The more things change…
Brad Gibbens reflects on nearly 40 years at UND’s Center for Rural Health.
On a fall day in 1985, Brad Gibbens began working at the Center for Rural Health (CRH) on the campus of the University of North Dakota (UND). A recent graduate with a master’s degree in public administration from UND, he was looking for his passion – or at least something that interested him.
Gibbens took a job at the North Dakota Office of Rural Health (which eventually became the Center for Rural Health) at UND, planning to get professional experience until he found the passion he was searching for.
Thirty-nine years later, Gibbens is ready to retire from the same office. Although he didn’t know it in 1985, it turns out his passion was always rural health in North Dakota.
From recruiter to acting director
Gibbens, who grew up on a durum farm outside of Cando, N.D., was hired to work in health manpower, now known as health workforce. Before he knew it, he’d been conscripted as a physician recruiter.
“I like to joke I was the world’s worst recruiter,” laughs Gibbens, who is set to retire this year. “I never recruited a physician and I was never likely to do so. Fortunately, in the recruitment process, we were doing placement reports associated with the community, describing the community environment and context. They discovered I was a good writer, so I started working on Community Health Needs Assessments (CHNAs) and other reports.”
About two years later, says Gibbens, his team secured its first Rural Health Research Center grant: “With my background in policy, I became the health policy analyst. In 1991, Dr. Jack Geller, our director, made me an associate director and I became a faculty member. I also assumed the role as the State Office of Rural Health (SORH) director.”
Gibbens fully admits today that he had no intention of building a career in rural health. He just “got lucky” he says, and “kept finding things that were fun to do and important” to him.
“Opportunity was given to me and I took advantage of it,” Gibbens muses. “That’s advice I give younger staff: to take advantage of every opportunity, learn from it, and overtime it will add to your skill set and your value to an employer.”
As he prepares for retirement at the end of the year, Gibbens has spent time thinking about the past four decades and what that has meant for rural health, in and out of North Dakota, and at CRH. During that time he has served as: physician recruiter, health policy analyst, SORH director, North Dakota Medicare Rural Hospital Flexibility (Flex) Program director, editor of the CRH newsletter Focus on Health, CRH associate director, CRH deputy director, and for the past four-plus years as the CRH acting director.
This is the fourth time in almost 40 years that Gibbens has been the Center’s acting or interim director.
“I think I am now a semi-professional acting director,” says Gibbens, who served in leadership roles not only with the National Rural Health Association, the National Organization of State Offices of Rural Health, and the North Dakota Rural Health Association, but on numerous state and UND committees. “It seems to be one of my skill sets, and I have always enjoyed it.”
The origins of rural health
CRH has been known under several names: the North Dakota Office of Rural Health, the Center for Rural Health Service, Policy, and Research, and finally the Center for Rural Health. The division was officially created in 1980. The Center’s first director and graduate of SMHS, Dr. Kevin Fickenscher, traveled across the state to find out what rural communities needed and wanted. The answer: More physicians and assessments to know what communities need from their local hospital. Equipped with staff to do the physician recruitment and health assessments, a new era in rural health was born.
“The Center for Rural Health really began by helping communities address healthcare workforce and understanding community health needs,” Gibbens says. “Forty-four years later, we are still doing work focused on those two areas, but we have expanded to meet the needs of the state. We also try to help with strategic planning for health facilities, facilitating community dialogues, and identifying financial resources to better serve community needs such as grants, offering grant-writing workshops, and providing training and education.”
Gibbens points out that while CRH still has a strong focus on rural North Dakota, it has diversified over the years.
“I am proud that we now have staff and programs addressing rural behavioral and mental health, aging, Indigenous health, human service needs, brain injury, and other significant rural needs,” he continues. “And we have a national footprint with six national programs addressing Native American aging, information dissemination, and research dissemination.”
Gibbens gave credit for the original idea of a rural health office to Dr. Robert Eelkema, former chair of the Department of Community Medicine at the SMHS. In the 1970s, Eelkema wrote the original grants for the Area Health Education Center, Indians Into Medicine (INMED), and the physician assistant program (then known as MEDEX), all while helping guide SMHS in its transition to becoming a four-year M.D. program.
