Organization Newsletter

Sept. 2017

In this issue...

  1. Executive Director's Message
  2. Getting to Know Your Board Member - Weston Davis, President
  3. Implicit Bias
  4. New Member/Sponsor Activity Highlights
  5. Back to School with Shriner's
  6. Washington State ORH Updates
  7. New Sentinel Network Available!
  8. Practice Transformation Strategies for Success
  9. Keeping You in the Know
  10. Reflections on Rural Practice
  11. Time is Your Pain Patient's Enemy!
  12. Last but Not Least....


Welcome to the
September 2017 issue of the Washington Rural Health Association e-Newsletter.
Inside this issue you will find news and information from the Executive Director and board of directors, members, and community partners from across the state of Washington. 

If you would like to submit your own story, please click here.

The WRHA e-newsletter is a publication of Washington Rural Health Association, a not-for-profit association composed of individual and organization members who share a common interest in rural health. This e-newsletter seeks to disseminate news and information of interest to rural health professionals and stakeholders to help establish a state and national network of rural health care advocates.

WRHA Members

WRHA members include administrators, educators, students, researchers, government agencies and workers, physicians, hospitals, clinics, migrant and community clinics, public health departments, insurers, professional associations and educational institutions. If you are interested in joining or renewing your membership with WRHA click here.


Executive Director's Message


Submitted by:  Beionka Moore
[email protected]

I was driving through Eastern Washington on my way to a Regional Council Meeting at Central Washington Hospital and Clinics, when something caught my eye.  Looking over to the side of the road into the woods, was an old reddish colored truck.  I decided to pull over and get a closer look.  As I walked toward the old abandon truck covered in rust, leaves and overgrown brush, I became increasingly curious.  Many different thoughts crossed my mind. I wondered how long the truck might have been there and why?  Also, how far would it be to the nearest hospital in case of an emergency or injury? 

I decided to get better informed, so I timed the drive to the nearest clinic.  I thought about people that might have encountered a snake bite or hurt themselves while hunting or fishing.  It would have taken 20 minutes to get to the nearest hospital and 16 minutes to arrive at the clinic.  And if you are anything like me, you can add 5 minutes on to those estimates.  I can be a directionally challenged individual.     

This is an example that has become very familiar of the distance between medical providers in rural Washington.  In many areas, the distance and care needs are far greater.  Preservation of rural health is vitally important.  In most cases, rural hospitals are one of the largest employers in communities.  For our providers, the importance is knowing you are serve a population that needs you.  For patients, it’s trusting that you can and will receive quality care.

The closures of rural hospitals are real and unfortunately, continue. The Washington Rural Health Association (WRHA) is working hard on your behalf.  We, and the State Office of Rural Health stand shoulder to shoulder with administrators, providers, and other citizens to maintain and improve our rural health care system.  The Senate listened to your voice, and the efforts to pass legislation to repeal and replace the Affordable Care Act (ACA) that would have harmed the rural health care safety net, were defeated.  But health care reform is still on the table - - let's make sure Congress gets it right this time!  When Congress returns to regular session, which is today, the Senate HELP and Finance Committees are expected to hold bipartisan hearings to discuss marketplace failures and other ACA concerns.

This is our opportunity to tell Congress how to make health reform work in rural Washington. While members of Congress are home in their districts, please tell them to repair the harm the ACA causes to rural America and to build upon the provisions that are effective in rural America. Attending town hall meetings will be a great opportunity to share your experiences with health care reform and what changes that are needed.  

In closing, research shows that when members of an association get involved at the board level or on committees, their personal sense of satisfaction increases markedly.  Are you looking for something worthwhile to do?  Would you like to increase your own sense of personal satisfaction?  WRHA needs more members.  If you are reading this and are not a member of WRHA please consider becoming one.  See our website at and learn what we’re all about and the benefits you can gain by becoming a member. If you are already a member, perhaps you could do some recruiting in your community?  Further, you could consider volunteering to work on a committee.  You will find a list of committees on the website and descriptions of what these committees do in the ‘Bylaws’ page.

Together, we will keep Washington state healthier and stronger!

Beionka Moore, Executive Director
Washington Rural Health Association


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Getting to Know your Board Member!

Happy Summer!  Washington Rural Health Association continues to reestablish itself as being the collective voice strengthening and advocating for the preservation and improvement of rural health in Washington state. To further engage you in the mission of the WRHA, we have added a new feature to our e-Newsletter: a Board Member Profile. In each issue, we will introduce you to one of our hard working board members to learn a little about who they are, their personal and professional interests, and why they became involved in WRHA.


Q:      Please tell me your name, where you work, title, your role with WRHA and how long you have been a board member?
Weston Davis, I work at Inland Imaging and am the Executive Director of Rural Health Initiatives.  My professional role is to evaluate the financial service needs of rural hospitals and to provide revenue cycle services to those communities.  I have served on the WRHA Board for four years now.

Q:     How did you first become involved with the Washington Rural Health Association?
I met other WRHA members when I worked with the rural communities.  Many rural hospitals have the same financial service needs as large hospitals but staffing for those needs is a challenge.  By networking with WRHA members and meeting with rural healthcare providers we can all work together to provide services that are relevant and beneficial to rural hospitals.

