Chapter 5: Critical Access Hospitals and Community Development

Rural Hospital Flexibility Program Tracking Project

Chapter 5
Critical Access Hospitals and Community Development

Amy Hagopian, M.H.A.
WWAMI Rural Health Research Center, University of Washington

Introduction

While the Federal Office of Rural Health Policy has not made "community development" one of its five specific goals for the Rural Hospital Flexibility Program (Flex Program), it has certainly encouraged states to support such activity in rural communities and has funded efforts at local, state and national levels to promote it.

"Community development" is a term with multiple meanings, depending on the context and the motivation. These activities can include everything from "health fairs" to "needs assessments" to "community-based strategic planning." We would argue that initiatives that actively engage community members ("stakeholders") in decision making related to health care can be characterized as meaningful community development.

These decision-making activities usually bring together members of a community to engage in strengthening and expanding their health care systems. Typically, citizens are engaged in assessing the strengths and weaknesses of their health care system, and then work with each other to make improvements. Implementation of plans generally involves all parts of the health system, from public health and mental health to traditional and alternative providers to social support organizations.

The most obvious motivation for hospitals to engage in community development activities is that it builds market share.¹ By involving community members in identifying community needs, planning, fundraising, improving reputation, marketing, recruiting workforce, and expanding services, hospitals gain visibility and credibility, typically resulting in increased utilization. Building support from community leaders also provides opportunities for hospitals to gain support for tax subsidies through ongoing levies or capital bonds as well as increased private fund raising capacity through gifts, endowments, and capital campaigns. In addition, all of these types of activities help to ensure that the hospital is in touch with its community and meeting its needs.

As hospitals consider critical access hospital (CAH) status, many view conversion as an opportunity to engage the community's health care providers and consumers in a discussion about the local health care system as a whole.

Background

The National Rural Health Association (NRHA) published a report in 1995 ² summarizing a variety of approaches and techniques for community rural health development that were developed around the country by universities, state offices of rural health, Area Health Education Centers (AHECs), private consultants and other rural health advocates over the previous decade. That publication notes:

Reimbursement policies, provider shortages, and economic and population trends were blamed for the health system failures of the last decade, but new research shows that the level of community awareness of, confidence in and support for the local health care delivery mechanisms play critical roles in sustaining community services.

Many of the community development activities featured in that report were launched at a time when rural hospitals were particularly threatened by having to adapt to prospective payment systems in the mid-1980s. The publication classified the various activities into three models: comprehensive, planning and self-help. The comprehensive model approach includes "Community Health Services Development,"³ developed at the University of Washington through a grant from the W.K. Kellogg Foundation, and subsequent grants from the Northwest Area Foundation. The Community Decision Making model was developed at the Mountain States Group in Boise, Idaho, under sponsorship from the Area Health Education Center. The Rural Health Transition Model, funded by the Blandin Foundation, was developed by Minnesota's Center for Rural Health.

The planning models (second approach) were mostly single-state based, and included Hometown Health, developed in Iowa as a joint effort of the Center for Rural Health at the Iowa Department of Public Health, and programs at Iowa State University. Alabama County Health Councils were the brainchild of the University of Alabama and Auburn University. Community Wellness Councils were local planning organizations created by county extension agents and supported by the University of Georgia. The Missouri Rural Innovative Institute was another Kellogg-funded effort that also worked through extension, AHECs, and the University of Missouri. Not mentioned in the NRHA publication is the PATCH (Planned Approach to Community Health) program, described as a process that involves and enables members of a community to organize and mobilize members, collect and use local area data, set health priorities, select and implement appropriate interventions, and perform process and impact evaluation. PATCH was popularized in Nebraska and Wyoming, among other places.

The third approach is self-help. Community Voices was another Kellogg Foundation effort at North Carolina A&T State University that focused primarily on disadvantaged rural communities in the south. "Working Together for Rural Action," another Northwest Area Foundation effort, was developed by the University of North Dakota Center for Rural Health. Community Oriented Primary Care is another effort in this category, with a particular initiative funded by NRHA and Kellogg to demonstrate the value of combining epidemiology and primary health care skills to systematically identify and address the major health care needs, problems and concerns of rural communities.

