemedicine and Telehealth
  • 1) Oral Health ForsythKids School-Based Dental Health Program
    • Agency/Location : Forsyth Institute, Massachusetts
    • Model :
    • licensed dentists and DHs conduct exams, develop treatment plan, and do preventive care (cleaning, fluoride, sealants) on site
    • Expanded to include K-12, focusing on longitudinal nature of program
    • Impact:
    • 52 and 39 % reduction in caries in primary and permanent teeth, respectively
    • 25 and 53% reduction in newly decayed primary and permanent teeth, respectively
    • Now in over 50 schools in MA, 50-60% in rural areas
    • Challenges/Policy : Off-site follow-ups, DH practice regulations in VA
  • (Tangent)- Plug for upcoming Evaluation
    • Forsyth Institute is submitting a grant to NIH to fund a multi-site evaluation of this program in rural schools across the country. If interested in implementing this program in a Virginia school…
    • Richard Niederman, DMD
    • Director, Center for Evidence-Based Dentistry
    • The Forsyth Institute
    • Boston, MA
    • Contact :
    • [email_address]
    • 617-304-5626
  • 1) Oral Health: Common elements
    • Dental champion (physician)
    • Improved Medicaid reimbursement rates
    • Integration of services (into schools, social services, etc)
    • Focus on low-income families
  • 2) Maternal and Newborn Health Nurse-Midwife and Family Physician Co-Practice
    • Agency/Location : St. Claire Medical Center in Northeastern Kentucky
    • 3-Tiered Model:
    • Certified Nurse Midwives (CNMs) for conducting routine ANC, newborn care, and performing normal deliveries
    • Family Physicians for instrument deliveries, care for sick newborns, and emergency situations
    • Obstetricians (on contract basis) for high-risk deliveries (e.g. C-sections), provide consultation on complicated cases
    • Impact :
    • 12 % C-section rate compared to 30% nat’l average
    • Decline (3% to 0.3%) in women receiving NO prenatal care
    • Lower rate of LBW babies and neonatal mortality
    • Challenges/Policy : Malpractice insurance premiums for OB/GYN, CNM practice regulations
  • 2) Maternal and Newborn Health: Maternal & Infant Health Outreach Worker (MIHOW) Program
    • Agency : Vanderbilt University Center for Health Sciences
    • Location: TN, WV, KY, LA, and MS
    • Model :
    • Community women (no eligibility requirements) trained in obstetric and infant education (e.g. nutrition, parenting practices, child development)
    • MIHOWs visit families with children up to 3 years old, connected them to social services
    • Impact:
    • 90% MIHOW mothers began ANC in first trimester (75% in rest of MS)
    • 99% secured health insurance (82% average in the US)
    • Challenges/Policy : Volunteer program (prone to instability), funding
  • 2) Maternal and Newborn Health: Common Elements
    • Midwives for prenatal care and delivery
    • Regionalization
    • Female community health workers
    • Focus on low-income/high risk mothers and families
  • 3) Mental and Behavioral Health Telemedicine-based Collaborative Care Model
    • Agency: University of Arkansas for Medical Sciences (UAMS)
    • Location : Arkansas
    • Model:
    • Requires 3 types of providers-
    • On-site primary care providers
    • Off-site telephone nurse case managers (CM)
    • Off-site tele-psychiatrists
    • CMs conduct biweekly encounters via telephone to manage patient’s medications, monitor symptoms, provide education
    • Psychiatrists act as supervisors and consultants
    • Impact :
    • 31% of patients experienced a 50% reduction in depression symptom severity
    • Challenges/Policy : Insurance reimbursement (need capitation)
  • 3) Mental and Behavioral Health: Common Elements
    • Model of integration
    • System of medical records sharing
    • Global funding stream for provider reimbursement
  • 4) Telemedicine and Telehealth Maine Telemedicine System (MTS)
    • Agency: HealthWays/Regional Medical Center at Lubec (RMCL)
    • Location : Maine
    • Model: 2 unique features
    • Open, collaborative alliance of independent healthcare orgs
    • One of the “spoke” sites leading coordination
    • MTS facilitates introduction of new site through training, quality
    • assurance, protocol development, and continuing medical education
    • Over 200 sites, at least one site in every county
    • Impact :
    • In 2,619 home health televisits, 95% and 98% of patients and staff found technology “very satisfactory”
    • Total estimated savings for each tele-session over $400
    • Challenges/Policy: Reimbursement for telemedicine services, high volume of usage to offset cost of technology
  • 4) Telemedicine and Telehealth: Common Elements
    • Physician champion
    • Strong technical and administrative support from hub centers
    • Steady funding stream
    • Experienced and invested site coordination
  • Policy Opportunities
    • Medicaid presumptive eligibility (MPE)
    • Reimbursement rates
    • Malpractice insurance reform
    • Dental hygienist practice regulation reform
    • Medicaid eligibility
  • Policy Opportunities
    • Medicaid presumptive eligibility (MPE)
    • Reimbursement rates
    • Malpractice insurance reform
    • Dental hygienist practice regulation reform
    • Medicaid eligibility
  • Policy Opportunities
    • Medicaid presumptive eligibility (MPE)
    • Reimbursement rates
    • Malpractice insurance reform
    • Dental hygienist practice regulation reform
    • Medicaid eligibility
  • Policy Opportunities
    • Medicaid presumptive eligibility (MPE)
    • Reimbursement rates
    • Malpractice insurance reform
    • Dental hygienist practice regulation reform
    • Medicaid eligibility
  • Policy Opportunities
    • Medicaid presumptive eligibility (MPE)
    • Reimbursement rates
    • Malpractice insurance reform
    • Dental hygienist practice regulation reform
    • Medicaid eligibility
  • Thank you! Acknowledgments: Mara Servaites- VDH Fatima Sharif- Consultant Denise Daly Konrad- Consultant Beth O’Connor- VRHRC