News

‘We can help ourselves:’ Native women come together to confront high rates of maternal mortality

Posted: Jan 10 2020

Kyley Warren | Cronkite News

Monday, Dec. 16, 2019

WINDOW ROCK – As the sun begins to set on a blustery fall day, the rugged buttes of Navajoland glow red in the soft light and swift gusts spiral dust through the air.

About 40 women, most draped in traditional dress, stand in a circle as Melissa Brown, an indigenous midwife, asks the group to reflect on the day just ending – and the mission still ahead.

“We have talked about being safe here. That is our goal,” she tells them. “We’re going to cry, and we’re going to laugh. And that’s OK.”

One by one, the women share a word that best captures how they feel: Happy. Safe. Joyful. Supported. Sovereign. Brave. Then one sings a hymn in her native tongue.

These women have come to the Navajo reservation to be trained as doulas, aides who have no formal medical background but provide guidance for pregnant women up to and through labor, and sometimes beyond.

They’re here in Window Rock, capital of the Navajo Nation, to learn how to help their own, but also to help confront a tragedy plaguing women in Indian Country and across the United States.

Too many women are dying due to complications from pregnancy and childbirth – deaths that should be preventable with the right intervention and care.

“My first birth that I had when I was a teenage mother was very traumatic,” said Brown, who trains indigenous women as midwives and doulas across the United States and Canada. “I didn’t understand how my body worked … how labor and delivery worked. I was very scared, and I didn’t have much support.”

Now, she said, “people are recognizing that we are our own experts in our community. We can help ourselves. We can empower ourselves. We can educate ourselves.”

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The Health Care Worker/Hospital Shortage in Rural America

Posted: Jan 10 2020

National Conference of State Legislatures | By Mark Wolf | Dec 18, 2019

Phoenix—America’s rural hospitals are ailing; underpaid and squeezed by a population that is older, poorer, less insured and sicker than the nation at large.

And they're closing at a rate that alarms health officials, who are witnessing the emptying of the health infrastructure for a wide swath of rural America.

Rural hospital closures (118 since 2010, including 17 this year alone) are escalating, panelists told a session on “Health Care Access in Rural America” during NCSL’s Capitol Forum.

The closures contribute to a growing lack of health care coverage in rural America, said Dr. Dan Derksen, a family physician, rural health care expert and associate vice president for health equity, outreach and interprofessional activities at the University of Arizona.

“Once a critical access hospital (25 beds with a 24/7 emergency department and at least 35 miles from another facility) closes, they almost never come back,” he said.

Before Arizona expanded Medicaid under the Affordable Care Act, it ranked in the bottom five states for uninsured residents at 19%. Last year, the uninsured rate was 10.9%.

“We almost halved it but that’s still unacceptably high; 750,000 people don’t have ready access to care because they can’t get coverage,” Derksen said. “Half of those would be eligible for Medicaid or marketplace subsidy, but for a host of reasons, a significant portion doesn’t take advantage of it.

“Medicaid expansion stabilized the rural health situation. Administrators don’t like what Medicaid pays but it beats trying to get money out of folks who don’t have it.”

Legislation passed last year in Arizona will provide more than $18 million for Medicaid Graduate Medical Education (with a $10 million federal match), expanding medical students in primary care and tuition remission, rural broadband, rural prenatal telemedicine equipment and state loan repayment.

“We need to move the training pipeline closer to the area of need,” he said, citing the need for more residencies in rural areas. “The more likely you are to get them in a residency program, the more likely they are to stay.”

John Supplitt, a senior director (“I’m the rural guy”) at the American Hospital Association, said occupancy rates at rural hospitals average 40% and those with fewer than 50 beds have the lowest rate (33%) since 2015.

“They have a challenging payer mix that makes them more vulnerable to federal payer changes,” he said, adding that 56% of their revenue comes from Medicaid and Medicare. The broader trend of more outpatient procedures also hurts rural hospitals, where the increase in outpatients doesn’t offset the loss of inpatient volume.

Compounding the dependence on Medicaid and Medicare, rural residents are more likely to have high-deductible policies than city-dwellers, which means they may be unable to afford care.

On a hopeful note, Supplitt cited communities in Vermont and Georgia who worked with state agencies to add facilities to small towns.

“Not every community can maintain a hospital, but every community needs a medical presence,” he said. “It takes a lot of mobilization from both policymakers and health care providers to make that happen.”

Hawaii Senator Roslyn Baker (D) said her state, which expanded Medicaid in 2014, is facing a shortage of 800 primary care providers, which is most acute on the less-populated islands and exacerbated by the high cost of living and an aging population.

The state provides loan repayments for nurse practitioners, doctors and physician assistants and is expanding its telehealth capacities.

Only 49% of Kansas’ needs for health professionals are being met, said Senator Elaine Bowers (R) and five rural hospitals have closed in the state since 2010. Nearly three-quarters of rural Kansas hospitals are operating at a loss.

A visa waiver program eliminates the two-year home country residency requirement for non-citizen physicians who are international medical graduates if they commit to practicing in a health professional shortage area.

Kansas has not expanded Medicaid. Proponents fell one vote short of adding expansion to the legislative calendar this year.

An intriguing program is the University of Kansas Medical School campus in Salina (population under 50,000), which admits eight students per year and is the smallest medical school in the nation. The aim is to train students who will work in rural areas.

Haley Nicholson, a senior committee director in NCSL’s State-Federal Relations Division, briefed the session on Disproportionate Share Hospital (DSH) Payments, which states are required to make to hospitals serving a high number of Medicaid and other low-income patients and the Rural Health Demonstration funding through the Centers for Medicare & Medicaid Services.

The program would give rural areas seed money to help redesign their health care systems and encourage providers in those areas to participate in value-based care. The money could be spent on telehealth development or hub and spoke models. Details are pending.

Mark Wolf is editor of the NCSL Blog.

