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April 18, 2016 - Kim Moore [see other posts]

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Rural Options--The Very Last Option--Innovate

Note: this is the fourth in a multi-part series on strategies for responding to the issues of rural population decline in Kansas communities.

The last approach I want to discuss for developing and maintaining rural services is innovation. As will be apparent, innovation may make use of parts of the other three, but it likely starts with and aims toward a different goal than the other three. Innovation could be about keeping a hospital in the community, for example, but I would suggest that real innovation starts with a different aim than keeping hospital services or K-12 or a public health department. It starts with more fundamental questions such as: how do we develop the health services necessary for a vital community or how will we educate our children (and adults) to maintain a vital community?  In the type of innovation I am suggesting, there is no pre-set determination that a community needs the normal K-12 structure, hospital or other traditional agency to provide the services a community needs  (or to have a vital economic life). Rather, there is an openness to development of the right agency and set of services within the available resources—that may be the traditional agency with many changes but it also might be something very different.

For example, Kansas Hospital Education and Research Foundation has been working through a Rural Health Visioning Technical Advisory Group to develop potential new models of health care delivery for frontier and rural areas. In an environment where critical access hospitals/rural health clinics (the pair of acute and primary care facilities supported by Medicaid and Medicare through cost-based reimbursement for low population, wide service areas) are struggling to survive in many rural communities nationwide, KHERF is experimenting with new models designed specifically for the existing patient bases and needs of those communities. The models being studied would limit their services to 12 or 24 hour inpatient stays, emergency rooms and EMS, 24/7 primary care,  some ancillary services (labs, diagnostic procedures, etc.) and potentially high-demand specialty physician care (perhaps delivered by telemedicine). These new facilities would be required to have strong referral relationships with larger hospitals. Early modeling, through chart reviews and financial analyses in several Kansas sites, indicates that this combination of services would provide a very large majority of existing service needs and be less costly than critical access hospital services.

Innovation is hard to do and even difficult to get considered as an option. Existing reimbursement approaches often are not transferrable to new models. Demonstration projects must be developed with payors—governmental and private—to fully test the proposed models and to prevent collapse if things have to be reversed. Innovative models are more acceptable to communities moving from nothing to something. For example, new rural delivery models have been proposed and tested successfully by HRSA for rural health care but are often tried in areas without any existing services versus areas which are accustomed to full hospital and primary care services. Of course, most innovative models are deliberately scaled to the existing and likely future service loads; this means employment is lean and probably lower to some degree than the employment in existing systems which were often designed for larger volumes of the past and more comprehensive services. Innovation, thus, can mean fewer jobs (and fewer costs and more sustainable operation) than current models. Clearly, situations where necessity is rapidly leading to collapse or collapse has already occurred are potentially the best sites for innovative experimentation. Communities in these circumstances will be balancing less against the known than against the prospect of nothing.

Conclusion

Declining and aging population. Lower volumes. Changing government support and requirements. New consumer expectations for quality and value. Limited resources. Workforce difficulties. Aging facilities.
The maintenance of services in many rural areas of Kansas is beset by growing problems. There are at least four general directions for communities to consider in responding to their service delivery dilemmas.  The most natural path is preserve and protect—it involves the least change and assures that local will stay local. Maintenance implicitly involves deciding to take the existing challenges head-on, to continue to fight the same challenges now facing the service delivery system. If this strategy fails, it will often be too late to move to something else. Consolidation and regionalization are ways to address declining population and volume by slightly scaling up in numbers. They can work to preserve communities and services if developed equitably among the parties. There can, however, be a loss of local control and problems of access due to distance if great care is not taken. Affiliation includes many levels of collaboration—peer to peer, upstream/downstream, regional, etc. Inter-dependence is developed and resources are shared; again, an equitable and symbiotic relationship is necessary if all affiliates are to benefit and receive vital services for their communities. Affiliation requires a new sense of who is competition and a reservoir of good will to share the benefits of working together. Innovation involves an attempt to answer the basic question about what needs to be delivered and how could it be delivered most efficiently and effectively without the burden of existing thinking about an institutional framework. It is work for pioneers (surely, there is still some pioneer blood in rural Kansas) and, like all risky work, holds out the promise of the greatest rewards with systems which are designed for current realities.

For those hoping for the answer to the dilemma of maintaining services in the declining population areas of Kansas, this blog is undoubtedly a disappointment. However, there is a gleam of hope. There are several viable approaches besides outlasting the community down the road. Some of those approaches involve seeing if your community and that Friday night football competitor down the road really ought to work together. Others involve re-thinking what is the right delivery format for your current community with its assets and opportunities versus struggling to maintain a format designed for your community three generations ago. There is also an amazing reservoir of good will throughout our State for its rural areas. Some comes from the reality that Kansas is not going to succeed economically unless our rural areas can succeed. Other support comes from some of us who were raised in rural Kansas and love it still. I will be looking at next year’s Kansas Statistical Abstract to see if the decades long decline has ended (my hope) but no matter the population report, the agency I work for—United Methodist Health Ministry Fund—will continue to work with rural Kansan communities to help them explore answers to equity and quality of life for those thousands of Kansans living in our frontier and rural areas.

KHERF is an affiliate of the Kansas Hospital Association.  The KHERF work to develop new rural health care models is supported by a grant of $103,950 from United Methodist Health Ministry Fund.

The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, is the primary Federal agency for improving health and achieving health equity through access to quality services, a skilled health workforce and innovative programs. HRSA's programs provide health care to people who are geographically isolated, economically or medically vulnerable.