Working Together at the State and National Level: Q&A with Karen Madden

by Beth Blevins

Karen Madden has been the director of the Charles D. Cook Office of Rural Health (ORH) in the New York State Department of Health (NYSDOH) since 2000. Additionally, she was the Director of the Bureau of Health Facility Planning for the department from 2010 to 2013. Previous to serving as director, she was the Rural Hospital Flexibility Program Director and a Health Planner at ORH.  Madden has been on the Board of the National Organization of State Offices of Rural Health (NOSORH) since 2000, and served as its president in 2008 and 2011.  She was a member of the National Advisory Committee on Rural Health and Human Services (NACRHHS) from 2012 to 2015. She was a Policy Board Member of the National Rural Health Association (NRHA) and was Chair of its State Office Council. Her awards include NYSDOH Commissioner's Excellence Awards in 2015 and 2014, the 2012 Andrew W. Nichols Distinguished Service Award from NOSORH, and Recognition Awards from NOSORH and NYSDOH. Madden earned an M.A. in Public Affairs and Policy at the University at Albany. She enjoys long-distance bike rides and is currently working on getting as many stamps in her passport as possible.

You've been at the New York ORH since 1994. What do you consider your successes? And what has changed since you started working there?

We've had success working with Critical Access Hospitals and helping them improve their financial and quality performance in the midst of a great deal of change happening within healthcare. Also, we've had some difficult budget years, but we've been able to continue working with our grantees to help them implement projects that are helping their communities.

We are doing much more work with evidence-based practices and focusing on collecting data on quantitative outcomes to demonstrate the impacts of our programs, both at the state and federal level. We knew that our programs had an important impact, but now we are putting more emphasis on collecting meaningful data to show that success. The programs that we are implementing and the data that we are collecting are far more sophisticated than when I began working in the Office, but the struggles for rural health are as prevalent as ever and challenges remain.

The rural health networks in your state have a reputation for being strong and effective. How does your office support them?

We have 32 networks funded through a state program. It's somewhat similar to the federal rural health network development program, but it's different in that the federal program has a limitation on the number of years of funding they allow and we don't institutionalize anything like that. There isn't any one type of network that is like another network, but they are mostly community-based networks, which means they include most, if not all, of the healthcare and human services providers within their service area, as they define it. We don't put any parameters around that because we don't believe that healthcare stops at a county border or town line. They design service areas based on service patterns in their community. Most of them are vertically integrated rural health networks. We still have one network that is horizontal, or hospital-based. Other networks include hospitals and also primary care practices, and are focused on ACOs and clinical integration work.

What needs do the networks address?

At one point we let them define their needs based on data and develop solutions to the needs. But in our last competitive funding cycle six years ago, we started to add more parameters so that they were focusing specifically on activities that are priorities for NYSDOH. Those priorities were our prevention agenda, which is our State Health Improvement Plan (the third iteration is about to be revised for the next five years). It's a plan for prevention, public health, and wellness throughout the state. There are measurable activities and metrics for every county in the state. So if any of our rural health networks are doing public health or wellness activities, they have to correlate with our prevention agenda activities and should be trying to meet the metrics established.

We are also focused on Medicaid reform, as many other states are. It's a big effort. If they are working on any of those activities, they have to be aligned with the activities happening at the Health Department. Much of what informed our Medicaid redesign was IHI Triple Aim. That's overarching everything that they do. We also have a grant in New York called the State Health Innovation Plan to create advanced primary care practices. If they're doing any kind of work associated with that, they have to be aligned with those goals. That was a change for many of our networks that were competing for funding that year, but they were able to meet our parameters. Part of the reason we did it that way is because it's difficult to measure the success of our rural health network program since what they're doing is different from network to network and it's difficult to come up with a set of defining measures for all of them. So we wanted to tie their individual activities to measures established on a statewide level. We're seeing some success with networks submitting data and meeting these goals.

…we know that there are good successes happening but if you can't articulate that with data and relate it back to something that's a priority with the state or federal government, then we're behind the eight ball in terms of keeping our program relevant.

We're at the point now where we know that there are good successes happening but if you can't articulate that with data and relate it back to something that's a priority with the state or federal government, then we're behind the eight ball in terms of keeping our program relevant. That was part of our challenge. It's not easy and I know that they struggle with this. It's hard to come up with measures for some of these things because it's process-oriented. But it's also not easy because a lot of the data is not rural-relevant — we don't have the numbers. That's a challenge, to capture successes when you have small numbers.

You've been credited as coming up with the idea of National Rural Health Day (NRHD). What inspired it?

At the 2010 American Public Health Association, seeing National Public Health Week posters on the walls reminded me of events in New York that focused on that week and all of the attention that was paid to innovative public health work happening around the state. I thought we should do the same for rural health! As a group of us (including Teryl Eisinger, NOSORH Director), were chatting over lunch I was thinking out loud and said, 'We should do a National Rural Health Day,' not thinking that anyone would take it seriously. A little over a year later, we celebrated the first NRHD in November 2011. I was surprised how people grabbed on to it and put resources into it to get it running — at first it was more people time and not so much money — and how many states did activities. That was just shocking to me — it was just a little idea but it quickly became popular with SORHs (State Offices of Rural Health) and it's grown every year. People at NOSORH say it's my idea – but I say, 'I had an idea and said it out loud. Everyone else made it what it is.'