“Dr. Eelkema had a vision recognizing that North Dakota was a rural state,” Gibbens shares. “Bob saw that a medical school in a rural state needed some form of organizational rural health presence. Dr. Fickenscher added his vision, which in many ways was an orientation to listening to communities and employing a form of public sector entrepreneurship, which I am proud we still follow.”
Following Fickenscher, says Gibbens, each subsequent CRH director – Jack Geller, Mary Wakefield, and Gary Hart – added their own touch to CRH. And according to Gibbens, by focusing on rural health and having a dedicated office for it, CRH played a “significant role in shaping what we consider the organizational structure of rural health nationally.”
“Our primary federal funder, the Federal Office of Rural Health Policy, used North Dakota as a model when the federal State Office of Rural Health program was created in 1991,” he says. “Before that, around 1987, the work we were doing on rural health research guided the development of the Rural Health Research program. There were only four other states that had state rural health offices in 1980.”
Eventually, the Health Resources and Services Administration and the Federal Office of Rural Health Policy developed the SORH program, ensuring every state had an office focused on rural health. CRH is the official SORH for North Dakota. The designation helps CRH partner with state medical, hospital, and nursing associations, work with rural economic development groups, and work with the USDA, the North Dakota Department of Commerce, and North Dakota Health and Human Services.
“Our being the SORH is a great connector for CRH and SMHS,” explains Gibbens. “It allows us to work with so many important stakeholders and partners, and has given us the opportunity to apply for other federal grants that are tied to a SORH.”
Structure of rural care
One of the opportunities that arose from being the SORH was when CRH received funding from the Centers for Disease Control and Prevention (CDC) to improve health equity. The CDC Health Equity funding first flowed to the North Dakota Department of Health and Human Services.
According to Gibbens, CRH used its CDC funding to address a range of rural and tribal health issues, including physical plant planning and assessment for CAHs to be better prepared for future pandemics, addressing community health workforce, understanding the impact of COVID on Tribal nations, and finding additional resources to help Tribes address behavioral health education and a dedicated effort on restructuring the rural health and payment systems.
The system restructuring means a new payment structure for Critical Access Hospitals (CAHs). This systemic change involves more than rural hospitals and medical providers, though. Over the past 50 years, the federal government has tried to find a reimbursement structure that works for all hospitals.
Unfortunately, urban and rural hospitals operate differently.
“Rural providers have always faced headwinds with health workforce, and inadequate payment or payment not well aligned for what they do,” Gibbens says. “These are twin issues that have challenged providers and policymakers. The goal has always been to increase access while simultaneously trying to control and lower costs.”
To that end, Gibbens adds that a new model, “value-based” care, modifies how healthcare is provided and how it is paid.
“CRH has played a significant role in exploring the type of structure for rural called value-based care, where providers are paid on showing positive health outcomes, instead of a straight fee for service,” says Gibbens of the model strongly supported by the Centers for Medicare and Medicaid Services (CMS). “We’ve seen that develop quickly in North Dakota. We used the grant to develop a relationship with an organization with expertise in both rural health and value-based care, called Rural Health Value, to conduct education, training, and one-on-one assistance to CAHs in our state.”
And so far, so good.
“We had Rural Health Value conduct a number of educational sessions with CAHs and providers to understand the nuts and bolts of value-based care and set up direct technical assistance with five CAHs,” Gibbens notes. “Together they ran financial scenarios looking at what happens in 5-10 years if things stay the same, what happens if they are part of an accountable care organization (ACO), and what happens if they are part of another model. The analysis found when CAHs are part of an ACO, there was a positive impact.”
As Gibbens puts it, a group of 23 CAHs in North Dakota formed their own hospital network, the Rough Rider High Value Network. The group entered into an agreement with an ACO. As a result, North Dakota has 65% of its CAHs in a value-based care structure.
