Category: Promising Practices

Helping Rural Hawaii THRIVE

By: Beth Blevins

Residents in rural communities across the Hawaiian Islands have been sharing their “stories of health” in community meetings as part of an effort to build a framework of health derived from community values and practices.

“A common thread in all these meetings is that having a connection to what matters is really what can make good, positive change in the community,” said Gregg Kishaba, Rural Communities Health Coordinator at the Hawaii State Office of Primary Care and Rural Health (HI OPCRH).

The meetings, sponsored by the Hawaii Public Health Institute (HPHI) and supported by HI OPCRH, are part of a larger, long-term strategy for achieving “Pilinahā”—a nonclinical, universal view of health and wellness developed by the communities themselves. The objectives of Pilinaha are: deepening a connection to place, to the past, to others, and to the best parts of one’s self. As part of the initial phase of this strategy, 17 community forums, which included discussions and storytelling sessions, were held on all six islands.

“We had the connections in a lot of rural communities already so they (HPHI) wanted to partner with us,” said Scott Daniels, FLEX Coordinator at the HI OPCRH. “We were part of the original planning committee. We had to do a lot homework beforehand to figure out how many meetings we would be having and who would lead in the community.”

HI OPCRH staff, trained in the THRIVE (Tools for Health Resilience in Vulnerable Environments) method in 2015, helped facilitate the meetings. “THRIVE really does involve the whole community,” Daniels said. “It provides an interactive method for communities to get out there and record and discover their community.”

“THRIVE is a unique tool that focuses on community and the concept of health equity,” Kishaba added. “The process guides communities to assess and identify root causes through a health equity lens. THRIVE allows for multi-sector partnerships to develop, facilitates a deeper understanding of the social determinants of health, and builds a foundation for future action and activities.”

For example, Kishaba explained, “if a community chooses to focus on a particular disease, like diabetes, THRIVE has an online tool that walks you through what kind of questions should be addressed. Or if a community says ‘it’s not all about the disease state, it’s more about where we live, our economy, education’—you can take that path. But that will eventually connect you back to a health issue, like asthma, which can be exacerbated by roaches or dust.”

Most communities chose not to focus “on the disease or on deficit or scarcity, but on the positive side of health,” Kishaba said. “So, we might start off a meeting, by asking: ‘When was the last time you felt good about yourself or you were healthy?’ Many of the seniors at the meetings went back to a time when they were younger and had the freedom to ride bicycles or walk safely in the community.”

“It’s useful getting the community to think of those other factors that contribute to the health of the community,” Daniels said. “It’s getting back to social determinants. The focus is on trying to establish a framework where people live healthy in their environment and the people that they are around so that creating those connections will ultimately improve A1c counts.”

Daniels said that they have found their THRIVE training useful for other efforts, including Community Health Needs Assessments (CHNAs). “It’s another tool and another way to look at health in your community,” he said. “We have been using THRIVE training to help hospitals break out of the hospital-clinic-medical thing and think more about the environment.”

The National Public Health Institute provided funding for the 17 meetings and the statewide forums, and the original THRIVE training was coordinated by the Hawaii Public Health Institute, Kishaba said.

HI OPCRH is supporting the creation of a video that captures what was learned from these community meetings. “Our office understands the importance of storytelling through digital media, so we provided the resources to tell this in a digital format instead of just having a booklet or pdf,” Kishaba said. “We sent film crews to the meetings, based on everyone’s input, to pick and choose unique stories that will captivate audiences.” The film will serve as a roadmap and springboard for future activities, Kishaba said.

“Once the video is developed, we will go back to those 17 communities to show it,” Kishaba said. The video also will be shown at statewide conferences and be available for free on the HI OPCRH website.

Click here to view the THRIVE participant packet

Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Beth Blevins at (301) 260-0556 or thebethblevins@gmail.com to set up a short email or phone interview in which you can tell your story.

Nevada SORH Digs Up Data on Rural and Frontier Counties

County-level data—particularly for rural counties—wasn’t always readily available in Nevada. But the Nevada Rural and Frontier Health Data Book (and the associated Nevada Instant Atlas website) changed all that.

Now in its eighth edition, the Data Book, complied by the Nevada State Office of Rural Health (NV SORH), provides comprehensive information on all counties in the state. The data in its more than 100 tables varies from the broad—e.g., county populations—to the more specific, e.g., number of licensed physical therapists by county. Though issued only every other (odd) year, when the Nevada legislature is in session, the data is dynamic rather than static, according to Tabor Griswold, Health Services Research Analyst at the NV SORH.

“Data goes into the Nevada Instant Atlas on our website first, then we pull it out for the Data Book,” Griswold explained. “We continually add or update new points of data to the website.” In addition, the Instant Atlas, which boasts more than 200 users each month, “is unique because it offers time trending,” she said. “When you bring it up visually, there is a bar that shows all the data going back to when we first started collecting it. When possible, the source of the online data is linked between the website and the original source.”

Click Here to See Data Poster
Griswold said that users can also use the Nevada Instant Atlas to assess the impact of legislation over time. For example, she said, “the expansion of public nursing programs over the past decade, and changes in advance practice nursing scope of practice have led to dramatic increases in RNs and advance practice RNs, which is documented in the Atlas.”

The Data Book is available electronically as a PDF, as well as a limited number of hard copies. “We bring copies of the Data Book to “Rural Health Day at the Legislature” to share with members of the legislature and the governor’s staff, as well as hospital administrators attending the event,” said John Packham, Director of Health Policy Research at the NV SORH.

The first Data Book rose out of the frustration Packham experienced after he arrived at the Nevada SORH, whenever he needed to find rural data. The state was collecting data for Clark County (i.e., Las Vegas), Washoe County (i.e., Reno), “and the ‘balance of the state’,” Packham said. “But the ‘balance of the state’ was the 14 rural counties we worked with on a routine basis. Whether it was for a grant or a county commissioners’ meeting, we would have to mine existing data to try to find out what was going on at the county level.”