Q:      There are several rural health organizations in Washington State. Why did you choose to work with WRHA?
The WRHA desires to be an “umbrella” organization for many rural health functions in Washington.  We are able to support a range of health specialties depending on community needs.  Some communities may need behavioral health support and others may need dental or hospital focused support.

Q:      Why is Rural Health important to you?
I grew up in a rural setting and have a passion for small rural communities.  If rural communities can maintain a strong health care delivery environment then the other areas of the community are more likely to thrive.

Q:     What has surprised you most about working with Washington Rural Health Association?
I am impressed by the desire of the rural providers to serve the local communities and find ways to replicate care that is available in larger towns and cities.

Q:     What is the best part of working with WRHA?
Best thing is meeting more and more people associated with rural Washington healthcare.

Q:     What do you see as some of the most challenging issues facing WRHA and Rural Health in our state?
The continued viability of rural healthcare delivery systems.  Like hospitals, various types of clinics such as therapy, dental and behavioral.  Also, attracting healthcare professionals to small communities for long term service continues to be a challenge.

Q:     What do you wish other people knew about Washington Rural Health Association?
It would be great if people knew the WRHA is interested in all types of community healthcare and services. These include dental, behavioral, senior care and quality of life issues.

Q:     If you could change one thing about Washington Rural Health Association what would it be?
A:     Our ability to communicate better with the rural communities of the value of being part of the WRHA.  Then identify exactly what communities need from an organization with the membership base the WRHA has.

Q:    Do you volunteer for any other organizations? Why do you feel it is important to volunteer?
Yes, I am active on a volunteer committee tasked with doing construction at a parochial school.  I also am a volunteer for a prison ministries program and am active in my local church.

Q:    How do you like to spend your time outside of work and volunteering?
A:    Spending time with family (five kids).  We love to be outdoors.   Also like working with my hands doing woodworking and landscaping.

Q:    What might (someone) be surprised to know about you?
I would love to work at an orphanage in India someday.

Q:    What do you think will change about Washington Rural Health Association over the next five years?
A:    We intend to grow the WRHA membership. This will enhance our ability to support an ever expanding range of programs to support rural healthcare.

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Implicit Bias and it's Unintended Consequences in Healthcare

Submitted by:  Premier Insurance Management Services

No one can deny the role that cognitive (conscious) bias plays in our everyday lives. Cognitive bias research has found that some people operate under the “halo effect,” when we attribute positive traits to attractive people and deem them to be more trustworthy, friendly, and intelligent than unattractive individuals. This bias can lead to faulty decision-making based upon our assumptions. In healthcare providers, it may influence their treatment decisions leading to inequality in healthcare for certain groups, decreased patient satisfaction, poorer treatment outcomes, and higher healthcare costs.

What is “conscious” cognitive bias?

Conscious bias is very common, and it affects everyone to some degree. Researchers have discovered that our individual biases begin to form as early as the first year of life, and are based upon our experiences and interactions with the environment. [i] Cognitive biases are usually known to us at some level within our consciousness, which makes them easier to control if we are mindful of their influence.

What is “unconscious bias” (Implicit)?

Unconscious stereotyping was first described by three psychologists in 1995, who later went on to develop Project Implicit at Harvard University.[ii] They believed that much of our social behavior is driven by learned stereotypes that operate automatically when we interact with other people, and that past experiences influence our judgment in a way that is not consciously known to an individual. It becomes our default thinking, especially during times of caregiver stress, such as occurs when a provider is seeing a high volume of patients or during emergencies. These effects are likely to influence decisions in very important ways, and can impact the economic welfare, social status, and physical/mental well-being of our patients. 

Unconscious bias cannot be measured by self-reporting surveys. Instead, computer-based instruments have been developed that reveal our unconscious association of images with good and bad attributes of certain races, disabilities, sexual orientation, weight, and gender. The Implicit Association Tests (IAT) are free and are available to the public at the Harvard website.

Impact on treatment decisions

Significant attention has been paid in recent years to the possibility that unconscious bias in health care givers contributes to healthcare disparities. In its 2003 report, “Unequal Treatment” The Institute of Medicine concluded that unrecognized bias against members of a social group may affect communication and the care offered to those individuals. Several more recent studies bear this out-especially as is relates to race, gender, obesity, and sexual orientation. 

What can healthcare organizations do to reduce unconscious bias in the workplace?

In 2016, The Joint Commission issued a Quick Safety Alert ™ on this subject containing some good suggestions for addressing this issue:

  • Conduct a cultural competence self-assessment (many tools available, including one from the American Hospital Association)
  • Establish an interdisciplinary and multicultural diversity committee that includes community members from minority groups
  • Identify and work to transform workplace customs that contribute to healthcare disparities and unequal treatment of minority groups
  • Provide ongoing training that celebrates diversity and encourages empathic dialogue[iii]

Individual healthcare providers can combat implicit bias by taking some of the Implicit Association Tests on line and checking their scores. Once we make these biases a part of our consciousness, they become easier to control. Additional suggestions include acquiring a basic understanding of the cultures that we serve and viewing the patients from their perspective. Let’s shine a light on implicit bias and work to reduce healthcare disparities for all.

