by Beth Blevins
The Federal Office of Rural Health Policy (FORHP) in the Health Resources and Services Administration (HRSA) was established as a centralized federal voice for rural health within the U.S. Department of Health and Human Services (HHS) in 1987. According to The Office of Rural Health Policy Celebrates 20 Years, a history of FORHP published in 2007, FORHP was originally “charged with collecting and analyzing information relevant to rural health concerns, working with State and local partners to enhance the delivery of health services at the local level.”
In the nearly 23 years since it was established, FORHP has grown from an original leadership team of six to a staff of more than 40, and from a single division/grant program to 20 grant programs across four operating divisions. In addition, FORHP supports the Rural Health Research Centers Program, National Advisory Committee on Rural Health and Human Services, and Rural Health Information Hub, as well as other policy and research functions.
FORHP continues to undergo changes and to take on new roles. A Federal Register notice from January 5, 2010 announced, among other changes for HRSA, that the Office for the Advancement of Telehealth (OAT) grant programs will be moved back into FORHP (HRSA’s telehealth program originally began in FORHP in the early 1990s).
Rural Spotlight recently sat down with Tom Morris, HRSA’s associate administrator for rural health policy and FORHP director, to discuss plans for FORHP’s future and to look back at the FORHP’s recent past. Morris joined FORHP full-time in 1998 after working there earlier as an intern while in graduate school. Morris received his master’s in public administration from East Carolina University. Prior to joining the government, Morris was a reporter and editor at two daily newspapers in North Carolina.
What are some of the most significant changes at FORHP in the 12 years you’ve been working there?
When I first came here in 1998 there were around 12 folks. Back then there were no divisions, it was a very flat organization, just the director, the deputy director and associates. We’ve quadrupled in size since the early 1990s. There were four main grant programs in the late 1990s and now there are 20 with the addition of the telehealth programs.
Probably one of the biggest changes that has happened was the creation of the Flex program (Rural Hospital Flexibility Grant Program) in 1999. We had always focused our regulatory review, our policy analysis, on rural hospitals throughout our history, but we didn’t really have a way to engage with them directly. When the Flex program was created, it gave us money to give to the states to work with critical access hospitals. And so it created a stronger link, which also helped our policy analysis. It gave us an easier way to ask questions in the field and find out what was going on. Once that happened, it really changed the stature of the Office and also it changed, I think, people’s awareness of how we could help them.
I think the other change was one that took place in the last year with the Outreach (Rural Health Outreach Grant Program) line. When I came to the office in the mid-90s, Outreach was the only community-based program we had. Now that line authority has more than doubled (it has about $50 million now), and it has six distinct grant programs in it. So we’ve been investing in rural communities since the mid-90s. About a year ago we put a contract out to start evaluating our community-based grantees to try to find out what models work, which ones should be replicated. And so we’re moving more toward evidence-based programs. I think we’re all really excited about what that means. We’ll learn more from that evaluation. We’ll also have performance measures in place for the first time in the history of that program, so we’ll not only know what the impact of the program is, from a performance stand-point, but it will allow us to disseminate some of the good stuff we learned. Not only will the grantees benefit, but also folks all over rural America will benefit from what we learn in the grants.
Has rural research changed since you’ve been there?
The research has always been tightly linked to what we do in our policy role. It’s very hard to support a change within the department on regulatory issues if you don’t have data behind you and so the research centers were set up early on to help make sure we had that sort of capacity. But it had a dual purpose back then, too, which was also to get more rural health research into the published literature. It’s still doing those things, but as the research centers have gotten more experience and as we’ve ramped up our policy efforts, I think we’ve done a better job collectively of identifying policy-relevant issues that are being discussed in Washington, in the states and in the nation. I give a lot of credit for that to the folks who started the research program as well as to the Center Directors who have done a great job.
What do you think is the most significant change overall in FORHP since you’ve been there?
I think Flex is probably one of the most significant changes, mainly because it started out as a demonstration in CMS, as the EACH (Essential Access Community Hospitals) program and the Medical Assistance Facility program. In 1997, when they created the critical access hospital (CAH) designation, they were taking findings from two Medicare demonstration programs. There was a problem with the way rural hospitals were reimbursed. They were struggling financially, they were very dependent on Medicare, and the way they were paid was not working for them. And so CMS and Congress tried out different ways of paying them and different ways of treating them, through the demonstrations, and then, once they got the results from the demonstrations, they tweaked it a little and created a permanent designation. They didn’t just stop there. They said those folks are always going to be a little bit vulnerable—we need a grant program to go along with them, to help them along the way with quality improvement, performance improvement, integration of emergency medical services, and that was the impetus behind creating the Flex grants.
The reason I think it’s so important is that it’s a public policy success model—it spanned two separate agencies within HHS as we’ve worked extensively with CMS on these issues. We have 1,300 CAHs now. So, what happened was the government identified a problem, looked at some alternatives and then used the findings from those experiments to create a permanent solution that continues to work well today. You could say that’s 1,300 communities that have a viable rural hospital because the process worked the way it should.
According to the January 5, 2010 Federal Register Notice, the Office for the Advancement for Telehealth is coming back to FORHP. Can you talk about the reason for that organizational shift, and how you see telehealth fitting into the other functions of FORHP?
It is an interesting development. The telehealth programs started out in our office and then were moved out into a new entity in 1998 so we’re happy to have it back in here. I don’t think it’s just a rural issue—it’s important to rural communities, but we’re seeing urban areas start to benefit from it, too. It’s a wonderful tool for bridging isolation. Primarily, people think of that in rural terms but it also can be true in urban areas. The bulk of the grant still has some rural elements, but we have some rural telehealth networks that also have links to urban.
