Department  of Health  and Human  Services 
OFFICE OF 
INSPECTOR GENERAL 
ACCESS  TO  RURAL HEALTH CARE: 
SUCCESSFUL  COMMUNITY  INITIATIVES 
JULY  1993  OFFICE OF INSPECTOR GENERAL 
The  mission  of the  Office of Inspector  General  (OIG),  as mandated  by Public  Law 95-452, as 
amended,  is to protect  the  integrity  of the  Department  of Health  and Human  Services (HHS) 
programs  as well as the  health  and welfare  of beneficiaries  served  by those  programs.  This 
statutory  mission  is carried  out  through  a nationwide  network  of audits,  investigations,  and 
inspections  conducted  by three  OIG  operating  components:  the  Office of Audit  Sewices,  the 
Office of Investigations,  and the  Office of Evaluation  and Inspections.  The  OIG  also informs  the 
Secretary  of HHS  of program  and management  problems  and recommends  courses  to correct 
them. 
OFFICE OF AUDIT  SERVICES 
The  OIGS  Office of Audit  Services  (OAS)  provides  all auditing  semices  for HHS,  either  by 
conducting  audits with its own audit  resources  or by overseeing  audit work done  by others. 
Audits  examine  the  performance  of HHS  programs  and/or  its grantees  and contractor  in carrying 
out  their  respective  responsibilities  and are intended  to provide  independent  assessments  of HHS 
programs  and operations  in order  to reduce  waste,  abuse,  and mismanagement  and to promote 
economy  and efficiency throughout  the Department. 
OFFICE OF INVESTIGATIONS 
The  OIGS  Office of Investigations  (01)  conducts  criminal,  civil, and administrative  investigations 
of allegations  of wrongdoing  in HHS  programs  or to HHS  beneficiaries  and of unjust  enrichment 
by providers.  The  investigative  efforts  of 01  lead to criminal  convictions,  administrative  sanctions, 
or civil money  penalties.  The  01  also oversees  State  Medicaid  fraud  control  units which 
investigate  and prosecute  fraud  and patient  abuse  in the  Medicaid  program. 
OFFICE OF EVALUATION  AND  INSPECTIONS 
The  OIGS  Office of Evaluation  and Inspections  (OEI)  conducts  short-term  management  and 
program  evaluations  (called  inspections)  that  focus on issues of concern  to the  Department,  the 
Congress,  and the  public.  The  findings  and recommendations  contained  in these  inspection 
reports  generate  rapid,  accurate,  and up-to-date  information  on the  efficiency, vulnerability,  and 
effectiveness  of departmental  programs. 
OEIS Atlanta  Regional  Office staff prepared  this report  under  the  direction  of Jesse  J. Flowers, 
Regional  Inspector  General  and Christopher  Koehler,  Deputy  Regional  Inspector  General. 
Principal  OEI  staff included: 
Atlanta Region  Headquarters 
Maureen  Wilce, Project  Leader  Cathaleen  Ahern

Ron  Kalil

Paula  Bowker

Ruth  Reiser

For  additional  copies  of this report,  please  contact  the  Atlanta  Regional  Office  at 404-331-4108.
 Department  of Health  and Human  Services 
OFFICE OF

INSPECTOR GENERAL

ACCESS  TO  RURAL HEALTH CARE:

SUCCESSFUL  COMMUNITY  INITIATIVES

JULY  1993  OEI-04-92-00730
 EXECUTIVE  SUMMARY

PURPOSE 
To  describe  successful  initiatives  for  providing  access  to  health  care  in rural  communities 
that  do not  have  a local  hospital. 
BACKGROUND 
Many  changes  in the  provision  of medical  care  have  resulted  in an increase  in hospital 
closure.  Specialization  and  advanced  technologies  have  drastically  changed  the  patterns 
of care  at  hospitals.  Occupancy  rates  at hospitals  have  decreased  as many  procedures 
are  treated  with shorter  inpatient  stays.  Further,  procedures  once  requiring  inpatient 
stays can  now be  performed  on an outpatient  basis.  Likewise,  improved  mobility  of those 
living in rural  areas  has  contributed  to closures  of local  hospitals.  Rural  residents  can, 
and  often  do, bypass  local  hospitals  to obtain  more  specialized  care  that  is typically 
available  in larger  regional  or urban  hospitals.  Nationally,  193 rural  hospitals  closed 
during  1987 through  1991.  This is 7.1 percent  of all rural  hospitals  that  were  open  in 
1987. 
The  closure  of local  hospitals  had  limited  effect  on access  to medical  care  for most 
people.  Most  communities  where  a hospital  closed  were  within  20 miles  of another 
hospital.  However,  communities  without  a nearby  hospital  and  certain  populations  within 
the  communities,  such as the  poor  and  elderly,  can  have  problems  accessing  health  care 
services.  The  hospital  closures  have  led to strong  interest  in providing  health  care  locally 
without  a hospital.  This  desire  of local  communities  to take  responsibility  for their  own 
health  care  needs  was recently  endorsed  by the  Secreta~  of Health  and  Human  Services. 
She  expressed  her  intent  to help  rural  communities  empower  themselves  to meet  their 
own health  care  needs. 
SCOPE  AND  METHODOLOGY 
We  surveyed  health  professionals  in 39 States  where  one  or more  rural  hospitals  had 
closed  to identify  communities  that  had  developed  a successful  initiative  for providing 
health  care  after  their  hospital  had  closed.  We selected  six initiatives  for case  study.  We 
visited  each  selected  community  and  described  each  of their  initiatives  and  compared  and 
contrasted  the  services  provided. 
FINDINGS 
Rural commundia  can empower  themselves to create  succewfid  health  care  initiatives 
The  six initiatives  we selected  for this study demonstrate  commitment,  hard  work,  and 
creativity  to provide  access  to health  care  locally.  Once  communities  accepted  their 
inability  to  sustain  a hospital,  they  created  an alternative  which  reflected  individual  needs 
i  and  resources  within  a community.  Often,  traditional  community  boundaries  had  to be 
ignored  to create  a successful  health  care  initiative.  Thereafter,  the  community  must 
support  the  initiative  or it too will fail as have  many  small  rural  hospitals. 
Successjhl initiativceans irnpmve  ddwy  of  health care senices 
Through  their  initiative,  the  communities  we selected  generally  improved  the  supply  of 
health  care  professionals.  They  established  (1) programs  to attract  health  care 
professionals  to their  community,  and  (2) networks  to share  health  professionals  between 
communities.  Likewise,  they  tailored  health  care  to their  community  -- eliminating 
duplication  and  underused  services. 
Sttwasskance  is*al  fw succiwjid  cornrrudy  hitiiztiveis 
State  governments  provided  grants  and  technical  assistance.  Further,  States  revised 
legislation  and  policies  to allow communities  to develop  and  operate  their  health  care 
initiatives. 
Local  commudies  relied on exhting Federal programs h  developing their ikitidves 
Virtually  all of the  initiatives  relied  on existing Federal  programs,  such  as Medicare  and 
Medicaid,  for funding  and  technical  assistance.  To  illustrate,  Newton,  Texas,  Ekalaka, 
Montana  and  Oxford,  Nebraska  received  Medicare  and  Medicaid  reimbursements  as part 
of the  existing  Rural  Health  Clinic program.  Significantly,  no community  initiative  was 
funded  through  new Federal  programs. 
CONCLUSION 
Rural  communities  where  hospitals  have  closed  and  those  that  are  trying  to save  a failing 
hospital  can  find  other  ways to meet  their  health  care  needs.  Local  residents  who  accept 
the  notion  of health  care  without  a hospital  can  empower  themselves  to design  and 
implement  a strong  health  care  system  for their  communities.  The  success  of local  health 
care  initiatives  depends  heavily  on creative  use of all available  resources  by community 
leaders.  A community  must  first obtain  strong  local  support  and  then  seek  available 
State  and  existing  Federal  support. 
ii  TABLE  OF  CONTENTS

PAGE 
EXECUTIVE  suMMARY

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4

Communities  Empowering  Themselves  . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4

Improving  Delivery  Of Services  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...8

State  Assistance  Is Critical  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...10

Using  Existing  Federal  Programs  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...10

CONCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...11

APPENDIX  :  DESCRIPTION  OF  COMMUNITY  INITIATIVES  . . . . . . . . . . .  A-1

Newton  Education  Center,  Newton,  Texas  . . . . . . . . . . . . . . . . . . . . . . . . ..A-2

Rural  Health  Clinic, Lewisville,  Arkansas  . . . . . . . . . . . . . . . . . . . . . . . . . ..A-4

North  Penal Oreille  Health  Semices  Consortium,

Metaline  Falls,  Washington  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-6

Oxford  Medical  Center,  Oxford,  Nebraska  . . . . . . . . . . . . . . . . . . . . . . . . . .  A-8

Jane  Phillips  Community  Health  Clinic, Caney,  Kansas  . . . . . . . . . . . . . . . .  A-10

Medical  Assistance  Facilities,  Circle,  Ekalaka,

Jordan,  and  Terry,  Montana  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-12
 INTRODUCTION

PURPOSE

To  describe  successful  initiatives  for providing  access  to health  care  in rural  communities

that  do not  have  a local  hospital.