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Rx for Ailing Indian Health Service: Changes in Spending, Recruitment

Posted: Jan 7 2020

PBS | Frontline | Dec. 31, 2019
By Christopher Weaver and Anna Wilde Mathews, The Wall Street Journal

Some of the biggest problems plaguing the troubled Indian Health Service, which cares for 2.6 million Native Americans, could be addressed by taking some relatively straightforward steps, according to IHS employees, tribal members, U.S. lawmakers and outside health-care experts.

A series of articles by The Wall Street Journal has identified numerous deficiencies at the federal agency, including problem employees, recruitment challenges and regulatory lapses. The turmoil has sparked calls for changes.

The agency has chronic problems, and it is underfunded and overwhelmed, said Earl Pomeroy, a former Democratic North Dakota congressman.

Nevertheless, said James Bresette, a former deputy director of the agency’s clinical-services arm, “there’s definitely some low-hanging fruit” that he believes the agency is capable of addressing.

The Journal’s reporting on the agency and new interviews with people who have faced the problems suggest several possible courses of action.

Seek More Funds

Congress has provided modest increases to the IHS’s operating funding in recent years, but that still leaves the agency far behind other federal health programs. Medicare spends about three times as much per patient.

“We’re at Congress’s whim in that regard,” the agency’s acting director, Michael Weahkee, said in a meeting with tribal leaders earlier this year. Rear Adm. Weahkee was nominated to become the agency’s permanent leader in October.

The agency’s leaders and federal overseers have stopped short of asking Congress for major new infusions during annual budget negotiations.

At a December Senate hearing on his nomination, Adm. Weahkee was asked if he would commit to advocating for more upfront funding for the IHS. Doing so might set him at odds with his superiors in the Trump administration. He declined to say he would seek more funding.

In a written statement, the IHS said it “works proactively within the administration and with the Congress to ensure the needs of Indian Country are fully understood.”

Change Spending Practices

The IHS, which doesn’t offer a full range of medical services at its hospitals, is supposed to pay for patients to get additional necessary care from outside hospitals and doctors. That funding falls short of what patients need, according to the agency’s own data, and the IHS distributes it unequally.

In its Tucson, Ariz., region, the IHS allocated about $8,100 per uninsured patient in 2020, compared with around $1,000 in its Oklahoma area, a Journal analysis of 2017 agency data and budget records shows. In the Great Plains region, which includes the Rosebud Indian Health Service hospital in South Dakota, the allocation is about $2,200 per uninsured patient.

The disparities result from an outdated allocation formula that doesn’t take the needs of the patients into consideration — and means that in low-spending areas common services are often denied.

At Rosebud, orthopedic procedures such as knee replacements and diagnostic services like certain lung tests often don’t get covered, doctors said.

“It’s basically rationing,” said Douglas Lehmann, a former IHS doctor at Rosebud.

The agency could fix this, said Ron Cornelius, a former Great Plains regional leader. But with finite resources, he said, “you’d have winners and losers, and so far nobody has taken that up.”

The agency said one of its work groups recently recommended keeping the formula the same, and that its ability to change it was limited.

Repurpose facilities

Eight IHS-run hospitals with a combined 82 beds averaged less than one patient a night in 2018, according to IHS reports to federal regulators.

The agency could close seldom-used inpatient wards located where there are other options and redirect the money, including toward better primary care for patients with serious chronic health problems.

The agency said it might be appropriate to redirect resources from inpatient care to other services, such as specialty medical treatment, at some facilities where admissions have declined, and that it would consult the tribes before making any decisions.

Parker Indian Health Center, in a tiny Arizona town, is about 1.5 miles from a private facility, La Paz Regional Hospital. La Paz’s 22 beds were about one-quarter full last year, regulatory records show. The IHS hospital, with around 20 beds, was only about 3% full, the records show.

Neither facility delivers babies, forcing women to travel at least 40 miles for that service, according to the Arizona Center for Rural Health.

It doesn’t make any sense to have two critical-access hospitals so close together, but not other needed services, said Daniel Derksen, a University of Arizona professor and the center’s director.

Kevin Brown, the chief executive of La Paz Regional, declined to comment. The Colorado River Indian Tribes, which the Parker hospital serves, said in a written statement “the facility is underutilized due to operational issues such as a lack of staff, and treatment decisions in which patients are released too soon.” The tribe said any reallocation of funding there would be a disservice to members that it would oppose.

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Ponderosa Family Care — A rural family practice with Alan Michels, M.D.

Posted: Dec 12 2019

PAYSON ROUNDUP | Dec 10, 2019

Dr. Alan Michels is a man who, as most know, is practically synonymous with health care in Rim Country. Beginning in the late 1990s as a part-time postgraduate medical resident physician, Dr. Michels was enchanted by the small-town dynamic. That enchantment coupled with seeing the clear need for more physicians in our rural community, he, along with his wife and daughter, moved to Payson permanently after his residency, beginning full-time private practice in 2001. The Michels family went on to have two sons since moving to Payson. The boys were raised and educated in Payson schools.

In the two decades since he first began to practice medicine in Payson, he has treated patients everywhere from “two seconds to 102 years old,” signing birth certificates, death certificates, and tending to the myriad health care needs that come along with every stage of life in between.

With private practice, Dr. Michels became involved with the hospital staff from the beginning of his work in Rim Country. As he became more involved in the community, his involvement in hospital leadership became a natural extension of his professional life, dedication that culminated in his appointment as Chief of Staff of Banner Payson Medical Center in January of 2019. His other projects have included being a primary founder and champion of the nonprofit Payson Christian Clinic, whose work has been essential for the treatment of the uninsured and underinsured “working poor” of the community. He has also been dedicated to the MHA Foundation in numerous branches of community outreach and educational enrichment programs.