How are they linked to urban?
The one we’re seeing a lot of are eICU units where you have one intensivist who looks at four or five hospitals in a region and monitors intensive care beds, so you wouldn’t need five intensivists in five hospitals, you can have one monitoring them remotely. You still have clinicians in the room, physicians, advanced practice nurses, but it’s a nice way to utilize the resources more effectively.
There are also urban telehealth applications, in terms of home monitoring, for folks who are disabled or have mobility problems. Why have them have to trek across town to get a checkup when they can check in on their diabetes via home monitoring. It started out very much a rural tool, but as it has matured, people are seeing that it has broader applications than just bridging distance. It can also bridge isolation, and sometimes that isolation can be purely situational.
Is it possible to describe what the associate administrator for rural health policy does, in a few sentences?
I try to keep my finger on the pulse of what’s going on in both our policy and our program activities and lend my expertise where I can. I’m really lucky to have a great management team in place. Carrie Cochran is the deputy associate administrator and also our acting policy coordinator and while she is doing that I have no worries at all about how we live up to our policy mandate. Heather Dimeris is our associate director/senior advisor and she’s been the acting director of the Office for the Advancement of Telehealth during the transition. Heather is a wonderful resource. The two of them are essential to making the office functional.
Nisha Patel runs our Community division. I think she’s been visionary in what she wants to do with that program in terms of performance measurement and moving towards evidence-based in how we evaluate the program. Similarly, Kristi Martinsen in the Hospital-State division has overnight done a great job of understanding the challenges of rural hospitals and thinking about our programs and how Flex and the small hospital improvement programs can work with them. I should also note that Julia Bryan, our grants program coordinator, has been incredibly important in terms of coordinating all the activities associated with our many grant programs.
Because all those folks are in place, it’s very easy for me to parachute in and out, but leave the day-to-day operations to them.
What’s a typical workweek like for you?
A lot of meetings, mostly just checking in with folks. I probably travel about two times a month, on average, to speak or take part at a meeting. And then a lot of it is working with rural communities. We try to be an information resource. So we get emails and phone calls from folks asking us to research a question. Sometimes I’ll do that, sometimes people on the staff will. We’re always looking at trying innovative approaches to things. We have about one million dollars we spend on special projects each year and we spend a lot of time brainstorming about how we’re going to do that.
I’ve been to all but three of the states. That’s been one of the most rewarding parts of the job. To see the impact of the policy work that we do and the programs we invest in. You see some of the great things that people are doing out in rural areas despite the tremendous challenges they have. It’s always different, every community you go to.
What kind of special projects has FORHP funded?
Last year we did a meeting with the Appalachian Regional Commission to look at prescription drug abuse in coal country and some of the economically depressed areas of Appalachia. It was interesting because that dealt with a whole group of people we normally don’t deal with that much, like substance abuse counselors. You realize that the health needs of the people run the gamut. We tend to sometimes focus on primary care and you go to a meeting like that and see the other great need out there.
The other thing we’re doing is we’re finishing up work on a demonstration we’re doing with CMS on a thing called the Frontier Extended Stay clinic, which is where folks who are weathered-in at a clinic in remote Alaska can stay overnight for observation and avoid being transported unnecessarily by plane. So we’re looking at alternative delivery models for folks in severe isolation.
You came to FORHP first in 1996 as a Presidential Management Intern. What led you to FORHP? And what led you, in the first place, from your work as a newspaper reporter to health care policy, especially rural health?
I was covering health care stories in eastern North Carolina as a reporter and it just blew me away to know that there were counties without a physician out in the eastern part of the state. Then I did a series on poverty and health care and I was exposed to the Medicare and Medicaid policy issues and workforce challenges that providers were facing. It was eye opening. I grew up a suburban kid and the thought that you wouldn’t have a physician nearby never dawned on me. I remember also visiting Washington County, North Carolina and I don’t think there was a physician at that time in the entire county and the public health department was operating out of a small trailer. It was really eye-opening and yet the folks were so dedicated. It really amazed me that there was this much of a dire need in some of these communities in my own state.
I wanted to take my writing skills and interest in health care policy and marry them in some way so I went back and got a Master’s in public administration. For a summer practicum between my first and second year, I was offered an internship with the N.C. office of rural health and the federal Office of Rural Health Policy and I decided I should take the one with FORHP because I thought, “I’ll never leave North Carolina and I’ll never get a chance to live in D.C. again.” Then my school (East Carolina) nominated me for a Presidential Management internship. It was a whirlwind, two-year, self-guided tour through government. I worked on a telemedicine report, I worked for Senator Kent Conrad’s office, and then I worked at CMS. By the time I got back to FORHP in 1998 Wayne Myers had come on as the new director. The Office was taking off back then. He was charged with reinvigorating the policy activities of the office. He had me review all these Medicare regulations. It was a wonderful experience. Then the jobs just happened one after another. I was a grants project officer in most of the grant programs I’ve talked about. Wayne and Jake Culp were great teachers. Then Marcia Brand came on and she was a wonderful mentor. At every crossroads I came to in my career I was lucky enough to have a guiding hand that pushed me in the right direction. And now I have my dream job.
What do you envision FORHP will be like in five years? And, what would you like to see FORHP accomplish in that time?
I’d love for all our programs to be well evaluated and great performance measures in place so that we can show the impact our investments have. And I also hope that we continue to play an important role in making sure that there’s a voice for rural in the policymaking process at HHS. I think we have a great foundation towards that, so it’s just a question of building on it.
Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.
Back to: Winter 2010 Issue