BACKGROUND

Changes  In The  Provision  of Medical  Care  Contrhte  to Hospital  Closures

Significant  changes  in provision  of medical  care  in recent  years  have  resulted  in an

increase  in hospital  closures.  The  once  prevalent  general  practice  of medicine  has

Yielded toincreased  specialized  care.  Specialized  care  requires  advanced  technologies

plus physicians  andother  medical  professionals  whoaretrained  to use  it.  Likewise,  the

improved  mobility  of people  in rural  areas  further  contributed  to hospital  closures.  The

availability  of automobiles  and  interstate  highways  allows rural  citizens  easy and  fast

access  to hospitals  and  other  medical  services  in distant  locations.  People  in rural

communities  can,  and  do, bypass  a local  hospital  to obtain  more  specialized  care  that  is

typically  available  in larger,  more  urban  locations.  Advances  in emergency  ambulance

services  also  allow bypassing  a local  hospital  even  in emergency  cases.

Our  study  of hospital  closures  during  1987 through  1991 showed  that  193 rural  hospitals

closed  nationally  (Trends  in Rural  Hospital  Closure:  1987-1991  0EI-04-92-O0441).

This  is 7.1 percent  of all rural  hospitals  that  were  open  in  1987.  The  majority  of the

hospitals  that  closed  were  small  and  had  low occupancy  rates.

Hospital  Closures  Had  Limited  Effect  on Access  to Medical  Care

The  closures  of local  hospitals  had  limited  effect  on access  to medical  care  for most

people.  In our  five years  of hospital  closure  studies,  we found  that  for most

communities,  hospital  care  was still available  within  20 miles.  Further,  the  Office  of

Inspector  General  reported  on the  effects  of hospital  closure  on access  to hospital  care  in

1990 (Effects  of 1988 Rural  Hospital  Closures  on Access  to Medical  Care,  0EI-04-89-

00742).  In the  1990 study we found  that  most  residents  did not  use the  local  hospital

before  it closed.  Residents  chose  to bypass  the  local  hospital,  and  perhaps  other  small

rural  hospitals,  to travel  to newer,  larger  and  more  specialized  facilities.  The  study

showed  that,  overall,  most  residents  did not  have  serious  problems  accessing  health  care

as a result  of hospital  closure.  Although  many  residents  in communities  which  lost their

hospitals  had  inpatient  and  emergency  care  available  nearby,  some  residents  had

problems  accessing  medical  care.

1
 Interest  In Providing  Hezdth  Care  Without  A Hospital

During  ourevaluations  ofhospital  closuresin  1987 through  1991, many  Federal,  State

and  local  health  care  providers  expressed  interest  in how communities  successfully  meet

health  care  needs  without  a hospital.  They  wanted  to know what  communities  had  done

to continue  providing  health  care  in their  communities  when  their  hospital  closed.

Further,  they wanted  to know if the  techniques  used  by these  communities  could  be

applied  in other  communities,  including  communities  facing  hospital  closure,  and

communities  which  have  never  had  a hospital.  Finally,  Dr.  Shalala,  Secretary  of Health

and  Human  Services,  recently  expressed  her  strong  intent  to help  rural  communities

empower  themselves  to meet  their  own health  care  needs.

This  report  provides  information  on initiatives  developed  by selected  communities  to

successfully  meet  their  health  care  needs.  We believe  examination  of the  successful

community  initiatives  will help  decisionmakers  at the  Federal,  State  and  local  level  design

policies  and  programs  to meet  local  health  care  needs  during  a period  when  the

provision  of, cost  of, and  access  to health  care  are  changing  drastically.

SCOPE  AND  METHODOLOGY

We  interviewed  State  health  and  hospital  officials  and  health  care  advocates  in 39 States

where  one  or more  rural  hospitals  had  closed.  We  obtained  information  on  (1) what

specific  rural  communities  had  done  to provide  local  access  to health  care  following

closure  of their  hospital,  and  (2) what  standards  and  characteristics  indicated  successful

initiatives  in those  communities.  We  then  interviewed  State  health  professionals,

researchers,  and  other  officials  in State  and  national  organizations  that  have  an interest

in rural  health  issues  to identify  communities  they believed  had  developed  successful

health  care  initiatives.  They  identified  18 rural  communities.

To  determine  the  types  of health  care  provided,  we interviewed,  by phone,  community

health  officials  in each  of the  identified  rural  communities.  We  classified  each

community  initiative  based  on extent  and  level of health  care  services  provided.  We  then

selected  six initiatives  which  (1) met  our  standards  for a successful  initiative,  (2)

represented  different  types  of initiatives,  and  (3) gave geographic  dispersion  among  rural

communities  that  had  developed  initiatives.

We visited  each  of the  selected  six communities  to  (1)  document  the  services  actually 
provided,  and  (2)  obtain  information  on  the  development  and  operation  of the  initiative. 
We  obtained  information  by interviewing  the  administrator,  health  care  professionals, 
former  hospital  administrators  and  staff,  board  members  and  community  leaders,  and  by 
reviewing  hospital  and  community  records.  Where  appropriate,  we  also  interviewed  State 
officials  who  were  involved  in the  transition  from  a closed  hospital  to  an  alternate 
method  (initiative)  of providing  health  care.  Finally,  we  compared  and  contrasted  the 
development  and  operations  of the  six selected  community  initiatives  (see  Appendix  A). 
2
 We  collected  and  analyzed  information  during  June  1992 through  March  1993 to identify 
successful  community  initiatives  for providing  local  health  care  when  a hospital  closes. 
We  conducted  this inspection  in accordance  with the  Quality Standards for Inspechons 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
3
 FINDINGS

RURAL  COMMUMHES  CAN  EMPOWER  THEMSELVES  TO  CREATE 
SUCCESSFUL  HEALTH  CARE  INITIATIVES 
Initiatives  Reflect  Individual  Cmmmnity  Needs  And  ResourCes 
Each  of the  six initiatives  we selected  reflected  the  varied  needs  and  resources  within  a 
community.  We briefly  summarized  each  of the  six selected  case  examples  below. 
The  Newton  County  Education  Center:  This  initiative  includes  a 
Q