Following these efforts, which spanned from the mid-1980s to the mid-1990s and beyond, the Federal Office of Rural Health Policy (FORHP) committed to a national community development effort in some of America's most economically-deprived rural communities. "Community Solutions for Rural Health" was implemented in three waves, starting first with communities in the Southeast states. Leaders from the community development efforts of the previous decade were recruited to design a program and train local "encouragers," who implemented local projects. This effort was evaluated and described in another NRHA publication.⁴

The next (and current) wave of related activities, "Operation Rural Health Works," was developed at Oklahoma State University.ⁱ In this project, a methodology has been developed to assess the economic impact of the health system on rural communities (economic multiplier values are calculated). This FORHP-funded effort is training state offices of rural health and other interested parties to adopt the approach, develop the information, and bring it to communities where local decision making can be performed.

Community development is not easily described, nor does it have a large or powerful national constituency or following. There are national interests, however, that can be achieved most effectively and efficiently through community development initiatives. One of these is quality of care. The recent Institute of Medicine's report on quality⁵ has encouraged a more coordinated health care system nationally. Rural communities are well positioned to implement and demonstrate strategies quickly and effectively as their systems are small and can be agile.

State Offices of Rural Health

When we investigated community development activities spawned by the Flex Program, we encountered the inevitable problem of defining what qualifies as serious community development activity. Some of the state offices and hospitals would characterize very limited efforts as "community development," while others would only include activities similar to those characterized in the 1995 NRHA report, summarized above.

Thirty state offices of rural health ("state offices") responded to a Flex Program Tracking Team e-mail survey regarding how communities are engaging in health system development coincident with CAH conversion. Eighty-three percent of these state office respondents indicated they were using some of their Flex Program grant dollars to conduct, facilitate or promote community development activities in CAH locales. Two-thirds of these state offices reported that "many" communities were taking advantage of conversion as an opportunity to engage in development, and 86 percent of the states were convinced that these activities were valuable.

Fewer than half the state office respondents, however, said they were requiring community development as a condition of participation in the Flex Program or CAH conversion. Five states ⁱⁱ indicated that they "strongly encouraged it," while 14 states ⁱⁱⁱ said they required it.

It's interesting that some states that are known to be active in the community development "movement" and that invest considerable resources in these activities, are not necessarily requiring it. This would include, for example, North Dakota, Idaho and Montana. One of the explanations given is that to be a meaningful activity, community development activities must be entered into and embraced wholeheartedly and sincerely, and not as part of an institutionalized requirement.

Tennessee has employed the unique strategy of institutionalizing a community-based planning approach. Community Health Councils, which began as a grass-roots community planning effort, are a strong force in Tennessee and have been instrumental in identifying rural communities' health needs for the Flex Program. Locally-based Community Health Councils have been turned into formal entities (staff are state employees) and are organized into eight offices for the state's 95 counties (some regional offices are responsible for up to 15 counties). Community Health Councils initiated and continue to be responsible for the formal needs assessment process called "Community Diagnosis." It was reported to us that the Department of Health funnels significant responsibility to this organization for community development. The Flex Program has encouraged the Health Councils to become much more involved with local hospitals.

Tracking Team members found in our first round of site visits in 2000 that several hospital administrators had managed to convert their facilities to CAH status without informing their communities at all. They were quite deliberate about not wanting to "upset" their citizenry about a change that was not going to lead to any visible change in scope of services or operations. Other administrators viewed the new designation as an opportunity to fully engage business people, elected officials, the news media, patients and other providers in a discussion about the future of health care in their towns, and even celebrated the new designation as a federal recognition of the "critical" nature of their hospitals (Tracking Team Finding From the Field, Vol. 1 , #6).⁶

Only five of the 30 state offices surveyed reported that they believed there were communities in their states engaging in "stealth" conversions. The Tracking Team did not encounter such conversions during our second round of site visits (2001).

Florida reported that some hospitals "have come out with a big ribbon-cutting ceremony," while others view it as strictly a reimbursement strategy. In Maine, it was reported there were community meetings about the conversion decision that brought out "citizens who were worried about the services being limited," while other communities had similar meetings that no one attended. In Texas, town hall meetings are a mandatory part of the application process for every converting hospital.

Some states reported that their offices were highly involved in local community development activities. Arkansas is using the "Hometown Health Initiative" in 11 of its communities. California is helping communities conduct needs assessments, and is doing economic impact statements for three communities this summer. Florida's office has worked with 29 communities, meeting with hospital boards and staffs and local government officials, and conducting community meetings. Iowa reports working with 20 communities. Louisiana has worked with a similar number, and has organized teams to meet with county commissioners and others. Michigan offers technical assistance, and has sent state office staff into 22 communities. North Dakota's office works with communities to conduct needs assessments and strategic planning, and has visited 22 communities under the Flex Program. Twelve of North Dakota's 14 CAHs have engaged in some form of community development, including assessments, community forums, key informant interviews, and strategic planning. Minnesota's office of rural health is very busy in communities, as is Oklahoma, Tennessee and Oregon.

