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Capacity-Building Needs of Rural and Frontier Health Service Organizations: Results from the Health Service Organization Capacity Building Survey Health Resources and Services Administration Office of Rural Health Policy Network Development Planning Grant Grant Number: P10RH26422

April 2014

Prepared for: National Network for Frontier and Rural Capacity

Prepared by: The Office for Community Health University of New Mexico Health Sciences Center

Capacity-Building Needs of Rural and Frontier Health Service Organizations

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Table of Contents Executive Summary ........................................................................................................ 5 Introduction ..................................................................................................................... 7 Methodology .................................................................................................................... 7 Findings ........................................................................................................................... 8 Conclusion .................................................................................................................... 32 Appendix 1: Health Service Organization Capacity Building Survey ............................. 33 Table of Figures Figure 1: Type of Health Service Organization ................................................................ 9 Figure 2: Capacity Implementation Level – All Survey Responses ............................... 12 Figure 3: Internal Factors that Helped with or Motivated Implementation of Capacities 17 Figure 4: External Factors that Helped with or Motivated Implementation of Capacities ...................................................................................................................................... 18 Figure 5: Internal Factors that Hindered Implementation of Capacities ......................... 21 Figure 6: External Factors that Hindered Implementation of Capacities........................ 22 Figure 7: Internal Factors that Helped with or Motivated Implementation of Capacities by Health Service Organization Type ................................................................................. 23 Figure 8: External Factors that Helped with or Motivated Implementation of Capacities by Health Service Organization Type ............................................................................ 24 Figure 9: Internal Factors that Hindered Implementation of Capacities by Health Service Organization Type ......................................................................................................... 25 Figure 10: External Factors that Hindered Implementation of Capacities by Health Service Organization Type ............................................................................................ 26 Figure 11: Reasons Capacities Challenging to Implement by Health Service Organization Type ......................................................................................................... 31

Table of Tables Table 1: Response Count by State ................................................................................. 8 Table 2: Type of Health Service Organization ................................................................. 9 Table 3: Business Model of Health Service Organization .............................................. 10 Table 4: Role of Person Completing Survey ................................................................. 10 Table 5: Capacity Implementation Level – All Survey Responses ................................ 11 Table 6: Capacity Implementation by Health Service Organization Type ...................... 13 Table 7: Average Implementation of All Capacities by Health Service Organization Type .............................................................................................................................. 15 Table 8: Internal Factors that Helped with or Motivated Implementation of Capacities . 15 Table 9: External Factors that Helped with or Motivated Implementation of Capacities 16 Table 10: Internal Factors that Hindered Implementation of Capacities ........................ 19


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Table 11: External Factors that Hindered Implementation of Capacities ....................... 20 Table 12: Most Challenging Capacities to Implement ................................................... 27 Table 13: Most Challenging Capacities to Implement by Health Service Organization Type .............................................................................................................................. 29 Table 14: Reasons Capacities Challenging to Implement ............................................. 30


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Executive Summary This report summarizes the findings of a survey of rural and frontier-serving health service organizations (HSOs) around the nation conducted between December 2013 and March 2014. The survey is part of a Health Resources and Services Administration Rural Health Network Development Planning Grant. The purpose of the Network project is to develop the infrastructure for deployment of capacity building resources to support health providers in frontier and rural areas achieve better care, better patient health and lower costs. The purpose of the survey was to inform the creation of a subsequent survey of State Offices of Rural Health (SORHs) that will assess the ability of SORHs to meet the needs identified. The results of both surveys will be used to develop a “Rural Capacity Building Framework” that includes a curriculum, resources, tools, and methods to better serve rural and frontier healthcare providers.

A total of 291 health service organizations (HSOs) completed the survey, representing 28 states and a variety of HSO types, including critical access hospitals (CAHs), rural health clinics (RHCs), community health centers, combined RHCs and CAHs, and rural hospitals. The vast majority of those who completed the survey had either a senior management or an administrative/operations role in the HSO.

Most of the HSOs had either implemented or were in the process of implementing all of the eleven capacities about which they were surveyed. The capacities were based upon the patient-centered medical home model. The capacities with the highest levels of implementation were clinical care coordination, safety, management, and organization-based services. Access to care and information and care management were the capacities least likely to have been implemented, but the majority of those who had not were “in the process of implementing” them. Only one of the capacities was “not a priority at this time” for more than 10% of respondents – insurance enrollment assistance. It appears that community health centers are the furthest along among the HSO types that responded, with over 90% of them reporting they had implemented nine of the 11 capacities.

