Michelle Goodman and CAPT Maureen Quinn Department of Health and Human Services Health Resources and Services Administra

1. New England Rural Health RoundTable September 28, 2011 Michelle Goodman and CAPT Maureen Quinn Department of Health and Human Services Health Resources and Services Administration Office of Rural Health Policy & Bureau of Primary Health Care

2. Summary Collaboration between rural providers Examples of Successful Collaborations

3. Collaboration between rural providers

4. Rural Safety Net Providers • Health Center Grantees and FQHC Look-Alikes • Section 330 of the Public Health Service (PHS) Act • Enhance the provision of primary care services in underserved urban and rural communities. • Rural Health Clinics (RHCs) • Rural Health Clinic Services Act of 1977 • Encourage and stabilize the provision of outpatient primary care in rural areas through cost-based reimbursement provided by physicians, nurse practitioners, physician assistants and certified nurse midwives. • Critical Access Hospitals (CAHs) • Balanced Budget Act (BBA) of 1997 • Authorized states to establish State Medicare Rural Hospital Flexibility Programs (Flex Program), under which certain facilities participating in Medicare can become CAHs.

5. CAH-FQHC Manual Effective Collaboration Between Critical Access Hospitals and Federally Qualified Health Centers • The manual documents the experiences of several rural CAH/Health Center collaborations. http://www.hrsa.gov/ruralhealth/pdf/qhcmanual042010.pdf

6. Benefits of Collaboration Between CAHs and Health Centers Each provider contributes unique resources to the collaboration that foster infrastructure, access, and quality of care improvements. • Health Centers benefit through sharing CAH unique resources. • CAHs benefit through association with the Health Centers. • The local rural health infrastructure – made up of CAHs and Health Centers - benefited.

7. How has collaboration worked? Lessons Learned • Leadership, Continuity, and Commitment • Compelling Needs and Solutions • Collaboration Instead of Competition • Regional Linkages for Frontier Counties and Tribal Health Services • The Pay-off: Significant Benefits

8. Collaborative Relationships Health Center Statutory Language: “…The center has made and will continue to make every reasonable effort to establish and maintain collaborative relationships with other health care providers in the catchment area of the center….” (Section 330(k)(3)(B) of the PHS Act)

9. Collaboration and Applications Collaboration is a criteria in health center funding opportunity announcements • Formal and informal collaboration and coordination of services with other health care providers must be documented…

10. Collaboration and Applications Letters of support are required from: • Current health center grantees • FQHC Look-Alikes • RHCs • CAHs • Health Departments in the applicant’s proposed service area • Reference specific collaboration and/or coordinated activities with community organizations

11. Contractual Arrangements • Section 5601(b) of the Affordable Care Act amended section 330(r)(2)(4) of the PHS Act: • Expressly states health centers are allowed to contract with many types of rural providers for the delivery of primary health care services. • Authorizing statute permits health centers to provide both required primary health services and additional health services necessary for the adequate support of required primary health services to residents of the area served by the center through contracts and/or cooperative arrangements.

12. Considerations for Contractual Arrangements Health Center Program grantees: • Are responsible for maintaining oversight over all sites and services within their federally approved scope of project, including assuring that patients have access to the health center’s full range of services. • Must assure that all services included under their federally approved scope of project, including those performed under contract, are available to all patients, regardless of their ability to pay.

13. Considerations for Contractual Arrangements Health Center Program grantees (cont): • Must comply with Section 330 of the PHS Act and the HHS grant regulations. These include: • Required services (and payment for those services to the extent that they are not provided directly by the health center) • Procurement of goods and services, as outlined in 45 CFR § 74.40 through 74.48 or 45 CFR § 92.36(b) through (i), as applicable. • Benefits that are afforded to health centers from programs other than under Section 330 are determined by the applicable laws and rules of the respective programs.  Terms of the contractual agreement should be constructed accordingly.

14. Opportunities for Collaboration • Comprehensive community health care needs assessment • Integrated strategic and business planning and shared quality improvement programs • Referrals/coordination of services: • Primary and preventive • Laboratory • Radiology • Specialty • Telemedicine • Health Information Technology: • Electronic Health Records • Telemedicine • Provider credentialing, recruitment/retention services, training programs • Admitting privileges, call coverage

15. Opportunities for Collaboration Organizations: • State Office of Rural Health (SORH) • State Primary Care Association (PCA) • State Primary Care Office (PCO) • State Rural Health Association (SRHA) • State Hospital Association • State Medical Association • Free Clinic Association • State Health Department

16. Additional Resources UDS Mapper Tool: http://www.udsmapper.org State/Regional Primary Care Associations: http://bphc.hrsa.gov/technicalassistance/pcadirectory.htm State Offices of Rural Health: http://www.hrsa.gov/ruralhealth/about/directory/index.html National Rural Health Clinic Association: http://www.narhc.org National Technical Assistance for FQHCs: http://bphc.hrsa.gov/technicalassistance/ncadirectory.htm Manual for Effective Collaboration between CAHs and FQHCs: http://www.hrsa.gov/ruralhealth/pdf/qhcmanual042010.pdf