wide  mix of (1) public  health  services,  including  immunizations  and 
well-child  care  provided  by nurses,  (2) a Rural  Health  Clinic  (RHC) 
where  a physician  provides  basic  primary  care  including  lab  and x-
ray services,  (3) vocational  educational  services  provided  by county 
school  system  employees  at the  initiative  site, and  (4) a day care 
center.  The  center  is located  in the  former  Newton  County 
Memorial  Hospital  at Newto~  Texas.  It is administered  by Jasper 
Memorial  Hospital,  located  in a neighboring  county. 
The  Rural  Health  Center:  The  center  is located  in Lewisville, 
Arkansas.  The  initiative  is intended  to be  a one-stop  shopping 
center  for health  care.  When  completed,  it will combine  health  care 
and  social  services.  The  clinic provides  basic  primary  care,  lab, x-
ray, and  public  health  services.  Four  part-time  physicians,  several 
nurses,  a visiting nurse  pediatrician,  and  a nutritionist  staff  the  clinic. 
Renovations  are  underway  to include  county  social  services  at the 
center.  The  clinic also operates  a satellite  clinic two days a week  in 
another  community  that  is 18 miles  away -- Bradley,  Arkansas.  The 
center  is located  in the  former  Lafayette  County  Memorial  hospital. 
The  North  Penal Oreille  Health  Services  Consortium:  The 
Consortium  is located  in Metaline  Falls,  Washington.  The 
Consortium  of health  care  providers  is centered  around  a RHC, 
located  in nearby  Ione,  Washington.  The  consortium  provides 
primary  care,  emergency  care  services,  transfer  agreements  with the 
nearest  hospital,  case  management  and  referrals,  home  health 
services,  psychiatric  services  through  a nurse  practitioner,  and  a van 
to provide  non-emergency  transportation  for handicapped  persons. 
The  clinic is staffed  by a full-time  physician,  one  physician  assistant, 
and  three  part-time  health  care  assistants. 
4
 The  Oxford  Medical  Center:  Thecenter  islocatedin  Oxfor& 
Nebrakka.  Community  leaders  and  board  members  of the  Fritzer 
@6~ealth  center  inxford  established  an 
affiliation  with  a neighboring  hospital  in Cambridge  after  the 
hospital  in Oxford  closed.  The  Cambridge  hospital  already  had  four 
satellite  clinics.  They  converted  the  closed  hospital  in Oxford  into  a 
fifth clinic.  The  clinic, which is a RHC,  is staffed  by a full-time 
physician  assistant.  Three  physicians  visit weekly  from  the  affiliated 
hospital.  The  clinic offers  general,  family practice  services,  lab, x-
ray, on-call  urgent  care  after  hours,  emergency  transportation 
through  a volunteer  EMT  service  and  helicopter  transport,  a van 
service  to nearby  hospitals,  health  education,  and  a pharmacy. 
The  Jane  Phillips  Community  Health  Clinic:  The  clinic is located  in 
Caney,  Kansas.  Because  of serious  financial  problems,  the 
administrator  of the  Caney  Hospital,  an acute  care  facility,  started 
planning  for continuation  of health  care  before  the  hospital  closed. 
She  obtained  agreement  with the  Jane  Phillips  Episcopal  Memorial 
Hospital  in nearby  Bartlesville,  Oklahoma  to provide  medical 
support  services.  The  Caney  Clinic provides  offices  for three 
physicians  (although  at present,  only two practice  at the  clinic)  and  a 
part-time  physician  assistant.  The  initiative  provides  primary  care, 
lab  services,  an opticians  office,  24-hour  urgent  care,  and  emergency 
transportation  to the  hospital  in Bartlesville.  It is also planning  to 
house  the  towns remaining  pharmacy.  The  Jane  Phillips  Hospital 
was already  serving  as a hub  for supporting  medical  facilities  in 
several  other  communities.  Because  of the  upfront  planning,  the 
Jane  Phillips  Clinic  opened  and began  providing  semice  on the 
Monday  following  closure  of the  Caney  Hospital  on Friday. 
The  Medical  Assistance  Facilities:  The  Medical  Assistance  Facilities 
are  part  of a demonstration  program  in Montana  sponsored  by the 
Heath  Care  Financing  Administration,  Department  of Health  and 
Human  Services.  Four  rural  Montana  communities,  Circle,  Elcal@ 
Jordan  and  Teny,  are  participating  in the  Federal  demonstration 
Medical  Assistance  Facility  program.  The  Medical  Assistance 
Facilities  offer  low-intensity  inpatient  care,  24-hour  emergency  care 
and  outpatient  medical  services,  including  basic  laboratory  and x-ray 
services.  All MAFs  are  currently  staffed  by physician  assistants. 
One  community,  Circle,  also has  a physician  on site.  In addition,  all 
of the  MAFs  share  facilities  with nursing  homes,  and  all have 
transfer  protocols  established  with full-semice  hospitals.  See  OIG 
report  number  OEI-04-92-00731  for further  details  on The  Medical 
Assistance  Facility  demonstration  program. 
5
 Each  of the  rural  communities  above  is similar  to many  other  rural  communities,  where  a 
hospital  closed.  ~ehospitals  e~etienced  adowward  spiral  inoccupanq,  la~ing 
revenues  and  rising  costs.  The  communities  feared  that  when  their  hospital  closed,  the 
citizens,  particularly  the  poor  and  elderly,  would  have  unnecessary  difficulty  obtaining 
access  to health  care.  Because  they realized  that  their  community  could  not  support  a 
full service  hospital,  the  communities  found  other  alternatives  for meeting  their  health 
care  needs. 
Cmmmmity  Residents  Must  First  Amept  That  They  Can  Not  Sustain  A Hospital 
Many  community  leaders  and  residents  believe  that  a hospital  is essential  for  access  to 
health  care.  Even  when  a hospital  is under-used,  a community  will often  take  extreme, 
costly measures  to t~  and  save their  hospital.  They  are  proud  of their  hospital  and 
believe  it will keep  medical  professionals  in the  community.  For  example,  despite  great 
cost, Metaline  Falls,  Washington  maintained  its former  hospital  building  for three  years. 
They  hoped  that  eventually  they  could  reopen  the  hospital.  Trying  to keep  its hospital 
open,  Oxford,  Nebraska  passed  two bond  issues totalling  one  half million  dollars.  Both 
communities  are  now faced  with paying  the  debt  plus interest. 
The  first step  in developing  a successful  initiative  for providing  local  health  care  through 
means  other  than  a hospital  is acceptance  that  the  community  can not  sustain  a hospital. 
In some  communities  that  we visited,  this acceptance  started  with one  individual  who 
believed  something  else  could be  done.  In other  communities  a group  of people,  such  as 
the  hospital  board  of directors,  saw that  closure  of their  hospital  was unavoidable. 
Thereafter,  they  provided  the  leadership  in creating  an alternative  way to provide  access 
to health  care  in their  community. 
Community  Teamwork  And  Planning  Are  Critical  For  A Sueeessful  Initiative 
People  in each  of the  communities  we selected  for study had  obtained  cooperation  and 
assistance  from  throughout  the  community  in planning  and  developing  their  successful 
initiative.  Although  State  and  Federal  financial  and  advisory  support  helped  several  of 
the  communities,  local  people  conceived,  designed  and  led  development  of their 
successful  initiative. 
Each  community  determined  their  own health  care  needs  and  worked  cooperatively  in 
designing  and  implementing  a plan  to meet  those  needs.  Some  communities  adopted  a 
very  structured  approach.  For  example,  Metaline  Falls,  Washington  followed  a formal 
process  developed  by the  Area  Health  Education  Center.  First,  the  community  leaders 
accepted  the  closure  of their  hospital  and  agreed  to start  planning  for providing  health 
care  in the  absence  of a hospital.  Second,  they  obtained  a professional  facilitator  to lead 
them  through  a needs  assessment  process.  Third,  the  community  board  designed  an 
alternative  (the  initiative)  for providing  health  care  in the  absence  of a hospital.  Finally, 
the  community  leaders  worked  cooperatively  in implementing  the  initiative.  As new 
health  care  needs  arise  and  additional  resources  are  generated,  the  community  expects  to 
repeat  the  process.  Other  communities  used  a less structured  approach,  but  teamwork 
6  and  planning  were  very important.  For  example  in Caney,  Kansas  the  hospital

administrator  worked  with the  administration  of the  Jane  Phillips  Hospital  in Bartlesville,

Oklahoma  directly  to develop  plans  for the  initiative.

Ignoring  Traditional  Community  Boundaries  May Be Essential  For  A Sueeessful  Initiative

Local  people  in all of the  communities  selected  for our  study had  to change  the

definition  of their  community  in order  to successfully  provide  local  access  to health  care

for their  citizens.  They  had  to redefine  the  community  boundaries  in terms  of who would

be  served  by the  health  care  initiative.  For  example,  Lewisville,  Arkansas  redefined  its

boundaries  for health  care  to include  the  southern  part  of the  county  near  Bradley,

Arkansas.  Likewise,  In Caney,  Kansas  the  local  people  decided  to become  a part  of a

larger  community  for health  care  that  crossed  the  State  boundary  into  Oklahoma.  In

Oxford,  Nebraska  rivalries  which  had  existed  between  small  neighboring  towns were

changed  into  alliances  in order  to develop  a new local  health  care  arrangement.  Finally,

in defining  their  community  for health  care  purposes,  Newton  and  Jasper,  Texas  realized

that  their  football  team  rivalries  did not  have  to extend  to the  health  care  system.  One

initiative  director  said cooperating  with  other  communities  is the  key for a successful

alternative  to hospital  care.  A State  Commissioner  of Health  said they put  aside  their

personal  and  political  differences  and  demonstrated  an all-too-rare  kind  of cooperation.

By deciding  to redefine  their  boundaries,  communities  were  able  to establish  networks  for

successfully  providing  access  to quality  health  care.  The  networks  between  communities

allowed  an individual  county  to  access  a wider  range  of health  care  services  and

resources  than  those  that  were  available  through  the  former  small  hospitals.  To

illustrate,  the  Rural  Health  Clinic in Metaline  Falls,  Washington  could  not  provide  all the

services  needed  such  as home  health,  psychiatric  care,  and  transportation.  By

establishing  a network  with health  care  providers  in neighboring  counties,  Metaline  Falls

was able  to obtain  those  services.  Likewise,  citizens  of the  neighboring  counties  can

benefit  from  services  offered  in Metaline  Falls.

Community  Support  Is Vital  To  Maintaining  A Successful  Health  Care  Initiative

No initiative  could  be  successful  if community  residents  chose  not  to use  the  services

offered.  Although  record  keeping  systems were  not  comparable,  all initiatives  appeared

to be  prospering  and  growing  in the  communities  we studied.  For  example,  in Metaline

Falls,  Washington  the  average  number  of patients  per  month  at the  Rural  Health  Clinic

doubled  in the  first two months  after  the  physician  arrived.  In Oxford,  Nebraska  1100

new patients  have  been  added  since the  initiative  opened  in January  of 1990.  Also,  a

new doctor  is presently  being  recruited.  A physician  assistant  at a Medical  Assistance

Facility  in Montana  said,  the community  has been  very supportive.  They  feel  confident

in the  care  we provide.  If they feel  theyd get  second-rate  care,  theyre  going  to drive

those  50 to 80 miles to another  source  of care.