The survey asked respondents to identify the internal (i.e., within the HSO) and external factors that both helped and hindered them from successfully implementing the capacities. The most commonly chosen internal factors that helped with or motivated capacity implementation were supportive leadership, the belief that implementation would improve patient health outcomes, and the belief that implementation would improve community health.

The external factors most commonly chosen as contributors to successful capacity implementation were incentives or penalties, external collaborations and partnerships, and sufficient information about the initiative. The external hindrances to the responding HSOs’ efforts to implement the capacities were varied, with none of the suggested


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factors selected by a majority of the respondents. However, it should be of interest to capacity-building organizations that the factor chosen most often by respondents was “Lack of ability to hire or lack of access to experts/consultants”.

Finally, survey respondents were asked “of the capacities you have implemented or are in the process of implementing, which were the most challenging and why?” Over half of the respondents provided responses related to health information technology. Four of the five “Other” responses mentioned the challenge of attaining patient-centered medical home (PCMH) recognition, and since most of the eleven capacities reflect PCMH standards, the “All” responses could also be considered a selection of PCMH recognition as the second-most challenging capacity.

The reasons respondents gave for why the capacities were challenging to implement were multiple and varied. Nearly half of respondents gave responses related to lack of funds or resources, while the next three most common responses had to do with a lack of buy-in on the part of providers or staff, lack of time, and lack of staff.


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Introduction This report summarizes the findings of a survey of health service organizations (HSOs) around the nation conducted between December 2013 and March 2014 as part of a Health Resources and Services Administration Rural Health Network Development Planning Grant1. The survey will inform the work of the National Network for Frontier and Rural Capacity, a project coordinated by the National Center for Frontier Communities in Silver City, NM in partnership with the National Organization for State Offices of Rural Health and the University of New Mexico Health Sciences Center. The purpose of the Network project is to develop the infrastructure for deployment of capacity building resources to support rural health providers in frontier and rural areas achieve better care, better patient health and lower costs. The results of this survey will be used to inform the development of a survey of State Offices of Rural Health (SORHs), the results of which will form the basis of the capacity building resources. Individual reports for each of the 28 states that participated in the HSO survey are available by request. Please contact Paige Law at the National Organization of State Office of Rural Health (NOSORH) at [email protected].

Methodology The survey summarized in this report was designed by the project’s Steering Committee, which includes Susan Wilger with the National Center for Frontier Communities, who serves as the Network’s Project Director; Teryl Eisinger, Executive Director of NOSORH; and Molly Bleecker, Program Manager at the University of New Mexico’s Office for Community Health (and the author of this report), as well as the project’s Capacity Workgroup, which includes representatives of five SORHs: Graham Adams at the South Carolina Office of Rural Health, Natalie Claiborne at the Montana Office of Rural Health, Lisa Davis at the Pennsylvania Office of Rural Health, R. Scott Daniels at the Hawaii State Office of Rural Health, and Lucrecia Johnson and Tina Turner at the Primary Care & Rural Health Program at the Ohio Department of Health.

A request to distribute an invitation to complete the survey was extended by NOSORH to the SORHs. The SORHs then sent the invitation along to the health service organizations with which they work.

1 Grant number P10RH26422

mailto:[email protected]


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Findings A total of 291 HSOs completed the survey, representing 28 states and a variety of HSO types (see tables 1, 2, and 3 and Figure 1, below). The vast majority of those who completed the survey had either a senior management or an administrative/operations role in the HSO (Table 4).