One community development trainer told an audience at the 2000 National Rural Health Association conference in New Orleans that the most important requirement for a community developer is the possession of a valid driver's license. We believe the states where staff have developed active and meaningful relationships with the hospitals in their states, and who make frequent trips to visit those facilities, are the states making the most effective use of their Flex Programs.

Some state offices of rural health reported communities in their states were very enthusiastic about the Flex Program. "Nearly all communities are positive about the CAH program because this program may add to the longevity of the hospitals in their areas," Hawaii reported. In Illinois, we were told, "Board members are very positive. They see the CAH program as an opportunity. They have to make very tough decisions to keep a hospital viable." Virginia concurs: "They are very grateful for something that can save their hospital." And in Washington: "Since communities are supporting the hospital with their taxes, it's a pretty strong statement (that they want to keep them open)."

We learned in one of our site visits that West Virginia places considerable emphasis on community development when it awards grants to CAHs, although some hospitals engage in significantly more visible activities than others. Nebraska's state office encourages CAH administrators to inform their communities of conversion decisions, and has developed a "communications kit" to assist hospitals with that process. The kit is posted to the Web at http://www.nahhsnet.org/html/CAH/cah_communicat.htm. Tennessee has institutionalized a community development process by creating standing community committees, but still finds the spirit of these activities varies widely and depends largely on local leadership.

Survey of CAH Administrators

In the fall of 2000, the University of Minnesota conducted a survey of all hospital administrators whose facilities had converted to CAH status by September 1, 2000 (see description of survey in the Introduction). Questions in the survey inquired about community support for the hospital, the frequency of meetings among all the community's health care providers, and local tax support for hospitals (as an expression of local support). Our survey finds the following associations (which may not be causal):

Community support of hospitals (both general and financial support in tax dollars) improves with frequency of provider meetings.
Communities that support their hospitals with tax dollars have experienced lower turnover in their hospital administration.
Hospitals with lower turnover tend to be in communities rated supportive by the administrators.

When asked "how would you characterize the community's level of support for the hospital before conversion?" 57 percent of administrators reported that support was "high," 32 percent "medium," and 12 percent "low."

Only 35 percent of hospital administrators said they met monthly or more frequently with "representatives of local public health, mental health, EMS and/or other similar community-based health care providers that were not formally affiliated with the hospital." Of the administrators who responded that they met with local providers at least monthly, however, 70 percent characterized their communities as "highly supportive" of the hospitals. Only half of the administrators who met less frequently reported that their communities were highly supportive (significance: p < 0.01).

About half the administrators reported that they received local tax dollars to support the hospital. Two-thirds of the administrators who reported at least monthly meetings with other providers received tax support, while three-fourths of those who did not receive tax support met less frequently than monthly. We may conclude from these findings that administrators who take the time and make the effort to engage with non-hospital health care providers in the community are reaping rewards of better community support. Site visits support this conclusion.

As we discuss in our chapter on hospital administration (see Chapter 3I), administrator turnover is a serious problem in rural hospitals, and tends to be associated with hospital financial distress. Almost a third of the hospital administrators reported that their hospitals had more than two administrators in the past five years. However, only 25 percent of communities that support their hospitals with tax dollars experienced high turnover (defined as more than two administrators in the last five years) compared to 37 percent of communities that provided no tax support (significance: p = 0.075). These associations probably flow from a complex web of community culture, and it is difficult to tease out the root cause (does tax support lead to reduced turnover, or does reduced turnover lead to the stability that leads communities to support their hospitals with taxes?).

Another survey finding was that hospitals with lower administrator turnover tended to be associated with communities that were rated highly supportive by the administrators. While 62 percent of the low-turnover hospitals were in "high support" rated communities, only 46 percent of high-turnover hospitals were in "high support" communities (significance: p = 0.079). A conclusion we can entertain from these latter findings is that communities that support their hospitals with local tax dollars and that have general community enthusiasm regarding the hospital may enjoy lower hospital administrator turnover.

Community Site Visits

Tracking Team site visits in both of the past two years lead us to believe there are few communities where conversion is controversial. This is especially true since the 96-hour stay rule became a facility-wide average rather than a per-case requirement.

