Franklin Community Health Network (FCHN) is the sole hospital network serving the rural community of Greater Franklin County, Maine, population 40,000. Nestled in the foothills of the west central Maine region, with an average of just 17 persons per square mile, this is one of the nation’s most rural communities. The more sparsely populated parts of the region are in the north, with some federally classified as “frontier”; the most densely populated spot is a quaint university town and Franklin County seat, Farmington, population 8000.
The community struggles with the challenges common to many other rural communities: poverty, isolation, lack of transportation, substance abuse, and sparse resources and services to support healthful lifestyles. It is the third poorest community in one of the nation’s poorest states. Yet, paradoxically, this community has long held a reputation for civic engagement, innovation, and problem solving, giving many residents a quality of life that defies the traditional barriers of low income and rural isolation. That reputation underlies the heritage and culture of Franklin Community Health Network (FCHN) and its flagship hospital, Franklin Memorial Hospital, enabling the Network to overcome the extraordinary obstacles inherent in serving this geographically and economically challenged service area.
Indeed, this little health network that might be expected to labor in obscurity has achieved statewide and national attention for excellence and innovation. Among the nation’s more than 5,000 hospital systems, FCHN is one of only a handful that have been recognized with no fewer than five separate awards from the American Hospital Association: twice a finalist award for the Foster G. McGaw Prize (1998 and 2005); once a finalist award for the NOVA Award for innovation (1996), once recipient of the Hospital Award for Volunteer Excellence (2005), and in 2003 the sole recipient of the Carolyn Boone Lewis Living The Vision Award. FCHN and its leaders have also earned unprecedented statewide attention, with dozens of awards ranging from the Governor’s Award in Technology (1996), to the Dr. Dan Hanley Leadership Award (2004), to the Ruth Shaper Award (2004) and Program Excellence Award (2000) from the Maine Public Health Association. In 2000, Maine Governor Angus King and state public health director Dr. Dora Ann Mills touted the “Franklin Model” as the basis for the administration’s statewide program for use of state tobacco settlement funds.
The FCHN community has been buoyed by the recognition received from colleagues in Maine and across the country. But by far the most meaningful tribute comes from a source closer to home: the impact of the health network’s work on the lives of people in the Franklin Community. In this, FCHN excels. According to State epidemiological data, over the past decade Franklin County has consistently demonstrated the lowest adult smoking rate of all counties in Maine, even in comparison with much more affluent communities - statistics entirely at odds with the traditional association of poverty with tobacco use. In complete defiance of its demographics, the community has one of the lowest rates of cardiovascular disease mortality, highest rates of cholesterol and blood pressure screenings, and excellent indicators on quality of life, longevity, and self-reported health status. Moreover, independent testimonials and data attest to the extraordinary quality of care and compassion of caregivers within the delivery system.
This paper explores some of the values and characteristics of this health network and the community it serves to shed light on the source of some of its achievements and offer ideas and lessons learned for our colleagues to consider.
The Franklin community has long enjoyed a culture that tolerates deviation from the norm and values innovation and courage, and as a result boasts a disproportionate number of interesting historical figures. From Chester Greenwood, the inventor of ear muffs, to Lillian Nordica, an internationally known opera singer, to Cornelia “Fly Rod” Crosby, a woman who invented modern techniques for fly-fishing and was the first registered Maine guide, the community has boasted famous residents including significant poets, Nobel Laureates, playwrights, cartoonists, politicians, attorneys general, and athletes.
In the late 1960s and early 1970s, the Franklin community’s reputation helped attract a cadre of diverse, brilliant, and creative physicians who shared an unusually idealistic vision for the future of health care. These medical pioneers had an idea considered fairly radical, even by the standards of the 1960s: that a health care delivery system ought to value prevention and community health as part of its business model. They believed that it was not sufficient to reimburse providers for downstream emergency and acute care; they argued that complementary financial incentives needed to be available for clinicians and others who worked to prevent disease and injury in the first place. With the aid of a grant obtained from the federal Office of Economic Opportunity, this innovative group of individuals formed Rural Health Associates (RHA), one of the nation’s first HMOs in an era long before HMOs became the subject of cynicism.
