National Rural Health Day Webinar: Rural Clinics’ Role in Hypertension and Diabetes Management

National Rural Health Day Webinar: Rural Clinics’ Role in Hypertension and Diabetes Management


[Begins mid-sentence] office manual that we
created and learning opportunities such as this webinar. Since tomorrow is National Rural Health Day
it’s an annual opportunity to focus on the unique challenges and opportunities related
to health care in rural communities. So this webinar is intended to highlight a
successful state partnership between the primary care and rural health office and then the
state health official’s office can measurably improve care delivery and outcomes in rural
areas. So thanks again to Marcella and Alisa for
agreeing to do this. Great. Thanks Megan. Yes, I just wanted to come back with a couple
of housekeeping notes. I’d like to remind everyone if you’re hearing
this you’re on the telephone dial-in. We’re using that for the audio and not the
web platform. So the web platform is only for slides; there’s
no audio functionality through the webs platform. Please also take a moment to go ahead and
please mute your lines now. We’ll have an opportunity for Q&A at the end. So you can unmute yourself to ask questions
at that point. Without further ado I’d like to introduce
our two presenters today who will be discussing how to use rural health clinics to improve
chronic condition management. Marcella Jordan Bobinsky is the acting director
for the Division of Public Services for the State of New Hampshire. She is also the bureau chief of public health
systems, quality and performance in the Division of Public Health Services. She was the New Hampshire immunization section
chief for seven years. She has worked in the not-for-profit sector
for 40 years. Experiences include six years as the campaign
director for the Central Illinois United Way, nine years as the director of marketing, training
and planning for the mental health centers of Central Illinois, and adjunct faculty member
for the University of Illinois at Springfield. She has served as president and treasurer
of the National Association of Immunization Managers during her five-year tenure on the
board of directors. She attended the University of New Hampshire
for her undergraduate degree, and she earned her master’s in public health from the University
of Illinois at Springfield. And Alisa Druzba has been administrator for
the Rural Health and Primary Care Section at the New Hampshire Department of Health
and Human Services Division of Public Health Services since May 2006. In this capacity she oversees the state office
of rural health, the New Hampshire primary care office, the Medicare Rural Hospital Flexibility
Program, State Health Care Workforce Loan Repayment and J1 visa waiver program and associated
staff and contractors. She has a background in information technology,
clinical mental health and care of adolescents, family therapy, youth development and community
dynamics. Ms. Druzba has a bachelor’s degree in political
science from Centenary College of Louisiana, and a master’s of community and social psychology
from the University of Massachusetts. We greatly appreciate both of their time and
willingness today to present. In the interest of time I’ll turn it over
to them to get underway with their presentation. Great. I’m going to start. This is Marcella Bobinsky and thank you very
much for giving us this opportunity to speak about our rural health programs. We’re very proud of them in this state. And I think we’ve done a tremendous amount
to make sure that the folks in our rural areas have access to health care of many kinds,
and actually through the good work of Alisa and her team that access is expanding into
arenas other than primary care. And so that is very exciting. I’m not sure what our next slide is. Oh okay, the acknowledgments. I just want to talk a little bit about the
leadership role of the state health official, and as you can see here we have put up essentially
a picture of what our New Hampshire State Health Improvement Plan looks like on its
cover. And this essentially references the idea that
a state health official is foremost the person who can offer vision and leadership to an
entire division of public health, department of public health, any kind of entity. And it is that leadership that essentially
should be pointing all of the partners, all of our stakeholders, all of the staff within
the division in some kind of direction. And so we certainly have – in 2013 we chartered
the course for about seven years, and our bureaus and our sections and programs within
our division of public health have been working towards reaching the outcome goals that were
set in 2013. So it’s essentially how can the leadership,
how can the state official set up this framework so that staff leaders throughout the division
have a sense of where they are going. It’s not up to the leadership to day, “Oh
yes, that’s a good idea. Oh of course that’s a good idea. Of course that’s a good idea.” It’s up to the entire staff to create those
ideas, create those relationships and conversation. But they’re all headed towards the goal that
has been agreed upon, not only with leadership but our partners and our stakeholders throughout. So one of
the elements of our state health improvement plan include these areas: tobacco, obesity,
diabetes, cardiovascular disease and on and on. I have set within this not only was it these,
if you will, diseases that we are trying to bend the needle on, bend the curse but also
what’s very critical is the surveillance in epidemiology that we understand the data,
that we are able to gather the data on a real time basis – which of course for us continues
to be a challenge. And also the issue of local data which continues
to be a challenge. But that’s something we’re working on. And of course essentially what we’re trying
