By Amundsen, Hagopian and Robertson

This community study (in Improving Rural Health) lends support to the belief that the ability of a community to attract physicians is closely related to the ability of that community to confront problems and take necessary actions - Tom Bruce in Improving Rural Health 1984 p 66

ABSTRACT

A community health services development model was developed and disseminated through the AHEC at WAMI. The critical common components involved community leadership, comprehensive analysis of the community health services, hospital and community-wide strategic planning, and implementation of goals and objectives identified. The crucial elements of this process are:

1) a multidisciplinary team;

2) clear delineation of participant roles and responsibilities;

3) flexibility in application of the model;

4) community leadership and wide participation;

5) community commitment;

6) intra-community cooperation;

7) comprehensive identification of problems in the local health care system;

8) education and experiential learning opportunities during the course of the work.

The initial impression is that the model is helpful, although objectively not proven.

Twenty-five rural communities participated. Most had low hospital market share, high percentages of elderly and low income residents, shortages of health care providers, long distances to referral hospitals, low resident satisfaction levels, and threatened hospitals.

INTRODUCTION

Declines in rural hospitals have been fueled by the implementation of prospective payment, increasing costs, declining manpower, and failing rural economies. These problems were mostly out of the control of local communities. Within the community, out-migration of residents is a major problem. Other common problems include poor public image of local facilities and services, limited technology, absence of health planning, weak institutional governance, inadequate management and financial systems, intra-community conflict, ineffectual provider recruitment, minimal collaboration among community providers, and a limited local understanding of the problems.

DEVELOPMENT OF THE MODEL

Assumptions of the Hospital Project:

1) The community health care system ideally should be the portal of access for all residents of a service area seeking care.

2) The optimal scope of health services should be based on demographics and needs of the local population.

3) Within the limits of quality and cost, health services should be provided in the rural community.

4) Each rural community should determine the appropriate spectrum of local services and accept responsibility for its support and financing.

 

RURAL HOSPITAL PROJECT AND GOALS

1) Clearly and comprehensively identify the issues confronting rural health services

2) To assist each community in defining an optimal scope

3) To develop approaches and models that would be useful for rural communities to sustain the strength of the local delivery systems

4) To disseminate the findings and models to other rural communities

 

THE COMMUNITY HEALTH SERVICES DEVELOPMENT MODEL

The CHSD Model integrates knowledge and skills from three important content areas:

community development (CD), organizational development (OD), and strategic planning (SP). CD involves identification and involvement of important members of the community; OD refers to the body of knowledge and skills necessary to reduce group process issues; SP involves the process by which an organization or community helps its missions, goals and objectives.

The Four Phases of the CHSD Strategy:

1) Community Preparation involves a Memorandum of Agreement between the community and the sponsoring organization.

2) Community Analysis involves:

a) A needs assessment by key informants in the community

b) A community-wide survey

c) A thorough financial analysis of the hospital

d) A management or organizational analysis of the hospital

e) A developmental, economic and demographic profile of the community

f) A scope of services inventory/compilation. This information is compiled into a comprehensive report with a summary section highlighting strengths and weaknesses.

3) Strategic Planning - A critical component is delineation by the community of a rational, affordable scope of health services involving all participants. This usually involves OB, prenatal care, surgery, EMS, critical care services, and appropriate technology.

4) Implementation and Review - During this phase the implementation of the plan begins. Attention is given to assure the existence of the structure of leadership resources for continued planning and problem-solving.

 

Critical Elements in the Sponsorship of the CHSD Model:

The quality of relationship between a community and the collaborating organization is important. It is difficult to effect change in rural communities. The sponsoring organization may often be able to serve as a critical external facilitator to insure progress.

The Composition of the CHSD Team:

The team should include a full-time program director with rural health care, human service knowledge, group skills, and reasonable administrative abilities; a team member with rural hospital organizational experience; a financial analyst; a strategic planner; and a rural physician. Difficulties were noted when the team lacked members with certain critical skills. Outsiders may be used judiciously to fill these gaps. The team roles and responsibilities differ and team members must cooperate to identify problems and decide who is the most appropriate person to address problems that are identified.

Flexibility in Application of the Model:

A community experiencing a crisis needs assistance in dealing with that issue before it can address more comprehensive approaches. Examples included sudden physician shortage, problematic hospital administrators or doctors, and intraprofessional conflicts. Crises provide CHSD staff access to the community and often can be used to point out the need for a comprehensive plan. Flexibility is needed in this strategic planning phase.

COMMUNITY ISSUES

1) Community Leadership and Breadth of Participation:

The two most important predictors of community success are the quality of community leadership and the breadth of involvement of community "stake holders" in health care. A major goal is expanded community participation and involvement to find problems and come up with solutions.