RHA employed physicians and, again a first in Maine, physician assistants, to provide primary care to members. The organization developed and operated three ambulatory health centers at strategic locations in remote corners of the region, and connected members to specialty care by employing RHA specialists based at the hospital. RHA physicians and other clinicians offered blood pressure screenings in supermarkets and schools—unprecedented at this time—and even set up interactive telemedicine and computerized records long before satellite technology or the internet were in use. The organization trained a group of local people to serve as health advocates, assigned to different towns to visit people and offer health education and resources. Eventually they formed a partnership with the area university, University of Maine at Farmington, to develop a training program for advocates.
Although in its heyday in the early 1980s RHA boasted 11,000 members—one in every three residents of the service area—ultimately the HMO model needed many more members to sustain the financial risks involved. It was disbanded and the membership folded into the state’s Blue Cross and Blue Shield organization.
Despite the RHA’s eventual disintegration its influences are still felt in the Franklin community and at FCHN today. The original clinicians and advocates who ignited this movement have remained in the community, and many continue to be leaders at FCHN. Many innovations originated by RHA remain as unique elements in today’s health system, including the presence of rural health centers with telemedicine capacity, the widespread availability of free screenings in community settings, and the integral involvement of physician assistants and now nurse practitioners. The University of Maine at Farmington program for health advocates grew to become Maine’s first Community Health Education program, now one of the university’s most popular majors and a key supplier of talented young people for Maine’s growing community health infrastructure. In the early 1990’s the hospital network and some of the former RHA physicians worked with others in the community to form the Healthy Community Coalition, with the goal of organizing and reinforcing community health efforts. Most of all, the RHA experience instilled in the health system of the region the belief in the centrality of community health and prevention to the operations of the delivery system.
Franklin Community Health Network was formed in 1991 as the parent entity for a system that would include a variety of affiliates and owned enterprises, most prominent among them a 65-bed, 78-year-old Franklin Memorial Hospital. In 1993 the network hired a new President and CEO, Richard Batt, who led efforts to formalize the structure of the health network, affiliate with and support the Healthy Community Coalition, and initiate numerous innovative programs and new services, reinforcing the original vision of a delivery system with a community health core.
Also included in this system are: Franklin Health physician practices representing more than 50 physicians and other clinicians who provide the vast majority of the region’s primary care and specialty practices; Evergreen Behavioral Services, an emergency mental health service; NorthStar, the region’s ambulance service; and Healthy Community Coalition of Greater Franklin County that is dedicated to prevention and health promotion. FCHN houses these diverse organizations, providing accounting and financial oversight, human resources, planning, facilities, maintenance, purchasing, and other administrative supports for all entities within its umbrella.
Franklin Memorial Hospital is the sole hospital serving the region, with a market share exceeding 70 percent for nearly all services provided. In recent decades, economic forces and new technologies caused a shift in health care delivery (both nationally and locally), from mostly inpatient to mostly outpatient care, with a much greater emphasis on education and prevention. Reflecting that trend, the hospital logged approximately 3,000 patient admissions in 2006 and more than 130,000 outpatient visits.
The scope of services available through FCHN has grown exponentially since the 1970s, when there were 18 physicians practicing in the area, 9 of whom offered specialty services. Today the network owns practices employing more than 60 physicians and other clinicians, including nurse practitioners, physician assistants, and a nurse midwife. The hospital has a full time hospitalist practice with six clinicians and a wide range of specialists. For a small rural hospital network the scope, sophistication, and quality of services have grown to extraordinary levels, with a full suite of radiology equipment including the most advanced CT technology available; a full-scale laboratory as comprehensive as any in Maine; a surgical program with thousands of surgeries performed annually; one of the largest and most comprehensive physical therapy, occupational therapy, and speech therapy units of any hospital in Maine; and a range of specialty services in partnership with other Maine hospitals providing local care for oncology, wound care, and other specialties.