to do is promote health, protect our communities and prevent disease. So once we decided essentially on these ten
major factors in the state of New Hampshire, bureau chiefs, section chiefs, we’re able
to look around, look at each other and say, “How can we improve the health of New Hampshire
citizens regarding these – what we think are critical diseases, is you will, in our state.” So this particular program – and Alisa will
tell you much more about this – was able to look at the issue of diabetes and look at
the risk factors that make up cardiovascular disease and say, “How can we work with these
and look around and find more partners?” And I think that’s what we’re going to be
hearing about in a few minutes. But again, back to what a state health official
can do to create, to make sure that these improvement plans are moving forward. It’s not only creating some vision in offering
up that leadership but it’s been empowering the staff to do what needs to be done. I am a great believer in the fact that there
are so many experts within the field of public health and the range is so diverse that I
don’t believe that one person sitting at the top should be – can have all of that expertise. So how can I empower the people who are really
responsible for these programs to lead within their program field and to be that strategist
within that program field. So really it’s about empowering. And the other big issue, of course, in terms
of empowering, how do we make sure that these people are being creative, are looking with
their heads up around about them to make sure that they’re getting all the stakeholders
that they need. It’s also about managing up. It’s very important for the leadership as
a state health official to manage up, whether it’s to a commission or whether it’s to an
executive council, whether it’s to a government, a legislator. It’s about creating space so that the people
who are trying to improve the health of New Hampshire are able to gain the footing that
they need, were able to break down the barriers that they may be meeting up against. So really it’s managing up and out in terms
of a state health official. What do these folks need? What can I do to make sure that they are getting
what they need to do the jobs that they have been empowered to do? And of course the other major thing that I
think all leadership should do is let’s celebrate, saying thank you. I hope that I get to say thank you a dozen
times a day to the staff throughout this building for something that they have done. And when you empower people to work and you
give them goals, say meet these goals, please create these positive outcomes it’s then up
to the state health official or that leader to say thank you. And how did you do that? And let’s hear the good news. And we try to celebrate that every day. We had a celebration today because our food
protection program was able to stand up after many years of work, an information technology,
a management tool, and it’s important to celebrate. So it’s the vision, it’s the empowerment,
it’s the barrier busting and it’s celebration. And I don’t know – I’m not going to say I
don’t know much – I don’t know nearly enough about what has happened or what does happen
in terms of Alisa’s shop, how she goes out and works with all of the different critical
access hospitals. But that’s her job, that’s her world. How can I help her? How can I support her and encourage her? That’s my world. So in terms of state health officials working
with programs and creating these fabulous projects that actually improve the health
of people in our rural communities. What we can do at a leadership level I think
is to empower and celebrate and give the vision. So again, nothing real specific, but I think
it really is offering up that opportunity as the critical portion of what we can do. We’re going to literally switch chairs so
that I can take over. So I just wanted to start with one of the
first things we did working together in public health, even though the state office and the
primary care office have I think always sat inside public health I don’t know that we
really sort of understood each other until a few years ago. And so one of the first things we did was
we have regional public health networks and we work together to classify them as either
rural or non-rural. And that’s been incredibly helpful moving
forward because that way programs that are not used to working in rural can immediately
see whether or not they have priority areas based on health disparity data that fall into
rural and then hopefully teach out to me and we can work together on doing some programming
and solutions, which is exactly what happens with this project that we’re going to highlight
today. So the first thing is that we – our state
officers are pretty small funding-wise and staffing-wise, and I think a lot of primary
care offices are also the same. I’m the same person, so I’m the state office
director and also the primary care office director. So it really makes it easy to coordinate work,
which is great, and also to coordinate funding resources. And so what I wanted to do was we wanted to
start working with rural health clinics because we recognize that there’s no other entity
that’s specifically funded by the federal government to work with them. So we have critical access hospital programs
that work with them. We have the federally qualified health centers
and we have a number of other programs. But really nobody was reaching out to rural
health clinics. So knowing I had limited expertise and resources
we started out with what I call our baby steps. So just really reaching out, finding out who
they are, finding out who the contacts are and then offering them some very concrete
opportunities like traveling to conferences or updating them on things that might be applicable