The  communities  also support  their  initiatives  in other  ways,  For  example,  some

communities  support  the  initiative  with local  tax dollars.  Others  had  fund-raising  events

7  to support  their  health  care  initiative.  All communities  we studied  tried  to win back 
residents  who  did not  use  the  local  hospital  before  it closed  or obtained  service  of other 
communities  after  the  hospital  closed.  They  worked  hard  to communicate  a message  that 
the  new health  care  facility was reliable,  and  that  it was a high  quality  source  of health 
care.  They  published  stories  about  the  new facilities,  the  physicians,  and  other  health 
care  providers  working  at the  initiatives.  The  initiative  in Metaline  Falls,  Washington  for 
example,  publishes  a monthly  newsletter  to inform  the  community  residents  of initiative 
activities.  One  registered  nurse  said,  people  arent  going to let  it (the  initiative)  stop. 
They  saw the  problem  and  want  to help.  Local  newspapers  also helped  support  the 
community  initiatives  by publishing  articles. 
SUCCESSFUL  INITIATIVES  CAN  IMPROVE  DELIVERY  OF  HEALTH  CARE 
SERVICES 
Initiatives  Increased  The  Supply  Of Health  Care  Professionals 
All of the  communities  that  developed  a health  care  initiative  had  lost physicians  and 
other  health  care  professionals.  Such losses  clearly  contributed  to the  eventual  close  of 
rural  community  hospitals.  Therefore,  a major  objective  of most  of the  community 
initiatives  we examined  was to recruit  and  retain  health  care  professionals.  For  example, 
community  leaders  in Lewisville,  Arkansas  worked  with the  Area  Health  Education 
Council  to establish  a residency  program  for physicians  at the  clinic.  The  work  at the 
clinic served  to meet  physician  residency  requirements.  The  residency  program  is 
expected  to provide  a constant  supply  of physicians  in the  community,  while  allowing 
medical  residents  valuable  experience  in providing  rural  health  care.  The  Caney,  Kansas 
community  was able  to recruit  a new doctor  because  of an initiative  arrangement  which 
allowed  staff privileges  for physicians  at the  Bartlesville,  Oklahoma  hospital. 
The  supply  of health  care  professional  was also increased  through  community  networking 
for health  care  services.  To illustrate,  the  network  among  communities  broadened  the 
base  of doctors  for  consultation.  It also broadened  the  base  of health  professionals  for 
back-up.  For  example,  one  physician  in a community  did not  have  to be  on call  100 
percent  of the  time.  The  community  could  spread  the  on-call  duty to all physicians  in the 
network.  One  initiative  director  said that  one of the  biggest  benefits  of the  consortium 
is having  someone  else  to call on for help  not  only with health  care,  but  also with 
computer  problems.  This  arrangement  allowed  physicians  and  other  health  care 
professionals  some  free  time  to pursue  their  own interest.  Some  physicians  and  health 
care  professionals  used  that  time  to upgrade  their  skills.  For  example,  two directors  of 
the  nursing  staff told  us their  staff have  upgraded  their  skills to respond  to the  wide 
variety  of services  needed  in rural  communities. 
Health  Care  Servkxs  Were  Tailored  To  Cmmmnity  Needs 
Local  people  tailored  their  initiatives  to meet  their  community  needs.  They  chose  what 
services  the  community  could  provide  and what  services  would  be  obtained  outside  the 
community.  For  example,  while  all communities  wanted  physicians  for general  medical 
8  practice,  they  could  notalways  afford  them.  Instead,  several  employed  physician

assistants.  Likewise,  all communities  wanted  to provide  emergency  care.  To  do so, some

used  an emergency  room  of a former  hospital,  but  other  communities  established

arrangements  with nearby  community  hospitals  and  referred  patients  as needed.  Further,

all communities  established  agreements  for air and  road  ambulance  services  to transport

patients  to appropriate  emergency  facilities.

One  community,  Metaline  Falls,  Washington  established  a 911 system.  Through  the  911

system,  the  community  can provide  24-hour-a-day  emergency  selvice.  The  911

monitoring  equipment  is located  at the  clinic during  the  normal  work  day, and  volunteers

take  it home  with  them  at night  to monitor  emergency  calls.

Unlike  hospital  requirements  which  dictate  how resources  will be  used,  community  health

care  initiatives  are  flexible.  They  allow any services  needed  by a community  to be  added

if resources  are  available,  and  to be  eliminated  when  the  services  are  no longer  needed.

For  example,  the  Newton,  Texas  community  initiative  included  using resources  provided

by the  school  system  to offer vocational  education  and  day care  services.  Several

communities,  including  Ltnvisville, Arkansas,  Circle  and  Ekalaka,  Montana,  Newton,

Texas,  Metaline  Falls,  Washington  and  Oxford,  Nebraska,  added  non-emergency

transportation  services  to their  initiative.  The  local  hospital  could  not  have  provided  such

services  as easily as the  community  added  them.  Several  community  initiatives  included

using the  former  hospital  kitchen  to prepare  meals  for a meals-on-wheels  program  for

senior  citizens.  Finally,  each  of the  Medical  Assistance  Facilities  in Montana  offered  a

dental  clinic one  day a week.

Such  flexibility  enables  community  initiatives  to continue  changing  as needed  to meet

community  health  care  needs.  Oxford,  Nebraska,  for example,  is currently  planning  an

expansion  of its health  care  services.  Likewise,  the  Lewisville,  Arkansas  community

expects  to add  another  wing to its facility and  to add  county  social  services,  such as public

assistance  offices.  Also,  the  Newton,  Texas  community  is planning  to include  another

community,  Kirbyville,  Texas,  into  its network  initiative  for health  care.  The  hospital  in

Kirbyville,  a small  rural  town,  closed  in 1988.  After  observing  the  effectiveness  of

Medical  Assistance  Facilities  in four  rural  Montana  communities,  Culbertson,  Montana

recently  converted  its small hospital  to a Medical  Assistance  Facility.  One  board

chairman  of a rural  community  initiative  told  us, we used  to talk  survival.  Now we talk

about  expanding  services  and  updating  equipment.

Successful  Initiatives  Eliminated  Duplicative  And  Underused  Services

By tailoring  health  care  sexvices to meet  their  needs,  the  six initiatives  we analyzed

eliminated  services  that  local  people  were  not  using, and  those  that  were  available  to the

community  from  other  sources.  All initiatives  except  MAFs  eliminated  inpatient  care.

The  MAFs  we visited  had  eliminated  surgical  care.  Residents  who need  this type  of care

are  transferred  from  the  initiative  to a hospital.

9
 The  community  initiative  designers  deleted  services  that  were  once  provided  by the 
former  hospital,  but  not  used  by the  community.  For  example,  in Lewisville,  Arkansas 
the  former  hospital  provided  pharmacy  services.  In developing  its initiative  for health 
care  after  the  hospital  closed,  the  community  did not  include  pharmacy  services.  Instead, 
the  community  issued  vouchers  for patients  to use  at private  pharmacies  in town where 
adequate  selvice  was available.  Likewise,  in Caney,  Kansas  before  the  hospital  closed,  it 
operated  seldom-used  and  outdated  laboratory  and x-ray services.  Both  services  were 
eliminated  when  Caney  developed  its initiative  for providing  access  to health  care  after 
its hospital  closed.  They  dropped  the  services  because  they  could  get  the  same  services 
at better  quality  from  the  Bartlesville,  Oklahoma  hospital  which was only about  18 miles 
away. 
STATE  ASSISTANCE  IS CRITICAL  FOR  SUCCESSFUL  COMMUNITY 
INITIATIVES 
Support  from  State  governments  has been  vital  to the  development  and  operations  of 
some  community  initiatives.  For  example,  State  health  departments  and  special  task 
forces  in Montana,  Washington  and  Arkansas  have  supported  local  community  initiatives 
through  technical  assistance  and  grants. 
Further,  some  community  initiatives  required  State  legislation.  Montana,  for  example, 
had  to change  its State  law to expand  the  role  of non-physician  health  care  providers 
before  communities  could  implement  the  Medical  Assistance  Facilities  program.  The 
State  of Kansas  revised  its policies  on Medicaid  reimbursement  to allow the  partnership 
between  Caney,  Kansas  and  the  Bartlesville,  Oklahoma  hospital.  Likewise,  as part  of its 
managed  care  program,  Washington  State  policy would  have  caused  Metaline  Falls, 
Washington  Medicaid  patients  to be  sent  to health  care  providers  in another  community. 
However,  the  policy was changed  and  the  patients  are  selved  through  the  Metaline  Falls 
health  care  initiative. 
LOCALCmmmwmm  RELIED  ON EXISTING  FEDERAL  PROGRAMS  TO 
DEVELOP  SUCCESSFUL  INITIATIVES 
As is true  of virtually  all health  care  programs,  the  six initiatives  we examined  relied  on 
existing  Federal  programs  to a large  extent.  Of particular  significance,  none  of the 
community  initiatives  were  funded  through  new Federal  programs.  To  illustrate,  Newton, 
Texas,  Ekalaka,  Montana  and  Oxford,  Nebraska  received  Medicare  and  Medicaid 
reimbursements  as part  of the  existing  Rural  Health  Clinic program.  The  network  of 
clinics which  includes  Lewisville,  Arkansas,  uses existing  funds  available  under  the 
Community  Health  Center  program. 
Other  Federal  health  programs  were  used  by several  communities  to help  fund  special 
projects.  For  example,  Ekalaka,  Montana  used  a Rural  Transition  Grant  to design  and 
plan  a satellite  clinic in the  south  end  of the  county.  For  the  Medical  Assistance 
Facilities  program  in Montana,  the  Health  Care  Financing  Administration  provided 
funding  and  approved  waivers  under  a demonstration  program. 
10  CONCLUSION