Responding HSO Characteristics

Table 1: Response Count by State

State CountAL 9AR 11CA 3CO 7DE 2GA 14HI 3IL 19

KS 31KY 10LA 3MD 1MO 7MT 22NE 20NM 6NY 13OH 13OK 9OR 4PA 2SC 6SD 12VA 5VT 3WA 19WI 32WY 5

Response Total 291State Count 28


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Table 2: Type of Health Service Organization

Figure 1: Type of Health Service Organization

Type Count PercentCritical Access Hospital 140 48%Rural Health Clinic 60 21%Community Health Center 29 10%Combined Rural Health Clinic and Critical Access Hospital 25 9%Rural Hospital 25 9%Other 8 3%Rural Health Network 4 1%Total 291 100%


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Table 3: Business Model of Health Service Organization

Table 4: Role of Person Completing Survey

Capacity Implementation

Survey respondents were asked to indicate the level of implementation of eleven HSO capacities2. Most of them had either implemented or were in the process of implementing all of the capacities, with the highest levels of implementation in clinical care coordination and safety (85% of respondents), management (78%) and organization-based services (76%). Access to care and information and care management were the capacities least likely to have been implemented (59% of respondents had implemented them), but the majority of those who had not were “in the process of implementing” them. Only one of the capacities was “not a priority at this time” for more than 10% of respondents – insurance enrollment assistance (Table 5 and Figure 2).

Looking at the level of capacity implementation by HSO type (Table 6, over two pages, and Table 7), it appears that community health centers are the furthest along with over 90% of them reporting they had implemented nine of the 11 capacities. Rural health clinics also indicated impressive levels of implementation of the capacities. HSOs that were combined rural health clinics and critical access hospitals demonstrated the least amount of implementation of the 11 capacities.3

2 The project’s Steering Committee and Workgroup chose the eleven capacities. Many of the capacities relate to the patient-centered medical home model, as elaborated by TransforMED (https://www.transformed.com/). See a copy of the survey in Appendix 1 for further description of each capacity. 3 Four rural health networks responded to the survey. While not health service organizations per se, their responses are included in this report because they offer a valuable perspective on the capacity-building process.

Model Count PercentNon-profit 208 71%Public 56 19%For-profit 27 9%Total 291 100%

Role Count PercentSenior Management 186 64%Administrative/Operations 99 34%Service Provider 5 2%Other 1 0%Total 291 100%


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Table 5: Capacity Implementation Level – All Survey Responses

CapacityClinical Care Coordination 247 85% 36 12% 5 2% 3 1%Safety 246 85% 39 13% 1 0% 5 2%Management 227 78% 60 21% 1 0% 3 1%Organization-Based Services 220 76% 48 16% 14 5% 9 3%Quality 217 75% 70 24% 2 1% 2 1%Non-Clinical Care Coordination 205 70% 48 16% 23 8% 15 5%Health Information Technology 205 70% 78 27% 7 2% 1 0%Insurance Enrollment Assistance 199 68% 43 15% 36 12% 13 4%Organization-Based Team Care 186 64% 82 28% 14 5% 9 3%Access to Care & Information 172 59% 98 34% 14 5% 7 2%Care Management 171 59% 90 31% 19 7% 11 4%

ImplementedIn the process

of implementingNot a priority at

this timeDon't know/Not

applicable


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Figure 2: Capacity Implementation Level – All Survey Responses


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Table 6: Capacity Implementation by Health Service Organization Type

Implemented 27 93% 43 72% 77 55% 12 48% 9 36% 1 25% 3 38% 172 59%In the process of implementing

