Minnesota's Essentia discovers that, in rural medicine, creativity is often the cure

ELY, Minn. – To understand the latest challenges of rural medicine, meet Matt Smolen. He has multiple sclerosis, which has spread through his 6-foot-4 frame, stranding him in a wheelchair, slurring his speech and contorting his hands into claws.

Flare-ups of the disease and related bladder infections sent Smolen, 46, to the hospital 17 times between April 2012 and March 2014. Then he enrolled in a research project run by Essentia Health, where nurse Sandi Kari coordinates all his medical care and personal needs.

Since then, he's sought treatment at the hospital just twice. "She's my medical advocate," Smolen said, smiling.

The project that helped Smolen is just one of 290 research ventures and clinical trials underway at Essentia as it tries to analyze and solve the distinct problems of medical care in the rural Midwest, where poverty is high, specialists are scarce and many people are uninsured.

Nearly six in 10 of Minnesota's hospitals are in rural areas and have no more than 25 beds. Rural residents share the health problems of their urban counterparts, but have less access to medical specialists and mental health workers, according to the National Rural Health Association. They also tend to be poorer, to rely more heavily on food stamps and to have high blood pressure and other chronic conditions.

Dr. Joe Bianco, who oversees Essentia's primary care practice, captures the challenges with the story of a young Ely patient who was being treated for diabetes. When the boy's condition worsened, Bianco checked his medical record and noticed that he'd been skipping appointments with diabetes specialists in Duluth, a two-hour drive away.

The diabetic center had described the patient as "noncompliant, which is a word we don't use at Essentia," Bianco said. He called on Heidi Favet, a care team leader, who found the boy's household in distress. The parents, who were poor, were about to split up. The mother lacked basic financial and cooking skills.

If a patient can't heat their home, "diabetes is not in the conversation," said Laurie Hall, the Ely Clinic's administrator.

Favet tapped her sources in the community, helping the boy's mother get counseling, learn to manage a checkbook and arrange telemedicine consults with the diabetes clinic.

"We treated his blood sugars not with medicines — we treated them by dealing with all of this other stuff," Bianco said.

70 ER visits

Founded just five years ago, the Essentia Institute of Rural Health has received more than $3.7 million in federal and state grants, plus $870,000 in industry funds, to research topics as diverse as Alzheimer's disease, human genetics, chronic illnesses, palliative care and rural health disparities. In August, it was selected as one of 34 collaborators nationwide for a five-year study of cancer treatment in underserved communities, including people in rural areas.

Its parent company, Duluth-based Essentia Health, has about 900,000 patients spread across 66 clinics and 17 hospitals in mostly rural areas in Minnesota, Wisconsin, North Dakota and Idaho.

Bianco says coordinated care makes business sense in addition to helping patients.

"We had one patient who had 70 visits to our ER last year," Bianco said. "Because we intervened with her, we cut that down by 60 percent."

The Affordable Care Act, the landmark federal law now before the U.S. Supreme Court, was designed to reward clinics and hospitals for quality and efficiencies. Essentia, with its robust research program, is prepared to prove that its methods benefit patients at bargain prices.

To succeed, however, Essentia must overcome obstacles not found in urban areas. Rural patients, for instance, are far more likely to see primary care doctors than their urban counterparts, and today much of the country faces a shortage of primary care physicians.

Essentia's Ely Area Community Care Teams, established in 2011, allow primary care docs to work with other professionals — advanced nurse practitioners, social workers, educators and others — to look after patients.

"The idea is that if we can free up the doctor, the doctor will be so much more effective," Favet said.

Hall said Favet was hired because of her connections with community groups like the Girl Scouts and Outward Bound. She lacks industry preconceptions, Hall said, and can see fresh ways to help patients.

"I definitely walk in the door and say, 'Why do you do it this way?' " Favet said.

Cassie Eggebraaten, 29, is one of her success stories. Eggebraaten suffers from a psychiatric disorder and severe anxiety. She returned to Ely from Arkansas about 18 months ago and had difficulty getting her Social Security disability payments transferred to Minnesota. Favet helped resolve the problem and connected her with community resources.

Eggebraaten now does volunteer work and has gained enough confidence to enter her artwork in juried shows. She called Favet "my rock."

Essentia's primary care doctors also use computerized tools that help them diagnose cases and prompt them to collect research data. One, for example, prompts them to administer a quick, three-minute dementia test in older patients as part of another study. The sooner dementia patients can set up community services, the better they will fare, said Steve Waring, a senior research scientist at Essentia who formerly worked at Mayo Clinic.

"Early on we recognized that probably 90 percent of what a person with dementia needs isn't provided by the health care system," he said.

Church and brunch

Frances Brin, 81, moved to an Ely nursing home in September with her husband, Robert, 80. They had been living in a memory care unit in Wichita, Kan., but their children grew concerned after a psychiatrist prescribed powerful, expensive antipsychotic medications for Frances.

"We felt like she was disappearing," said their daughter, Becca Brin Manlove. She said the doctor in Kansas was so busy that the family could never discuss their concerns with him.

Now Peggy York-Jesme, an Essentia nurse practitioner, coordinates "wraparound" care for the retired schoolteacher. Simply by reassuring her and surrounding her with memorabilia from home, the care team has reduced her bouts of agitation, while weaning her from most of the powerful drugs.

"What's emerged is this really delightful lady," York-Jesme said.

Frances Brin and her husband of 59 years now get out to church and brunch regularly.

Brin Manlove said that despite the shortage of experts like geriatric psychiatrists, she's thrilled to have her parents in Ely.

"You have more experts [in the urban areas], but you don't have these people that know you, like Peggy," she said. "She sees my parents at church."

Dan Browning • 612-673-4493