1. Rural Health Home Care Association of Washington Pre-Conference, April 2015

3. Washington’s Population % rural: Census 2000 = 18% Census 2010 = 16% Urban (%)Rural (%)Total 20106,144,138 (91.4)580,341 (8.6)6,724,479 20116,183,266 (91.4)584,553 (8.6)6,767,819 20126,227,755 (91.3)589,932 (8.7)6,817,685 20136,291,609(91.4)590,708(8.6)6,882,317 Population (%) Washington State, 2010 - 2013 Data Source: Population Estimates: Washington State Office of Financial Management, Forecasting Division. Asnake Hailu | DOH – HSQA – OCHS - RAD: Rural Community Health Profile - Data Miniround | March 2015

4. Factors influencing health in rural areas Older population, fewer working age adults, lower per capita income, more unemployment, and fewer years of formal education Higher percentages of Hispanic/Latino and American Indian and Alaska Native populations

5. Health risk factors where rural areas have higher rates than the state average Adults who are overweight or obese. Adults who smoke. Women who smoke during pregnancy. Rate of teenage births. Children who are hospitalized for unintentional injuries. Adults with unmet medical needs due to cost.

6. Health risk factors where rural areas have lower rates than the state average Adults who received yearly dental care. Adults with healthcare insurance coverage. Adults with personal healthcare provider. Adults 50 years of age and over who received colorectal cancer screening. Pregnant women who received prenatal care during the first trimester. Women who received screening for breast cancer. Data Source: Behavioral Risk Factor Surveillance Survey

7. Age-adjusted hospitalization rates (CAHs) Primary DiagnosisRate All Causes1,215 Single live birth in-hospital without cesarean section147 Pneumonia, organism NOS63 Single live birth in-hospital with cesarean section54 Localized osteoarthritis NOS lower leg25 Obstructive chronic bronchitis with acute exacerbation25 Congestive heart failure NOS20 Urinary tract infection NOS19 Atrial fibrillation15 Septicemia NOS15 Cellulitis of leg14 Data Source: Washington State Comprehensive Hospital Abstract reporting System, 2013. Asnake Hailu | DOH – HSQA – OCHS - RAD: Rural Community Health Profile - Data Miniround | March 2015. Per 100,000 for 10 leading primary dx codes for 39 CAHs

8. Age-adjusted rural/urban mortality

9. Rural Health Clinics and Hospitals

10. Financial Challenges Declining revenues due to decreasing inpatient care, reimbursement cuts, and increasing labor and operating costs Continued wrangling over Medicaid reconciliation for clinics Shift to value-based payment Increasing emphasis on population health, prevention, and care coordination and lack of adequate reimbursement for these services.

11. Workforce Challenges Most rural areas have fewer physicians per capita and higher percentages of them are age 55 or older than in the rest of the state. Projected healthcare personnel shortages statewide show large shortfalls in physical therapists, physicians, emergency medical technicians/paramedics and pharmacists among other professions. Lack of providers qualified to treat psychiatric patients in both inpatient and outpatient settings.

12. New Blue H

13. Recommendations New rural facility and payment models Comprehensive local community assessment, planning, and system development Telehealth Evaluate and invest in the rural health care work force

14. WA Rural Health Access Preservation Work Group Design a new rural health facility and payment model(s) to preserve access to health care in rural areas at risk of losing their hospitals and a demonstration project(s) to test it. Design and test under Healthier WA Payment Model Test 2

15. Recommendations Transportation Hospital and acute care Workforce Long term care Behavioral health Primary care and prevention

16. Rural Home Health Home health services are not readily available in rural areas, nor are they used to their full capacity. Reasons for this include: Regulatory barriers in Medicare, Medicaid, and state certificate of need requirements. Lack of knowledge about home health services and eligibility in communities, particularly for care coordination. Inadequate reimbursement, particularly in rural areas where longer travel times and costs are not taken into account in reimbursement rates.

17. Two primary intentions Preserve access to long term care services in rural areas, and increase resources for these services where needed. Support aging in place by providing long term care for people in their own communities, at home where possible, and in coordination with other health and social services.

18. Care Coordination Expand care coordination and transitional care services to all people who need them. Use home health care coordination and management to the full extent, including long term care management. Provide services in the home where feasible.

19. Care Coordination Requires changes to the federal and state statute and regulations and possibly the Medicaid waiver: Address home health reimbursement issues, including an add-on for mileage/travel costs. A waiver from federal regulations such as “face to face” and “homebound” for home health care eligibility. Addition to home health services of a one-time nursing visit benefit to help with medications reconciliation and transition from hospital to home. Review certificate of need requirements for home health services for opportunities to expand home health services in rural areas. Certificate of Need RCW 70.38.015, WAC 246-310.

20. Collaborative Planning Include long term care providers, AAAs, and ALTSA regional representatives and resource developers in local and regional health care systems planning along with public health, hospitals, primary care, home health, and behavioral health.

21. Accountable Communities of Health Ensure rural and long term care providers and policy makers are included in regional planning for the State Health Care Innovation Plan’s (SHCIP) Accountable Communities of Health.

22. Workforce Increase access to long term care worker training in rural areas, via telehealth and more on-line training. Address workforce shortages by cross-training therapists and nurses from hospitals for home health care as hospital census decreases and more health care is provided in the home.

23. New Blue Status WRHAP Telehealth Mobile Integrated Health

24. Discussion… Kim Kelley, MSW Kim.kelley@doh.wa.gov 360-236-2807