Imaginative Responses to Problems

March-April 2004


Ms. Sherard is executive director, Avera Rural Health Institute, Sioux Falls, SD.

The definition of "rural health" tends to change from location to location, but in eastern South Dakota and neighboring states it means maintaining reasonable access to essential health services in a five-state, 76-county, 64,466-square-mile service area that has a total population of 850,000.

Approximately 250,000 of those people live within a 10-mile radius of Sioux Falls, a rapidly growing city on South Dakota's eastern edge. Beyond Sioux Falls, only seven counties in the service area have a population of 20,000 or more. Towns located near the region's two interstate highways are growing; most other towns are not.

The Sisters of the Presentation of the Blessed Virgin Mary, Aberdeen, SD, and the Sisters of St. Benedict of Sacred Heart Monastery, Yankton, SD, have provided health care in the region for more than 100 years—first in their separately sponsored hospitals and nursing homes and now, since 2000, through Avera Health, their cosponsored health ministry. They have responded to the region's health care needs with a variety of creative structures and strategies.

Together the two congregations sponsor seven hospitals in the region. Each of those facilities includes a continuum of long-term care services such as skilled nursing, assisted living, and congregate apartments. Most of the hospitals also sponsor one or more physician practices. In the 1980s, many county-owned hospital boards asked the sisters to provide management services to their hospitals.

Four Management Centers
Although the system's office in Sioux Falls originally provided all the management services, it soon became apparent that because of the size of the service area, it would be more effective to designate the sponsors' four largest hospitals—in Aberdeen, Mitchell, Sioux Falls, and Yankton—as management centers for their four respective regions. The decentralized structure has resulted in some challenges, but for the most part has been efficient, in that the regional center hospital can use its existing staff to provide human resource, computer technology, and plant operations assistance to the other facilities in its region. The four regional-center hospitals also organize the specialty clinics and other clinical outreach services that strengthen the viability of hospitals in small communities.

Many management services are shared by both sponsored and managed facilities. These services, provided through the system's central office, include legal services, clinical engineering, risk management, property insurance, fund-raising, managed care contracting, and others. Of particular value is the coding review service conducted by six health information specialists in the central office. For many years, the specialists spent most of their time on the road, driving from facility to facility to reviewªmedical records. Now much of their work is accomplished through eWebCoding, a technology that allows them to review scanned charts through a secure Internet connection.

Not surprisingly, Avera Health has been an early adopter of other computer technologies that help neutralize the challenges of both distance and a climate that is not always conducive to travel. A robust telecommunications infrastructure supports telemedicine and teleconferencing connections that are part of everyday operations; this infrastructure has placed the system on Modern Healthcare's "Most Wired" list for five consecutive years.

Rural Health Institute
The Avera Rural Health Institute exists as a natural extension of the system's mission to improve rural health. Through the institute, Avera Health collaborates with leaders of rural communities and other agencies in the multistate service region. After an environmental assessment, which includes demographic and socioeconomic analyses, community leaders focus on measurable and achievable goals for community development and assign responsibilities for participants to implement. This discussion often includes a frank, realistic assessment of the community's understanding of how health care is delivered, as well as recognition of the limitations rural people have in locally accessing dental care and such specialty services as chemotherapy. The institute also sponsors an annual fall conference that brings national leaders to the region to provide rural health care and economic insight. A major activity of the institute staff is coordinating and writing proposals for grants and conducting project development for new programs and rural health services. Recent successful applications have resulted in the institute's receiving more than $1 million of federal funds for rural projects.

In addition, the Benedictine sisters and the Presentation sisters have together created their own source of funding for rural health projects. Since its inception in 1999, that source, the Avera Community Service Fund endowment, has awarded nearly $2.7 million in start-up funding for health and wellness projects in rural communities in the region. The funds have been used to replace aging ambulances and other safety equipment, to start wellness programs, and to help communities establish needed health services.

In 2000, to create a more unified and effective voice on legislative matters, Avera Health established its Center for Public Policy. The center's director is a nurse and a former member of South Dakota's state legislature. Through the center, she has nurtured a grass-roots network of Avera employees, physicians, and trustees that sends hundreds of letters to federal and state legislators regarding health care issues of concern. As a result, political leaders recognize Avera Health as a powerful ally in ensuring that the health care needs of their constituents are met.

Economic Development
In spite of these efforts, the underlying challenge of most rural communities in the northern Great Plains is a lack of economic development. The historic role of the rural community as a retail and service center for farm families has been altered dramatically in recent decades. In fact, a significantly larger portion of family farm income now comes from off-farm jobs located in larger communities; as a result, the farmer-commuter often finds it more convenient and cost-effective to purchase groceries and other necessities in the larger community.

Avera Health's response to this situation is twofold.

LeadershipPlenty First, the system is collaborating with South Dakota Rural Enterprise, Inc., and the East River Electric Cooperative to sponsor the Pew Partnership's "LeadershipPlenty" program in the state. Twenty-nine community leaders recently participated in a "train the trainer" program and committed themselves to work with others in rural communities to make decisions that may well determine the viability of those communities. The goal is to form a cadre of strong, well-trained leaders who will assist rural communities that are committed to strengthening their viability and to developing the skills needed to identify community assets and build strategic partnerships for economic success.

Investment of Financial Reserves Avera Health has committed itself to invest a portion of its financial reserves in companies that will create jobs and benefit the economies of the rural communities in its service region. Investment guidelines stipulate that the companies must be likely to succeed, provide jobs with fair and just wages, practice nondiscriminatory policies, be environmentally responsible, and meet several other financial criteria. The first such investment, announced in December 2003, is in a company that will grow tomatoes in a 10-acre greenhouse, specifically designed for its purpose and the climate, near O'Neill, NE. The company will create 35 new jobs in the O'Neill community.

How can health services be maintained in rural areas of the country? In the northern Plains region, the Benedictine sisters and the Presentation sisters are creating an eclectic array of responses to this challenging question. Future directions are unknown, but it is certain that the sisters will, through their health ministry, Avera Health, continue their century-long commitment to the people of the region.

Copyright © 2004 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Imaginative Responses to Problems

Copyright © 2004 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.