17. Specific Examples of Successful Collaborations

18. Models of Collaboration: Health Centers and Hospitals Collaboration can be achieved at many points along a continuum, from referral agreements to the creation of new organizations

19. Model 1: Rural Maine Model of Collaboration

20. Rural Maine Model of Collaboration Pines Health Services (Health Center Grantee): • Non-profit status in 2005 and certified/funded as a Health Center Program grantee and FQHC in 2007 • 5 sites in Caribou, Limestone, Presque Isle and Van Buren, ME • Serves ~14,500 unique patients generating over 65,000 encounter annually • Employs ~30 physicians, 10 mid-level providers and 90 nursing, clerical and administrative staff

21. Rural Maine Model of Collaboration Cary Medical Center: • Non-profit community hospital serving Caribou and surrounding area for 85+ years • 74 acute care beds and 9 Intermediate Care Facilities for the Mentally Retarded (ICFMR) beds • Largest employer in Caribou • Initiated the formation of Pines Health Services, originally to provide pharmacy services • All Pines providers are part of Cary’s medical staff

22. Rural Maine Model of Collaboration Reasons to Collaborate: • Serving the same population and same geographically isolated area. • Limited supply of available clinical, other professional and technical workforce. • Natural outgrowth of efforts to improve access to services and meet community needs. • Maintaining the strength of both organizations is critical to health care service delivery.

23. Rural Maine Model of Collaboration How they Collaborate: • Shared medical, IT, public relations, maintenance, housekeeping staff • Provision of ancillary services • Health Center leases hospital clinical space • Group purchasing • Joint physician recruitment • Monthly board member exchange, shared review of strategic plans, and quarterly joint Board Executive Committee meetings • Legislative affairs

24. Model 2: Rural Vermont Model of Collaboration

25. Rural Vermont Model of Collaboration Springfield Medical Care Systems (SMCS) Health Center Program: • Located in Springfield, VT with additional sites in Chester, Ludlow, and Bellows Falls, VT and Charlestown, NH • Serves a patient population of ~25,000 • Provides full array of primary care services as well as behavioral health, dental, and discount pharmacy services. • A 501(c)(3) non-profit that is parent to Springfield Hospital

26. Rural Vermont Model of Collaboration Springfield Hospital (CAH): • Wholly owned subsidiary of SMCS • Average daily census of 19 • ~17,000 Emergency Department visits/year • Directly employs specialty, surgical and hospitalist providers

27. Rural Vermont Model of Collaboration SMCS: Springfield Hospital: Governed by a community-based Board, with certain reserved authorities retained by the Health Center parent Board. Governed by an Health Center Program-compliant Board of Directors that consists of community members representative of the population served. • There is limited overlap between the two Boards (required by Health Center Program regulations), they meet separately although certain Board committees meet together or have mirror membership. • A single executive team has administrative and management responsibility for both primary care and acute care operations. 27

28. Rural Vermont Model of Collaboration Obstacles Overcome: • Creating a structural model that satisfies all IRS and HRSA laws and regulations, as well as provider, administrative team, and Board concerns. • Obtaining support and buy-in of the Board and medical staff leadership was of utmost importance. • Springfield Hospital’s concerns (its future prominence and authority) were addressed through carefully crafted by-laws that emphasize the symbiotic interdependence of primary and acute care services and the existence of a single leadership team that would be mindful of the impact of decisions on each organizational activity.

29. Rural Vermont Model of Collaboration Surprises/Unintended Consequences: • The philosophical “fit” of the model with federal and state health reform agendas. • Increased community involvement, stewardship of the organization. • Effectiveness of the Health Center Program model re: governance, business operations, quality improvement, community needs assessment and response. • Amount of unmet need for access to primary care services, especially for Medicaid and uninsured populations. • Outreach efforts has resulted in the establishment of primary care relationships with these patients and has had a detrimental impact on the hospital’s payer mix.

30. Rural Vermont Model of Collaboration Opportunities/Benefits: • Financial benefits that accompany Health Center grantee status: health center grant funding, reimbursement under the FQHC payment system, 340B pharmacy program, Federal Tort Claims Act malpractice coverage. • Quality improvement successes in the acute care arena support similar efforts in primary care. • Community Health Center model, which emphasizes comprehensive primary care and enabling services, together with chronic disease management and patient-centered medical home activities, may shift the system’s activities and resources away from acute care, but can expect overall growth.

31. Takeaways • Collaborative models can be successful, particularly in rural communities. • Start with a level playing field regarding what each party brings to the table, sharing all relevant information. • Throughout the relationship building process ensure that the PATIENT remains the focus for why to collaborate

32. Contact Information Office Of Rural Health Policy Bureau of Primary Health Care CAPT Maureen Quinn USPHS Regional Nurse Consultant/ Public Health Analyst Phone: (617) 565-1480 E-mail: mquinn@hrsa.gov Michelle Goodman Policy Coordinator Phone: (301) 443-7440 E-mail: mgoodman@hrsa.gov