From Silos to Bridges: Collective Action to Build Rural Health Care Capacity

January 2017

By David Mortimer, MDiv, Hospital Sisters of St. Francis Foundation Innovation Institute

I grew up on a rural farm in Wisconsin. Two silos next to the barn were a picturesque fixture, and they were designed to store fodder, forage, or grain. Although they may be a critical feature to some farming livelihoods, silos in rural health care organizations are a metaphor for systems, processes, or departments that operate in isolation. These silos tend to drain the organizational lifeblood because a lack of interaction with other groups can result in inefficiency, missed opportunities for innovation, and even stagnation. 

Over the decades, rural health care has been experiencing a cultural shift away from silos. This shift has been accentuated by advances in communications technology and remote presence telemedicine. Many rural organizations have been energized by exploring new self-governed collaborative, network, consortium, and cooperative models that actually replace silos with bridges.[1] The basic idea is that collective action is an indispensable tool to counter the great challenges faced by rural communities.
 

Articulating the need for collective action

It’s no secret the typical rural health landscape in America faces growing challenges and that rural dwellers face a kind of penalty when compared to urban populations. Not only has rural America experienced declining population, jobs, opportunities, and resources, but a digital divide creates barriers in education, business development, and quality of life. (Many young rural friends of mine graduate high school and leave home, and will never even consider settling down in a community with poor internet connectivity.) Due to demographics and the impact of globalization on local economic development, many rural counties are experiencing an eroding tax base and declining representation in state and federal government. 

These complex and incremental changes are causing substantial disparities in patient access to health care—particularly behavioral health—and provider shortages.  Because they have less access to health care, rural Americans experience the “distance decay” effect—the lower use of health care services with increasing distance—which can result in more advanced and higher levels of disease.[2] Rural dwellers face greater barriers in follow-up care, appointments, and compliance, and have higher rates of chronic disease, readmissions, and emergency department utilization. While these great challenges might seem overwhelming to rural stakeholders and providers, they have become compelling drivers of collective action and bridge-building.

Recognizing opportunities to collaborate

Collective action allows rural organizations to leverage limited capacity, maximize economies of scale, and share resources. The critical first step on this journey is to identify silos and opportunities for collaboration. Literally, this requires getting the right organizational representatives around a table, and this can happen in a variety of ways. I’ve personally been involved with two networks that successfully navigated this step:

  • The Chippewa Valley Inter-Networking Consortium (CINC) is a community area network in western Wisconsin that began in 1999 as a “breakfast club.”  IT managers and chief information officers of a city, county, university, school district, and others met weekly to discuss preparations and contingency plans for Y2K. After Y2K passed without incident, the stakeholders began to realize they had several common interests in advanced fiber optic connections and could collaborate on infrastructure to share applications and save costs. Sixteen years later, the vertically-integrated network has leveraged public-private investments with support of federal and state grants to create more than 230 miles of 96-strand fiber and 16 towers with a value in excess of $13 million. Today, CINC has 39 members, an elected board, bylaws, and a tagline that reads “collaborate-connect-save.” In addition to libraries, universities, and colleges, the network includes regional EMS and Hospital Sisters Health System and Mayo Clinic Health System (competitor providers!) that use the fiber infrastructure to share applications, to reduce costs, and to help bridge the digital divide by extending services into rural areas.
  • The Illinois Telehealth Network (ITN) is an emerging network that was launched in 2014 by C-suite hospital leaders who realized common needs and opportunities, and sought to formalize a network planning process through a simple MOU. Members received financial support from Hospital Sisters of St. Francis Foundation Innovation Institute and the HRSA Rural Health Network Planning program to advance telehealth and telemedicine in rural communities with a needs assessment and strategic planning. Today, ITN has a board, bylaws, 26 mostly rural hospital and health care members (including many competitors!), and is dedicated to its mission “to improve access to health care, in rural, underserved and disadvantaged communities, through the application of telehealth and telemedicine solutions.” The collaborative serves a rural service area with a patient population of more than 1.2 million. ITN is currently supported by a diverse portfolio of more than $1 million in highly competitive federal and private foundation grants. ITN’s tag line is: “Connecting resources, strengthening rural health care, saving lives.”