[i]University of Toronto. "Infants show racial bias toward members of own ethnicity, against those of others: Racial bias begins earlier than previously thought, new insights into cause." ScienceDaily. April, 2017.
From the Project Implicit website: “Project Implicit was founded in 1998 by three scientists – Tony Greenwald (University of Washington), Mahzarin Banaji (Harvard University), and Brian Nosek (University of Virginia). Project Implicit Mental Health launched in 2011.”
[iii] Implicit bias in health care (2016). Quick Safety Advisory, Issue 23. Joint Commission.
PIMS is an Illinois for-profit corporation and subsidiary of Premier Inc., providing contracted management services for AEIX, and its attorney-in-fact. PIMS also serves as program manager offering enhanced endorsed programs with leading commercial insurers through a comprehensive portfolio of property, casualty and employee benefit products. Other services include providing claims and risk management assessments and education offerings regarding medical professional liability for hospitals and their physicians. For more information, visit

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       Welcome to New Members or Sponsors!

Submitted by: Beionka Moore
[email protected]

Welcome Back and Thank You to returning Sponsors!
Platinum Sponsor:  Inland Northwest Health Services (INHS) is a non-profit 501(c)(3) organization in Spokane, Washington providing collaboration in health care services on behalf of the community and its member organization Providence Health Care
INHS divisions and services include: 

CHARGE: Reduce rapidly spiraling health care costs and, at the same time, increase the quality of patient care.
INHS was formed to do just that, and delivered on its founding mission — bringing high-quality, cost-effective health care to the region through innovative and successful collaborations of health care services.

Collaboration and a patient-first approach drives everything INHS does; educating patients, improving access to health care, facilitating the sharing of resources among providers, developing new efficiencies through the smart use of technology and more. INHS oversees health care companies and services that work together to improve outcomes, lead the way in health care innovation and create healthier communities.


Silver Sponsor:  In 2004, physicians and community leaders throughout the northwest raised the awareness and resources to build a health sciences university, beginning with an osteopathic medical college where the next generation of osteopathic physicians would train.  PNWU-COM welcomed its first class of 70 medical school students into the College of Osteopathic Medicine in 2008 and graduated them in 2012.  Today, Butler-Haney Hall accommodates 280 medical students who are training under the careful instruction of highly qualified faculty.

Welcome Aboard and Thank You to new Sponsor! 

Gold Sponsor:  Wipfli’s health care practice serves a wide array of health care organizations nationwide, including hospitals, health systems, and senior living providers.  Our team of experts uses an outside perspective coupled with insider knowledge to develop practical solutions that deliver sustainable results.  Wipfli’s integrated service model incorporates reimbursement, revenue cycle, behavioral health integration, facility planning, audit/tax compliance, performance improvement, and clinical consulting to provide innovative solutions to demanding health care issues.

Welcome Aboard and Thank You to new Member!

North Valley Hospital, Tonasket, WA.  

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Back-to-School HEALTH CHECK at Shriner's!

Submitted by:  Kristin Monasmith
[email protected]

Back-to-School HEALTH CHECK! Before school is the perfect time to screen for scoliosis.  The leisurely days of summer are over and it's time to re-establish healthy habits and back-to-school routines.  In addition to dental checkups and annual physicals, pediatric medical specialists recommend adding a scoliosis screening to back-to-school checklists.  A team of doctors at Shriner's Hospitals for Children developed SpineScreen, a free app for parents to check their child's spine for possible signs of scoliosis during back-to-school preparation.  Scoliosis often turns up during adolescence so early detection is crucial. Scoliosis, a musculoskeletal disorder that causes an abnormal curvature of the spine or backbone (sometimes resembling an 'S' or 'C'), is the most common deformity of the spine, affecting an estimated 6-9 million - or approximately 2% - people in the United States.  Early detection can mean more and better treatment options.  Scoliosis often turns up between 10 and 15 years of age, when kids are growing quickly and may not need as many immunizations, so doctor visits could be less frequent.  There is no one-size-fits-all treatment.  Many new and non-invasive treatments are available.

Early Detection is Key.  Developed by the orthopaedic specialists at Shriner's Hospitals for Children, SpineScreen is a free app for parents to perform a preliminary spine check on their child in the comfort and privacy of their own home.  SpineScreen is available on the App Store and Google Play!  How does it work?  SpineScreen uses the phone's internal level to measure a child's back for possible signs of scoliosis.  Simply move your smartphone along your child's back and it will detect any abnormal curves of the spine.  You will be asked to perform the scan twice to ensure an accurate reading.  If the app measures a curve greater the acceptable range, you will receive a reading that states your child's spine rotation appears outside the acceptable range for a healthy spine.  As this is strictly an initial check, it will then prompt you to consult a professional health care provider for further examination to determine if this result is accurate and if further treatment is needed.  For more information on SpineScreen and the importance of routine screening, parents can learn more at  If your child does have scoliosis, Shriners Hospitals for Children is a trusted leader in scoliosis care, with comprehensive scoliosis treatment options available at 20 of its locations in North America, always regardless of the families' ability to pay.

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 Washington State Office of Rural Health Updates

Submitted by:  Pat Justis, Washington State Office of Rural Health
[email protected]

The State Office of Rural Health (SORH) at Washington State Department of Health offers set of federally and state funded programs.  Below, please find some updates from Washington's SORH.