There are a few towns where citizens, staff or physicians fail to understand the true nature of the program, in which case there may be local opposition. This has occurred, for example, in communities in some of the original states that participated in the pre-cursor Rural Primary Care Hospital (PCH) program. In communities where facilities and opinion leaders had considered participation in the PCH program and rejected it (for whatever reason), it seems to be more difficult to "re-visit" the conversion decision under this new Flex program. There are also communities where physicians whipped up local opposition by characterizing the program as a "downsizing" initiative. Nonetheless, these are rare exceptions to the general experience.

A few, but not many, of the CAH conversion communities we visited are spending considerable effort on creating collaborative relationships between and among health care providers within the same town. The efforts of four of the hospitals that we visited provide interesting examples of intra-community networking. Their preliminary efforts suggest the benefits that may accrue to hospitals and communities that engage in this exercise. Providers from one New Mexico CAH routinely meet with other community providers as part of a local perinatal providers' group and a maternal and child health coalition. These committees serve as an informal case management service for low-income women in their community.

A northern Michigan CAH has worked with the local county health department and the local American Indian tribes to expand women's services, including diagnostic testing. Representatives from the same hospital also serve on the local human services collaborative board with a wider variety of community agencies including public health, mental health, and domestic violence agencies. The board is charged with analyzing and addressing local coordination and service issues.

A North Carolina CAH has close relationships to the local health department and supports part of the Director's salary. In addition to expanding programs (a diabetic program, for example) to underserved populations, the hospital has also been in a position to maintain public health services in their community in the face of state budget cuts.

A CAH in central West Virginia has partnered with the local school department to open a clinic at the school. The clinic is available to students and staff as well as their families on a sliding fee scale. No patient is turned away because of an inability to pay. The hospital is planning an additional school-based clinic in a nearby community. This clinic will be the only source of primary care in that town.

These CAH-based programs have not only expanded services to vulnerable populations in the communities where they are located, but have also helped to identify the hospital as essential community provider. As a result, the administrators report greater community support, which has translated into the maintenance of tax support in one community and expanded private fund raising capacity in another. Three of the administrators specifically noted increased utilization of ambulatory and outpatient services resulting from their local networking efforts.

Summary

While not the highest Flex Program priority, it does appear that a substantial amount of community development activity is associated with the program and that this activity varies by state. State offices of rural health are involved in varying degrees with facilitating community development work in CAH conversion and non-conversion communities. There are complex interrelationships between community development, hospital success, administrator turnover, and the CAH conversion process. While not all of the community development activities we enumerate were a direct consequence of the Flex/CAH Program, we believe the program is directly responsible for some of them and has acted as a catalyst for many of the rest. Furthermore, we believe these types of activities are essential to the long-term viability of the CAHs.

Chapter 6: Small Rural Hospitals that Have Chosen Not to Convert to CAH Status

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Footnotes / References

ⁱ For further information on Oklahoma State University publications, go to http://www.rupri.org/ and find the ORHW link.

ⁱⁱ Arizona, Kansas, Illinois, Mississippi, and Oregon.

ⁱⁱⁱ Florida, Georgia, Hawaii, Iowa, Louisiana, Massachusetts, Minnesota, Nevada, New York, North Carolina, Tennessee, Texas, Utah, and Wisconsin.

¹ Amundson B, Hughes R. Are Dollars Really the Issue for the Survival of Rural Health Services? WWAMI Rural Health Research Center working paper #3, June 1989.

² Mayfield J for National Rural Health Association. Community Development Applied to Health Care. NRHA publication, available from Publications Department, 1 W Armour Blvd., Suite 301, Kansas City MO 64111.

³ House P, Hagopian A. Community Health Services Development Program. Proceedings of the Conference held by the Rural Education Research and Development Centre, Townsville, Queensland, Australia, July 1994.

⁴ Hagopian A, House P. Community Solutions for Rural Health: An Empowerment Initiative for Rural Communities. NRHA Publication Order #PU0696-45. Undated (circa 1997).

⁵ National Academy of Sciences. Crossing the Quality Chasm: A New Health System for the 21st Century. 2000.

⁶ Gale J. From Wisconsin: Strategies for Hospital Communication with the Community. CAH/Flex National Tracking Project. Findings from the Field, 1:6. October 2, 2000. Available from project Web site: http://www.rupri.org/rhfp-track/.

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