Creating a Web of Rural Health Care in Nebraska

    • October 16, 2015

Originally posted: March 1, 2002
Last updated: October 16, 2015

Position at time of the award: Coordinator, Office of Rural Health, Nebraska Department of Health, Lincoln, Neb.

Current Position: Principal, Nebraska Times, LLC; Lincoln, Neb.

He is the most systemic thinker I've ever encountered in state government, consistently leading people to think beyond the usual categories, and constantly calling people to a renewed sense of health and hope and wholeness. There are rural hospitals that remain open because of Denny Berens. There are physicians who remain in rural practice because of Denny Berens. There are networks of providers—mental health, nurse practitioners, physicians, pastors—that work together because of Denny Berens. There is a coalition of rural state senators working on health issues because of Denny Berens.—Executive Secretary, Interchurch Ministries of Nebraska

I don't care if you remember my name five or ten years from now—if you think something good happened here, more important is that you felt that you did it.—Denny Berens

A passion for rural health. From 1990 to 2012, Dennis Berens (Denny, as he is universally known), was the coordinator of Nebraska's Rural Health Office, with responsibility for improving the state's rural health care. As a government worker, he was an unusual choice for the Robert Wood Johnson Community Health Leadership Award. But Berens' accomplishments are equally uncommon. As he puts it, "I'm a farm boy by birth; I'm a teacher by training; I was a newspaper publisher by accident; I'm a public servant by choice."

Growing up in a small community, Berens loved the rural farm lifestyle. "None of us had insurance," he recalls. "We were each other's insurance. We celebrated birthdays and anniversaries, and it was our whole social life. We went to the same church. We would take eggs and cream into town on Saturday nights, and stand on the street corner talking to each other. We did hay together, we milked cows together. That gave me an understanding of what community ought to look like. And I think I was very blessed."

After getting his undergraduate and graduate degree from Concordia College in nearby Seward, Neb., in 1971, Berens went to work as a teacher and athletic director at local schools. He continued teaching for 10 years, until fate intervened. When a position as co-publisher of the town's only newspaper, The Seward County Independent, became open in 1976, he took the job and remained there for the next 14 years. In his role as co-publisher, Berens became more conscious than ever of the plight of America's rural communities and the need to preserve them as a precious, living resource. "The newspaper experience taught me what a community can be," he remembered later. "But in order to remain a community, people have to be willing to risk for each other, at least a little bit—one on a ten-point scale."

Keeping rural Nebraska connected. He began to see his post as an information hub—a powerful force in keeping his community together. He had his newspaper sponsor Learning Activities for the Community, where specialists in subjects such as the arts, culture, and downtown preservation would be brought in to speak with residents. There was also a travel program, helping local residents see the rest of the world and understand the issues being addressed beyond their small Nebraska community. While at the paper, Berens chaired several Chamber of Commerce committees, became a member of county, district, and state advisory boards, and in 1995 helped establish the Nebraska Main Street program, which is dedicated to preserving Nebraska's small towns.

As a result of his efforts in rural economic development, Berens' work came to Nebraska Governor Kay Orr's attention. In 1990, she offered him the post of Coordinator at the Nebraska Department of Health's Office of Rural Health. He took the job, perceiving the great need for better rural health care and seizing the chance to do something about it.

"I didn't have a health care background," he recalls, "but Governor Orr was more interested in my community background. I'd lived in rural areas all my life [45 years], and I decided this was what I should be doing. It was almost a religious experience for me. I'd struggled with how I could be of service to my fellow man at that point in my life, and given what was going on in my community, it seemed that was what I ought to be doing."

The need was truly great. Health care all over the United States was becoming more centralized and more urbanized, and rural areas did not fit well into this new model. Berens knew he needed to find alternative models, if the web of health care for rural communities was to be saved and restored. He found those models outside the usual health care paradigms, looking for them instead in the worlds of business and community service.

All over the state, because of declining community populations, hospitals were in danger of closing down. Nebraska had more than 500 communities with 1,000 or fewer residents, many of which were hours away from health services. Berens knew that getting people and organizations to work together, crossing the traditional lines that divided them—public/private, church/state—would be crucial in bringing communities together to fight for health care services.

Forming new alliances. A parallel upheaval in service provision was occurring within the Nebraska government in the 1990s. Five state "departments" in health and human services were being merged into three "functional" units. Berens knew that, inevitably, procedures and people would fall through the cracks. His concern that the new model would be predominantly urban motivated him to take risks in forming a new alliance—Nebraska Health Partners—that included the State's Community Action Agencies, the Department of Health, the statewide Council of Churches, the Mexican-American Commission, Native American groups, and a host of others, to address these issues. He employed the Interfaith Volunteer Caregivers (IVC) to establish units throughout the state. (IVC, through its national federation, provides a network and support for churches, agencies, and individuals to address unmet community needs.)

He was instrumental in forming the Rural Response Partnership—a consortium of public and nonprofit groups that provided a network of mental health services to rural residents, in response to the continuing rural crisis brought on by the fall crop prices (due to worldwide abundance of food) and hence in land values, and to natural disasters such as the long drought that afflicted Nebraska during the 1990's and continues to this day.

Another group Berens gathered together in 1996 began discussing ways to prevent and defuse conflicts between communities fighting over scarce resources. Rural sociologists from the University of Nebraska, the director of the Office of Dispute Resolution, church leaders, mental health professionals, extension educators, and rural residents from several areas of the state took part, with impressive results. A network began to take shape, with trust and respect developing between bureaucrats and citizens, working together for the common good.