2) Community Commitment:

The basic assumption is that given the tools and necessary assistance, rural communities can help initiatives to strengthen their delivery systems. Unfortunately, experience shows that many rural communities feel that outside resources will "fix" things. Important commitments include reaching an early consensus that the entire CHSD Model should be employed, members draw up a formalized memorandum of agreement, there is participation by a broad range of community providers and leaders, and the community absorbs some of the costs of the project.

3) Inter-Community Relationships:

Cooperation is extremely important. Continual unresolved conflicts or physician and other provider turnover will effect rural professional recruitment. Hospital board stale-mates and turnover are common, as are administrator problems. These all have secondary financial impacts. Conflict resolution efforts are often complex but usually effective. Involvement of CHSD staff was critically important.

4) Comprehensive Identification of Problems:

Many of the problems are inter-related and pertinent data are often not available. Many times, this analysis is performed from outside the community. Perceived poor quality in physicians, services, and facilities all tend to conspire to decrease market share and set up a vicious downward spiral.

5) Concurrent Education and Experiential Learning Opportunities:

Health care is extremely complex and demands specialized skills and information. Continuing education for all participants was important.

 

Cost and Time Frame to Complete the CHSD Program:

The cost per community was $50,000: $9,000 for the survey, $3,000 for organizational review, $2,000 for community needs assessment, $6,000 for strategic planning and $27,000 for direct support of team members. Half of the communities contributed 1/3 of the total cost, and these studies all required between 8 and 20 months.

CONCLUSION

The fundamental problem in almost every community study is the inability of the community health care system to adequately meet the needs and resolve the conflicts of its residents. Through the CHSD, resources and commitments can be rekindled. Informal evaluation of the effectiveness of the CHSD proved favorable. National efforts should be initiated to develop in each state at least one organizational structure to work with rural communities whose health care systems are at risk.

Efforts to improve conflict resolution, deal with barriers of economic or social disparity (i.e. racism), and facilitate collaboration may be a useful adjunct to any program. The role of "outsiders" can be a positive or negative factor in this resolution.

PART II: DEMOGRAPHIC SURVEY OF THE FINANCIAL DATA

Data for 25 communities were compiled. A typical CHSD community had population of

5,719 with a catchment area of about 10,000. The typical community had 4.6 practicing physicians and a hospital with 28 beds. The next hospital was an average of 71 miles away. Forty per cent of the people felt that the number of physicians and health services are inadequate. Demographically there were high proportions of lower income and elderly people. Surveys sought answers as to a hospital and physician market share, the reasons for non-local provider use, the kinds of specialty care sought elsewhere, and the satisfaction with all community health services. The survey measured attitudes about the local hospital, public funding, public confidence in on-call systems, problems in the health care system, and knowledge levels of local health care system.

Most of the rural residents were extremely satisfied with the ambulance, pharmacy, and dental services. Fifty to sixty per cent felt that the nursing home and home health services were satisfactory. Less than half were satisfied with OB care, mental health care, alcohol treatment. The median hospital market share was 38%, physician market share was 49%. Young people were universally less satisfied with health care services by 20 points or more. Specific areas of concern to the younger group include lack of physicians, problems in scheduling, increased waiting time, access to night and weekend care, problems with billing services, food services, and cost. In summary, CHSD survey data indicated market share was at least 20 points below what is potentially achievable. Physician and hospital market shares are inextricably linked.

FINANCIAL DATA In general, the CHSD hospitals have poor financial performance. Operating margin is -.04, indicating reliance on non-operating revenue such as debt financing or tax based revenue. Debt service coverage ratios were -60 to 9.41. The median of 1.3 compares unfavorably with national medians. Long-term debt to equity ratio, hospital median of .16 (although this may mean than hospitals are unable to get financing. Net days and patient accounts receivable is very high in many hospitals. The median of 74.42 days is comparable to state and national averages. The average age of the plant at 10.79 years is above other industry medians. The replacement viability index is rough approximation of the hospital's ability to replace fixed assets with existing funds. Ideally this ratio is 1.0. Median for CHSD hospitals is .01. The financial flexibility index measures eight standardized ratios. CHSD hospitals had a median of -2.01 compared to the median for U.S. hospitals at 1.02.

DATA LEADS TO PLANNING The following data were collected: information on physician recruitment, public relations and image improvement, scope of services development, joint planning among health providers, financial improvements (bond issues, grant writing, formation of hospital districts, reduction in contractual allowances, improved collection of accounts receivable, better cash management, stronger relationship between planning and budgeting), employee performance and compensation enhancements, board education, leadership diffusion enhancements.

Again the above is a summary. Further details available upon request. Comparisons must allow for regional variations. Also the specific figures have certainly changed over the years given inflation and other factors. The information is useful for general comparisons and planning, as was the projects main intention.