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How do you track change in something as complicated as rural health care? You can compile statistics about how healthy residents are; you can examine financial margins for hospitals and clinics; you can tally up the doctor shortage.

You also can pick a half-dozen places in Minnesota where change seems to be in the wind and revisit them every once in a while to see how people are faring. So we at Ground Level have chosen six towns to look at over time. Here's an introduction to each. We'll revisit.

Virginia Regional Medical Center is a publicly owned 83-bed hospital on the Iron Range that's been around since 1936. As the health care landscape has changed, the hospital has fallen on hard times. Admissions are down and the facility is now saddled with more than $7 million in debt.

City leaders are negotiating with Duluth-based Essentia Health to forge a merger or sale. 

Hospitals are joining health systems at a rapid pace in Minnesota. Just since the beginning of 2010, eight hospitals — all in rural areas — 

 by larger systems like Essentia, Sanford, Avera, CentraCare and Allina. 

 "A stand-alone hospital just doesn't work anymore," says Virginia Mayor Steve Peterson. "You just don't have the networking capabilities. You don't have the affiliations. You don't have the benefits when buying medical supplies and pharmaceuticals. Unless you can collaboratively work with other hospitals — and we are trying to do that with other independent hospitals — you just can't be competitive.

 Virginia and Essentia have signed a letter of intent and will be hashing out the collaborative details in the coming months.

Bigfork Valley Hospital is a 20-bed hospital in a town of 450 people in Itasca County. It's owned and run by the citizens of its "hospital district," which includes Bigfork and surrounding communities. It enjoys an amicable relationship with the people it serves and ranks high in patient satisfaction: A national survey found that 94 percent of patients said they would "definitely recommend" the hospital, compared to a statewide average of 72 percent.

The population of Itasca County is aging. The most recent census data shows that 18 percent of the county's population is 65 and older, compared to 13 percent statewide. So, Bigfork Valley is tailoring its services to suit the needs of older people.

Customization is key to the hospital's survival, says Bigfork Valley CEO Dan Odegaard. "Our local market is full of retirees, people who want to live here and move here. We understand that. So what we're trying to do is position ourselves to meet their needs."

 The hospital is building a cluster of senior town homes and a "commons," which will include an expanded kitchen, a cafeteria, a conference room and a gift shop.

When it comes to innovative thinking on rural health care issues, Duluth has emerged as an epicenter.

It's home to the University of Minnesota medical school campus that turns out more rural doctors than any other  school in the country. The university targets recruiting and runs a preceptor program that matches students with rural doctors who show them the ropes. [link to Boulger UpClose]

Duluth is also where the National Rural Health Resource Center is based, acting as a force for progress, a clearinghouse for information, and a hub that connects people across the country. The organization helps recruit rural doctors and holds training sessions for those charged with keeping rural hospitals functioning. [link to Hill UpClose]

SISU Medical Systems, a consortium of 22 rural hospitals, is also located in Duluth. SISU's full and associate members share technological know-how in order to save money and supplement a meager pool of IT people in rural Minnesota. By working together, the hospitals are better able to compete in the modern health care marketplace and survive. [link to Nelson UpClose]

 On June 27 and 28, the city will play host to the Minnesota Rural Health Conference, where a "rural health hero" will be named.

In rural Minnesota, a lack of physicians, dentists and nurses 

has opened the door for midlevel practitioners

 to take on a greater role in providing health care. The public has largely grown accustomed to treatment by nurse practitioners, specially-trained nurses who can perform physical exams and prescribe medications.

But the idea is spreading to include new classes of care providers: "community paramedics" and "dental therapists." Both target underserved populations, including those in rural areas. 

Minnesota is the first state in the nation to pass a law-signed by Gov. Dayton in April — establishing certification for community paramedics. A specially-trained paramedic might suture a wound, adjust a medication, address an asthma attack or talk through a mental health issue, all under the supervision of a licensed doctor. In the greatest divergence from their traditional role, they attempt to provide these services on the spot, without automatically driving a patient to an emergency room.

