August 2004

Grant Results

SUMMARY

From 1998 to 2003, project staff from AcademyHealth, Washington, a nonprofit policy institute, and consultants provided technical assistance to 46 rural health networks that were seeking to establish themselves or to embark on specific projects to expand access to services, improve quality of care or strengthen the viability of rural providers.

Rural health networks are a way for providers to pool their resources and work together to purchase equipment, share services and enter together into managed care contracts.

Results

  • Project staff conducted five technical assistance workshops and two policy conferences primarily for rural health network staff and board members but also involving state and federal officials responsible for rural health issues.
  • Project staff conducted 19 site visits to assist network leaders to gauge their network's stage of development and the steps they would need to take to develop further.
  • Project staff awarded grants of up $40,000 to 27 networks to engage consulting services to assist with projects to expand access to services, improve the quality of care or enable rural providers to participate in managed care contracts.
  • Project staff produced technical assistance materials including six monographs, two self-assessment tools and 25 profiles of the networks that received targeted consultations and completed their work.

Funding
The Robert Wood Johnson Foundation (RWJF) provided $2,983,044 to fund the project from August 1998 to June 2003.

 See Grant Detail & Contact Information
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THE PROBLEM

Rural hospitals, physicians and clinics often find themselves without the resources to provide certain health care services to patients because of the sparse population, scant resources or remoteness of their geographic areas. Rural hospitals may not have the funds to purchase high-technology equipment on their own, and small physician practices may be overwhelmed with demand but not have the resources alone to mount a search for more physicians, including specialists, or to compete for managed care contracts. One potential solution to these problems is a network of rural health providers.

Rural health networks are relatively new. In 1989, the U.S. Congress created the Essential Access Community Hospital program, which exempted small rural hospitals in seven states from federal regulations that made it difficult for them to stay in business. (For example, under the new law, certain rural hospitals could be paid on a cost basis, rather than by diagnosis-related group, which pays a flat fee for each case no matter how long a patient is in a hospital. Rural hospitals often do not have enough patients to balance out the high-expense patients with the lower-expense ones).

The federal program required these limited service hospitals to form networks with larger hospitals. RWJF gave the Alpha Center for Health Planning, a nonprofit policy institute in Washington (which later merged with Academy for Health Services Research and Health Policy to become AcademyHealth, the grantee for this project), a series of grants to provide technical assistance to these hospitals in forming networks (see Grant Results on ID#s 020111, 020765 and 022539).

Through that work, the AcademyHealth staff, including Daniel Campion, saw the potential for rural health networks for all rural health providers, not just hospitals. In 1997, the federal Office of Rural Health Policy began funding a broader program, the Rural Health Network Development Grant Program. Rural hospitals, physician's offices and clinics could apply for grants to form these networks. The program, however, did not provide any technical assistance to help these groups form networks.

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RWJF STRATEGY

In addition to its earlier funding of technical assistance projects for rural hospitals, RWJF also supported Ira Moscovice at the University of Minnesota School of Public Health to conduct research on rural health care that documented the growing popularity of the networking concept (see Grant Results on ID#s 023911, 029069 and 032659) and produced a report, Rural Managed Care: Patterns and Prospects. RWJF also funded a national health care policy conference on the health care needs of rural areas, run by AcademyHealth (see Grant Results on ID# 029744). In 1998, RWJF funded a $32.9 million national program, the Southern Rural Access Program, which provides funds to eight southern rural states to strengthen the health infrastructure, thereby increasing the number of primary care providers in those states, establishing revolving loan funds and building rural health networks (for more information see Grant Results). RWJF, however, had no projects to provide help to rural health providers that wanted to form networks in other parts of the country.

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THE PROJECT

This project provided rural health leaders with a variety of assistance to promote the growth and maturation of rural health networks. This project also provided a national forum to assess the implications of rural network development for public policy. The project directors were Campion and Moscovice.

At the beginning of the project in 1998, staff anticipated that managed care would continue to grow, forcing rural providers to form more integrated, managed care delivery networks. However, both the Medicare+Choice program (a Medicare managed care program) and state Medicaid managed care programs stalled in their movement into rural areas, and private purchasers in general cooled their push into managed care. Fewer networks than anticipated sought assistance for implementing managed care strategies. Instead, networks focused on areas that would help them save money (such as establishing joint human resources staffing, employee benefits purchasing and computer purchasing) and/or expand or create new services (e.g., primary care clinics, laboratory services and preventive care).

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RESULTS

Project staff and consultants provided technical assistance to rural networks through one-on-one consulting, publishing monographs and holding conferences. Some of the networks were receiving federal funds through the Office of Rural Health Policy; others were not.

