The numerous far-flung health care providers and community organizations that make up California’s rural health landscape may soon once again have a single, integrated association working to bring a cohesive voice to all.
After closing last year with insufficient funding and soaring debt, the California State Rural Health Association is slowly becoming active again. A website was launched this week, a 13-member board has been established and the group is planning a conference by the end of the year.
“We’re alive,” said board member Mario Gutierrez, “We stuck together over this past year, throughout debts and our lease obligation and everything else, and I feel we have proven our credibility.” He hopes the association will have a director and office by next year.
CSRHA was forced to close its Sacramento office and lay off staff last year after nearly two decades of service in California. Grants, donations and member fees could not keep the organization afloat, and it was no longer able to afford staff. CSRHA also faced considerable debt in the form of unpaid rent, which required legal assistance and lease negotiation.
The trade association, formed in the 1990s as an informal gathering of regional groups, officially incorporated in 1995. It didn’t start having real issues with funding until about 2009, members say. That led to operational disagreements between board and staff members for the next several years, and the board had to cancel staff contracts, lay off the executive director and conduct an investigation into how it could survive.
“It kind of took some of us by surprise,” board member Will Ross said. “It looked like we were taking in money from grants, but that didn’t begin to address our lease agreement and payroll and office expenses. It just wasn’t enough.”
The association voted to disband in 2013, but was still able to hold its 13th annual conference thanks to a donation from a former staff member. At the time, CSRHA still had $60,000 in unpaid rent to grapple with and much of the past year was devoted to negotiating lease terms and settling the debt.
After disbanding, several board members set out to secure funding and were able to get grants from the California Wellness Foundation, the National Rural Health Association, and a few private donors to get the organization solvent by July.
“The short version is we had a near-fiscal-death experience,” Ross said. “We persevered and negotiated and volunteered and received a few very generous donations, and now we’re here.”
Ross, project manager for Redwood MedNet health information exchange in Northern California, spearheaded the effort to build CSRHA’s new website.
Ross said now that the first, young phase of being an organization with staff in a lot of offices effectively across the street from the state capitol is over, it’s time to rebuild and function on a shoestring budget. The 13-member board has two committees — conference and bylaws — and is working to return governance to members and re-normalize the annual schedule of the board.”
“Now we’re in a phase of being a volunteer board with no staff, and we’ll keep running that way until there is a big change in funding,” Ross said.
Unifying Rural Health Communities
Board members said this incarnation of CSRHA will not immediately have paid staff members or a brick-and-mortar office, but will maintain the original mission: a unifying network of clinics, hospitals, social services and technology participating in ongoing conversations about rural health.
“I like to think of us as a phoenix rising from the ashes,” said board member Gail Nickerson, who is also the director of the California Association of Rural Health Clinics. “It is really important for those of us in rural areas to be able to come together in this way, because when you are in rural areas you don’t always get to network.”
Nickerson, who is also a member of the National Rural Health Association and expert on the aging rural population, said the large swaths of rural California — 44 of the state’s 58 counties are considered rural — are often overlooked when people think about coordinating services.
“People don’t think about California as rural; they only think about the urban areas,” she said. “But about 5.5 million Californians live in a rural area, accounting for 14% of the state’s total population. That’s a lot of people who need good, preventive health care just like those in the cities.”
Most rural health care organizations already belong to one statewide association or another. For example, rural hospitals often belong to the California Hospital Association, or a health officer at a rural county public health department will belong to the state health officers group. But those affiliations don’t always work in the most effective way in rural communities, experts say.
“A lot of these existing associations are vertical,” Ross said. “The purpose of the California State Rural Health Association is for those in the rural health community to share cross-cutting experiences. Instead of networking with the hospital that is an hour away, how about networking with the primary clinic across the street?”
Ross said a lot of useful conversations can start when different types of health care providers are all engaged, from policy interactions and talking with legislators to figuring out what benefits can come from telehealth delivery.