to them, telling them about the work that we do in case it comes up later. I’ve sent people to grant writing classes
virtually online. We pay their way for that. Really easy resources like that. And then the other thing we did is we created
and actually had approved by both our government and the secretary of health and human services
for the U.S. a certified rural health clinic designation policy. And so what this does is it enables an alternate
format for applying for rural health clinic status. And then we wanted to get sort of bigger into
doing TA. So what I did is we worked with the National
Organization of State Offices of Rural Health, NORSORH, and I actually engaged their services
for a fee – for a reasonable fee – and they did a needs assessment of all of our rural
health clinics so that I could get even a sense of whether or not they wanted TA, what
kind of format it would need to take. And then that was the building blocks for
us to start moving forward on this idea. And then the next thing we did is I identified
some internal partners in public health that might have goals of reach rural health providers. So I am very familiar with – and I�m sure
anyone who works in rural health is very familiar with the disparities of your populations. And so what we needed to do was find the chronic
disease program or whatever program was working in public health that may have had an interest,
either as guided by a funder or by their own data in rural. And we did that. And so we started working with the chronic
disease section here in public health and we decided to combine our funds and craft
and RFP together so that my needs could be met and their needs could be met, and most
importantly we could have an impact in a way that we couldn’t have a loan and also meet
the needs of our funders. So we did that and we did the RFP and we had
some really – I mean it wasn’t a lot of money you that. So about $30,000 from my shop and $80,000
the first two years and then now $65,000 going. So really in the grand scheme of things not
a lot of money. So I was very pleasantly surprised to get
a number of very well-crafted proposals from very reputable companies. And so we’re delighted and we ended up scoring
and selecting one through a competitive bidding process and moving forward with contracting
and the actual creation of the technical assistance network. This is our contractor and it’s JSI Research
& Training and they have a community health institute they’re a national company but we’re
lucky the community health institute just happens to be located here in Bow, New Hampshire,
and then our Institute for Health Policy which is part of our University of New Hampshire. And then we have a sort of local expert on
hypertension management and that’s Dr. Fedrizzi and he does work out of a rural hospital and
so that’s the team that they presented as part of their RFP. So I’m going to go through – I have a lot
of slides and a lot of them are just going to be references for you for later but I just
wanted to go through and give you just a general overview in case folks are new to the concept
of rural health clinics. This is how many there are and where they
are and you can see some states have a whole bunch and some states don’t really have that
many. And there’s I don’t think a particular rhyme
or reason for that it’s just sort of what works – which model works in particular in
each state for the type of providers and needs of their communities. So these are the rural health clinics in New
Hampshire and all but one of them are hospital-owned and of the ones that are hospital-owned a
majority of them are owned by critical access hospitals. So that’s a 25-bed or less rural hospital. And so they just have a number of different
needs and supports. And some of them are part of very formal ACO
or other value-based payment modeling or chronic disease management and some of them are not. And so they have a lot of different things
going on. So I think that was probably one of the challenges
and why we really needed their feedback was how do we program for such a diverse group
of folks and with so many different needs, or actually really I think asks from other
groups besides us as far as being their level of involvement. This was just sort of a goal and strategy
overview and then these are basically the things that we wanted to do. So it’s sort of if you think about it as a
reverse pyramid model. What we wanted to do is we want to do a needs
assessment for all 14 rural health clinics and then we would offer technical assistance
webinars to all 14 of them based on topics that they had identified. And then we would ask all 14 but not really
expect all 14 to collect clinical measures focused on hypertension. And we started with hypertension and diabetes
comes later, and then we gave them an incentive to do that in a form of a gift card. And then we knew a smaller group then would
actually be able to commit to the Action Learning Collaborative which has focused its first
session on hypertension and then kicking off now with diabetes. So that’s how we structured it, knowing that
we would be programming to meet the needs of everyone and then sort of winnowing down
who was able to make that full commitment to more intense work,
and that’s fine, and that’s a model that I’ve used with critical access hospitals for the
past 12 years and it seems to work really well. And so the needs assessments, some of the
outcomes, I just wanted to show you the types of things that you can learn about your rural
health clinics if you do an intense needs assessment like this. And so we learned that these are some of the
kinds of services that they provide. And a lot of them are a little bit beyond
the scope of what you would consider traditional primary care but it’s very reflective of what
the community needs are and what some of the market influences may be in their area. These are the kind of providers we found out