The Network takes an unusually expansive view of its role in promoting education, with educational programs going far beyond a significant investment in clinician education to include community education in health topics and promotion of the health professions. The hospital has a newly added wing called the Ben Franklin Center, which includes state of the art distant learning technology and meeting and seminar space, as well as a medical library open to clinicians, patients, and the public. Community organizations offer programs consistent with FCHN’s mission, and the Network puts on workshops and conferences inviting its clinicians as well as the public.
The fusion of health care delivery and preventive health continues to drive the region forward over the decades that have followed the RHA experiment. Today, the mission of the Franklin Community Health Network reflects that legacy directly: “to work cooperatively with other concerned individuals and organizations to achieve the highest level of health and wellness possible for the people of west central Maine.” This emphasis on the health of the community at large is deliberately more ambitious than a mission statement that focuses on delivering health care services. The mission recognizes in theory what the Network has put into practice: that providing top-quality health care services is important, but not sufficient to improve the overall health and well-being of a community. As the RHA founders articulated, as much as 70% of early mortality is due to factors unrelated to the quality of health services, such as poor nutrition, tobacco use, sedentary lifestyle, and economic and other stressors. Recognizing the importance of prevention and community engagement in improving health, the Network not only maintains a top-notch infrastructure for treating disease but also supports an unprecedented, sustained effort in the community for preventing it.
The Network expresses four main values that guide its daily work: caring, pride, innovation, and excellence. Nine foundation stones categorize the functions and goals of the organization:
Each foundation stone braids together functions related to patient care with functions related to community health and well-being. The Network’s commitment to these values and foundation stones are made apparent to employees, patients, and the community through signage and media to assure a continuous daily focus and reminder of the Network’s fusion of health care delivery and community service. But these values are more than words written on a plaque or repeated in FCHN brochures or annual reports. Indeed, the sense of common values and purpose has been a guiding force for employees, and is part of what makes FCHN a unique place to work. For example, in 2002 the Network contracted with an employee opinion research firm to conduct an anonymous survey of workforce engagement. In each of the four years subsequently, the scores for network employees were among the highest of all hospital systems in the firm’s national database, and one year the scores were the highest the firm had ever recorded.
Central to FCHN’s achievements is a spirit of collaboration and innovation, which has led to the development of a number of exciting programs.
Community Health Visioning: The event that epitomizes the centrality of community in FCHN’s strategic planning and operations is the Community Health Visioning Conference, held every other year since 1994. Through the Visioning, the Network learns from residents what the priorities for health care should be in the coming few years, and sets its strategic direction accordingly. To make best use of information from the Visioning, FCHN first assembled the leaders of all health and social service agencies in the community in what is now called the Health Leaders Forum, which meets quarterly to track progress by all agencies in addressing the issues raised in the Visioning.
In response to the priorities over the years, FCHN has been at the core of creating partnerships to address major issues. With nearly 12 years of Visioning, a significant number of identified priorities have been addressed – and, in some cases, solved - through these collaborative efforts. For example, in 1994 the top priority in the community was access to primary care, and as discussed above the result was a major expansion in clinical capacity throughout the service area. Similar Visioning priorities around mental health services and dental services resulted in expansions: the creation of Evergreen Behavioral Services and the establishment of two separate dental facilities serving low-income residents.
Each Visioning involves a series of local meetings with key organizations, specialized outreach to solicit opinions from every corner of the community, a survey of local residents, and a culminating conference to set priorities and assign responsibilities for achieving goals. In 2006 for the first time the Visioning was launched with an initiative called 50 Stories in 50 Days, which identified health leaders in the community and assigned them to a resident recipient of one of a safety net service. Leaders visited their assigned recipient to ask about their stories and their lives, and reported what they learned, which was compiled into a full report. The process of visiting homes galvanized leaders in new ways, evoking strong emotions and new ideas for action, which in turn lent new power to the Visioning process.