Operating from bedrock principles. In all of these coalitions, Berens operated from the same bedrock principles: that relationships matter more than programs, that people need a face and a name, and that process is as important as product. He helped all participants understand that every change is an opportunity, every challenge a chance. He encouraged the crossing of traditional boundaries, and the bringing together of people for common purposes, without regard to the roles and distinctions that too often separate them. He worked to achieve meetings that were characterized by a spirit of cooperation and collaboration.

Seeing also that nothing positive and lasting could be accomplished without change at the policy level, in 1994, Berens formed the Rural Health Stakeholders' Legislative Coalition, which met regularly with policymakers and state legislators. That year, he also convened Rural Health Conferences, bringing widespread attention to important health care issues. All the while, he continued traveling the state, helping desperate regions find solutions to seemingly intractable problems. In north-central Nebraska, he brought together a group of physicians, nurses, mental health practitioners, and citizens to provide coordinated services to consumers by means of telecommunications technology, which expanded treatment options for patients. In the southeastern part of the state, he began working to convince six communities that they'd be better off converting their six separate hospitals, which were struggling to find enough patients to stay open, into one flexible health center, serving all six communities.

The Community Health Leader award. In 1997, Berens was nominated for the Robert Wood Johnson Community Health Leadership Award. One of his nominators wrote of him, "There are rural hospitals that remain open because of Denny Berens. There are networks of providers—mental health people, nurse practitioners, physicians, pastors—that work together because of Denny Berens. There is a coalition of rural state senators working on health issues because of Denny Berens. There are groups in countless rural communities working to better community health services because of Denny Berens. What is perhaps most impressive is that, while all of these things bear Denny's stamp, none of them are Denny's. He manages to generate local ownership and accomplish a great deal without the recognition he so richly deserves."

With the award came recognition that on one level, made Berens uneasy. "I felt a little awkward, getting all that attention," he admits. On the other hand, the award gave his efforts a sense of legitimacy, both personal and institutional, up to the state level. "To have an entity like the Foundation recognize your efforts says to the folks inside state government, 'Hey, this is probably pretty important,'" Berens points out. And on a more personal level, "It was really nice to be patted on the back, and their saying, 'You're doing a great job, and here's $100,000 to go and do something that you always wanted to do and couldn't do.'"

Work engendered by the award. That "something" was the Rural Health Institute, an idea. Berens had conceived many years earlier. Now, with money to back its formation, he began melding yet another new coalition of providers and other health care leaders to teach up-and-coming leaders from the community, helping them form a new model for rural health care. As of fall 2000, that coalition is in place, and the first of the award money is being spent on making the Rural Health Institute a reality.

After receiving the award, Berens launched several other new ventures. One was a coalition focusing on farm and ranch stress. Part of this venture is a voucher program, backed by state and foundation funding, with the support of the Interchurch Ministries of Nebraska, to help fund counseling, retraining, education, and whatever other assistance may be needed for farmers and workers in related industries. The coalition's goals are: getting immediate assistance to rural residents in distress—some of whom are suicidal; addressing the effects of fluctuations taking place in agriculture on farmers and residents of small towns that depend on agriculture for survival; and developing a strategy to have additional funds allocated to the problem. As part of this effort, the coalition has placed one of its members on the Governor's Drought Task Force. It now operates in Nebraska and six other states.

Another venture for Berens was a nonprofit corporation called Bridges, whose purpose is to help the 10 communities that make up Seward County bridge a number of differences over service provision, so that they don't waste precious resources. Bridges hopes to get communities and individuals inside the county to realize that they have to do things more from a county viewpoint.

Perhaps the largest program Berens worked on was the creation of Nebraska's Critical Access Hospitals—a category of hospitals initiated in 1997 under the federal Medicare Rural Hospital Flexibility Program, providing for hospitals with two dozen beds or less, and geographically far from a major hospital, to realize cost savings through flexibility in staffing and other means. Critical Access Hospitals may adjust the number of critical care beds to meet local need, while still meeting specifications for Medicare reimbursement. This project has been funded by the federal Centers for Medicare & Medicaid Services (CMS) formerly the Health Care Financing Administration (HCFA), and there are now 65 such hospitals operating across Nebraska, by far the largest number of any state.

Yet another dream of Mr. Berens' came to fruition in 2002—the historic preservation of downtown Seward, a project he fought for 20 years ago, as co-publisher of the town's newspaper. "It took 20 years for that dream to come together," he mused. "Patience is a big requirement of leadership."

Postscript. Berens retired from the Nebraska Office of Rural Health in 2012 after 22 years there. As of this October 2015 update, he heads Nebraska Times, LLC, a consulting, polling, and advocacy company in the rural health field. One of the firm's major projects is providing information to journalists on rural health, including a rural health news service covering eight states.

He has also been working on expanding the use of paramedics beyond emergency situations. "This is easier to do now that I'm out of state government," he says. "I'll do it until I'm six feet under or go up in smoke."

RWJF perspective: The Foundation recognized the first 10 RWJF Community Health Leaders in 1993—unsung and inspiring individuals who work in their communities, often among the most disenfranchised populations, to address some of the nation’s most intractable health care problems. The last round of leaders was chosen in the fall of 2012. The program closed at the end of 2014. For more information, see the Special Report.