and the numbers they had so I was really interesting to find some podiatry in there and I’m excited
to see some psychiatry in there as well and a little bit of surgery. And then a general payer mix – and these ranges
are pretty big, so it’s interesting. I’m not sure how helpful it is to look at
it but I think it’s a nice wake-up call for trying to figure that out. And then these were their identified technical
assistance needs that we asked them about and it really helped us sort of take a look
at what our expertise was, what could be offered by our contractor and what we might want to
bring somebody else in on. And some of these are very much related to
the CDC funding which had some specific requirements about asking about meaningful use and HIE
and what kind of EMR you’re using. And so the CDC side of the funding was a lot
more I think prescriptive in what they wanted to know but it was a great basis for asking
some of our questions. So these are the four technical assistance
webinars that we offered in the first year and they’re recorded and available to our
RHCs or anybody’s RHCs frankly at any time and so they can be used as a continuing resource. And in the first one the introduction seems
kind of silly for rural health clinics but a lot of them have new staff and so they wanted
to have an existing tool that they could use over and over again so that they had new staff
come on so that they could get an introduction to the rural health clinic model. Then this is under the collections, the second
part of what we wanted to do which was collect some hypertension data. So this was anybody that was willing to share
it with us. This doesn’t mean that they were committing
to the learning collaborative project it just meant that they were going to be submitting
their data. So we have quite a few folks who are working
with other health systems that were already collecting hypertension data for their pockets
so they were really willing to help and to share so that we could have a better benchmarking
across the board. And we already had an accountable care project
going by one of our sub team members. And so this just fed into an existing portal
which was really, really helpful for getting them up. And really one of the goals of this project
was also for those people who don’t collect data to teach them how to do that and to give
them some experience in doing that and helping them along the way. So I think that was really valuable for some
folks as well. So you may not get a lot of usable data the
first few times out but they’re really getting that, they’re building that skillset and they’ll
eventually be able to get data that’s useful for both you as a project and for themselves
for their clinical environment. So these are the action learning collaboratives. So this is where literally the rubber met
the road with our sub-team going out and physically going to these rural health clinics that had
committed to the project and so these are some of the objectives that we were looking
for and sort of overall guidance for how we wanted it to be delivered and then the contractors
on the project team figured out exactly what format that would take moving forward. I just want to highlight the last bullet point
refers to a resource that I’m also going to share with you later. We were lucky enough to have Dr. Fedrizzi
had developed this with the American Heart Association and so it was ready to come off
the shelf as a curriculum and be used in a clinical environment. And so that was a really wonderful thing to
get us kind of moving faster and using it as a guide. So this is the basic learning collaborative
process and so it took these different stages and I’m going to go through each of these
very briefly just because I’m not sure how much time it’ll take and the level of interest
but we can go back and talk about any of it. I did not run – as an aside – I did not run
the learning collaborative so as far as the actual like on the ground stuff that happened
I’m not as well-versed in that but if you had questions I definitely could share that
with you but along through these slides you’ll see some of the tools and things that they
used and the approaches they use like the planning use study act and so forth. So this is basically the timeline that we
laid out and we did this – our chronic disease folks met directly with the contractor and
laid this timeline out and really worked collaboratively to decide how could we meet the goals of our
funders and the contracts but also what could we do to set ourselves up for success. So this is an overview of everything that
happened in the course of the work with the learning collaborative. So part of the pre-work was this building
relationships and shared knowledge. And so they worked on the idea of the 5 Ps
and then talking about this global aim. And so the global aim for this is that they
wanted to start establishing a baseline. I mean these practices that participated were
all very, very new to this idea of managing – using their EMR in a way that they could
manage their patients and really hone in on quality improvement goal and then actually
implement some clinical process change and some patient encounter change to actually
make a difference. So a lot of this project was very much about
the teaching and learning and the experiential aspect of the project. This is the global aim for all of them and
then – so in order to establish a baseline we had to teach them how to collect all of
that and then that they were going to be using it with the achievement of 85 percent of their
patient population’s blood pressure is in control for three months. There was a survey used that they used for
engaging providers on the staff, and so these are the things we found out is that most of
them did these three things and fewer of them did these other things. And so it gave us some – for the side with