2 7% 15 25% 53 38% 12 48% 13 52% 1 25% 2 25% 98 34%

Not a priority at this time

0% 2 3% 7 5% 1 4% 3 12% 0% 1 13% 14 5%

Don't know/Not applicable

0% 0% 3 2% 0% 0% 2 50% 2 25% 7 2%

Total 29 100% 60 100% 140 100% 25 100% 25 100% 4 100% 8 100% 291 100%


1 3% 5 8% 29 21% 3 12% 5 20% 1 25% 4 50% 48 16%


0% 3 5% 7 5% 1 4% 1 4% 0% 2 25% 14 5%


0% 2 3% 4 3% 1 4% 0% 1 25% 1 13% 9 3%

Total 29 100% 60 100% 140 100% 25 100% 25 100% 4 100% 8 100% 291 100%


3 10% 13 22% 53 38% 6 24% 10 40% 0% 5 63% 90 31%


0% 4 7% 11 8% 1 4% 2 8% 0% 1 13% 19 7%


0% 2 3% 4 3% 1 4% 2 8% 2 50% 0% 11 4%

Total 29 100% 60 100% 140 100% 25 100% 25 100% 4 100% 8 100% 291 100%


1 3% 2 3% 18 13% 6 24% 5 20% 1 25% 3 38% 36 12%


0% 1 2% 2 1% 0% 0% 0% 2 25% 5 2%


0% 0% 0% 1 4% 0% 2 50% 0% 3 1%

Total 29 100% 60 100% 140 100% 25 100% 25 100% 4 100% 8 100% 291 100%


3 10% 5 8% 25 18% 6 24% 6 24% 1 25% 2 25% 48 16%


0% 6 10% 10 7% 3 12% 3 12% 0% 1 13% 23 8%


1 3% 5 8% 5 4% 1 4% 2 8% 1 25% 0% 15 5%

Total 29 100% 60 100% 140 100% 25 100% 25 100% 4 100% 8 100% 291 100%

Implemented 22 76% 40 67% 91 65% 14 56% 16 64% 0% 3 38% 186 64%In the process of implementing

7 24% 16 27% 40 29% 9 36% 6 24% 1 25% 3 38% 82 28%


0% 2 3% 8 6% 1 4% 2 8% 0% 1 13% 14 5%


0% 2 3% 1 1% 1 4% 1 4% 3 75% 1 13% 9 3%

Total 29 100% 60 100% 140 100% 25 100% 25 100% 4 100% 8 100% 291 100%

Org

aniz

atio

n-B

ased

Ser

vice

sC

are

Man

agem

ent

Clin

ical

Car

e C

oord

inat

ion

Non

-Clin

ical

Car

e C

oord

inat

ion

Org

aniz

atio

n-B

ased

Tea

m C

are

Acc

ess

to C

are

&

Info

rmat

ion

Combined RHC and

CAH

Com-munity Health Center

Critical Access

Hospital

Other (please specify)

Rural Health Clinic

Rural Health

NetworkRural

HospitalGrand Total


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Table 6: Capacity Implementation by Health Service Organization Type, Cont’d


3 10% 26 43% 27 19% 4 16% 6 24% 1 25% 3 38% 70 24%


0% 0% 0% 1 4% 0% 0% 1 13% 2 1%


0% 1 2% 0% 0% 0% 1 25% 0% 2 1%

Total 29 100% 60 100% 140 100% 25 100% 25 100% 4 100% 8 100% 291 100%


0% 6 10% 21 15% 4 16% 3 12% 1 25% 4 50% 39 13%


0% 0% 1 1% 0% 0% 0% 0% 1 0%


1 3% 0% 1 1% 1 4% 0% 2 50% 0% 5 2%

Total 29 100% 60 100% 140 100% 25 100% 25 100% 4 100% 8 100% 291 100%


2 7% 16 27% 36 26% 8 32% 13 52% 1 25% 2 25% 78 27%


0% 3 5% 0% 0% 1 4% 0% 3 38% 7 2%


0% 0% 0% 0% 0% 1 25% 0% 1 0%

Total 29 100% 60 100% 140 100% 25 100% 25 100% 4 100% 8 100% 291 100%


2 7% 9 15% 33 24% 5 20% 7 28% 0% 4 50% 60 21%


1 3% 0% 0% 0% 0% 0% 0% 1 0%


0% 1 2% 1 1% 0% 0% 1 25% 0% 3 1%

Total 29 100% 60 100% 140 100% 25 100% 25 100% 4 100% 8 100% 291 100%


0% 12 20% 19 14% 6 24% 4 16% 0% 2 25% 43 15%


1 3% 7 12% 18 13% 1 4% 6 24% 0% 3 38% 36 12%


0% 5 8% 4 3% 0% 3 12% 1 25% 0% 13 4%

Total 29 100% 60 100% 140 100% 25 100% 25 100% 4 100% 8 100% 291 100%

Qua

lity

Safe

tyH

ealth

Info

rmat

ion

Tech

nolo

gyM

anag

emen

tIn

sura

nce

Enro

llmen

t A

ssis

tanc

eCombined RHC and

CAH


Critical Access

Hospital


Rural Health Clinic

Rural Health

NetworkRural

HospitalGrand Total


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Table 7: Average Implementation of All Capacities by Health Service Organization Type

Contributing and Hindering Factors for Capacity Implementation

The survey next asked respondents to identify the internal (i.e., within the HSO) and external factors that both helped and hindered them from successfully implementing the capacities. The most commonly chosen internal factors that helped with or motivated capacity implementation were supportive leadership (89% of respondents chose this factor), the belief that implementation would improve patient health outcomes (88% of respondents), and the belief that implementation would improve community health (78%) (Table 8 and Figure 3).