Rural  communities  concerned  about  access  to health  care  can  find other  ways to meet 
their  health  care  needs  without  a hospital.  Local  residents  who  accept  the  notion  of 
health  care  without  a hospital  can  empower  themselves  to design  and  implement  a strong 
health  care  system  for their  communities.  The  success  of local  health  care  initiatives 
depends  heavily  on creative  use  of all available  resources  by community  leaders.  A 
community  must  first  obtain  strong  local  support  and  then  seek  available  State  and 
Federal  support. 
This  desire  of local  communities  to take  responsibility  for their  own health  care  needs 
was recently  endorsed  by Secreta~  Shalala.  She  expressed  her  intent  to help  rural 
communities  empower  themselves  to meet  their  own health  care  needs. 
We believe  many  other  rural  communities  could  follow the  same  processes  described  in 
our  report  to develop  an initiative  to meet  health  care  needs. 
11
 APPENDIX  A

DEXRIPTION  OF  COMMUNITY  INITIATIVES 
Newton,  Texas:  Newton  Education  Center 
Lewisville,  Arkansas:  Rural  Health  Clinic 
Metaline  Falls,  Washington:	 North  Penal Oreille  Health 
Services  Consortium 
Oxford,  Nebraska:  Oxford  Medical  Center 
Caney,  Kansas:	 Jane  Phillips  Community 
Health  Clinic 
Circle,  Ekalaka,  Jordan,

and  Terry,  Montana:  Medical  Assistance  Facilities

A-1
 Newton  Education  Center 
Newto~  Texas 
What is the initiative? 
The  Newton  Education  Center  offers  a variety  of services,  including  a rural  health  clinic, 
public  health  services,  educational  programs,  and  community  services  at the  former 
community  hospital. 
What was the hospital like before it closed? 
The  occupancy  rates  at the  Newton  County  Hospital  had  been  steadily  declining  before 
its closure  in 1989.  The  hospital  had  been  built  eighteen  years  earlier,  under  a Hill-
Burton  loan.  Virtually  all physicians  in the  community  had  ceased  practicing  at the 
hospital  and  services  were  seriously  reduced.  Other  doctors  in the  Newton  area  did not 
refer  patients  to the  hospital.  Most  people  traveled  to other  hospitals  in Jasper,  12 miles 
away, or in Beaumont,  60 miles  away.  County  funds  supported  the  hospital,  but  could 
not  continue  indefinitely.  The  hospital  closed  when  the  last  doctor  working  at  the 
hospital  resigned  and  ceased  practicing  in the  community. 
How  was the successji.d initiative developed? 
When  the  hospital  closed  in 1989 the  county  was faced  with nearly  a half million  dollar 
debt  and  penalties  owed  for defaulting  on the  Hill-Burton  loan.  A new  county judge 
searched  for  a way for the  county  to fulfill an indigent  care  commitment.  A vocational 
teacher,  who was also a former  hospital  board  member,  was searching  for a way for the 
community  to provide  a program  to help  teen  mothers  stay in school  and  learn  parenting 
skills.  Grant  money  for  a teen  parent  program  was available  from  the  State,  but  there 
was no space  to operate  the  program.  The  teacher  obtained  a State  grant  and  part  of 
the  former  hospital  was renovated  for classrooms  and  a day care  center.  As this was 
happening,  the  not-for-profit  hospital  in Jasper  hired  a new administrator  who  had  run 
satellite  rural  health  clinics before.  The  former  hospital  board  in Newton  and  the  former 
board  of another  closed  hospital  in Kirbyville  approached  the  Jasper  hospital 
administrator  about  opening  rural  health  clinics (RHCS)  in their  former  hospitals.  The 
hospital  in Newton  was county  property,  and  the  county judge  obtained  agreement  to 
convert  part  of the  former  hospital  building  into  a RHC.  The  RHC  opened  as part  of 
the  Newton  Education  Center  in February  1992.  The  county  health  district  needed  a 
larger  space  and  also moved  into  part  of the  former  hospital. 
What services does the initiative provide? 
The  Newton  Education  Center  operates  a RHC,  public  health  services,  transportation

services,  and  educational  services.  The  RHC  provides  basic  primary  care,  normal

doctors  office  services  from  8:00 am to 5:00 pm, five days a week.  As part  of the  RHC

basic  lab  and  x-ray services  are  available.  A doctor  from  Jasper  Memorial  Hospital  staffs

the  clinic.  The  Newton  Education  Center  provides  public  health  semices,  such  as

A-2  immunizations,  Women  and  Infant  Care  (WIC)  services,  and well-child  care.  As part  of 
the  health  services  provided  by the  RHC  and  public  health  offices,  people  needing 
hospitalization  or more  specialized  care  are  referred  to Jasper  Memorial  Hospital  or 
other  hospitals  in Beaumont,  Houston  or Galveston. 
The  Newton  Education  Center  provides  limited  van  service  to transport  people  in need 
of care  to the  RHC,  and  to affiliated  community  health  clinic and  referral  hospitals. 
The  county  school  system  funds  many  educational  programs  operated  at the  Newton 
Education  Center.  The  program  for teen  mothers  opened  in August  1990.  It provides  a 
place  for pregnant  students  to continue  high school,  learn  parenting  skills, and  train  for 
careers  in child care.  A day care  center  that  is open  to the  public  provides  a needed 
community  service.  Newton  Education  Center  also offers  other  vocational  programs. 
For  example,  a food  education  program  is offered  in the  former  hospital  kitchen.  The 
food  education  program  provides  training  for  careers  in food  service.  It also provides 
meals  to the  elderly  that  are  distributed  through  a meals-on-wheels  program.  The  Center 
built  a horticultural  education  center  in the  field  adjacent  to the  center.  It provides 
training  while  growing  food  for meals  programs.  The  horticulture  center  is partially 
funded  through  a contract  to provide  plant  care  at county  offices.  Newton  Education 
Center  also provides  special  education  for students  with learning  disabilities.  The  Center 
plans  to use  former  hospital  equipment  for training  material  and  add  health  service 
career  programs. 
How has the initiative ajfected  community  health care needs? 
Many  people  who  had  to travel  to get  care  in other  places  are  now able  to get  care 
locally.  Newton  residents  and  patients  from  a 50-mile  radius  come  to the  busy clinic. 
Since  the  clinic physician  is on staff at  a hospital,  referral  for care  is facilitated. 
Additional  benefits  result  from  offering  a range  of services  in one  location  like  the 
Newton  Education  Center.  For  example,  teen  mothers  get  prenatal  care,  health 
education,  and  WIC  services  while  participating  in a stay-in-school  program.  Their 
children,  and  other  children  in a day care  center,  have  access  to medical  professionals 
whenever  necessary.  A food  setice  program  provides  a nutritional  diet  directly  to the 
elderly  in the  community.  Secondly  it teaches  students  about  the  importance  of 
nutritionally  balanced  diets.  The  horticulture  program  supplies  some  fresh  foods  for 
better  nutrition,  and  education  on how agriculture  processes  can  affect  health. 
The  Newton  Education  Center,  as part  of the  health  care  network  with Jasper  Memorial 
Hospital,  refers  many  patients  to the  hospital.  As the  patient  base  expands  at Jasper 
Memorial  Hospital,  the  hospital  is able  to add  staff and  state-of-the-art  medical 
equipment.  This  results  in the  community  of Newton  having  access  to a more 
sophisticated  hospital  just  12 miles  away. 
Contact:  James  Singletaxy,  Newton  Education  Center  (409/379-2522),  or Ernie 
Domenech,  Administrator,  Jasper  Memorial  Hospital  (409/384-5461). 
A-3  Rural  Health  Clinic 
Lewisville,  Arkansas 
What h the initiative? 
The  Rural  Health  Clinic is a community  health  clinic and  the  local  health  department 
sharing  the  former  hospital  building.  The  clinic serves  primarily  Lafayette  County,  an 
area  of about  10,000 people.  A satellite  clinic is located  in the  southern  part  of the 
county  in Bradley.  The  board  for the  initiative  has plans  to include  county  social  services 
into  the  building  to create  a one-stop  shopping  center. 
What was the hospital like before it closed? 
For  several  years  before  its closure  in 1987, Lafayette  Memorial  Hospital  had  lost 
physicians  and  was forced  to reduce  semices.  The  hospital  had  downsized,  but  still had 
an occupancy  of only eleven  percent.  Several  larger  hospitals  that  are  located  about  25 
miles  away in surrounding  counties  offered  more  specialized  care.  Most  people  who 
were  able  to travel  to any of these  other  hospitals  did so, leaving  Lafayette  Memorial 
Hospital  serving  primarily  elderly  and  poor  patients.  Despite  low use,  community  leaders 
desired  to keep  the  hospital  open.  The  county  levied  a one  percent  sales  tax to support 
the  hospital,  and  the  hospital  board  developed  plans  to convert  part  of the  hospital  into  a 
rehabilitation  facility.  The  plans  failed  and  the  hospital  closed.  After  the  hospital  closed, 
all but  one  physician  ceased  practicing  in the  county. 
How was the initiative developed? 
Prior  to closure,  a group  of concerned  community  leaders  formed  a board  to plan  for 
county  health  care  needs.  They  sponsored  a needs  assessment  which  showed  that  the 
county  was one  of the  poorest  and  most  underserved  in Arkansas. 
At the  same  time,  the  State  Health  Department  formed  a State  Committee  on Indigent 
Health  Care  to give a rare  surplus  of Medicaid  money  as grants  to needy  communities. 
The  Lewisville  board  asked  State  health  officials for a grant  and  technical  assistance  in 
planning.  Together,  they  developed  a plan  to combine  a health  care  center  with  a social 
services  center  to create  a one-stop-shopping  center  to provide  care  for the  poor.  The 
board  received  a State  grant  of over  $600,000 to renovate  and  staff  a medical  clinic in 
the  former  hospital  facility. 
The  Rural  Health  Clinic needed  a constant  supply  of operating  funds.  Several  nearby 
counties  belonged  to a network  of community  health  clinics, called  Cabun.  The  Cabun 
network  participates  in the  Federal  Community  Health  Clinic  (CHC)  program.  To 
obtain  CHC  funds  the  clinic at L.ewisville joined  the  network.  Cabun  handles  the 
administration,  quality  assurance  and  supervisory  work  involved  in running  the  clinic. 
A-4
 The  State-run  health  department  which had  offices located  in Lewisville  had  outgrown  its