Minnesota also was the first state to license dental therapists, who perform duties that fall between those of an assistant or hygienist and those of a dentist. They can fill cavities and even pull baby teeth, under the supervision of a licensed dentist. Two groups of students are making their way through the state's education systems, one at Metropolitan State University and the other at the University of Minnesota, where a class of nine will graduate in December.

 In the coming months, these practitioners will be deployed to rural parts of the state. One University of Minnesota student, formerly a dental assistant in Montevideo, will return to that practice.

When people talk about independent hospitals doing well in the state, they often mention Lakewood Health System, which is based in Staples. Thanks largely to its CEO of 31 years, Tim Rice, Lakewood has become a model for innovation.

While health care reform is pushing providers toward integrated care — where a group of doctors and nurses cooperate to treat a patient in a more holistic fashion — Lakewood has been doing this for years, as part of its medical home program. Teams work to treat health issues before they land a patient in the emergency room, which saves money. Rice calls this approach, "patient centered and physician driven."

While hospitals and clinics across rural Minnesota are struggling to recruit physicians, Lakewood has doubled its number of doctors since 2006, from 20 to 40. "Recruitment is going well," says Rice, in part because, "We open up our organization for medical students. We really believe in providing support for educational systems. It creates a lot of exposure. Word gets out because they are here and like what they see."

Lakewood runs in the black and operates four nearby satellite clinics, which extend the system's footprint. Yet healthcare reform, especially provisions encouraging "accountable care," poses challenges. "With accountable care, you're responsible for the entire delivery, including specialty care," says Rice. "We are so small, could we take that risk? I don't know if we are at that point."

Instead, says Rice, Lakewood hopes to strike up partnerships. "Our plan is to remain independent, but that means instead of looking at systems as adversaries, we have to collaborate with them ... and develop some unique arrangements for how we can perform a role if they pursue accountable care."

"I have to admit, I have things in theory," Rice adds. "How it will work and what it will look like, I have no idea. We're learning as we go."

 Lakewood is talking with larger health systems in the state to strike up partnerships so it can better weather changes brought by health care reform.

Last November, North and South Dakota-based Sanford Health announced it was merging with North Country Health Services, Bemidji's hospital since 1898. 

 staff from both organizations have touted the merger as good for health care in the city, saying it will save money through efficiencies and bring greater access to specialists.

No money changed hands in the deal, but Sanford expects to pay $75 million over the next 10 years for upgrades to the facility, technology and staff. They'll also pay $2 million for naming rights to the city's new events center.

In late May, Andrew Richburg, Sanford's executive vice president of marketing, 

 the merger was going smoothly. He said there are always tricky points, such as getting everybody on the same electronic medical records system and convincing doctors to use the same supplies in order to save money on volume discounts.

Richburg said an existing Sanford clinic in Bemidji helped pave the way. "In Bemidji, we've worked so closely with that medical center for so long, in terms of operationalizing the merger, there weren't many bumps," he said. "We're in union negotiations with the Minnesota Nurses Association. But that's not necessarily a bump. I think the cultures were very similar. The community has been fantastic. They very much embraced the merger."

 Most are optimistic the merger will improve health care in Bemidji, but others wonder if there will be downsides to losing fully local control.

Small town docs: The search for someone who does it all

Telemedicine, midlevel practitioners start to fill physician gap

Electronic records mandate strains rural hospitals

Doctor as renegade -- accepts cash, checks, eggs or pie, not insurance

Can a small, independent hospital survive? A tale of two northern Minn. hospitals

Rural health care in Minnesota: a primer

A growing force in rural Minn. health care: 8 questions for Sanford Health

Rural health care: People taking action to make a difference

Health

Jennifer Vogel

Author

A introduction to half-dozen in rural Minnesota where change in the way health care is delivered seems to be in the wind.

Rural health care: Places to watch

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