Extensive community collaboration: In line with its mission to promote community health through collaboration, the network has extensive ties in the community and brings an unusually high level of attention and resources to community initiatives that may not directly rate to health care. These have had a major impact on the community. For instance, FCHN was a founding member and is a continuing sponsor of the Greater Franklin Economic Development Corporation, which helps rebuild the region’s changing and challenged economy and has in the past year attracted three major companies to the region. FCHN also had a supporting role in community initiatives to resurface a walking trail and build a bridge to reach the trail, and to improve the State’s formula for subsidizing local school districts, resulting in a very significant increase in support. The Network was the founder and continued administrator of Peace in Our Families, a collaborative initiative to reduce sexual assault and domestic violence.
Using the internet for community benefit: The network was an early adopter of internet technology as a resource to its own service area and beyond, reinforcing its emphasis on service to the community as integral to its health mission. FMH was one of the first hospitals in Maine to host its own website, and now has an additional website offered as a service to the community: TheCommunityConnector.org, offering referrals to agencies, services, and organizations in the community.
Collaboration to improve access to mental health: From the earliest days of the Visioning, residents ranked the need for mental health services as a top priority. In response, the network partnered with Sisters of Charity Health System to institute Evergreen Behavioral Services, now a full service outpatient mental health organization with a team of highly qualified providers including social workers, psychologists, nurse practitioners, and two psychiatrists. Evergreen collaborates with school districts to offer services, including counseling services on site at schools. Evergreen also provides a full continuum of care in the areas of mental health and substance abuse services, including all of the region’s crisis intervention and emergency mental health services, employee assistance programs for the business community, and children’s services, as well as general clinical assessment, evaluation, and medication management.
Innovation and Action for the Uninsured: The Network offers a range of options to help uninsured residents navigate the health care system and obtain affordable services. The network set aside $3 million of its $12 endowment to sustain Franklin Health Access, an initiative to connect uninsured residents with services donated by area clinicians and offered to Franklin Health Access members on a sliding fee scale. Franklin Health Access advocates for its members and helps them identify and obtain needed services, subsidizes the cost of prescriptions, offers free screenings and educational programs, and connects members to other services they may need such as fuel assistance or day care.
Another innovative program for the uninsured is Contract for Care. Income-qualified residents or their friends or family may make a pledge to volunteer for the network, and on the strength of that pledge FCHN will write off their outstanding hospital bill. Contract for Care volunteers cannot be identified among other volunteers, but the program has invigorated the network with thousands of hours of volunteer time to produce beautiful gardens and landscaping, quilts, support for dying patients, and administrative supports otherwise unaffordable to the network. For many participants, the program offers a measure of dignity and a welcome opportunity to give back to the health care system and the community.
The network was also the first and still the only one in Maine to help small businesses unable to afford health insurance for workers. The network funded Greater Franklin Economic Development Corporation to offer a 30% subsidy to uninsured small businesses offering health insurance for the first time. The network also offered seminars and programs for business to educate on health insurance, and offer worksite wellness and occupational health programs.
Healthy Community Coalition: The network set aside a $1 million endowment, with interest to be used to sustain the work of this affiliate. The Coalition raises nearly $1 million each year in grant funds, employs 14 staff, and engages over 200 volunteers, making it the largest such Coalition among 25 in Maine. The Coalition operates a mobile health unit staffed with nurses and health educators offering screenings and information in every town in the service area. The Coalition brings together organizations and individuals to pursue common purposes in improving health and quality of life. Among its many award-winning innovations in the community is its tobacco-free Franklin Families program, which brings together all clinicians, social service agencies, and individuals serving pregnant women and parents of children under five with the purpose of reducing tobacco use among that population. An epidemiological study of the program suggested that smoking among pregnant women declined by 20% in a two-year period as a result of the program.
This is a strong health system that has grown exponentially in the range and sophistication of services, while at the same time profoundly integrating community collaboration and service. The investment in community service has not undermined network performance, but reinforced it. This has resulted from a community culture that values innovation and collaboration, excellent leadership from physicians as well as administrators, and well-defined values and foundation stones motivating employees over the decades.