As healthcare providers managed the second wave of the H1N1 flu virus last fall, the South Dakota Health Department implemented a strategy that could be an example for other rural states during a pandemic.
Following a rural recipe
South Dakota's H1N1 strategy might provide pandemic blueprint
With more than $1 million in funding from HHS that was allocated specifically for the H1N1 pandemic, the state’s health department asked two of South Dakota’s largest healthcare providers—Avera Health and Sanford Health, which is part of the Sanford Health & MeritCare system—to combine their efforts and resources and host joint vaccination clinics at various locations throughout the eastern part of this largely rural state. A third system, Regional Health, Rapid City, covered the western region.
“As we began our planning for mass vaccination for the fall, we looked at our own capacity and we looked at where other resources were,” says Colleen Winter, the health department’s division director for health and medical services. “We had three of the largest health systems: Avera, Sanford and Rapid City Regional,” she says, adding that Rapid City is located in the very western part of the state. But given that Avera and Sanford—normally competitors—are located in the east, the two health systems came together for a common purpose.
Winter says that South Dakota does not have local health departments, so it relies on community health nurses in most counties of the state. Employed by the state health department, these nurses provide services such as immunizations and well-child exams, and they worked at many H1N1 vaccine events.
“We connected with them, and they were all very interested in working with us on how to best reach the population,” Winter says of all three systems. “Those health systems focused on the more populated areas. Our community health nurses focused on the rural areas,” she says, adding that in some communities, Avera and Sanford co-hosted events, while in other regions, the two systems worked independently.
Representatives for both systems also say the collaborative approach worked well. The partnership between the two systems is unusual not just because they are competitors, but because they haven’t always shared the same philosophies, for instance on physician-owned hospitals. Avera Health—which is part owner of Avera Heart Hospital of South Dakota with MedCath Corp. and North Central Heart Institute—believes physician ownership is a viable option in the delivery of healthcare “as long as they are partnered with a community hospital,” says Daryl Thuringer, vice president for marketing and public relations at Avera Health. Sanford, on the other hand, has strongly opposed the physician-ownership model since 1997 and established the Coalition for Full-Service Hospitals in 2003, says Cindy Morrison, vice president for health policy at Sanford & MeritCare. The system sees it as a “conflict of interest where the physician is profiting from each admission.” But she says the two systems have come together before on other issues, such as trying to make sense of the current health reform legislation in Washington.
And after receiving an invitation from the state health department last fall, Avera and Sanford began working together to plan and host vaccine events in which members of the public received the H1N1 vaccine free of charge. Typically, there is a fee involved for administering the vaccine; in South Dakota, the state covered the cost.
“In Sioux Falls, our largest city, we worked collaboratively,” says Deanna Larson, vice president of quality initiatives for the Avera Health system. Larson explains that for smaller rural communities, the systems ordered the vaccine, delivered equipment and trained vaccinators, who then conducted the events on their own. “When you get to the rural communities, they’re close-knit and want to utilize local talent and keep things at home,” she says.
“We tried to divide and conquer. We standardized processes and procedures,” says Terri Carlson, vice president of Sanford Clinic in Sioux Falls. “We did Sioux Falls, Watertown, Aberdeen, Brookings—then we took forth our best practices and worked with local hospitals and communities to deploy vaccination clinics.” For example, Sanford has a hospital and clinic in the town of Chamberlin, S.D., where it took the lead in hosting an event. But even in cases in which one provider coordinated the clinic, all three systems—including Regional Health—were mentioned in the marketing materials, Carlson says.
According to Bill Chalcraft, the health department’s administrator for public health preparedness and response, the department had contracts with each of three systems to receive up to $500,000 for the costs involved to develop and host vaccination events, which were held in health clinics, senior centers, school gymnasiums and malls throughout the state. Chalcraft says as of late January, there were 322 of these public events that resulted in about 250,000 vaccinations in South Dakota, which has a total population of about 804,000.
“They worked shoulder-to-shoulder,” Chalcraft says of Avera and Sanford. Attributing this partly to a Midwestern attitude of “neighbor helping neighbor,” Chalcraft also says the systems had previously worked closely on regional planning committees for preparedness.
At Avera Health, the planning “took the better part of four people’s work time for 45 to 60 days,” according to Larson, who says the system used a command center and had weekly meetings or phone calls with representatives from the state health department and Sanford. She says it was a great exercise for a pandemic that would require a quicker turnaround than the current global pandemic, which the World Health Organization declared last June.
While the two systems hosted these events, they had to do so when the second wave of the flu had peaked. “I oversee our acute-care clinics,” says Sanford’s Carlson. “They were up 30% from the previous year.” She says some of the vaccine events administered up to as many as 6,500 doses of the H1N1 vaccine, but a more typical event administered about 2,000 vaccines in two to three hours.
The events happened just as the state saw a rise in influenza hospitalizations and deaths. The health department reports there were 116 influenza-related hospitalizations and seven deaths in South Dakota as of Oct. 31, 2009. Since then, the virus appears to be leveling off at the national level, according to the Centers for Disease Control and Prevention. The Atlanta-based agency estimated that 41 million to 84 million cases of the deadly H1N1 virus occurred in the U.S. between April 2009 and mid-January 2010, with the midlevel range being about 57 million people infected with the virus.
During this same time period, there have been anywhere from 183,000 to 378,000 H1N1-related hospitalizations and between 8,330 and 17,160 people have died from the virus. Meanwhile, about 124 million doses of the H1N1 vaccine have been shipped with millions more available.
Now that the disease’s presence has declined, South Dakota’s health department is focusing on more typical vaccine outlets, such as provider clinics and community health clinics.
“We’ve worked with these partners on various other projects and our state comes together when there is a challenge,” Winters says, “and the partners stepped up to the plate to help us.”
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