Economics drive viability
Healthcare is often the economic driver in a rural community. Often a local hospital is one of the top two employers. And if that healthcare system also has a clinic and a nursing home, then the system itself becomes the largest employer.
This structure, Gibbens says, results in significant economic impact on the community.
“It makes a difference to the schools, the local tax base, the number of people who can shop locally, and attend church,” he says. “A strong rural health system helps to maintain community viability, and a strong community contributes to the viability of the health system. It all intertwines. Living in a rural community means taking care of your friends, neighbors, and families. The level of intimacy in rural communities is greater than in urban.”
The economic and population demographics of rural North Dakota are not the same as those of larger cities. Where rural areas tend to be more dependent on one or two primary economic sectors (such as agriculture and/or energy), urban communities have a more diverse economy. And while urban populations tend to experience steady growth, much of rural North Dakota has experienced population declines over the past 40 or 50 years. Even so, some rural areas have seen acute population spikes due to the expansion of the energy sector. Rural areas also tend to be older and less diverse culturally.
“My background in public administration, and generally a strong core in political science and organizational theory also includes sociology,” says Gibbens. “The people who taught me rural health tended to be sociologists, and even rural sociologists, and that has always guided my thinking. That means we pay attention to how broader environmental factors – such as economics and population – influence not only community development but also rural health development.”
Or, as Gibbens quips, “the old joke is that if you’ve been to one rural community, you’ve been to one rural community. The same holds true for Tribal communities. If you stereotype rural or Tribal, you miss the uniqueness of each.”
Looking for challenges
Challenges exist for all rural communities, but so do opportunities for growth.
“What we have done in our 44 years is constantly try to think of what more we can do,” concludes Gibbens. “We don’t provide services like medical care, but we try to help the people who do provide health services do their job better.”
Because CRH operates on soft funding, only 10% of its budget comes from state appropriations, explains Gibbens. The other 90% the CRH pursues through state and federal grant opportunities.
“We have a culture of entrepreneurship, a culture of really wanting to try to address problems,” Gibbens says. “Our staff loves to help people and to make a difference. Honestly, our staff like problems. They seem to thrive on working toward solutions that improve the lives of rural people.”
Many of the grant funded projects have received state, regional, and national attention for the work they are doing in rural health. CRH has set up networks for CAHs and Rural Health Clinics, providing guidance, training, and leadership over changing regulations and policies. The North Dakota Brain Injury Network, for example, has become nationally known for education and resources for survivors of brain injuries and those caring for them. Likewise, the North Dakota Qualified Service Provider Hub offers assistance and resources for individual and agency in-home care providers. Two national centers – the National Resource Center on Native American Aging and the Resource Center on Native Aging and Disability – focus on Native American aging and disability. Finally, the Rural Health Information Hub is a clearinghouse on rural health issues, and the Rural Health Research Gateway provides access to research publications focused on rural health.
“It amazes me that an office that started with one person, a director, now has about 70 staff and faculty, 30 or more separate funding sources, and national programs,” Gibbens admits. “We are frequently cited as a national leader, and, yes, we have influenced much of the work found elsewhere in rural health. However, always understand rural health is a two-way street and CRH has greatly benefited from other states.”
The future of rural health
As he imagines what the next 40 years will bring to rural health, Gibbens explains that CRH exists to help improve and maintain the health status of people who live in these communities. One important development is learning and working with concepts like population health, health equity, and social determinants of health.
“All of those factors flow into value-based care, which is a process that can deal with improved population health,” he says. “Health equity is aspirational. It will take many years of hard work to ensure all people, regardless of who they are or where they live, have the same right to good health status.”
Gibbens never intended to dedicate a lifetime to rural health, or spend his career as a champion for improving rural communities through healthcare. In fact, he considered leaving UND and North Dakota a time or two.
But once he found his passion, he never looked back.
“I’ve had a career where I have been able to help the people I grew up with,” he smiles. “I get a genuine thrill when I am able to get into the car and drive out to a rural community and do something with the people there. I’ve had opportunities to do other things, but it always came back to: I am a farm boy from rural North Dakota, so I decided to stay here.”