The external factors most commonly chosen as contributors to successful capacity implementation were incentives or penalties (71% of respondents), external collaborations and partnerships (52%), and sufficient information about the initiative (47%) (Table 9 and Figure 4).


Rural Health Clinic

Critical Access

HospitalRural

Hospital

Com-bined RHC and

CAH

Rural Health

Network Other TotalImplemented 91% 74% 71% 69% 62% 43% 40% 72%In the process of implementing

8% 19% 23% 25% 28% 18% 39% 22%


1% 4% 4% 3% 7% 0% 17% 4%


1% 3% 1% 2% 3% 39% 5% 2%

Total 100% 100% 100% 100% 100% 100% 100% 100%

All

Cap

aciti

es

Com

bine

d


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Table 8: Internal Factors that Helped with or Motivated Implementation of Capacities

Table 9: External Factors that Helped with or Motivated Implementation of Capacities

Factor Count PercentSupportive leadership 254 89%Belief that implementation would improve patient health outcomes 252 88%Belief that implementation would improve community health 224 78%Staff buy-in, will, motivation and interest 202 70%Ability to communicate key issues and value to staff 182 63%Sufficient computer hardware, software, IT support and bandwidth 178 62%Sufficient number and skills of staff 174 61%Ability to assess and adapt to continuously changing environment 171 60%Belief that implementation would improve ability to compete with other health care providers 158 55%Sufficient education about the initiative to inform the decision to implement 149 52%Sufficient capital 120 42%Sufficient time to dedicate to the initiative 94 33%Other (please specify) 12 4%None 1 0%

Total Respondents 287

Factor Count PercentFederal incentives/penalties 205 71%External collaborations and partnerships 150 52%Sufficient information about the initiative to inform the decision to implement 135 47%Assistance from a consultant outside of the organization 127 44%Competition for patients 112 39%Community planning, buy-in and support 105 37%Competition for providers 63 22%Competition for staff 50 17%Assistance from an academic health education center 20 7%Other (please specify) 13 5%None 9 3%



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Figure 3: Internal Factors that Helped with or Motivated Implementation of Capacities


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Figure 4: External Factors that Helped with or Motivated Implementation of Capacities


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There were fewer factors that large majorities of the respondents chose when it came to the factors that made it difficult for the HSOs to implement the capacities (tables 10 and 11 and figures 5 and 6). Just over half of respondents said both a lack of time and a lack of funds were HSO-internal hindrances (55% and 53% of respondents, respectively)4 and one-third chose “insufficient number or skills of staff”.

The external hindrances to the responding HSOs’ efforts to implement the capacities were varied, with none of the suggested factors selected by a majority of the respondents (Table 11). Still, it should be of interest to capacity-building organizations that the factor chosen most often by respondents (31%) was “Lack of ability to hire or lack of access to experts/consultants”. Nearly as many respondents chose “None” (26%), while two themes emerged in the “Other” category: lack of access to financial resources or sufficient funding from incentives or reimbursements (7 respondents) and conflicting requirements and lack of support from outside agencies and organizations (6 respondents).

Table 10: Internal Factors that Hindered Implementation of Capacities

4 This was echoed in the reasons given in response to the question “Of the capacities you have implemented or are in the process of implementing, which were the most challenging and why?” later in the survey. See below.

Factor Count PercentInsufficient capital 156 55%Insufficient time allowed to dedicate to initiative 151 53%Insufficient numbers or skills of staff 96 34%Insufficient computer hardware, software, IT support or bandwidth 77 27%Lack of staff will, motivation, and interest 56 20%None 42 15%Lack of sufficient education about the initiative to inform the decision to implement 31 11%Belief that implementation would not improve patient health outcomes 22 8%Belief that implementation would not improve community health 20 7%Inability to communicate key issues and value to staff 16 6%Organization leadership not supportive 15 5%Belief that implementation would not improve ability to compete with other health service organizations 14 5%Other (please specify) 12 4%



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Table 11: External Factors that Hindered Implementation of Capacities