old offices  and  needed  a larger  facility.  The  State  Health  Department  area

administrator,  working  with the  community,  obtained  a State  grant  to renovate  part  of

the  hospital  building  for use  as State  Health  Department  offices.

WL$atservices does the initiative provtie? 
The  Rural  Health  Clinic provides  basic  primary  care,  normal  doctors  office  services  from 
8:00 am  to 5:00 pm  for five days a week.  Basic lab  and  x-ray services  are  available. 
Public  health  nurses  at the  Clinic also provide  services  such  as immunizations  and  well-
child care.  A visiting  pediatric  nurse  and  nutritionist  supplement  care.  The  Clinic 
coordinates  home  health  semices  that  are  provided  through  the  State  health  department. 
The  Clinic provides  van  service  to bring  people  without  transportation  to the  Clinic or 
transfer  them  to their  choice  of hospitals.  The  Clinic will include  county  social  services 
when  a new wing is built  onto  the  former  hospital  building. 
The  Rural  Health  Clinic  also staffs and  administers  a satellite  clinic, which  is located  in 
the  southern  part  of the  county  in Bradley,  Arkansas.  Several  years  ago,  a large  hospital 
in Louisiana  donated  an equipped  trailer  to be  used  as a clinic in the  very undersexed 
Bradley  area.  Now all services  provided  in Lavisville  are  also provided  on a part-time 
basis  in Bradley.  The  high volume  of patients  has  outgrown  the  trailer,  and  needs  to be 
expanded.  The  Lewisville  board  is applying  for a State  grant  to build  a permanent 
facility. 
Currently,  four  doctors,  including  one  pediatrician,  work  part-time  at the  Clinic.  The 
doctors  are  employees  of Cabun,  and  all travel  into  the  community  to provide  care.  The 
Clinic board  in coordination  with Area  Health  Education  Council  is planning  to employ  a 
full-time  physician-educator  from  the  University  of Arkansas  medical  school  to staff the 
clinic.  The  physician  would  then  train  residents  in rural  health  care. 
How has the initiative aflected  community  health care needs? 
For  the  very poor,  the  Rural  Health  Clinic offered  them  an opportunity  to receive

needed  non-emergency  health  care  locally.  The  Clinic provides  reduced  cost health  care,

enabling  access  to poor  people  who would  otherwise  not  be  able  to pay for private  health

care.  Since  care  is locally provided,  children,  elderly  and  people  without  transportation

no longer  have  to travel  or rely on emergency  ambulance  services  to obtain  care.

Once  the  one-stop  shopping  center  is complete,  people  in Lewisville  will have  access  to a

full-range  of social  and  health  services.  One  short  application  form  will make  services

available  to patients  with  fewer  hassles  to clients  and  enable  providers  to better

coordinate  services.

Contact:  Charles  McGrew,  Director,  Section  of Health  Facility  Services  and  Systems,

Arkansas  Department  of Health  (501/661-2194).