It is no surprise that Dr. Michels would align with the MHA Foundation in the quest for health care advancement and improved medical education for the people of Rim Country. Dr. Michels would be at the top the list of experts with whom MHA Foundation would work alongside for this grassroots effort.

Dr. Michels began supporting the mission of the MHA Foundation when he was appointed to the board of directors in 2010, and he did not know anyone who was a part of the organization. He knew that the organization’s mission was in focus with his personal crusade to improve the standard of local health care via a twofold impact structure: improved patient care and technology alongside support of education programs targeting new medical practitioners who would ideally remain to practice in their rural community. Today, he is thrilled with the progress that has been made on both sides of that mission.

Sitting in his office, he is proud to reminisce about the human stories showcasing the work he has been a part of with the MHA Foundation. It is evident to see how it all works together. The MHA Foundation’s nonprofit projects align seamlessly with the operations of his own practice. The cohesion between the two align so well that patients are not even aware that so many hands, hearts, and minds have worked to bring their care to fruition. One thing he highlights is the blue paint color of the exam room walls, noting that they act in a manner similar to Hollywood green screen technology for video presentation. This enables his office to access medical experts in literally any specialty or sub-specialty of medicine by way of video phone conferencing (telemedicine), extending the ability to care for a greater variety of patients. This ability has previously been restricted to those practitioners who lived locally.

The blue walls, he explains, help to be able to accommodate any of the wide range of human skin color without distortion, an issue that used to be problematic for remote diagnostic purposes. With improvements such as this, the level of care available to people living in rural areas such as Rim Country, with the help of the MHA Foundation, is getting closer to what is available in bigger cities. Dr. Michels adds, “There is some amazing vision that has gone into this (MHA Foundation) for so many years before my time here and the forethought and innovative thinking was so impressive to me, and still is.”

According to recently published data by the Association of American Medical Colleges, Arizona’s Primary Care Physicians (PCPs) are aging, especially those practicing in rural and underserved areas. One-quarter of rural Arizona PCPs plan to retire in the next five years. To mitigate this, Dr. Michels has been partnering with the MHA Foundation through the development of educational programs with many schools (Payson Center for Success, Eastern Arizona College Payson Campus, and the University of Arizona College of Medicine Phoenix) whose students feed into his practice, and into other medical internships and later, into jobs here in our community.

He says, “We want to create opportunities for rural health care practitioners (including physician assistants, nurse practitioners, occupational therapists, and physical therapists) that live and thrive in rural areas such as ours, all over the state. This will create an amazing connected network.”

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Analysis: Disparities in Rural Child Mortality Rates Persist Despite Improvements

Posted: Dec 12 2019

THE DAILY YONDER | HEALTH | By Whitney Zahnd and Janice Probst Dec 9, 2019

While the U.S. is meeting its goals to reduce child mortality, rural children don’t have an equal chance of living into adulthood. The problem is especially pronounced for rural children who are Black or Native American/Alaska Natives.

In December 2018, research published in JAMA Pediatrics highlighted the improvements in child mortality rates in the United States. These improvements were substantial enough that the Healthy People 2020 objectives calling for a 10% reduction in child mortality rates had already been met among nearly all age groups by 2015. The Department of Health and Human Services’ Healthy People Initiative develops a set of health objectives every 10 years on a range of health metrics, including mortality.

The overall improvement is wonderful news! However, mortality rates among rural children, specifically, were not presented. To tweak Peter Drucker’s famous statement, “you can’t change what you don’t measure.” If we do not examine rural and urban populations separately, we miss an opportunity to improve rural children’s health.

Our research found that improvements in in children’s health have not been equal across all geographies—particularly children of minority race/ethnicity in rural areas ( December issue, Health Affairs). Using mortality data from the Centers for Disease Control and Prevention (CDC), we documented that Healthy People 2020 objectives for mortality had been met among urban children across all age groups by 2017, but rural mortality rates in every age group still exceeded Healthy People 2020 objectives.

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Governor Ducey Proclaims Nov. 21 Arizona Rural Health Day

Posted: Nov 20 2019

Arizona Rural Health Day Proclamation On November 21, 2019 many health and social services organizations throughout Arizona will celebrate Rural Health Day in Arizona, proclaimed by Governor Doug Ducey. The Arizona Rural Health Association has partnered with the Center for Rural Health at the University of Arizona to promote activities throughout the state on this day.

We are especially encouraging rural organizations to join us in celebrating the power of rural and become involved in advocating to advance health care in rural communities.

Organizations are being asked to showcase their support for National Rural Health Day and to implement ideas such as those listed below:

Answer the organization's telephone on November 21 by saying, "Hello, Happy Rural Health Day"
Plan a group run or some other kind of fitness activity
Do something healthy that day like eat more vegetables, bike instead of drive to work, get your blood pressure or cholesterol checked, etc.
Write a letter to the editor of you local newspaper and share the attached Proclamation, or contact a local legislator to stress the importance of addressing the health needs of rural communities
Enroll in the Arizona legislature Right to Speak (RTS) request system in order to give feedback to legislators on bills under consideration
Connect to the websites of the Arizona Rural Health Association and the AzCRH

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Arizona Center for Rural Health Receives National Award of Excellence

Posted: Nov 13 2019

Jennifer Peters receives SORH Award of Excellence The Arizona Center for Rural Health received the 2019 SORH Award of Excellence from the National Organization of State Offices of Rural Health (NOSORH) at its annual meeting in Albuquerque, New Mexico. NOSORH presents the award to a State Office of Rural Health making outstanding contributions to rural health. Nominations are made by NOSORH members, national rural health partners and other organizations.

Jennifer Peters, Program Manager for the Arizona State Office of Rural Health Program, accepted NOSORH’s 2019 Award of Excellence on behalf of the Center. She said, “The recognition from our national peers is a reflection of the vigorous efforts by the Arizona Center for Rural Health and its collaborators to promote health equity and address the health disparities faced by rural and underserved communities.”