the follow-up patients, the nurse clinic and particularly the printed educational materials
I think it was a real opportunity that was identified for things that we could help assist
them with. They all did this: their own 5 Ps assessment
with their rural health clinic name and they went through and they stated their purpose
and their people and all the fun stuff that goes with that and then they identified their
own opportunity for improvement that was at that point very specific to their RHC. So there they could look at themselves in
comparison to their other peers and assess where there were opportunities for improvement
that were specific to their RHC and the use the materials from our team to support those
opportunities. And so there were in-person learning sessions
and a lot of coaching – a huge amount of coaching in a good way. They were very, very active and engaged. So we did this in-person meeting with a kickoff
and then there was the problem identification that was part of it and there was this sort
of exchange of information of things that our team asked for that then the RHC teams
would provide back and then that helped feed into the in-person meeting so that the time
was really valuable and it was used in the appropriate way. So they presented to each other which I think
is a really nice format. It’s a very collaborative format. It’s a very safe format for sharing. And then they talked about evidence and using
an evidence base to inform their change ideas. So there’s a global aim again and then these
are the ten change ideas and they’re going to come into play with that resource. This is the ten steps for improving blood
pressure control in New Hampshire. It’s New Hampshire because it was created
here by the folks that are listed on this book and some other people who are part of
it but I’m sure it works in other states. I don’t think it’s New Hampshire specific
in any way but – and there’s the information for a free download of that resource. And then this just talks a little bit of a
different way of looking at it and sort of this sphere of influence so that people can
really assess where to spend their limited resources. This is another tool that we used that was
a specific assignment they could use to help outline their quality improvement projects
and then as a team understand that and then present that to our consultants and sub-team
so that they could really talk about what was reasonable. And even just basic stuff like you think everybody
agrees on what a measure is and it turns out that they don’t. So that way they could really talk about meaningful
measures. And then the coaching came into place so they’re
doing their own work at their organizations and then there are phone calls going on as
well as ad hoc calls as needed with coaching to do a number of things that you see here
on this slide. So the team needs were varied and so the coaching
was varied in response to that. And then they got a chance to talk about their
challenges and opportunities and then they mapped their current process of care in their
flow chart which I think is – you know, I’ve done that as part of our work here in public
health, improving our quality improvement training and processes and culture and it’s
just really eye-opening sometimes when you map a process and you work as a group and
you learn a lot about assumptions and a lot about opportunities. And then this is just some tips on how to
help them get through, so you just keep reminding them of the aim and then you make sure that
we’re providing the tools that they need in order to make those changes. And so the next few slides here are just some
of the tools. So these are, as you can see, they’re wallet
cards in a number of different languages and the creation of these is actually supported
by our medical society and so these were handed out and used as a resources patient. And then there’s this DASH eating plan, another
educational material that can be provided to a patient as part of that visit and that
disease management. And then another one here that talks specifically
about the factors that lead to heightened blood pressure. And then more tools that you can use for translating
your data into visuals. More tools indeed. And so there was support around teaching them
how to use the tools and teaching them how to put their data in, how to read their data,
what’s significant and anything that might be a trouble sign for data that looks a little
bit wonky and maybe we need to go back and look at some quality issues around the data. And this is just a really nice kind of poster,
if you will, overview that we can put together and that the rural health clinics themselves
can use and then put in their own data specific to just their RHC about what they did and
then it’s a really nice way to present to the other folks in their practice but also
in other environments they might be where they want to talk about their work and how
they got there. And then the next step really in this project,
in this network and specifically with the learning collaborative is the spread and sustainability. And so what we’ve done is we’re going to continue
to support the hypertension work but not as intensely and we’ll continue to collect their
data and keep it in our dashboard. But we’re going to be moving on to diabetes
next. And so that is where we are now is we are
in – if you looked at this and changed the – from 2015 on the left side – or 2016 – and
then put 2017 over this is basically where we are right now. The chronic disease program folks here are
working very closely with the sub-team to – unfortunately we don’t have a nice curriculum
already for diabetes the way we did with hypertension but they’re working on that and they’re going
to be rolling that out but they’ve already started to recruit rural health clinics. And what we found is not only are they current