“There is a pretty healthy set of dialogues that can happen,” he said. “Say for instance, you are a community hospital, owned by the district, with 25 beds. You don’t have any money for IT. But if you are actively talking with a group that specializes in telemedicine, you can bring in the right groups of people to make things happen.”
Increased connectivity between rural clinics and agencies will be a key part of measuring success for this revived association. Lee Barron, administrator at Southern Inyo Healthcare District and current president of the association, said technological advances in the past few years will help CSRHA maintain functionality in ways it couldn’t before.
“Even in California, technology can be a challenge,” said Barron, who will serve as president until president-elect Judith Shaplin moves into the role in the next few months. “It wasn’t until the past year that we have really had the level of connectivity to sustain these networks.”
On top of enhanced technology, Barron said each board members’ individual experience with rural health was paramount to reconvening the association.
“Everything in rural health is a struggle and a challenge, and we know that from our daily lives working as physicians or directors or any other role in these rural communities,” Barron said. “We are used to these challenges, which was why getting the association back together was very near and dear to all of us.”
Rural communities tend to approach public health in a different way than their urban counterparts, experts point out. Other agencies not necessarily dealing with health care — such as social services or police departments — play an active role in public health in many rural areas.
“Services not necessarily in health care are important in building rural communities and rural health care,” said Gutierrez.
Like all board members in the rural health association, Gutierrez wears two hats. His day job is executive director of the Center for Connected Health Policy, a statewide organization working to promote and expand telehealth in California. The center was created in 2008 by the California HealthCare Foundation, which publishes California Healthline.
“We have a really tall order to ensure those Californians in vast rural areas are going to be reached,” he said. “We have to make advancements in telehealth to allow hospitals and clinics in these areas to stay alive.”
Many rural inhabitants are low-income and also tend to be older than city dwellers, according to a 2012 study from the Department of Health Care Services. Medi-Cal expansion has been helpful to the rural population, but getting services in rural areas is still difficult.
“The implementation of the Affordable Care Act has some things that lend themselves very nicely into an urban setting, but not a rural one,” Gutierrez said. “It’s not enough to have a Medi-Cal card. You have to have the services in place to deliver it.”
Getting rural clinics and hospitals running in a manner as sophisticated and modern as their urban counterparts is a major goal of the CSRHA, Gutierrez said.
Words of Warning
While bringing together health care providers, physicians, hospitals and IT groups into one cohesive group may have been a good policy strategy for decades, some aren’t so sure it’s the best strategy for today’s rural health care landscape.
Steve Barrow, executive director of CSRHA when it closed in 2013, cautioned that putting all efforts into one group falls short of achieving a truly comprehensive rural health care strategy.
“This is a huge, huge state, and there’s actually three or four different variations on rural health,” said Barrow, now president and CEO of Ahead California, a health policy advocacy group. “There are these silos of organizations — hospitals, clinics, IT, administration — and we need to have a mix of three or four groups like CRSHA to bridge these silos, not just one.”
Barrow, who is not involved with the revival of CSRHA, pointed to a number of reasons the group disbanded last year. Allowing funders to be part of the leadership, for example, was a mistake he believed the association should be warned not to make again.
“Leadership is insular — they tend to punish those who don’t want to be in their camp,” he said. “If we have 5.5 million people spread across thousands of miles, there is no way a small organization can effectively build one group that speaks for everyone.”
While he supports the new efforts to bring CSRHA back together, he urged the group to make even more departures from previous practices. For example, Barrow suggested hand-selecting board members based on their area of expertise, organizations they are affiliated with and their geographic location. Previously, board members were elected by 40 individuals given a vote around the state
“I think it’s a really good thing that someone is bringing it back,” he said. “But they really need to think about how leadership is put together. To build a rural health association that has geographic, ethnic, gender and safety net diversity, you are going to need a big board, and it’s difficult to accomplish that if you are running it from a clinical administrative framework.”