Heather Carter, EdD, Associate Director for the Arizona Center for Rural Health, stated, “Arizonans living in our diverse, rural communities deserve high quality health care. Thanks to our many community partners we are able to identify and address unmet health needs in these areas and inform health policy at the local, state and federal levels.”

The Arizona Center for Rural Health serves Arizona through its core mission of over 40 years to improve the health and wellness of Arizona’s rural and underserved populations. It houses programs including the State Office of Rural Health (AzSORH), the Rural Hospital Flexibility Program (AzFlex), the Rural Health Professions Program (RHPP), Health Workforce & Data Analysis (CRHWorks), Arizona First Responders Initiative (FR-CARA), Data to Action and others. Learn more about the Arizona Center for Rural Health at www.crh.arizona.edu

NOSORH provides capacity building and support services to State Offices of Rural Health (SORH) in their efforts to improve access to, and the quality of, health care for rural Americans.

Learn more about NOSORH can be found at https://nosorh.org/about-nosorh/

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Hometown health care providers know importance of National Rural Health Day

Posted: Nov 13 2019

PAYSON ROUNDUP | Nov 12, 2019

National Rural Health Day recognizes rural communities are wonderful places to live and work, which is why an estimated 57 million people call them home. These small towns are places where neighbors know each other, listen to each other, respect each other and work together to benefit the greater good.

These rural communities also have unique health care needs. Today more than ever, rural communities must address accessibility issues, a lack of health care providers, the needs of an aging population suffering from a greater number of chronic conditions, and larger percentages of un- and underinsured citizens. And rural hospitals — which are often the economic foundation of their communities in addition to being the primary providers of care — struggle daily as declining reimbursement rates and disproportionate funding levels make it challenging to serve their residents.

That is why the National Organization of State Offices of Rural Health sets aside the third Thursday of every November — Nov. 21, 2019 — to celebrate National Rural Health Day.

First and foremost, National Rural Health Day is an opportunity to “Celebrate the Power of Rural” by honoring the selfless, community-minded, can-do spirit that prevails in rural America. However, it also gives us a chance to bring to light the unique health care challenges that rural citizens face — and showcase the efforts of rural health care providers.

Dr. Alex Vlahopoulos and his wife Dr. Lauren Vlahopoulos are examples of rural health care doctors that have come from Payson and returned to Payson, practicing medicine here.

MHA Health Scholar giving back locally

In 2004, Payson High School seniors, Alex Vlahopoulos and his future wife, Lauren Bartoli, were headed to University of Arizona for careers in the medical field. Although they both received substantial university scholarships, those scholarships did not cover room and board — which was expensive. To help with those expenses, Alex received an MHA Human Health career scholarship for $500.

“I was broke and the MHA scholarship helped so much. I had no resources at the time, so it was a huge help,” he said.

Today, they are giving back by caring for patients in their hometown of Payson.

Alex Vlahopoulos is now a Doctor of Osteopathic Medicine (DO) and works as an emergency medicine physician and director at Banner Payson Medical Center Emergency Department.

Lauren Vlahopoulos also has her doctorate degree (Doctor of Pharmacy, or PharmD) and is a pharmacist at the Payson Safeway.

After living in Iowa and Michigan and starting a family of their own, being close to family is part of what brought them back to Payson in 2018.

“It seems everyone gravitates back to home,” said Lauren.

Lauren and Alex agreed, “Our mentality is that this is our community of Payson ... these are our people, these are our patients, this is our place! We had the opportunity to live and work anywhere, and we made a choice to come back here.”

There are many reasons why they like practicing rural medicine in Payson. Dr. Vlahopoulos works with many of the people that he knew when he was younger.

He shared, “As a doctor in a rural setting, I get to do a lot of procedures (which I love); I don’t have the luxury of calling on a handful of specialists for each individual task, as can be found in an urban setting. Although it may be more difficult initially to master a wide variety of procedures, it is much more gratifying because of that variety. In our Payson emergency room, there is one physician at a time. If there is a bus accident involving 30 people, it is all on that single physician. Rural locations also present special challenges for staffing. For example, when we had the massive snowstorm back in February (36 inches in 36 hours), all the other ER physicians live out of town, so they could not get to Payson to work their shifts. Thankfully, Dr. Judith Hunt was able to assist me in covering the emergency department. She is an example of how we all row the boat together — we all help each other out! Living in a rural community, you also have a much greater ability to influence. I can contact the patient’s physician to follow-up because I know that physician personally and I know the patient will receive good follow-up, so I can safely discharge the patient.”

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‘In this for the long haul’: How a labor organizer’s daughter became a force for rural health care

Posted: Nov 13 2019

By Anikka Abbott, Cronkite News | Thursday, Nov. 7, 2019

PHOENIX – For more than three decades, Jill Guernsey de Zapien has fought to improve public health in underserved communities across the Southwest. She helped start a program in southeastern Arizona to bring better care to rural residents, and farmworkersin particular.

She was inspired by her father, a labor organizer.

Guernsey de Zapien, director of border, transborder and binational public health collaborative research at the University of Arizona, spent time with Cronkite News to discuss her efforts and a program in the colonia of Winchester Heights, north of Willcox, to bring more health care to more people.

What is the Arizona Area Health Education Centers Program (AHEC)?

AHEC has five centers and it has a centralized office here at the University of Arizona. The five centers cover the entire state. … There’s one in Nogales … Yuma … Flagstaff … Globe, and there’s one in Maricopa County. Its purpose is to deal with the maldistribution of health professionals. It’s not saying necessarily that we don’t have enough health professionals, it’s saying that they’re not distributed well.

How does AHEC work?