A-5
 North  Penal Oreille  Health  SeMces  Consortium 
Metaline  F- Washington 
W%at is the initiative? 
North  Penal Oreille  Health  Services  Consortium  is a network  of volunteer  and 
professional  primary  health  care  providers  from  in and  around  North  Penal Oreille 
county. 
U%at was the hospital like before it closed? 
Mt. Linton  hospital  in Metaline  Falls,  Washington  closed  in 1988 when  the  only physician 
moved  out  of town.  It had  23 beds  with  an occupancy  rate  of 9.25 percent.  Most 
residents  received  hospital  care  either  by driving  100 miles  to Spokane,  or 50 miles  to 
Newport.  Upon  closing, the  hospital  district  became  liable  for unemployment  insurance 
for the  former  employees  and  ran  up a debt  of $77,000, which  still exists. 
The  hospital  was run  by three  locally elected  Hospital  Board  commissioners.  The  Board 
receives  a portion  of the  property  taxes  -- approximately  $9,000 per  year  in this poor 
rural  area.  The  Commissioners  used  tax revenue  and  donations  from  local  companies  to 
pay for insurance  and  heat  to keep  the  building  in good  enough  condition  to reopen.  In 
1992, four  years  after  closure,  the  Hospital  Board  acknowledged  that  the  hospital  will not 
reopen.  They  surplused  the  building  and  are  accepting  bids from  potential  buyers. 
How  was the successjid  initiative developed? 
Community  members  formed  a Committee  after  the  hospital  closed.  Two  Committee 
members  attended  a rural  health  conference  and  learned  of a State  grant  program 
(Rural  Health  Care  Systems  Development)  and  the  community  encourage  program. 
The  pastor  of a local  church  completed  the  grant  application  and  the  community 
subsequently  received  $57,000 from  the  State.  The  local  Hospital  Association  paid  for 
one  Committee  member  to be  trained  to become  a community  encourage,  which  is 
basically  a community  organizer.  The  Hospital  Association  used  some  of the  grant 
money  to follow  a planning  process  developed  by Eastern  Washington  Office  of Rural 
Health,  Area  Health  Education  Center  (AHEC),  and  Washington  State  University.  The 
planning  process  entails  several  steps.  First,  AHEC  surveyed  residents  and  analyzed 
community  needs  and  resources.  Then,  the  community  convened  a meeting  to arrive  at 
consensus  on what  health  services  they wanted  and  would  support.  The  community 
decided  its main  goals were  to get  a physician  and  to obtain  24 hour  emergency  care. 
AHEC  told  them  about  a Federal  Office  of Rural  Health  Policy Outreach  grant.  The 
same  pastor  completed  an application  and  the  community  subsequently  received  $267,000 
for the  first year  of a 3-year  grant.  By following  the  planning  process,  developed  by 
AHEC,  the  community  established  the  basic  structure  of linkages  among  providers  that 
enabled  them  to meet  the  requirements  to obtain  the  Federal  grant.  The  Hospital 
Association,  after  years  of efforts,  successfully  recruited  a physician  in July  1992. 
A-6
 W4at services does the initiative provide? 
The  Consortium  provides  primary  care  to the  community  through  a clinic, staffed  with a 
physician,  one  physician  assistant,  and  three  part-time  health  care  assistants  who  are 
licensed  by the  State.  ~eclinic  isopen5days  aweekand  thephysician  protides  after 
hours  coverage  for life threatening  emergencies.  The  clinic has  a referral  agreement  with 
a group  of physicians  50 miles  away for specialty  services.  The  Consortium  also employs 
a community  health  worker  who  assesses  client  health  and  human  service  needs  and 
makes  referrals  using the  Consortiums  health  resource  inventory  and  an 800 line.  A 
nearby  rural  health  clinic provider  is helping  the  clinic set up  a pharmacy. 
The  Consortium  also  supports  emergency  care.  They  have  a volunteer  911 system, 
staffed  by the  clinic during  the  work  day and  five volunteer  households  on rotating  16-
hour  shifts at all other  times.  The  community  also has  an  all volunteer  first response  unit 
with EMTs,  Advanced  Life Support  (ALS)  and  High  Angle  Rescue  and  Dive  Team.  In 
addition,  they  have  an all volunteer  ambulance  service  staffed  with EMT  and  ALS 
personnel.  The  Consortium  paid  for EMT  training  and  upgrading  ambulance  equipment. 
The  Consortium  has  an  agreement  with the  nearest  hospital  in Newport  to provide 
telephone  consultation  for  (1) 911 operators,  (2) emergency  room  care,  and  (3) inpatient 
care.  A nearby  health  care  provider  has  agreed  to expand  home  health  services  to serve 
the  Metaline  Falls  community.  The  county  mental  health  department  will hire  two 
psychiatric  nurse  practitioners  to serve  four  counties  in the  area.  A third  organization, 
Rural  Resources,  used  Consortium  funds  to help  buy and  operate  a handicapped  van  to 
provide  transportation.  The  Consortium  has a continuing  relationship  with AHEC  for 
planning  and  evaluation. 
How has the initiative aflected  community  health care needs? 
Residents  are  very happy  to finally have  a physician.  Part  of the  Consortium  grant  of 
$267,000  pays the  physicians  salary  for now since the  clinics income  is not yet  sufficient 
to support  him.  In addition,  the  consortium  provides  for more  and  different  types  of 
care  beyond  what  the  physician  provides.  The  Consortium  has  enabled  better  emergency 
care  and  more  primary  care,  and  it provides  some  types  of care  that  were  previously 
unavailable,  such  as home  health  care  and  mental  health  care.  Although  many  residents 
still would  like  a place  where  people  could  stay overnight  for medical  observation,  such 
as a Medical  Assistance  Facility,  many  feel  the  Consortium  is a satisfactory  adaptation  to 
not  having  a hospital.  The  Consortium  anticipates  that  by the  time  the  grant  funds  are 
exhausted,  the  clinic will have  regained  enough  patients  to be  self-supporting. 
Contact:  Kathy  Grass,  Director,  North  Penal Oreille  Health  Services  Consortium,  Ione, 
Washington  (509/442-3514). 
A-7
 Oxford  Medical  Center 
Oxfor@ Nebraska 
JWtat k the initiative? 
The  initiative  is a primaxy  care  clinic staffed  by a physician  assistant  and  owned  by a 
general  acute  care  hospital  in Cambridge,  Nebraska,  30 miles  away.  The  clinic is housed 
in part  of the  closed  hospital  building.  It is one  of five satellite  clinics operated  by the 
Cambridge  hospital.  The  Oxford  clinic hours  are  9:00 am  to noon  and  1:00 to 5:00 pm 
Monday  through  Friday,  except  Wednesday  afternoons,  when  it is closed.  It is a licensed 
independently  certified  provider-based  rural  health  clinic. 
What was the hospital like before it closed? 
The  closed  hospital,  Fritzer  Memorial  Hospital  and  Health  Center,  was built  in the 
1920s.  In  1987 the  Fritzer  Foundation  gave  the  hospital  to the  city of Oxford.  During 
the  1980s the  financial  condition  of the  hospital  deteriorated  due  to problems  of 
physician  availability  and  a declining  occupancy. 
During  approximately  the  last  decade  the  hospital  was open,  it was staffed  by one 
medical  doctor  (MD),  except  for very brief  periods  when  a second  MD  was employed. 
One  physician  assistant  was also employed  the  last  two years,  1988 and  1989.  The  sole 
MD  had  gradually  narrowed  her  practice  to geriatrics,  so younger  patients  seeking 
OB/GYN  and/or  pediatric  services  had  to go elsewhere.  Some  community  members 
assert  that  people  had  begun  to migrate  to Holdrege  several  decades  earlier.  Holdrege  is 
21 miles  away, and  it offered  a wider  variety  of both  shopping  facilities  and  medical 
services. 
In  1988 the  one  MD  at the  hospital  was sanctioned  by the  Peer  Review  Organization 
(PRO),  and  could  no longer  seine  Medicare  and  Medicaid  patients.  Since  this sanction 
eliminated  most  of her  patients,  the  physician  tendered  her  resignation,  effective  January 
1, 1990.  A temporary  physician,  who was recruited  after  the  long-term  physician  left,  and 
the  physician  assistant  staffed  the  hospital  until  December  8, 1989 when  inpatient  services 
were  terminated. 
People  in the  community  exerted  extraordinary  efforts  to save the  hospital.  They  passed 
two bond  issues  totaling  over  a half million  dollars,  developed  a system  of Keno (a legal 
form  of gambling),  and  held  auctions  and  bake  sales  to raise  funds.  The  unabated 
decline  in occupancy,  however,  made  it impossible  to keep  the  hospital  open. 
How  was the successji.d initiative developed? 
Several  years  prior  to the  hospital  closure  the  CEO  from  the  hospital  in Cambridge  had 
begun  to foster  relationships  with people  in Oxford.  He  knew  the  Oxford  hospital  was 
having  a difficult  time,  and  wanted  the  people  in Oxford  to know  that  the  Cambridge 
hospital  was willing to try to help,  if they wanted  them  to do so.  Late  in 1989 when  the 
A-8  Board  at  Oxford  saw that  closure  was unavoidable,  they  approached  several  nearby 
hospitals  toaskwhat  each  could  dotohelp  maintain  health  care.  Only the  hospital  in 
Cambridge  responded  with  anoffer  toopen  aclinic,  initiallyon  a90-day  trial  basis. 
Three  physicians  from  the  Cambridge  hospital  provided  health  care  from  the  time  the 
hospital  closed,  until  the  clinic opened  on Januaxy3,  1990, and  until  afull-time  physician 
assistant  was hired  in July  1990.  Those  three  physicians  each  still work  at the  clinic one 
afternoon  a week. 
The  newspaper  in Oxford  supported  the  transition  of the  former  hospital  to a primary 
care  clinic by publishing  articles  about  the  new clinic.  Medical  and  non-medical  staff 
from  the  Cambridge  hospital  spoke  to groups  at meetings  in Oxford  to express  their 
commitment  to the  clinic.  Influential  citizens  in Oxford  openly  supported  the  clinic and 
encouraged  people  to use it. 
What services does the initiative provide? 
The  clinic offers  general  family practice  services.  Specifically  it offers  prenatal  care, 
physician  assistant  care,  laboratory  and  x-ray services,  urgent  care  during  business  hours 
and  on an  on-call  basis  after  hours,  emergency  transportation  services  through  a 
volunteer  EMT  service  and  helicopter  transport  to nearby  hospitals,  well-child  services, 
family planning  services,  vision  and  hearing  screening  for school  and  employment, 
nutrition  education,  EKG,  health  education  sefices,  and  a pharmacy. 
How  has the initiative affected community  health care needs? 