Factor Count PercentLack of ability to hire or lack of access to experts/consultants 89 31%None 73 26%Lack of incentives or penalties 55 19%Lack of external collaborations and partnerships 47 17%Lack of sufficient information about the initiative to inform the decision to implement 46 16%Lack of access to assistance available through an academic health education center 43 15%Lack of community planning, buy-in and support 39 14%Other (please specify) 27 10%Little or no competition for patients 23 8%Little or no competition for providers 19 7%Little or no competition for staff 12 4%



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Figure 5: Internal Factors that Hindered Implementation of Capacities


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Figure 6: External Factors that Hindered Implementation of Capacities


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Looking at the contributing and hindering factors by HSO type (figures 7-10), we see that they closely reflect the breakdown of the respondents as a whole described above.

Figure 7: Internal Factors that Helped with or Motivated Implementation of Capacities by Health Service Organization Type

12% 12% 12% 13% 10% 10% 12%

11% 12% 11% 12%12% 10%

12%

10% 12% 10% 10%10%

10%10%

9%8%

10% 9% 11%10%

12%

10% 9% 8%8% 10%

10%

12%

9% 9%8%

9% 8%7%

8%7%

9%8%

8% 8%

3%

6%

8%8%

8%6% 8%

10%

8%

7%7%

8% 8% 6%

3%

4%

7%7%

7% 6% 6%

7%

6%

5%4%

6% 4% 6%

3%

8%

4% 4% 4% 5% 4%

10%

4%1% 1% 1%

7%2%1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CommunityHealth Center

Rural HealthClinic

Critical AccessHospital

Rural Hospital Combined RHCand CAH

Rural HealthNetwork

Other

None


Sufficient time to dedicate to the initiative

Sufficient capital

Sufficient education about the initiative to inform the decision to implement

Belief that implementation would improve ability to compete with other health care providers

Ability to assess and adapt to continuously changing environment

Sufficient number and skills of staff

Sufficient computer hardware, software, IT support and bandwidth

Ability to communicate key issues and value to staff

Staff buy-in, will, motivation and interest

Belief that implementation would improve community health

Belief that implementation would improve patient health outcomes

Supportive leadership


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Figure 8: External Factors that Helped with or Motivated Implementation of Capacities by Health Service Organization Type

24%18% 21%

25%18%

7%14%

18%

13%

15%13%

15%

20%

18%

16%

16%13%

13%

13%20%

14%

9%

13%14%

19%

8%13% 14%

9%

12%13%

9%

14% 4%

8%11%

10%8%

13%20%

21%

7%7%

6%7%

7%4%

6%6%

5% 1%

7%

1% 2%2% 1% 3%

7%

7%

3%1%

1% 1% 1%

13%

4%3% 1% 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Rural HealthClinic



Rural HealthNetwork

Other

None


Assistance from an academic health education center

Competition for staff

Competition for providers

Community planning, buy-in and support

Competition for patients

Assistance from a consultant outside of the organization

Sufficient information about the initiative to inform the decision to implement

External collaborations and partnerships

Federal incentives/penalties


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Figure 9: Internal Factors that Hindered Implementation of Capacities by Health Service Organization Type

16%20% 22% 25% 25%

33%

24%

21%20%

22%24%

18%

17%

24%

14%14%

13%

14%

14%

33%

10%

14%12% 10%

12%

10%14%

15%5% 7%

8%

11% 5%

5%

5%8%

7%

1%

1%

6%5%

2%

3%5%

1% 3%3%

2%

5% 5%

1% 3%3%

2%

4% 10%5% 3%2%

1%1% 3% 2% 2% 4%

5%3% 1% 3% 1%1% 3% 1% 3% 3%

17%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Rural HealthClinic



Rural HealthNetwork

Other


Belief that implementation would not improve ability to compete with other health service organizations

Organization leadership not supportive

Inability to communicate key issues and value to staff

Belief that implementation would not improve community health

Belief that implementation would not improve patient health outcomes

Lack of sufficient education about the initiative to inform the decision to implement

None

Lack of staff will, motivation, and interest

Insufficient computer hardware, software, IT support or bandwidth

Insufficient numbers or skills of staff

Insufficient time allowed to dedicate to initiative

Insufficient capital


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Figure 10: External Factors that Hindered Implementation of Capacities by Health Service Organization Type