Each one of those centers works in the elementary schools, high schools, etc. to get kids interested in health professions. … The second prong is here at the university, where we … work with the centers to identify students to go out and do rotations in those areas. … And then the third piece is really (to address) why many health professionals, once they’re in an underserved area, why they leave – because they don’t have access to a community of continuing education. So the role of those centers is really to provide that continuing education and connection for health care professionals once they’re in there.

Why are you passionate about farmworkers’ health care?

My father was a labor organizer. As a child, I was very impacted by the film “Harvest of Shame,” by Edward Murrow. … I learned as a child what was going on in terms of the invisibility of farmworkers. Even as a child, it’s so easy to make the connection and go, `Well, wait a minute. Why don’t we support farmworkers? Why don’t they get a decent wage? Why don’t they have good housing? Because everything I’m eating, I couldn’t make it without them being here.

I had a real sense of the injustice of it. As citizens and people who care about social justice, we cannot be spending the rest of our time on this planet allowing the very people who produce the food and harvest the food that we’re eating not to be recognized and have decent wages, decent living conditions, and all the things that everybody else has the right to.

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Improving the health of 'invisible' farmworkers is a community effort in Willcox

Posted: Oct 16 2019

Sabine Galvis | Cronkite News | Wednesday, Oct. 2, 2019

WILLCOX – A handful of voices softly chattering in Spanish filter into a building that’s become the heart of Winchester Heights, a Willcox neighborhood filled with farmworkers. The community center is dedicated to connecting southeastern Arizona residents – with one another and with better health care.

As the clock nears 6 p.m., more men and women arrive, some coming straight from 10-hour shifts in the greenhouses of a tomato farm north of Willcox. Musculoskeletal problems, frequent exposure to excessive heat and long-term exposure to pesticides are common problems for Arizona agricultural workers, and just a handful of the many issues this year-old center aims to address.

“For this community in particular, it’s because they’re so rural and isolated that a lot of the time they can’t go to the doctor,” said Linda Cifuentes, a staff member of the Southeast Arizona Area Health Education Center, or SEAHEC, and coordinator at the Winchester Heights Community Center.

“They can’t make the drive all the way to Tucson to see a provider. And surely, they come across a lot of people who aren’t bilingual in these health facilities.”

Enter SEAHEC and its Healthy Farms Program....

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AzFlex Program Receives $3.5 million grant from HRSA

Posted: Oct 10 2019

The Arizona Medicare Rural Hospital Flexibility Program (AzFlex), a program of the UA Center for Rural Health has been awarded a $3.5 million, five-year grant from the Health Resources and Services Administration (HRSA) to continue its vital efforts in medically underserved areas of the state. This new five-year HRSA award will allow the program to expand its longstanding relationship with the hospitals, clinics and the Arizona Bureau of Emergency Medical Services and Trauma System. Founded in 1999, the AzFLEX Program offers support and technical assistance to CAHs in core areas including:

Performance and Quality Improvement
Operational and Financial Improvement
Population Health Management and Emergency Medical Services Integration

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Bike Ajo Program is Model for Rural Communities

Posted: Oct 2 2019

In rural Ajo, Arizona, Bike Ajo is working to improve the health of children and adults through two bike hubs: One is located at the school for the middle school bicycle program and the second hub is located in Desert Senita Community Health Center, where residents and visitors can borrow adult bicycles and helmets and attend safety education and community events.

The Bike Ajo Coalition includes community members, community health workers, Desert Senita Community Health Center, Ajo Unified School District, Arizona Department of Transportation, Organ Pipe Cactus National Monument, Southeast Arizona Area Health Education Center, Pima County Middle School Bike Education Program, and the University of Arizona Mel & Enid Zuckerman College of Public Health and the Department of Mexican American Studies. The coalition activities have been sustained through the efforts and resources from community, county, and state agencies.

Bike Ajo was originally funded by the Arizona Planning Association's Plan4Health grant. Besides program planning and evaluation and the programs themselves, the grant money was used for:

Adult bikes
GoPros
Water bottles
Backpacks
Reflective shirts, so cyclists are more visible in traffic
League Cycling Instructor training
Training in digital storytelling

Services offered

Community members and visitors can borrow helmets from the town's two bike hubs. Middle school students can borrow bicycles, which were purchased by the county. The Bike Ajo Coalition also provides:

Bicycle safety education
Bicycle repair training
Bicycle maintenance resources
League-Certified Cycling Instructor certification
Annual community bike and hike
Cub Scout bike rides
Riding groups for adults
High School Future Health Leaders Club
Annual Bike and Hike at Organ Pipe Cactus National Monument
Other community events providing information about the coalition's work

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Rural counties seek state, federal help to prepare for apocalypse

Posted: Sep 18 2019

PAYSON ROUNDUP | by Peter Aleshire consulting publications editor | Aug 27, 2019

Rural Arizona counties are preparing for the apocalypse.

Well — providing they get the grant.

Hey. Better late than never.

To be specific, Navajo County along with Apache and Gila counties are all lining up for state and federal money to plan a comprehensive response for the kind of pandemic that killed 50 million people after World War I — as a virulent strain of the flu flashed across the world.

The Navajo County Board of Supervisors at its last meeting approved the application for a $250,000 grant from the Arizona Department of Health Services and the federal Centers for Disease Control to establish a system to distribute antibiotics, vaccines and newly developed drugs if a pandemic rips through Arizona. The grant application will come before every county in the state in the next several months, courtesy of the Arizona Bureau of Public Health and Emergency Preparedness.

It sounds like science fiction spawned by a dark mind, but public health experts warn that the nation remains woefully unprepared for fast-spreading, potentially incurable diseases. A recent case in point is Ebola, now once again rippling through the Congo. The easily spread viral disease has a 65 percent mortality rate. The Congo has had 10 outbreaks in the past 40 years, with the most recent spread killing 1,800 people.

Most Americans think of the threat of such pandemics as a Third World problem, held at bay here by modern sanitation and health care systems.