How has NRHD evolved and how do you envision it evolving in the future?

I would love to have a Google Doodle that day with a rural health graphic!

The natural growth we seem to have each year is good, but something that we are trying to work on – and I don't know how it will materialize — is to have more of a presence in national media. We know we get lots of local press around the United States when there are local events, but we're not seeing that presence on a national stage. I would love to have a Google Doodle that day with a rural health graphic!

At the NOSORH Board retreat in January 2016, I made a presentation about the success we had had with NRHD and said we should try to make it more of NOSORH's brand and incorporate the message of NRHD on a daily basis. As we say, 'It's not just a day, it's a movement.' The board agreed and out of this came the Power of Rural website, among other things.

How is NRHD celebrated across the country, and what does your state do to celebrate it?

Across the country, states celebrate NRHD in a variety of ways including press conferences, social media posts, staff appreciation days, and fitness events. In New York, we work mostly through our rural health networks, to give them promotional materials and encourage them to have events in their communities. One of our groups does its own mini Community Stars, highlighting community providers in their region. A number do health screenings on NRHD, making it a fun type of event. Some have done health fairs. We don't have one statewide event, like some other states, but we work with our communities and let them design what would be best for them.

How do you think SORHs, in general, have changed over the last couple of decades?

It's very comforting to know that there are people in every state doing what you do and that you can reach out to them when you have a problem…

As far as being connected with one another, both regionally and nationally, we are much further along than we were when I began. I think that's directly related to the growth of NOSORH and the work that they do for us. It helps us be more connected. We're all unique in what we do, how we're situated in our states, and the funding that we have. Yet we still have one very unique thing in common — that rural health focus. It's very comforting to know that there are people in every state doing what you do and that you can reach out to them when you have a problem and ask, 'What have you done to solve it?' or 'What were your challenges?' When I look at other programs in our department, I don't think they have that cohesiveness that SORHs have among us, and I feel fortunate to have it. I also think SORHs have become more innovative over the years, probably because we have more resources available to us and we have much more information, but also because we had to be. The problems that we're trying to solve are very unique, so innovation is the key to what we do.

You have been a member of NACRHHS as well as other national committees. How does that enrich your work at the NY SORH?

Being a member of NACRHHS is a highlight of my career and I will always say that I learned far more than I brought to the table. Working on different national committees has shown me that there is a big difference between the states in how health policies and programs are implemented and the importance of innovation. The site visits that we did during the NACRHHS meetings exemplified that and I will always remember, in particular, two visits. One visit focused on the implementation of the Affordable Care Act (ACA). The differences between states that expanded Medicaid and had active navigator programs became very clear when a woman described her difficulties in trying to keep her job while caring for a special needs child and not knowing how the ACA could help. The other visit was in the upper Midwest where we talked to a man who told us how the care he received through psychiatric telehealth visits changed his life. Those services would not have been available without the use of telehealth and made all the difference to him.

You have spent your entire career in rural health. What led you to it?

When I went to college, I chose political science as a major because I fully intended to go to law school, but in my sophomore year, I took a class in public policy and realized that I'd found something that interested me. The class was taught by political science professor Lorrie Clemo, who became an important mentor to me. I took several classes with her and she convinced me to apply to graduate school in public policy and helped guide me through that process. She made a tremendous impact on me and I am so thankful for that. That was in the early 1990s and the debate about universal healthcare was coming around again. It seemed to me that people's lives could be improved if they had better access to healthcare, so I pursued a health policy concentration.

The job offer from the Office of Rural Health was the first one that I received after completing grad school so I took it, not realizing that I had found the place where I would create a career. Rural health was beginning to take off and we had a new rural health network program to address needs in rural communities that allowed us to work across sectors including public health, health systems, access, and finance. I have always appreciated that diversity. I thought that I knew rural health pretty well when my mom, who lived in a rural community, became ill. She was able to receive most of her care locally and I truly believe that improved her quality of life. I think that I understood the importance of rural healthcare before that but I don't know that I really understood the impact that having access to services, and the difference that makes, means to people and their families when living with chronic disease and illness. It gives people hope and makes a difficult time in their lives a little bit easier to bear.

Are you originally from New York State?

Yes, I grew up in Lyons, NY, in Wayne County, in Western New York between Rochester and Syracuse, surrounded by fruit orchards and dairy farms. There were 5,000 people there when I was growing up. It's what you would think of when you think of a small town. We lived in town and walked to school and rode our bikes everywhere and played outside all day long. People knew each other and they didn't lock their doors. I still have good friends from there. They are having the same issues most small towns are having — with many manufacturing jobs leaving. When places like that leave, the jobs leave and people leave. The school and the hospital in the next town over are probably the largest employers. But there are still people there who want it to be a nice small town and are working on keeping the downtown vibrant. The thing I love about living in New York State is that we have great mountains, beautiful lakes, wonderful small towns, and one of the most exciting cities in the world.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.