Washington Rural Palliative Care Initiative

An advisory team with experts from rural health organizations, telehealth and palliative care have designed a model for integration of palliative care in rural healthcare systems and communities.  Six to seven early adopter rural communities will be the first "cohort."  There are plans to spread further as well as offer education to the wider rural health community.  The effort will be closely collaborated with existing hospice and home health services, and will go beyond terminal illness to serve those with serious life limiting conditions who may want both active treatment and supportive treatment.  Efforts to develop sustainable funding will be focal in the work.  For more information contact SORH Executive Director and Washington Palliative Care Initiative Leader Pat Justis at  [email protected].

Population Health Mini-Grants

The Flex Program, a federal program that supports Critical Access Hospitals (CAHs), has funded ten CAHs to take on issues that impact health in their community in collaboration with community partners.  The projects range from diabetes care, to housing, to access to primary care and more.  For more information contact Rural Hospital Program Manager, Lindy Vincent at  [email protected]

Antimicrobial Stewardship Program

Flex funding is also supporting 10 CAHs to participate in The Antimicrobial Stewardship Program at the University of Washington (UW-TASP).  The Washington State Department of Health Healthcare Associated Infections Program has grant funding from US Centers for Disease Control and Prevention to help support CAH participation in UW-TASP for a limited time at a greatly reduced subscription fee.  The special offer of financial support is for critical access hospitals in Washington to participate extends to July 31, 2018.

Each hospital brings a “complete team” to the UW-TASP program working to improve patient outcomes and safety.  Multiple regulatory groups, including The Joint Commission and the Center for Medicare and Medicaid (CMS) are now requiring that Antimicrobial Stewardship Programs are active in all hospitals.  For more information contact Rural Hospital Program Manager, Lindy Vincent at [email protected].

Mock Surveys for Rural Health Clinics (RHCs)

Two experienced Rural Health Clinic Managers are now available to visit RHCs and perform a friendly, educational mock survey to help the RHC team identify strengths and areas for improvement.  Bonnie Burlingham, SORH Program Manager can be contacted to request the free service or ask questions at [email protected]

Multiple grant awards to benefit rural health

Recent announcements from HRSA and USDA bring a slate of exciting projects to our state. Grant applications take hard work and we applaud the successful applicant teams.

Clallam County - WSU Extension and community members are using a USDA Rural Health and Safety Education Grant to Clallam County to increase access to fresh produce and experiential nutritional education throughout the county, especially the more underserved areas of the West End.
Clallam County - A HRSA Network Development grant led by Clallam County Public Hospital District #1 (Forks Community Hospital) with nine other Critical Access Hospitals in the state will work on plans for a sustainable rural delivery and payment model for home and community-based long-term care.
Ferry County - A HRSA Network Development led by Ferry County Public Hospital District #1 will work to formally establish a rural health network that will assure that residents of the small communities scattered throughout the county have a consistent, effective mechanism for addressing health needs and for supporting changes in social determinants of health that will improve overall health. Their work will include a community health needs assessment.
Kittitas County - A HRSA Network Development applicant HopeSource will establish the Kittitas County Health Network to improve population health through cross-sector collaboration and systems integration. The Network will recruit members, develop an operations plan, conduct a community health needs assessment. Other work will include developing a care coordination system plan.
Okanogan County - A HRSA Network Development led by Aero Methow Rescue Service, a service affiliated with Methow Valley Home Health Agency, will fund development of an integrated healthcare network within the Methow Valley. The Network will work to alleviate the loss of local services and access to care through enhancing emergency medical services. The core network team will include five agencies, Aero Methow Rescue Service, Frontier Home Health and Hospice, Lookout Coalition, Family Health Centers, Twisp, and Three Rivers Hospital.

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 New Sentinel Network available!


Submitted by: Susan Skillman, MS
Deputy Director, Center for Health Workforce Studies
Associate Director, WWAMI Area Health Education Center (AHEC)
Investigator, WWAMI Rural Health Research Center

What are Washington’s greatest health workforce needs?
New Sentinel Network findings available!

Recent findings about health workforce needs around the state are available on the Washington Health Workforce Sentinel Network website. Educational institutions, healthcare organizations and state and local policy makers are using these data for planning.  

Sentinel Network findings highlights include: 

  • Registered nurses and medical assistants were among occupations with exceptionally long vacancies in all regions of Washington in April 2017.
  • Rural employers reported difficulty recruiting multiple occupations.
  • More training in the use of electronic health records and health information technology, as well as customer service skills, is needed in many settings.
  • High turnover rates in behavioral/mental health facilities are increasing workforce demand. See which occupations are most challenging.

These are just a few of the findings from the Sentinel Network.  Go to to learn more about the Sentinel Network and to View Findings explore more details about health workforce needs across the state.

The next opportunity for healthcare industry representatives to submit workforce needs to the Washington Health Workforce Sentinel Network will be in early September.  If you haven’t already registered, please follow this link: and click "Register Now" to be reminded when the next data submission opportunity is open.  Make sure your information is included in the next survey round!  It only take a few minutes to respond.

Washington’s Sentinel Network is a collaboration of the Washington Workforce Board and the University of Washington’s Center for Health Workforce Studies, with funding from the Washington State Health Care Authority.