The first step toward sustained collective action from a stakeholder’s point of view always involves the realization that there are tangible opportunities. In the CINC and ITN examples above, charter members began to realize that benefits of collaboration included being able to provide many more services with far fewer resources. Alone, members had little or no capacity, resources, or experience in successfully applying for a federal grant opportunity, but together, members combined the necessary resources to both apply and leverage opportunities with matching funds. 

Bringing stakeholders to the table

Shared activities open doors to opportunities for grants, collaborative fundraising, and other opportunities. Alone, most ITN and CINC members would not even be eligible for many federal and state and private foundation funding. Together, network members find they are not only eligible to apply for many grant opportunities, they find they have greater resources to pool financial resources to secure matching grant funding and operationalize new projects. (Another advantage is that having different network member calendar year or fiscal year end dates provides additional year-round financial agility in committing matching funding toward a project of interest, despite thin operating budgets.)

In ITN planning meetings, several small rural hospitals without emergency department telemedicine equipment initially thought they brought little value to the ITN network, only later to learn they had exceptionally high value to the greater network because they would score very high in a USDA Distance and Learning Telemedicine grant application. In fact, their rural status serving high-poverty communities also provided great value to ITN’s other federal grant applications. Successful ITN-led grant applications secured equipment, and they were able to participate in the network’s new emergency department tele-stroke program.

As a network matures, other opportunities often follow. Group purchasing may lead to shared costs and mutual savings. With growth, ITN leverages larger patient volumes to secure better vendor price points for telemedicine services. Other shared network resources (such as job descriptions, workflows, billing and payment protocols) help all members accelerate programs and reduce costs and duplication.  Depending on the project, some members contribute specific legal or financial services. Others may contribute advocacy, marketing, or public relations expertise. 

Keeping stakeholders engaged
 
Sustained engagement in network activities by pioneer members is driven by continued benefits and prospective opportunities. Without these, members will naturally lose interest and drop out. Economies of scale experienced in the CINC and ITN examples above include collaborative support to develop new services. These networks also share equipment, allow members to share costly software applications, and even services and staff. Lastly, collaboration provides access to new resources that are only available to larger organizations.  

Bridge building will always be more challenging than silo building. As Gregory Bonk noted, “Rural health networking is not easy; it requires time, trust, will, and skills.” He added, “Network members must have the ability to separate their individual goals from the common goals of the network, and the vision to see the potential benefits of joint action.”[3] Bonk outlines key elements of network development that include a compelling need, expected benefits, form and function, and key participants.

New and emerging networks can build momentum with smaller “easy wins” that are communicated to all members, and are followed by other good-faith efforts that are inclusive and innovative in meeting member needs. Eventually, silos are replaced by bridges that are shared by all members, and improve client services and reduce costs. As one network member in CINC commented about their old silo thinking, “We’d never go back.”
 
David P. Mortimer, MDiv, is Director of the Hospital Sisters of St. Francis Foundation Innovation Institute. He serves as the Administrative Director for the Illinois Telehealth Network (ITN) and chairs the Communications Committee for the Chippewa Valley Inter-Networking Consortium (CINC). The Hospital Sisters of St. Francis Foundation Innovation Institute provides program investments and infrastructure to support projects that improve outcomes, increase rural access to care and decrease costs through improved efficiencies. 
 
[1] Turning Point Initiative. From silos to systems: Using performance management to improve the public’s health. Turning Point National Program Office, p. 3; 2003. http://www.phf.org/resourcestools/Documents/silossystems.pdf
[2] Wong ST, Regan S.  Patient perspectives on primary health care in rural communities: effects of geography on access, continuity and efficiency. Rural and Remote Health (Internet) 2009; 9: 1142. Available: http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=1142 (Accessed 12/31/16).
[3] Gregory Bonk, Principles of Rural Health Network Development and Management (2000), p. 1.
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