21%16% 19% 20% 22%

13%

7%8%

11% 8% 4%

7%

9%10%

10% 18% 16%20%

2% 9%3%

3% 7% 13%

2%

8%3%

4%

13%

2%

5%

2%

13%

14%

8%

9% 8%

7%

12%8%

11%8%

9%

7%

5%

11%

10%

13%7%

7%

12%

14%17% 23%

13%

14%

2% 4% 3%11%

100%

7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Rural HealthClinic


Rural Hospital Combined RuralHealth Clinicand Critical

Access Hospital

Rural HealthNetwork

Other (pleasespecify)


None

Lack of sufficient information about the initiative to inform the decision to implement

Lack of external collaborations and partnerships

Lack of community planning, buy-in and support

Little or no competition for staff

Little or no competition for providers

Little or no competition for patients

Lack of incentives or penalties

Lack of access to assistance available through an academic health education center

Lack of ability to hire or lack of access to experts/consultants (e.g., SORH, electronic medical recordcompanies, practice coaching, etc.)


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Challenges to Capacity Implementation

Survey respondents were next asked “of the capacities you have implemented or are in the process of implementing, which were the most challenging and why?” Of the 212 respondents who answered this question, over half provided responses related to health information technology (Table 12). Four of the five “Other” responses mentioned the challenge of attaining patient-centered medical home (PCMH) recognition, and since most of the eleven capacities reflect PCMH standards, the “All” responses could also be considered a selection of PCMH recognition as the second-most challenging capacity.

Looking at the responses by HSO type (Table 13), health information technology was chosen as the most challenging capacity to implement by six of the seven HSO types, but it seems it was especially challenging for the combined rural health clinic and critical access hospitals, the critical access hospitals, and the rural hospitals, with at least 50% of representatives of each of these three HSO types choosing this capacity. Safety and insurance enrollment assistance were the least challenging capacities to implement for nearly all of the HSO types.

Table 12: Most Challenging Capacities to Implement

The reasons 197 respondents gave for why the capacities were challenging to implement were multiple and varied and are summarized in Table 14 and Figure 11. Over 40% of respondents gave responses related to lack of funds or resources, while the next three most common responses had to do with a lack of buy-in on the part of providers or staff, lack of time, and lack of staff.

The reasons HSO types gave mirror the combined results, overall (Figure11), though rural hospitals were more likely to mention a lack of funds or resources and slightly less

Capacity Count PercentHealth Information Technology 117 55%All 37 17%Clinical Care Coordination 21 10%Quality 13 6%Care Management 12 6%Access to Care & Information 9 4%Non-Clinical Care Coordination 8 4%Management 8 4%Organization-Based Team Care 5 2%Other 5 2%Organization-Based Services 4 2%Insurance Enrollment Assistance 2 1%Safety 1 0%Total Respondents 212


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likely to mention a lack of understanding or buy-in by providers and staff than the others. A lack of staff was cited more often by community health centers than the other HSO types, while lack of sufficient time was most often cited by rural health clinics and combined rural health clinic and critical access hospitals.


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Table 13: Most Challenging Capacities to Implement by Health Service Organization Type

Health Information Technology 9 32% 22 47% 60 53% 11 50% 12 67% 2 33% 1 13% 117 48%All 4 14% 8 17% 17 15% 4 18% 3 17% 0 0% 1 13% 37 15%Clinical Care Coordination 5 18% 4 9% 7 6% 1 5% 1 6% 1 17% 2 25% 21 9%Quality 3 11% 3 6% 7 6% 0 0% 0 0% 0 0% 0 0% 13 5%Care Management 1 4% 3 6% 4 4% 1 5% 1 6% 0 0% 2 25% 12 5%Access to Care & Information 0 0% 3 6% 4 4% 1 5% 0 0% 1 17% 0 0% 9 4%Non-Clinical Care Coordination 2 7% 1 2% 5 4% 0 0% 0 0% 0 0% 0 0% 8 3%Management 1 4% 1 2% 4 4% 1 5% 0 0% 0 0% 1 13% 8 3%Organization-Based Team Care 1 4% 0 0% 2 2% 2 9% 0 0% 0 0% 0 0% 5 2%Other 1 4% 2 4% 1 1% 0 0% 1 6% 0 0% 0 0% 5 2%Organization-Based Services 1 4% 0 0% 1 1% 1 5% 0 0% 0 0% 1 13% 4 2%Insurance Enrollment Assistance 0 0% 0 0% 1 1% 0 0% 0 0% 1 17% 0 0% 2 1%Safety 0 0% 0 0% 0 0% 0 0% 0 0% 1 17% 0 0% 1 0%Total 28 100% 47 100% 113 100% 22 100% 18 100% 6 100% 8 100% 242 100%