Putting that information into the Data Book made everything easier to access, Packham said. But it also made a compelling case for the state to begin collecting and breaking data down by county, he said, “because there were some pretty substantial variations between a healthy county and an unhealthy county—certainly on health workforce data. It also kick-started our practice of going to the 38 state licensing boards for health professions, getting their data, and breaking it out by county.”

The NV SORH has found effective use of the Instant Atlas for two purposes. “For community health needs assessments, one of our starting points is to abstract or pull out the county-level data, and package it in the form of a county-level report,” Packham said. The Nevada SORH also uses its data to help rural county commissioners who are trying to establish or convene local boards of health. “Of the 14 Nevada counties that are rural or frontier, none have local health departments—their public health services are provided through the state of Nevada,” Packham said. “But there’s been an awakening of interest among them to convene local boards of health—or at least put public health issues before their commissioners. Our office is supporting these efforts to the extent that they need data to start the discussion.”

Packham said that the Data Book is funded through a combination of staff partly supported by federal Flex funds, other types of state dollars, and pieces of grants and contracts. In other words, “funding is complicated,” he said. Since the Nevada SORH is university-based, “we train undergraduates in the data collection process and to understand data base development —that’s a win-win,” Packham said. “They’ve been really instrumental in loading and double-checking all of the new data.”

The Data Book has proven a success, used by legislators, county commissioners, and hospital administrators. Perhaps more importantly, according to Packham, it has improved the visibility of the NV SORH. “Over the 15 years we’ve been doing this, people know that this resource comes from the State Office and the School of Medicine at the University at Reno,” he said. “It’s our flagship publication. It has increased the degree that we’re the first resource that people go to, especially on workforce data.”

Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Beth Blevins at (301) 260-0556 or thebethblevins@gmail.com to set up a short email or phone interview in which you can tell your story.

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Advisory Group in Washington State Works to Bring Palliative Care to Rural Patients

By: Beth Blevins

An advisory team run by the Washington State Office of Rural Health (WA SORH) is looking at ways to bring palliative care to rural patients through telehealth and better community engagement.

Palliative care aims to relieve the suffering of patients with terminal or life-limiting illnesses. But in rural areas, palliative care isn’t always available locally, especially for patients who don’t immediately qualify for hospice services.

Pat Justis, director of the WA SORH, was drafting ideas for rural palliative care when inspired to start the Palliative Care Rural Health Integration Advisory Team (PC-RHIAT) after hearing a presentation at the 2016 NRHA Annual Meeting. “Seeing there what Stratis Health had accomplished and learned in Minnesota gave me velocity and concrete ideas on how to get this advisory group together,” Justis said.

Click to View the Model
PC-RHIAT includes a cross-section of perspectives from three domains: palliative care expertise, rural health expertise, and telehealth expertise. “Our role is to be a catalyst—primarily, to do the support to bring the right conversations together, link resources, and give the whole process structure,” Justis said. “We’re laying a framework, and providing tools, coaching, and facilitation for the rural hospitals, clinics, and community team members. The community teams will develop an action plan based in the community and rural community health care organizations. And the teams will decide how quickly they move and how much to take on.”

In addition, Justis affirmed, “we are going to work closely with rural home health and hospice agencies. There’s no way that we’re trying to supplant what they do. What we want is to collaborate and help build complimentary care processes.”

PC-RHIAT also aims to work on sustainable, multi-pronged funding. Justis said that might include grant funding for capacity building, such as helping a Critical Access Hospital or Rural Health Clinic send nursing staff or providers to a national training for palliative care; bringing in case consultation services like Project Echo; and providing paid internship stipends to engage students.

One barrier to funding, however, is that there is no defined Medicare benefit for palliative care, Justis said. “As it stands now, palliative care services under Medicare are covered on a piecemeal basis under the auspices of other types of Medicare-funded services: outpatient care by a physician or non-physician provider, or home health or hospice care if the patient meets the specific eligibility criteria for those programs.”

“So,” she said, “we’re also going to work on payer strategies both within our state and looking at whether we can organize multiple states on an approach to Medicare. We’re hoping to get a national change in policy for funding so palliative care outside hospice is a covered service under Medicare.”

After consensus on the conceptual model, the advisory team will convene its first work group this month. “There are two hospitals that have already done some work, and a few other early adopters,” Justis said. “One of those will move quickly because they’ve laid a lot of groundwork for it already. The pace at which communities take this up will depend on where they are developmentally, and on community engagement and how many resources they have for it.”

The overall goal, Justis said, is to have a model where the work groups are the instigators and tool providers. “(The advisory team) wants to gradually hand off the heart of the work to the community teams as we put our focus on policy change.”

According to Justis, the advisory team is currently being funded with in-kind contributions. “The new SORH budget has a small amount committed,” Justis said. “We have a grant writing plan and strategies to work with payers. And a small amount of Flex funding has helped CAH staff with travel costs, although most meetings, but not all, are done via Zoom.”

The advisory team is bringing to fruition Justis’ long-time interest in palliative care. “I began working with hospice as a concept as an undergrad and did internships around it in graduate school,” she said. “It has long been a desire of mine to look at ways for people to stay in their community without being sent away for treatment that might not be what they need or want.”

Justis added, “The conversation should be about quality of life. ‘How can we get you more comfortable? What are your goals? How can we support those?’ That’s true for patients and family. That’s what I love about palliative care and hospice—the goals of patients and family are at the center of what happens.”

Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Beth Blevins at (301) 260-0556 or thebethblevins@gmail.com to set up a short email or phone interview in which you can tell your story.