However, Bill Gates has been battling AIDS, malaria and other diseases for more than a decade through the world’s largest charity — the Bill and Melinda Gates Foundation. At a conference, he recently warned that the world remains woefully unprepared for deadly viruses and bacteria incubated by overcrowding, poor sanitation, overuse of antibiotics and global travel patterns.

Medical researchers have developed only a handful of effective vaccines against viral diseases. Many poor countries can’t afford the vaccinations and in many rich countries exaggerated fears of vaccine side effects have left much of the world vulnerable to even well-known viral disease like measles.

The Navajo County Board of Supervisors at its last meeting approved the development of a public health emergency preparedness program to train county workers to receive, distribute and stockpile critical items — like vaccines, antibiotics and other medications needed to cope with a pandemic or “outbreak event.”

The program would also help local hospitals to set up protocols and systems to handle the huge number of potentially infectious patients such an outbreak could generate.

Each county will have to provide a detailed budget to qualify for the state and federal support. The county will establish a point person in the event of such a medical emergency, train workers to handle the crisis and pull together local coalitions of health care workers and public safety officials.

The state has set up four regions to coordinate responses. Navajo and Apache counties are in the northern region, along with Coconino and Yavapai counties and the Hopi, Kaibab-Paiute and Navajo reservations. Gila County’s in the central region, along with Maricopa and Pinal counties and the Gila River, San Carlos Apache, White Mountain Apache and Salt River Pima-Maricopa tribes and communities.

Each county and tribe can apply for state and federal money to pull together its public health emergency plan.

Rural counties have lower population densities, which reduces the speed with which a pandemic can spread. However, rural areas in Arizona also have less access to health care — including vaccines. One survey showed only 51 percent of people living in rural America have job-based health care covered, compared to 57 percent in urban areas. The Affordable Care Act drove down the percentage of Americans without health coverage to the lowest levels in decades, but rural areas still lagged. About 30 percent of rural residents in the state get their health care covered through the Arizona Health Care Cost Containment System (AHCCCS), but the state-run health care system for low-income workers has far fewer health care clinics and facilities in rural areas.

Vaccination rates lag even for established diseases easily preventable with safe vaccines. It requires a 95 percent vaccination rate to acquire “herd immunity” from common viruses like measles, mumps and rubella. But statewide, the vaccination rate has fallen to 93 percent, according to the state department of health resources.

Only about 40 percent of the state’s kindergarten students have a vaccination rate high enough to prevent the spread of a measles outbreak — much less still incurable diseases like Ebola or the kind of flu strain that proved so lethal worldwide in 2018.

The vaccination rates by county for kindergartners in 2019 stood at 92 percent in Apache County and 93 percent in both Gila and Navajo counties, according to the state department of health resources. All three counties fall below the 95 percent threshold for “herd immunity,” which dramatically slows the spread of a virus through the population.

The potential for lethal damage from a new viral threat is possibly even greater, since such a virus would spread quickly without an effective vaccine and only limited drug options for treatment. That’s why the state is scrambling to get each county to set up an emergency response system in case such a virus gets loose.

The history of the 1918 flu epidemic remains a haunting reminder of what can happen, despite a century of advances in battling bacteria and viruses. The flu virus in 1918 spread from birds to humans, which meant most humans didn’t have natural defenses against the bird-based strain. About 500 million people were infected, about one-third of the world’s population. The strain killed roughly 10 percent of those infected, especially those younger than 5 and older than 65. The virus also had an unusually high mortality rate among those 20 to 40, a population normally resistant to fatal side effects from viral infections.

Medical experts are still not sure why that strain proved so lethal, although the lack of a vaccine or effective antibiotics coupled with the worldwide disruption of public health systems by World War I all likely played a role.

Less lethal flu pandemics afflicted the world and caused millions of deaths in 1957-58, 1968 and 2009.

And that’s just the flu — one of the most intensively studied viruses in the world, whose effects are limited by a sophisticated, worldwide flu vaccine system.

The state hopes to at least lay the groundwork for a coordinated response with grants to each county in the state to prepare an emergency response.

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Something Special Is Happening in Rural America

Posted: Sep 17 2019

OPINION | THE NEW YORK TIMES

There is a “brain gain” afoot that suggests a national homecoming to less bustling spaces.

By Sarah Smarsh | Ms. Smarsh is the host of the podcast “The Homecomers” and the author of the memoir “Heartland.”

WICHITA, Kan. — For more than a century following the Industrial Revolution, rural and small-town people left home to pursue survival in commercial meccas. According to the American story, those who thrived in urban centers “made it” — a capitalist triumph for the individual, a damaging loss for the place he left. We often refer to this as “brain drain” from the hinterlands, implying that those who stay lack the merit or ability to “get out.”

But that old notion is getting dusty.

The nation’s most populous cities, the bicoastal pillars of aspiration — New York City and Los Angeles — are experiencing population declines, most likely driven by unaffordability. Other metros are experiencing growth, to be sure, especially in the South and West. But there is an exodus afoot that suggests a national homecoming, across generations, to less bustling spaces. Last year, Gallup found that while roughly 80 percent of us live in urban areas, rural life was the most wished for.

If happiness is what they seek, those folks are onto something. A 2018 study by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health reported that in spite of economic and health concerns, most rural Americans are pretty dang happy and hopeful. Forty percent of rural adults said their lives came out better than they expected. A majority said they were better off financially than their parents at the same age and thought their kids would likewise ascend. As for cultural woes, those among them under age 50, as well as people of color, showed notably higher acknowledgment of discrimination and commitment to social progress. All in all, it was a picture not of a dying place but one that is progressing.

The University of Minnesota Extension researcher Ben Winchester has cited a “brain gain” in rural America. Mr. Winchester found that from 2000 to 2010, most rural Minnesota counties gained early-career to midcareer residents with ample socioeconomic assets. A third of them are returning, while the rest are new recruits.