  • Project staff conducted 19 site visits to assist network leaders in gauging their network's stage of development and the steps they would need to take to develop their networks further. In preparation for the site visit, project staff interviewed board members and had them complete a survey to assess the development of the network and the key issues and challenges facing the network. Staff then conducted the site visit where they presented their findings and helped leaders decide on next steps. Through the site visits, project staff realized that most network leaders needed more help with strategic planning. As a result, staff designed a series of workshops on strategic planning (see next bullet).
  • Project staff conducted five technical assistance workshops and two policy conferences primarily for rural health network staff and board members but also involving state and federal officials responsible for rural health issues. Three workshops focused on strategic planning. Two others concentrated on legal issues and leadership skills. The first policy conference was a small, interactive, expert meeting that focused on how government and foundations can best support rural network development. The second was a larger national conference to discuss collaborative approaches for addressing major rural health issues: access to care for vulnerable populations, quality improvement, workforce shortages, capital formation and payment policy.
  • Project staff awarded grants of up to $40,000 to 27 networks to engage outside consulting services to assist with projects to expand access to services, improve the quality of care or enable rural providers to participate in managed care contracts. Project sites had to match the funding dollar for dollar. AcademyHealth helped networks find appropriate consultants, screen the consultants and develop a contract with clear deliverables, a work plan and a due date. Consultants spent several days over the course of several months or longer helping more established networks work on specific projects. Among the projects were:
    1. Developing a health care plan, including health insurance, for low-income residents.
    2. Creating software to coordinate and manage health care for patients with chronic health conditions.
    3. Developing and educating staff in a comprehensive compliance plan to meet standards for care.
    4. Addressing the shortage of hospital coding staff, who prepare patient bills for reimbursement from insurance companies.
    One of the projects illustrates the possibilities and difficulties of rural health networks.
    • In Minnesota, three health systems formed the Lac qui Parle Health Care Network in 1998 to improve access to primary care services and technology in the southwest central region of Minnesota. The network had already collaborated on small projects including the group purchase and installation of a software program for charting home-health care, a plan to purchase and share a portable ultrasound and coordination of physician and other staff recruitment. In late 1999, the group received a $15,000 consultation grant from the project to assess the feasibility of developing satellite primary care clinics in up to three sites and implementing shared emergency room call coverage among the network's members.

      The feasibility analyses concluded that it was financially viable to run a satellite clinic that would be open two half-days a week. Based on the analyses, network members opened a satellite clinic in the town of Boyd in August 2002. The town had been without a medical clinic for about 50 years. The clinic is staffed two mornings a week (one morning by a nurse practitioner and one morning by a physician).

      Consultants also worked with network members to analyze the feasibility of sharing emergency room physician coverage among the three hospital members. The consultants found that the network members could save money by sharing emergency room (ER) call coverage. However, network members could not agree about how to implement shared ER physician call coverage. Barriers included concerns about the distance to some of the hospitals, turf issues related to caring for patients of physicians from another site and differences in physician call coverage contracts.
  • Project staff produced technical assistance materials including six monographs, two self-assessment tools (one to help network leaders evaluate a network's strengths and weaknesses and the other to organize relevant information and identify where to focus business planning efforts) and profiles of the 25 projects completed as a result of the targeted consultations. Monographs included a legal primer on forming rural health networks, principles of rural health network development and management, business and strategic planning for rural health networks, shared ventures, quality improvement in rural hospitals and case studies of ways to use rural health networks to address local health care needs. See the Bibliography for titles and other information.

Communications

The project's key communications activities included distributing the monographs and decision-support tools through mailings and their Web site as well as presentations at major national meetings. See the Bibliography.

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LESSONS LEARNED

  1. When seeking to form rural networks, network participants may find it more beneficial and practical to focus on areas such as joint purchasing and shared services than on system integration. "Most administrators are going to be willing to say, 'Why don't we use our influence together as a purchaser to get items for lower costs?'" said RWJF program officer Floyd Morris. "That's a lot easier than saying, 'Let's put together our financial systems,' which is very costly to do. It's not clear always what the benefit is for the different parties." (RWJF Program Officer/Morris)
  2. Because of the complexity of forming a health care network, network participants may need longer-term, intensive assistance rather than one-shot site visits to achieve results. Preparing for the site visits took a lot of time, and the network leaders invariably asked the project staff to come back again in a few months and help them with next steps. Given the complexity of forming these networks, and the needs of rural areas, groups seeking to help these networks will probably see more results if they limit their assistance to a smaller number of networks that they can work with over a period of months. (Project Director/Campion).

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AFTER THE GRANT

The project is no longer active. In 2002, the federal government established a technical assistance center at the Georgia Health Policy Center at Georgia State University, which is funded for $1.6 million and is providing assistance to rural health networks. Campion serves on the advisory board to the new center.

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GRANT DETAILS & CONTACT INFORMATION

Project

Networking for Rural Health

Grantee

AcademyHealth (Washington,  DC)

  • Amount: $ 2,983,044
    Dates: August 1998 to June 2003
    ID#:  033434

Contact

Daniel M. Campion
(202) 292-6700
daniel.campion@academyhealth.org

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

National Advisory Committee members

Sharon Avery
Rural Healthcare Center
Sacramento, Calif.