Questions?  Contact us at [email protected] or 206 543-9797.

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Practice Transformation Strategies for Success

Submitted by:  Rebecca Snyders, Qualis Health
[email protected]

From Collaborative Care, to fully integrated co-location, to enhanced access, there are a number of effective approaches for integrating behavioral health and primary care. This first in a series of “Practice Transformation Strategies for Success” videos tells the story of behavioral health integration at the Yakima Valley Farm Workers Clinics.  At the Unify Clinic in Spokane, behavioral health consultants are members of the primary care team, using warm handoffs and face-to-face communication to share information about their patients’ progress.

Watch the video below — and stay tuned for future videos from the Healthier Washington Practice Transformation Support Hub featuring other practices and other practice transformation topics!



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 Keeping You in the Know


CMS accepting hardship exception applications for 2017 Quality Payment Program  Full story

Eastern Washington University Announces New Online Degree in Health Sciences
he EWU College of Health Science and Public Health is offering a BS in Health Sciences, completely online, starting this fall.  For more information, please contact the College of Health Science and Public Health: | [email protected]  509.828.1351

HRSA awards WSU College of Nursing $1.3 M to expand NP program 
The Health Resources and Services Administration awarded Spokane-based Washington State University College of Nursing a $1.3 million federal grant to expand its nurse practitioners program to help fight the shortage of primary care in the state.

A Robust IT Strategy Helps a Critical Access Hospital Remain Independent

In picturesque and evergreen Western Washington state, a 25-bed critical access hospital is setting a ... The ACO's patients are in traditional Medicare. Most Wired Mason General Hospital may be small, but its managers think big when it comes to IT.  Link to full story: A Robust IT Strategy Helps a Critical Access Hospital Remain Independent

Kitsap Mental Health Services: Race to Health!

Need: To improve the physical health of individuals seeking mental healthcare.
Intervention: Race to Health! In Washington integrates mental health, substance use disorder treatment, and primary care for individuals with severe mental illness.
Results: Race to Health! helps reduce emergency department visits, hospitalizations, and costs (a total savings of $5,144,000 for Medicare patients).

Here is a list of all the models and innovations on RHIhub for Washington state:

CMS will cancel major bundled payment initiatives

CMS has proposed canceling the cardiac and expanded joint replacement bundled payment models.

The rule, which was sent to the Office of Management and Budget last week, would cancel the mandatory bundled payment programs for heart attacks and bypass surgeries as well as expansion of the existing Comprehensive Care for Joint Replacement model to include surgical treatments for hip and femur fractures. Those bundled payment initiatives have already been delayed twice. They're currently slated to take effect Jan. 1, 2018.

Physicians would have the opportunity to earn a 5 percent bonus for participating in the cardiac bundles or the expanded CJR model, as the initiatives qualify as Advanced Alternative Payment Models under the Medicare Access and CHIP Reauthorization Act's Quality Payment Program. Once finalized, the CMS rule would eliminate the bonus opportunity for physicians.

Washington state gets $368,000 under Medicaid fraud settlement

OLYMPIA — Washington state will keep a small fraction of a $280 million national settlement involving a pharmaceutical company accused of committing fraud by promoting two drugs for unapproved cancer treatments.

Celgene Corp. denied wrongdoing but agreed to pay the federal government, 28 states and the District of Columbia to settle a whistleblower claim brought by a former company saleswoman. Washington state will keep about $368,000 for its Medicaid program under the settlement announced Tuesday. The whistleblower could be entitled to as much as $84 million.

Washington Attorney General Bob Ferguson says that from 2000 to 2015, Celgene marketed and sold medications Revlimid and Thalomid for conditions the FDA had not approved, and that the company promoted the drugs by making false or misleading statements in medical literature and clinical studies.

Prosecutors also said Celgene paid physicians kickbacks for prescribing the medications.

End-of-life advice: Medicare covers the cost of care-planning sessions

In 2016, the first-year health-care providers could bill for an end-of-life consultation, nearly 575,000 Medicare beneficiaries took part in the conversations, new federal data obtained by Kaiser Health News show.

"The 90-year-old woman in the San Diego-area nursing home was quite clear", said Dr. Karl Steinberg.  "She didn’t want aggressive measures to prolong her life. If her heart stopped, she didn’t want CPR".  But when Steinberg, a palliative-care physician, relayed those wishes to the woman’s daughter, the younger woman would have none of it.  “She said, ‘I don’t agree with that. My mom is confused,’ Steinberg recalled, “I said, ‘Let’s talk about it.’  Instead of arguing, Steinberg used an increasingly popular tool to resolve the impasse last month.  He brought mother and daughter together for an advance care-planning session, an end-of-life consultation that’s now being paid for by Medicare.

In 2016, the first-year health-care providers could bill for the service, nearly 575,000 Medicare beneficiaries took part in the conversations, new federal data obtained by Kaiser Health News shows.  Nearly 23,000 providers submitted about $93 million in charges, including more than $43 million covered by the federal program for seniors and the disabled.  Use was much higher than expected, nearly double the 300,000 people the American Medical Association projected would receive the service in the first year.

That’s good news to proponents of the sessions, which focus on understanding and documenting treatment preferences for people nearing the end of their lives. Patients, and often, their families, discuss with a doctor or other provider what kind of care they want if they’re unable to make decisions themselves.