» Read the complete article at the link below:

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Rural Arizona towns wrestle with serious doctor shortage

Posted: Sep 10 2019

By Jeannette Hinkle | AzCentral Arizona Republic | September 2, 2019
Full article at azcentral.com (subscription required)

BENSON - The people of Benson didn’t know it, but their hospital was on the brink of closure. The management team at Benson Hospital kept the increasingly dire financial position from patients - even from staff members - as they searched for ways to bring the budget back into the black. But when the hospital couldn’t meet payroll, management decided it was time to send out an SOS.

Benson Hospital’s board reached out to Tucson Medical Center. Without a significant donation, the 22-bed “frontier” critical access hospital, open since 1970, would have to shut its doors.

Tucson Medical Center agreed to take Benson Hospital under its tent last year, a move welcomed by most everyone at Benson Hospital. Staff members, who maintained a high quality care rating throughout the turmoil, say they’ve since seen improvements they’d waited years for.
A one-time state appropriation of $900,000 for the current fiscal year gave Benson Hospital an added financial boost.

Earlier this summer, the halls of Benson Hospital, which are decorated with dozens of paintings by local artists, shuddered with the sound of drills and hammers. Workers were renovating the lobby, painting the walls and replacing the carpet, a color described as “just old,” with clean-looking synthetic wood planks.

Benson Hospital’s new CEO, Julia Strange, also vice president of community benefit at Tucson Medical Center, pointed to peeling, outdated wallpaper borders ringing the hospital’s hallways. Those are next, she said.

The aesthetic improvements at Benson Hospital are perhaps as important as giving staff long-overdue pay bumps.

Like most rural hospitals in the state, which provide medical care to vast areas that otherwise would be uncovered, Benson is facing a physician shortage. Talented new doctors want to work in hospitals with resources, and a tired lobby offers a bad first impression.

A glaring shortage
Arizona is just beginning to quantify its rural doctor shortage.

In 2019, the state Legislature passed a bill that will give researchers studying the shortage access to granular, standardized data that paints a more complete picture of health-care personnel needs than the dated county-level estimates being used now.

But even with imprecise data, the current shortage of doctors in rural Arizona is glaring. Several rural hospitals in the state either currently are experiencing a shortage or expect to experience one in coming years.

In 2018, an outside consultant evaluated Benson Hospital’s professional needs. According to that consultant, Benson currently has a deficit of doctors in family medicine, internal medicine and pediatrics.

Looking ahead to 2023, that deficit will worsen as a wave of current doctors retires. In Cochise County, where Benson is located, the consultant predicted a deficit of 51 full-time equivalent doctors, with a moderate deficit of doctors in family practice and a high deficit of doctors in internal medicine and primary care.

In Yuma County, 100% of residents live in a primary-care shortage area, according to the Arizona Hospital and Healthcare Association.

“In the winter, if you want to get an appointment with a primary doctor in town, it is possible that you will wait six weeks for something urgent, three months for something not urgent,” said Dr. Kristina Diaz, a family medicine practitioner at Yuma Regional Medical Center.

Without action, that wait will only lengthen. Roughly 50% of Yuma County’s primary-care physicians likely will retire in the next five years, Diaz said.

A ‘vicious cycle’
The shortage of physicians is especially pronounced in primary care. Arizona ranks 44th out of 50 states in total active primary-care physicians, and that shortage is worse in rural areas, according to the Arizona Hospital and Healthcare Association.

Doctors say the shortage can be dangerous.

With a dearth of primary-care physicians, patients discharged from rural hospitals who need follow-up appointments often can’t get them. Sometimes, that means patients end up back in the hospital; other times, it means patients elect to go without needed medical treatment or advice for weeks.

Recently, one of Diaz’s patients was discharged from the hospital with congestive heart failure. When the patient left the hospital, he had been prescribed a specific kind of medication, one he couldn’t afford.

For two weeks, until his appointment with Diaz, the patient went without the medicine he needed. By then, he was having trouble breathing.

“I had to admit him again,” Diaz said, “hoping that somebody will listen to him when he leaves the hospital and says, ‘I can't afford that expensive medicine.’ This is this vicious cycle, and I worry that it’s going to get worse as more people start retiring, if we don't start replacing the workforce.”

Benson Hospital’s Dr. David Brower is one of only a few primary-care physicians serving patients in the area. Benson itself has a population of just under 5,000.
Since Brower began working for Benson Hospital in 2018, he’s been inundated with patients who have let health problems fester because of a lack of access to primary care.

“There's like four doctors here and they're booked,” Brower said. “Patients come to you and they're like, ‘I have high blood pressure. That's all I know.’ Then you start kind of peeling back the layers and they have this condition and this condition and this condition and this condition.”

‘A special type of physician’
Springerville is a trading-post-turned-town nestled in the White Mountains. Incorporated in 1948, Springerville is home to about 1,900 residents, more than one-third of whom live below the poverty line.

On Main Street, across from the town’s post office, stands a reddish stone statue of a stern-looking woman in a bonnet. She holds a baby in her arms, and a small boy tugs at her flowing skirt. She is Madonna of the Trail, a tribute to “the pioneer mothers of the covered wagon days.”

Springerville was remote when pioneer mothers ferried their broods through the ponderosa pines that green the air in nearby Apache-Sitgreaves National Forest, and it’s remote now.

It’s not for everyone, said Greg Was, CEO of White Mountain Regional Medical Center.

After a protracted search that involved blanketing websites with hiring advertisements, the hospital turned to a costly outside agency to recruit a primary-care doctor, an expense that many rural hospitals can’t afford.

At Benson, rising costs associated with recruiting doctors, exacerbated by the high demand, contributed to the financial emergency that led Tucson Medical Center to assume control. It’s not a unique situation. Since 2010, nearly 90 rural hospitals have shut their doors, and many more are at risk of closure.