James Bernstein
Office of Rural Health and Resource Development
North Carolina Department of Human Resources
Raleigh, N.C.

Luisa Buada, R.N.
California Institute for Rural Health Management
Oakland, Calif.

Paul Fitzpatrick
Rural Health Development
Albany, N.Y.

Walt Gregg
Rural Health Research Center
Division of Health Sciences Research
School of Public Health
Minneapolis, Minn.

Mary Huntley
Office of Community and Rural Health
West Virginia Department of Health and Human Services
Charleston, W.Va.

Tom Martin
Lincoln Hospital
Davenport, Wash.

Keith Mueller, Ph.D.
Nebraska Center for Rural Health Research
Omaha, Neb.

Benjamin H. Robbins, M.D.
Carle Clinic
Urbana, Ill.

John Rugge, M.D.
Upper Hudson Primary Care Consortium
Glens Falls, N.Y.

Monnique Singleton, M.D.
Bamberg, S.C.

Tim Size
Rural Wisconsin Health Cooperative
Sauk City, Wis.

Stephen Wilhide
Southern Ohio Health Services Network
Milford, Ohio

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

Bonk G. Principles of Rural Health Network Development and Management. Washington: Academy for Health Services Research and Health Policy, 2000.

Browne K, Campion D, Stenger R and Folz C (eds.). Strategic Planning for Rural Health Networks. Washington: Academy for Health Services Research and Health Policy, 2001.

Browne K, Coluccio K and Folz C. Profiles of the Networking for Rural Health Project's Grantees. Washington: AcademyHealth, 2003.

Kemp K. Quality Improvement in Rural Hospitals: How Networking Can Help. Washington: AcademyHealth, 2002.

Moscovice I and Elias W. Using Rural Health Networks to Address Local Needs: Five Case Studies. Washington: AcademyHealth, 2003. Available online.

Teevans J. Forming Rural Health Networks: A Legal Primer. Washington: Alpha Center, 1999.

National Rural Health Resource Center. Rural Health Network Profile Tool. Washington: Alpha Center, 1999.

Wellever A and Robert C. The Science and Art of Business Planning for Rural Health Networks. Washington: Academy for Health Services Research and Health Policy, 2000.

Wellever A and Folz C (eds.). Shared Services: The Foundation of Collaboration. Washington: Academy for Health Services Research and Health Policy, 2001.

Business Planning Worksheets for Rural Health Networks. Washington: Academy of Health Services Research and Health Policy, 2001.

Sponsored Conferences

"Legal Issues and the Formation of Rural Health Networks," July 27–28, 1999, Chicago. Approximately 70 participants attended this meeting, which brought together rural network leaders, providers, state officials and others involved in developing rural health networks. Examples of institutions represented include Frontier Health Network, Community Health Systems and Minnesota Counties Insurance Trust. Six presentations.

"Strategic Planning for Rural Health Networks: Southeast Regional Meeting," November 30–December 2, 1999, Little Rock, Ark. Co-sponsored with the RWJF Southern Rural Access Program. Participants included 90 network leaders; state officials from Alabama, Arkansas, Georgia, Louisiana, Mississippi, South Carolina, Texas and West Virginia attended. Eight presentations.

"Strategic Planning for Rural Health Networks," July 24–25, 2000, Seattle. Participants included 43 network leaders, hospital administrators and state officials. Six presentations.

"Strategic Planning for Rural Health Networks," August 24–25, 2000, Boston. Participants included 94 network leaders, hospital administrators and state officials from institutions such as the MDI Hospital, Arkansas Department of Health, Rural Wisconsin Health Coop., Vermont Department of Health and Iowa Department of Health. Seven presentations.

"Rural Health Network Leaders' Conference," November 15–17, 2000, Arlington, Va. Co-sponsored by AcademyHealth and the federal Office of Rural Health Policy (ORHP). Participants included representatives from RWJF and ORHP grant projects as well as 95 network leaders including hospital administrators and state officials from institutions such as Health Partners of Southwest Iowa, Northland Healthcare Alliance and the Institute of Medicine of the National Academy of Sciences. Six presentations.

"Networks, Networking and Collaboration in Rural Health Care: An Expert Meeting," April 4–5, 2001, Washington. Participants included 24 network leaders, practitioners, researchers, federal and state officials and foundation representatives. Examples of institutions represented include the federal Office of Rural Health Policy, the Robert Wood Johnson Foundation and Galaxy Health Alliance. No formal presentations.

"Collaborative Strategies to Address Critical Rural Health Issues: A National Policy Conference," December 6, 2001, Washington. More than 150 attendees. Examples of institutions represented include the Rural Community Assistance Program, National Rural Health Association, Agency for Healthcare Research and Quality and Project HOPE. Sixteen presentations.

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Report prepared by: Susan G. Parker
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: Floyd Morris
Program Officer: Anne F. Weiss

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