rural health clinics who are participating in the action learning collaborative but there
are additional ones who are interested in being part of that project. And so we always – what we try and do with
the TA network is we just keep extending that TA back out to all of the rural health clinics
whether they’ve shown an interest before or not because you just never know when you’re
going to hit that key moment in time and it’s going to click for them. So I would say just to wrap up the key elements
what we did is when we had – when they agreed to participate in anything sort of beyond
the TA level and the webinar level we had an MOU and it had really clearly defined roles
and really clear set expectations and we really tried to live up to those expectations so
that the rural health clinics knew exactly what they were getting into. We have an active listserv which is great
that we use for not only letting folks know about the formal TA provided but also other
things that are offered for example when my office offered grant writing stipends to NOSORH
grant writing institute I put that on a listserv and immediately got responses. If we have rural-focused or what we consider
to be relevant to rural health clinic conferences or educational opportunities we put those
out on the listserv as well and it’s just the listserv is nice because it’s interactive
and so we’re always keeping up with like if there’s a practice manager change or an administrative
change or a staff change they let us know and so we know that most of the time at least
that we are getting that key core group of people who are really interested in getting
the message which is nice. We did the incentives which took the form
of gift cards that were given to the practice and then the method of sort of delivering
with the combination of the in-person visits and the frequent follow-ups with telephone. So some of those were around formal projects
like the assessment or webinars and some of that was just individual questions or issues
there’s always something coming up I think in rural health clinics and even if we don’t
have the answer it’s so nice to have our contractors who are incredibly well-versed and have a
lot of expertise and then if they don’t know the answer they usually know the person who
has the answers so we’re able to get back to both and eventually get them the answers
that they need. I think I’m going to wrap up now and we’ll
sit on this questions page and you guys can just fire away and hopefully we can answer
your questions. I see one question up and it says: “Any chance
of expanding this chronic disease self-management?” And I don’t know if I’ve already answered
that by saying that we’re moving on to diabetes from here, or if the person who’s asking that
question means expanding it to other provider types. So I don’t know that I can fully answer that
without a little bit more information. Does Trevor, who asked that question, want
to share any more details if they’re still on the line? Alisa this is Marie. Hi everyone. I work on 1305. I’m wondering if the question relates to the
chronic disease self-management program that was highlighted in one of the slides. And through our 1305 cooperative agreement
we’re actually not able to support CDSMP, so that’s something that they would be doing
on their own. I think that’s what that might have been referring
to. Thank you, Marie. So once again highlighting how important it
is to have partners. We just got a couple of additional clarifying
comments for it’s expanding beyond diabetes for clarification and then following actually
through the D4S4 part of the 1304 grant. So it sounds like he’s closed the loop on
that. So anyone else have any other questions? Now is a great time to take yourself off of
mute and feel free to pose any questions to Marcella or Alisa. Can you hear me? Thank you. This is Carol Eisinger with NOSORH. I really thank ASTHO for putting this webinar
together and for sharing that good work of that collaboration. I want to ask both of you – you have said
– you made a comment that the networks were really important in launching that work, the
regional public health networks. And I’m curious what kind of – if you could
talk a little bit about how those are formed and maybe I missed that. But I’m very curious about how those start. I think they’re just a great example of that
public and rural health collaboration. Maybe you could talk about funding and what
lessons you learned from starting those. Essentially our public health networks were
created – I’m going to say 12, 13, 14 years ago and the essential issue that helped them
come forward is that in the State of New Hampshire, as small as it is, we have two cities, Nashua
and Manchester, our largest cities, that have local health departments, full, comprehensive
local health departments. And so they are very small geographically,
down on the very southern part of the state. The rest of our state has no public health
infrastructure at all. So we are a very centralized state, and the
original funding for these public health networks – and at that time there were probably 20
of them. Every community wanted to be its own little
network. And the reason that the state began to fund
them with federal dollars primarily it was for emergency preparedness. So after the flood gates opened, after 2001
the Emergency Preparedness Fund started to come out. We created these networks so we would be able
to work more directly in a more organized fashion with the police departments, the fire
departments, the volunteers and started to develop these emergency networks. So as time has gone by we now are down to
13 and we use these in many different ways. We still use our emergency preparedness funds
and move funding out through the state to these regions. We have also added other elements, for example