“I think it’s great that half a million-people talked with their doctors last year.  That’s a good thing,” said Paul Malley, president of Aging with Dignity, a Florida nonprofit that promotes end-of-life discussions. “Physician practices are learning.  My guess is that it will increase each year.”

Still, only a fraction of eligible Medicare providers — and patients — have used the benefit, which pays about $86 for the first 30-minute office visit and about $75 for additional sessions.

5 Best, Worst States for EHR Adoption

Massachusetts is the best state for EHR adoption, according to a Center for Data Innovation report. For the report, the data-policy think tank benchmarked U.S. states based on 25 indicators related to data-driven innovation. The indicators assess states' strengths across three categories: data availability, technology platforms and human-business capital. Within the technology platforms category, the Center for Data Innovation ranked all 50 states on the extent to which physician and hospitals in the state used EHRs.

Here are the top five states based on EHR adoption:
1. Massachusetts
2. Wyoming
3. Washington
4. Minnesota
5. Indiana

Here are the bottom five states based on EHR adoption:
1. New Jersey
2. Rhode Island
3. Louisiana
4. Hawaii
5. Vermont

Click here to view the full report.

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UW Medical Student Reflections on Rural Practice

Submitted by: Justin Thompson, Soroosh Noorbakhsh, Tiffany Jenkins and Toby Keys, MPH

What do we know about student interest in practicing rural medicine in our state?  We are excited to share reflections from University of Washington Medical Students about their experiences in the Rural/Underserved Opportunity Program (RUOP).   These reflections shed light on how early immersion rotations in rural communities can contribute to Washington’s rural health care workforce pipeline. RUOP is a four-week rural/underserved rotation in communities across Washington, Wyoming Alaska Montana and Idaho (WWAMI).  Over half of each medical student class (there are 270 students in the 2017 entering class) participate in RUOP each year.  This summer, 63 RUOP students were placed in Washington.   RUOP is one of three rural programs based in the newly established UW School of Medicine’s Office of Rural Programs lead by UWSOM Assistant Dean, Dr. John McCarthy.  For some students, RUOP has opened their eyes to the possibility of working in a rural community. For others, it helped confirm their career trajectory in rural medicine.

Lessons from Patients

For RUOP, I returned to Moses Lake—the community where I spent a week before the start of medical school. Ironically, I began this experience by seeing the first patient I interviewed on my previous visit.  As a part of the Targeted Rural/Underserved Track (TRUST), I spent several hours with this patient last summer. It was so fulfilling to start RUOP with a familiar face and to hear how his year was like for him. To me, people’s stories are what make medicine human: their joys, successes, struggles, and triumphs.   It is this continuity and the ability to form meaningful relationships with patients that makes rural medicine so appealing.  My preceptor, Dr. Kearns, is extremely knowledgeable and a fantastic teacher.  He ensures that I learn not only the relevant clinical details, but also the interplay between the relevant anatomy and the systems of the body. Being immersed in a rural community was not only a great learning experience, but a striking reminder of why I am pursuing medicine in the first place.  I had the opportunity to be a small part of our patients’ lives, some of whom confided in me and allowed me the honor to bear witness to their pain.  These patients have taught me more than I could ever offer them, and their contribution strengthens my resolve to finish medical school and practice somewhere in need of young doctors.
***The first reflection ”Lessons from Patients”  was written by medical student Justin Thompson.  His primary preceptor, Dr. Dennis Kearns, works at Confluence Health in Moses Lake, WA.  Justin is based on the UW WWAMI Gonzaga Campus in Spokane, WA.  Justin is also a Targeted Rural Underserved Track (TRUST) Scholar.  Initiated in 2008,  TRUST’s goal is to channel students, primarily those from rural underserved backgrounds, into training that fosters their rural underserved interests.  As such, the program sends TRUST Scholars to the same rural community several times throughout their four-year medical school training.   This continuity creates a special learning environment that fuels student interest in rural medicine from matriculation to graduation.