Community Health Center

Rural Health Clinic

Critical Access Hospital

Rural Hospital

Combined RHC and

CAH

Rural Health

Network Other Total


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Table 14: Reasons Capacities Challenging to Implement

Reason Count PercentLack of funds or resources 80 41%Lack of understanding or buy-in by providers and/or staff 51 26%Lack of sufficient time 46 23%Lack of staff, difficulty recruiting 44 22%Lack of skills, knowledge among providers and/or staff 29 15%Vendor, software, IT, or network problems 26 13%Changing requirements, targets; legal issues 13 7%Lack of sufficient incentives, low reimbursements, low return on investment 10 5%Lack of integration with other electronic health records, inability to get medical information from referrals 10 5%Lack of control over implementation 7 4%Lack of established relationships with non-clinical organizations 7 4%Lack of specialists in region 6 3%Lack of support, guidance 5 3%Other 5 3%Lack of patient compliance, trust, or buy-in 4 2%Lack of non-clinical resources in region 3 2%Lack of primary care physicians or lack of funding for primary care 2 1%Lack of management buy-in 2 1%Total Respondents 197


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Figure 11: Reasons Capacities Challenging to Implement by Health Service Organization Type

24%20% 22%

29%24%

44%

14%

15%16% 13%

12% 21%

21%

3%

19%

12%

12%

18%

11%

14%

18%

7%

15%

12%

12%

7%

6% 4%11% 3%

6%

22%14%

12%6%

8%12%

6%

1%

6%3%

3%

3%6%

3%

3% 4%

1%

3%

3%

14%

3% 6%

1%3% 1%

2%

22%

6%1%

1%

3%7%

1%2%

3%

1%1%

3%1%

1%3%

1%3%3%

7%3%3% 1% 1%1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Rural HealthClinic


Rural Hospital Combined RuralHealth Clinicand Critical

Access Hospital

Rural HealthNetwork

Other (pleasespecify)

Insufficient numbers of patients, no-shows

Lack of community buy-in

Capacity not a good fit for HSO (e.g., eHR systems toocomplex for small clinics)Other

Lack of systems or protocols for care coordination

Lack of management buy-in

Lack of primary care physicians or lack of funding for primarycareLack of non-clinical resources in region

Lack of patient compliance, trust, or buy-in

Lack of support, guidance

Lack of specialists in region

Lack of established relationships with non-clinicalorganizationsLack of control over implementation

Lack of integration with other electronic health records,inability to get medical information from referralsLack of sufficient incentives, low reimbursements, low returnon investmentChanging requirements, targets; legal issues

Vendor, software, IT, or network problems

Lack of skills, knowledge among providers and/or staff

Lack of staff, difficulty recruiting

Lack of sufficient time

Lack of understanding or buy-in by providers and/or staff

Lack of funds or resources


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Conclusion This survey of health service organizations (HSOs) suggests that healthcare reforms such as the patient-centered medical home model are being implemented around the country, but not without struggles. While each HSO had different successes and challenges, the themes that emerged nationally indicate that most HSOs recognize the value in implementing the reforms but could use many more human and material resources to assist them in doing so.

The purpose of this survey was to inform the creation of a subsequent survey of State Offices of Rural Health (SORHs) that will assess the ability of SORHs to meet the needs identified. The results of both surveys will be used to develop a “Rural Capacity Building Framework” that includes a curriculum, resources, tools and methods to serve rural and frontier healthcare providers.

Individual state HSO reports were also created and are available by contacting Paige Law at NOSORH at [email protected].

If you have questions about this survey, please contact Molly Bleecker at 505-272-0732 or [email protected] or Susan Wilger at (575) 313-4720 or [email protected].




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Appendix 1: Health Service Organization Capacity Building Survey


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capacity-building needs of rural and frontier health ... · capacity-building needs of rural and...

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