the immunization program wanted to start school clinics – this is after 2009 we wanted to
start school immunization clinics. So we have funneled funds through those same
systems to have the volunteers and the staff, limited staff, in those networks also do essentially
what are drills by having school flu clinics. And we also have pushed funding out for climate
change adaptation, funding, and I think some of our chronic disease – and maybe some of
those folks could step up. So we have other public health units, essentially,
have begun to move money out into the public health networks in that fashion. The big change came I think about two years
ago when our substance misuse bureau, which is in a different part of our major umbrella
system, they aligned their alcohol and substance misuse funding – they aligned their networks
to our networks and so now that funding is all bundled and now we have increased our
staff out there, increased the funding greatly at that point. And then two years ago we also sent out funds
for them all to do a needs assessment, a community health – essentially an improvement plan,
a CHIP plan in each one of the networks. So they were able to create these community
– large public health network community plans and they are working on those. They are aligned to our state health improvement
plan. So all of our regions are now working on their
own improvement plan and developing hopefully a greater sense of stakeholders and collaboration. We also have, the most recent iteration is
we have an 1115 waiver in our state and we were able to use essentially that same framework
to set up our integrated delivery network system that was a part of that whole process. So they continue to be very much a part of
this integration of behavioral and physical health care out in our community. So the networks have become very important
for us because it gives us all a framework in which to work at the local level. And then I just wanted to add something from
a purely like practical sense. For data it’s been incredibly helpful for
them to be organized because what that means is that where possible the data that we put
out as a public health division is available by public health region. And so what the means is that our constituents
can use – we have an external facing system called Wisdom and it has all the data that
we have and some pre-established dashboards that match those CHIP goals that Marcella
– the CHIP areas of priority that Marcella mentioned in the beginning of our presentation
and so our folks can go up there and they can pull their data and what they can do now
because we have classified them as rural or non is they can pull their rural data in comparison
to non-rural and the state and instead of having to make a separate data request to
our data team and waiting six weeks in order to get that – and I used to myself in order
to go my rural data report for my funders and to assess our priority areas with I had
to pay an outside consultant to request the data from our group, bring it in to their
system and sort it into our own unique New Hampshire definition. And I was able to give that up and redirect
that energy and resources to other projects because now we can use this system. And so the more people in public health and
more people who in the department and eventually the state use this same classification the
more we’re speaking the same language when we talk about rural New Hampshire as opposed
to the 42 definitions of rural on a federal level. Well you are both tenacious women. Any other questions from the group, from the
audience? Otherwise I have one quick question for you
both around if you were to synthesize this down and get your top couple of takeaways
for other states trying to implement an intervention like this what would you recommend to those
other states doing this work? I would say I would recommend that if you
think your project is too small to be meaningful change that thinking because I don’t think
that’s the case at all. The really wonderful thing about rural is
that innovation can be done fairly easily because there’s so few people that you can
really come together. And they’re committed and passionate in a
way that I’ve never seen in any other setting. So even if it’s small, if it’s valuable they
will latch onto it and they will appreciate it. And you will start to develop networks and
relationships with people and they will start to see your value as a program and then you
can start adding more and more things on as you’re able to do so. I would also look for state resources that
you have that already have been created. Ideally an evidence-based but if not that
a best practice and then, you know, assess whether or not they’re appropriate for rural
or maybe it’s just a way the delivery method is. But I would say that don’t be hampered by
not being able to pull off something really big, but at the same time I would definitely
set your own capacity. And if you need to get some outside expertise
and contract that I would do that as well because what you really want is even if it’s
a little project you want it to be a roaring success so that you can start moving on to
other projects. Great. Thanks. Yeah, so do we have any other questions from
the group? I want to offer one more opportunity for that
from folks. Otherwise we can go ahead and wrap up here. Thank you all so much for your time this afternoon. We really appreciate it, especially Marcella
and Alisa. Thank you so much for taking the time to share
a little bit about your work and your project there in New Hampshire. We’re going to go ahead and put these slides
online so they will be distributed. Our contact information is up there so if
anyone has any further questions that come to mind after we wrap here feel free to reach
out to us and get in touch. With that we’ll let you all go. Thank you all so much. [End of audio]