More than Just an Assignment

Never had I heard of Brewster, Washington, but I somehow found myself living, learning, and working there for 4 weeks. From July to August 2017, I worked at Family Health Centers with Dr. James Wallace as part of the University of Washington’s Rural/Underserved Opportunities Program (RUOP).  I went into this experience expecting the worst, worried about making a good impression and finding my place in a small, tight-knit community, but my time in Brewster became one of the highlights of my summer.  Upon my first visit to the clinic, I found that the staff members were incredibly warm and more than willing to go out of their way to welcome a new face.  This became a pattern in Brewster and Okanogan County in general, as the hospital staff, public health officials, and the townspeople themselves were all similarly friendly and helpful.  All of this made it so my time in Brewster was extremely positive.  In the rural setting, doctors are required to work to the full scope of their ability, and this makes it possible for students to learn a great deal from clinical observation. The most memorable aspect of rural health for me, however, was the personal connection and continuity of care that is so integral to it.  An example of this was caring for one of Dr. Wallace’s OB patients who I first met for a routine appointment at the clinic.  During the final week of her pregnancy, I had the chance to interview her and see how she was doing.  The next week, she went into labor and had to have an emergency caesarian section, performed by Dr. Wallace.  I was present throughout this process, taking part in the anxiety of the surgery and seeing the exhaustion of everyone involved. The week after that, the patient returned with her husband and their baby boy for his first checkup in the clinic.  To me, this continuity of care defines family practice, and the best place to experience it is in a rural community like Brewster.  As part of the RUOP program, I worked on a public health project with members of the Okanogan County community.  During this time, I saw both the problems and strengths of public health in rural regions.  A recurring issue was simply a lack of resources.  Rural areas do not have the level of access to healthcare resources as more developed regions, and this is reflected in the concerns public health departments try to address.  What might be easily accessible in an area like Seattle, such as family planning services, may be almost completely unavailable in all of Okanogan County.  A benefit of being in a rural community, however, is that if you can figure out how things work for a given issue and can get in touch with the people in charge of handling it, you can make meaningful changes fairly quickly. Even though access is limited in rural areas, it is possible to make an impact by working with local leaders to solve health-related problems.  Overall, my time in Brewster was more to me than just a school assignment.  It gave me a chance to connect with people who I would not have met before and let me explore a region I had never seen.  My four weeks in Brewster will stick with me for life.
***The second reflection, “More than Just an Assignment,” was written by medical student Soroosh Noorbakhsh.  Soroosh’s primary preceptor was Dr. James Wallace of the Family Health Center in Brewster, WA.  Soroosh is based on the UW WWAMI Gonzaga Campus in Spokane, WA.

My RUOP experience with the Lummi Nation, a sovereign Native American tribe found on the northern shores of Washington’s Puget Sound, was one of the most unforgettable and meaningful experiences of my life.  The first two days of my stay, I was lucky enough to have arrived on some of the most important days of the year for the Lummi community; the canoe landing. This is when the tribe hosts canoe families from other local tribes and joins them as they voyage up Washington's Puget Sound to the Campbell River in Canada. As part of this celebration, the community gathered on the shore where the canoes landed to celebrate and welcome the canoe families from other tribes. During this time, the different nations shared their dances and songs with one another, something I felt honored to have seen.  While working with the doctors in the clinic, I got to hear patient stories, practice suturing, and brush up on my physical exam skills as I learned more about the Lummi people and the art of medicine. I’ll never forget examining a man’s abdomen, who, after years of alcoholism was starting to enter liver failure. As I felt the hard edge of his liver (something I’d not yet felt before), he looked at me with his jaundiced eyes and asked if I felt anything. I told him that I had felt his liver and asked if he’d like to feel it himself. When he said yes, I took his hand in mine and pressed it to his side, told him to breathe in and out and guided his hand down the angle of his ribcage. I helped him repeat the process on the other side too to give him a better comparison, and was surprised as tears started to roll down his face. I think the reality of his liver damage hit him then; it wasn’t just numbers on a page, it was something he could feel with his own two hands.  During my stay, I also worked really hard to design and implement a hands-on, culturally appropriate nutrition education program for the Lummi children, an idea inspired by the high rates of obesity and diabetes I saw in the clinic. I was fortunate enough to find a community partner that had recently been given a grant to support nutrition education for the youth, as well as 2 excited RDs that were more than happy to help support the project. During my last week I spent 4 days teaching the Lummi children about healthy habits (including eating healthy and exercising) and how to build a healthy plate from the ground up. We planted their own garden, went black berry picking, made yummy recipes together such as a rainbow pasta salad and blackberries smoothies, and more. The last day we talked about healthy proteins and I invited two elders to come share salmon stories with the children, as the Lummi people consider themselves “salmon people.” I felt I learned as much from the kids and the elders as they learned from me, and when the kid would hug me at the end of the day I knew all my hard work was worth it.
***The final reflection, “Unforgettable,” was written by Tiffany Jenkins.   Tiffany’s primary preceptor was Dr. Justin Iwasaki of the Lummi Tribal Health Center located in Bellingham, WA.  Tiffany is based on the UW WWAMI Seattle Campus.

A program as broad and complex as RUOP cannot operate without the help of many regional partners.  RUOP partners with multiple regional Area Health Education Centers, WWAMI campuses in Spokane, Laramie, Anchorage, Bozeman and Moscow, several state medical organizations and over 120 volunteer preceptors.  The RUOP program is particularly grateful for the long-term support of the Washington Academy of Family Physicians Foundation.  The WAFP Foundation offers many of the RUOP students placed in Washington a stipend to help support them financially over the summer.  Over RUOP’s 28-year history many former RUOP students have continued on to practice medicine in rural communities across Washington.  While it is still early to know where Jason, Soroosh and Tiffany will end up practicing, it is encouraging to know that these future physicians had profound experiences that deepened their appreciation for rural practice.  

The RUOP program is always looking for primary care preceptors who are interested in hosting a student on a four-week rotation over the summer. For information about RUOP and precepting, contact RUOP Program Manager, Sarah Lee at [email protected] visit the RUOP website:

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Time is Your Pain Patient's Enemy!

Submitted by:  Bobbi Meins, Pacific Rehabilitation Centers
Written by:  Dr. Michael D. Harris, Ph.D.

Decades have been spent researching and evaluating treatments and management strategies for chronic, non-cancer pain. The current opioid epidemic has cost patients and families dearly and has reminded us that magic rarely comes from a pharmacy. It has also compelled the experts in the treatment of chronic pain to pause and re-visit the options for reducing/managing this all-too-costly condition.