When  the  hospital  closed  the  community  was generally  in a state  of despair.  Now the 
community  in general  is happy  and  appreciative  of what  they  have.  Many  believe  the 
clinic health  care  is far  more  reliable  and  varied  than  that  previously  offered  by the 
former  hospital.  The  clinic has  preserved  a system  of primary  care  and  emergency  care 
in the  community,  made  Medicare- and  Medicaid-reimbursed  services  available  again, 
brought  people  back  to the  business  section  of town,  preserved  professional  and  technical 
level jobs,  saved  the  only pharmacy  in town  from  closing,  and  made  access  to care  better. 
The  addition  of a handibus  which  runs between  Oxford  and  Cambridge  on Tuesdays 
has improved  access  to hospital  services  -- particularly  for the  elderly  and  the  poor.  The 
initiative  has  helped  to erode  a strong  sense  of rivalry between  the  two towns  and 
enlarged  the  concept  of what  a community  is. 
The  Cambridge  hospital  continues  efforts  to recruit  a full-time  medical  doctor  to staff the 
Oxford  clinic and  hopes  to broaden  their  services  further  with the  addition  of specialists. 
Contact:  Jim  Naeve,  CEO,  Cambridge  Memorial  Hospital  and  Medical  Center, 
Cambridge,  Nebraska  (308/697-3329). 
A-9
 Jane  Phillips  Community  Health  Clinic 
Caney,  Kansas 
W%atis the initiative? 
In Caney,  Kansas  (population  2,300) the  former  acute  care  hospital  is now a doctors 
clinic and  a  10 bed  long-term  care  facility.  The  clinic is a satellite  of a large  regional 
health  center,  Jane  Phillips  Episcopal  Memorial  Medical  Center  in Bartlesville, 
Oklahoma,  just  18 miles  away. 
W+at was the hospital like before it closed? 
The  hospital  was staffed  to provide  24-bed  in-patient  acute  care,  24-hour  emergency  care, 
x-ray and  clinical  lab  services. 
Caney  hospital  served  a community  with a large  number  of elderly  people.  In the years 
preceding  closure,  the  Medicare  use rate  ranged  between  40 and  60 percent,  once  going 
as high  as 78 percent. 
Fewpeople  were  using the  hospital.  Ithadan  occupancy  rate  of about  25 percent  prior 
to closing.  From  1981to  1988 annual  patient  admissions  declined  from  521 to 217. 
During  the  last  two years  of its existence  as an acute  care  facility, the  Caney  hospital  was 
dependent  on fundraisers  and  private  donations  to  continue  operations.  As one  board 
member  of the  former  hospital  said, You cant tax enough  to keep  a rural  hospital  in 
business. 
How  was the successful initiative developed? 
The  vision  and  initial  groundwork  for the  initiative  was provided  by the  administrator  of 
the  former  hospital.  Many  communities  undertake  ill-advised  yet understandable 
refinancing  measures  in order  to ensure  their  hospitals  stay open.  However,  Caney, 
having  struggled  to keep  their  hospital  afloat,  was primed  to accept  another  means  of 
care.  The  administrator  responded  to evidence  of impending  financial  insolvency  by 
identi&ing  options,  which  included  recognizing  health  care  system  support  being  provided 
by the  Jane  Phillips  Episcopal  Memorial  Medical  Center  in Bartlesville,  Oklahoma. 
In fact,  the  Jane  Phillips  story is the  real  story here.  It was already  providing  a variety  of 
support  semices  as a hub  for several  other  formerly  independent  community  health  care 
facilities.  Included  in these  are  hospitals  in Pawhuska,  Oklahoma  and  Sedan,  Kansas.  A 
third  hospital  in Nowata,  Oklahoma  presently  serves  as a drug  and  alcohol  rehabilitation 
facility.  In addition,  two other  satellite  physician  clinics in Barnsdahl  and  Ramona, 
Oklahoma  complete  the  regional  picture.  In each  case  the  facility facing  closure 
approached  Phillips  Hospital  for support  ranging  from  management  services  to direct 
financial  aid.  In each  case,  Phillips  responded  by providing  the  appropriate  level  of 
support  to maintain  the  health  care  service  or some  altered  type  of service. 
A-10  While  this is not  a formal  EACH/RPCH  demonstration,  the  model  which  Jane  phillips 
pioneered  in the  region  is very similar.  The  major  hospital  at the  hub  is surrounded  by a 
number  of other  limited  health  programs.  One  important  difference  is that  in the  Caney 
instance  the  health  community  served  crosses  State  lines which  EACH/RpCH  prohibits. 
Foresight  and  careful  planning  allowed  the  Caney  Hospital  to close  as an  acute  care 
facility  one  Friday  and  open  on the  following  Monday  as a Jane  Phillips  24-hour  doctors 
health  clinic and  long-term  care  facility. 
J-Watservices does the initiative provide? 
The  Caney  facility  provides  offices for three  physicians,  lab services,  and  an  opticians 
office.  At the  time  of our  site visit, September  1992, Caney  was preparing  to house  its 
remaining  pharmacy  in the  same  complex  with the  clinic.  The  clinic also serves  the 
community  of Caney  and  the  immediately  surrounding  rural  area  with  24-hour  urgent 
care  and  emergency  transportation  services  to Jane  Phillips  Hospital  in Bartlesville, 
Oklahoma. 
At the  time  of our visit, Caney  had  two practicing  physicians.  Negotiation  to obtain  a 
third  practicing  physician  for the  community  was almost  completed.  The  former  hospital 
also employed  the  services  of a physician  assistant  on a part-time  basis.  With  lab  semices 
on site  and  access  to more  advanced  diagnostics  at the  Phillips  hospital,  the  arrangement 
meets  community  needs.  Physicians  shared  a waiting  room  and  reception  services.  Each 
had  a private  office  and  several  patient  treatment  rooms.  Each  also had  privileges  at 
Phillips  hospital. 
The  clinic was in the  process  of becoming  a focal  point  in town  for all health  services 
except  dentistry.  An  optician  had  recently  moved  offices  into  the  facility  and  a pharmacy 
was also preparing  to do so.  The  clinic also has the  ability to transport  patients  with 
both  a helipad  and  an ambulance  available  for cases  requiring  stabilization  and  transport. 
How  has the initiative affected community  health care neeak? 
The  implications  for one-stop  health  care  are  obvious.  With  the  convenience  offered 
here,  buoyed  by the  capability  of Phillips  to provide  more  sophisticated  medical  services, 
the  initiative  is meeting  Caney  health  care  needs  better  than  the  original  hospital.  In 
fact,  the  transition  to the  clinic concept  was so smooth  that  most  citizens  we contacted 
expressed  a belief  that  it is still a hospital  with more  services.  While  the  former  hospital 
was underused,  the  clinic now has  a waiting  list of patients  wanting  health  care  service. 
Contact:  Catherine  H. Abrams,  Vice President  for Regional  Development,  Jane  Phillips 
Episcopal  Memorial  Medical  Center,  Bartlesville,  Oklahoma  (918/333-7200  Ext.  748). 
A-II
 Medical  Assistance  Facilities 
Circle,  Ekala@  Jorckq  and  Terry,  Montana 
What is the initiative? 
A Medical  Assistance  Facility  (MAF)  offers  low intensity  inpatient  care,  24-hour 
emergency  care,  and  basic  outpatient  medical  services.  As designed  under  Montana  law, 
a MAF  must  be  in a county  with  a population  density  of no more  than  six residents  per 
square  mile.  Further,  it must  be  located  more  than  35 miles  from  the  nearest  hospital. 
MAFs  operate  without  meeting  the  same  licensing  requirements  as hospitals.  In MAl?s, 
care  may be  provided  by physician  assistants  or nurse  practitioners,  with  a supervising 
physician  visiting  the  MAF  once  every  30 days.  The  MAF  does  not  need  to be  staffed 
24-hours  a day unless  a patient  is in the  facility.  Only one  MAF  staff member  must  be 
on duty  or on call at all times.  Patients  may receive  up to four  days of inpatient  care  in 
a MAF.  However,  patients  with  serious  illnesses  or injuries  are  stabilized  at the  MAF 
and  transported  to a full-service  hospital. 
W+at was the hospital like before it closed? 
At the  time  of our  review,  four  Montana  communities  had  MAFs.  They  are  Circle, 
Ekalaka,  Jordan,  and  Terry.  All four  of the  community  hospitals  had  low occupancy 
rates.  Most  of the  hospitals  had  scaled  back  services.  None  of the  four  hospitals 
provided  specialty  care.  Finally,  most  surgeries  and  obstetrical  services  were 
discontinued. 
How  was the successful initiative developed? 
Unlike  other  communities  with  successful  initiatives,  the  four  Montana  communities  were 
invited  to participate  in the  MAF  project.  Early  in the  1980s, the  governor  of Montana 
created  a task  force  to study the  future  of rural  hospitals.  The  task  force  determined 
many  rural  communities  could  not  continue  to support  a full-service  hospital,  yet 
communities  needed  access  to primary  and  emergency  care.  In  1987, the  Montana  State 
legislature  authorized  the  MAF  program.  This  program  was designed  to provide 
continued  access  to health  care  by converting  a full-sefice  hospital  into  a low-intensity, 
short-stay  health  care  service  center. 
In  1988, the  Montana  MAF  program  received  planning  and  development  funding  through 
a Health  Care  Financing  Administration  (HCFA)  demonstration  grant.  Also,  HCFA 
waived  numerous  hospital  requirements  so that  MAFs  could  receive  Medicare 
reimbursement.  In  1990, HCFA  authorized  a cost-based  reimbursement  system  for 
MAFs.  HCFA  also  established  quality  assurance,  utilization  review  and  certification,  and 
life safety  standards  for MAFs. 
A-12
 W%atservices does the initiative provide? 
MAFs  provide  up to 96 hours  of inpatient  acute  care,  24-hour  emergency  services, 
stabilization  and  transfer  services  for severe  cases,  basic  lab  services  and  basic  x-ray 
services.  All MAFs  also  offer  outpatient  medical  service,  and  are  collocated  with nursing 
homes.  Each  MAF  may offer  other  services  based  on the  needs  and  resources  of the 
community. 
How  has the initiative affected community  health care needs? 
MAFs  meet  most  of the  health  care  needs  of a community.  With  the  combination  of 24-
hour  emergency  care  and  limited  inpatient  care,  MAFs  are  providing  basically  the  same 
care  as that  provided  by the  former  hospital.  Providers  at the  MAF  are  performing  only 
limited  and  clearly  defined  services  which  they  are  fully equipped  and  trained  to handle. 
When  patients  need  care  that  is not  available  at a MAF,  the  MAFs  transfer  them  to a 
facility that  can  provide  the  needed  care. 
Contact:  Keith  McCarty,  Director,  Montana  Hospital  Research  and  Education 
Foundation  (406/442-8802). 
A-13