Eventually, the agency that White Mountain Regional Medical Center hired found a former neurosurgeon looking to finish out his career at a slower pace. But the area still needs practitioners who specialize in family medicine, general surgery, women’s health, urology and psychiatry.

It’s just hard to convince doctors to practice in rural areas, Was said.

Some doctors want to work in hospitals with the latest medical equipment, some discount rural hospitals because they expect the pay to be lower, and others are uncomfortable shouldering so much responsibility for patients’ health. But for many hospitals, selling doctors on a rural lifestyle is the most difficult part of the hiring pitch.

“You need a special type of physician, one that wants to come in and settle here,” Was said. “We don't have the shopping conveniences or the entertainment that would attract a physician and his family to a larger city, so it makes it a more difficult sell. We have hiking, fishing, a lot of outdoor activities, but to go to Walmart you have to drive an hour to Show Low.”

Benson Hospital has it a little easier than most rural hospitals. One of the biggest draws for potential employees is the small town’s proximity to Tucson. About half of Benson Hospital’s staff commutes.

The pipeline problem
Doctors raised in rural areas are far more likely to build a career in rural medicine, which is why health-care advocates in Arizona are working to convince people in towns experiencing a doctor shortage to study medicine, then go back home.

“It’s a pipeline issue,” said state Sen. Heather Carter, a Phoenix-area Republican and chairwoman of the state Legislature’s Health Committee.
Carter said the pipeline to rural medicine should start in elementary school with strong science programs and pitching kids from small towns on health care as a career.

But until that infrastructure is strengthened, the state is betting that exposing new doctors to rural medicine will fill the growing gap.

Brower was raised in Phoenix, a decidedly urban setting, but his internal medicine residency in Sierra Vista, not far from Benson, gave him a window into what rural practice could look like. He was “enamored.”

When he was offered a job at Benson, Brower accepted enthusiastically.

“I tell my patients all the time, ‘I plan on being in Benson for a long time, so if you're planning on being here a long time, we'll get to know each other,’” Brower said. “I see very little that I can see someone else offering me that I don't already have here. And I see a lot that Benson Hospital and this community offers me that I can’t get other places.”

Brower said that while his role as one of Benson's few doctors has been stressful at times, it has also allowed him to practice a type of medicine that is deeply personal and fulfilling.

“I’ve had patients where it’s been the case that they haven't seen the doctor for 20 years,” he said. “Now, six, nine months later, them being like, ‘Doc, you changed my life. You absolutely changed my life. I didn’t think I was going to live five years and now I'm hopeful for the future.’ That’s not something you can get from city practice.”

Doctors aren’t choosing rural medicine because, unlike Brower, they haven’t been exposed to it, Carter says. They go to medical school, then they go to residency, and that residency is usually at an urban hospital, too often in another state.

Only 42% of Arizona’s medical students remain in the state after graduation, according to a report by the Association of American Medical Colleges. When doctors do complete a residency in Arizona, they stay to practice in the state 48% of the time, the report found.

“Typically where a student completes his or her residency is where they will set up practice, because during their residency they're building those professional and community relationships,” Carter said.

“That is typically where they will remain in their professional career.”

Carter argues that the state offers too few opportunities for medical students to find a residency in Arizona, let alone in rural Arizona.
In the 1990s, the federal government froze funding dedicated to helping hospitals subsidize the cost of resident placements, and after the Great Recession, Arizona cut all state spending on residencies, Carter said.

In years since, health-care advocates have worked to marshal private dollars to make up for the lack of state funding for residencies, called graduate medical education in budgetary terms, but it wasn’t enough. According to the Arizona Hospital and Healthcare Association, the average cost to train a physician resident is about $165,000 per year.

State finds money to help grow doctors
In May, partly because of Carter’s advocacy, the Legislature passed a budget that included residency funding for the first time in roughly a decade.

In fiscal year 2020, a total of about $5.6 million in combined state and federal dollars will go toward funding graduate medical education in rural areas. That number will rise to about $11.1 million in fiscal year 2021, then to $16.7 million in fiscal year 2022. The funding is expected to result in hundreds of new residency slots.

The budget also included funding for telemedicine and broadband improvements in rural areas, money aimed at helping hospitals like Benson fill patient health needs for specialists without having to hire or contract with doctors to take patients at rural hospitals in person.

“This is a very big deal,” Carter said.

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There’s also been movement to address the pipeline problem on the federal level. In July, U.S. Sen. Kyrsten Sinema, D-Ariz., joined other lawmakers in signing a letter supporting a policy that reimburses medical students for their residencies at critical access hospitals like Benson Hospital.

Sinema also supports the Resident Physician Shortage Reduction Act of 2019, which would increase the number of residency positions eligible for graduate medical education funding through Medicare.

Staff at Yuma Regional Medical Center are already planning to use the funds to reinvest in the hospital’s residency program, which has been successful in keeping doctors in Yuma after they finish residency there.

“For the class that starts in July of 2020, we will go from 18 residents to 24 residents,” Diaz said.

The newly appropriated state funds, bolstered by a federal match, mean the hospital can fund a sports medicine fellowship, and it’s now considering starting two new residency programs, one of which would be for psychiatry.

Currently, Yuma County, with a population of about 208,000, has only one psychiatrist.

The new state funds are “huge” for Yuma, Diaz said.

“We've been sitting at the starting line to be able to move so many things and meet the needs of our community, but we haven't had the funding for it, so we've had to stay at the starting line,” Diaz said.

“Now we can run the race. And I'm really excited for that.”

Diaz, who graduated from Yuma High School, said she’s confident that when residents come to Yuma, they’ll choose to stay.

This summer, Diaz attended a conference to speak with potential residents. She brought a banner that read “Experience the warmth of Yuma.”

“We're not talking just about the heat,” Diaz said. “We're also talking about the people. There is a strength in our community, and that has been our recruiting tool.”

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