Although there continues to be debate about the best clinical methods, the evidence has consistently shown that multidisciplinary, structured functional restoration paired with changed expectations and beliefs about the pain is the superior option in terms of risks, costs, efficacy, durability and access. We have an excellent, working model for addressing pain. And still a large percentage of the population experiences disabling, non-cancer pain. Why?

The answer is in no one conversation, case or treatment approach. However, decades of experience treating chronic pain patients brings story after story of how the pain went from acute to subacute to chronic in the weeks, months and years of suffering. “Try this and wait/watch. Let’s see if this will work. That is not paid for by the insurance. Try that and wait/watch. Try the other thing and wait/watch.” And therein lies the answer… Time is THE enemy!

How can the mere passage of time be the most dangerous element in the care of a patient with non-cancer pain? Our own experience and the scientific literature has shown us that even brief periods of inactivity can have devastating consequences for even very healthy individuals.

De-activation – loss of muscle tissue, reduction in range of motion and lowered cardiovascular fitness secondary to inactivity are common among individuals with chronic pain. Then when the patient attempts to function, engage and participate of course the pain is worsened. The patient typically interprets the pain exacerbation as proof that the original problem is still there, undiagnosed and in need of acute intervention, all of which is probably not true.

Family-Social Role Disruption – forced changes in one or more family and/or social roles are the norm. The pain causing developing disability are frequently the cause of involuntary role changes within families. The primary bread-winner is no longer working and the stay-at-home spouse is forced into the workplace. It is typically the case that neither want or are fully prepared for these changes. Financial disruption and family dysfunction are almost universal in these situations. The impact is not limited to the spouses – the children are also directly impacted. Routines of care, quality time, etc. are abruptly stopped or continued in ways that they get less, feel less in ways that can lead to more serious school and/or social difficulties.

Workplace Disenfranchisement – lost/changed relationships with the employer and coworkers are almost universal among injured workers with pain. It is frequently the case the employer and co-workers believe the injured worker is ‘costing the company money’ and consequently premiums for workers’ compensation benefits will rise. Furthermore, a few unscrupulous injured workers fraudulently abuse the system, which casts doubt on all workers who have L&I claims. As pain-related work absences continue, roles change in the workplace and routines are adjusted, making a smooth return for the worker and employer challenging. Clearly, the stay-at-work and early return-to-work programs minimize many of these issues and significantly improve the chances of pain NOT becoming the enemy.

Secondary Gains – can be powerful disincentives for full participation and engagement in family, work and social activities. They are typically very subtle reinforcers for disability behavior related to pain. Sometimes they are not-so-subtle – some injured workers receive more in untaxed time loss benefits than they did after tax while working. More typically, the reinforcers come in the form of increased attention to demonstrations of pain, i.e. offers to do tasks for the pain patient that probably could be done safely by him/her. The other person feels badly for the suffering patient and believes that ‘helping’ is the moral, charitable thing to do.

Medication issues – have been at the forefront of public safety conversations in recent years. The opioid epidemic has extracted a major toll for many families and Washington State has suffered dearly from loss of life via overdose. The risk of issues grows with each week a patient is given opioid analgesics. Other medications (benzodiazepines, etc.) are also not without risk.  The sooner the patient learns and incorporates non-medication pain management strategies (as provided in interdisciplinary pain management treatment) and discontinues pharmacological treatment of the condition the better.

New or Worsened Mental Health Issues – are common among individuals with pain. It is not surprising that depression, anxiety, and stress-related disorders occur at levels significantly higher than the base rate in the US. Population. Family and relationship problems are universal among this patient group. Furthermore, risk of suicide is almost double among individuals with chronic pain issues.

The sooner and more effectively individuals with pain conditions can be provided with low-risk, self-managed pain coping strategies the better. Time increases the risk of comorbid issues and long-term disability. There are many evidence-based treatment alternatives available in most communities. The advent of telehealth service deliver has been a major step forward in making these services available to underserved/rural communities. Remember, time is your pain patient’s enemy. Act now!

Dr. Michael Harris is the Clinical Director and Chief Operating Officer at Pacific Rehabilitation Centers.  He has been treating patients with chronic pain for over 25 years.  For more information about evidence-based treatment of pain, please call Bobbi Meins, 425-777-4003.

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Last but not Least, More Items of Interest....




After 25+ years of service, WRHA understands the unique challenges of reaching rural health professionals.  They trust us to advocate for them, provide education and share opportunities.  WRHA enhanced its sponsorship offerings by adding a NEW advertising opportunity to engage and excite rural health leaders and build brand loyalty for your company.

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2018 NW Rural Health Conference:  
Dawn Bross of the Rural Health Clinic Association of Washington, has been named conference manager.  Krista Loney from WWAMI - Area Health Education Center and Beionka Moore will serve as the 2018 conference leadership team.  This conference, also organized with the assistance of the State Office of Rural Health, Washington State Department of Health (SORH/DOH), includes representation from many agencies and organizations in the Pacific Northwest.  This popular & informative event will take place at The Davenport Grand, 333 West Spokane Falls Blvd, Spokane, WA.  March 26-28, 2018.
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