June 2000 
and 
Planning today to improve the lives of tomorrow 
State of Delaware 
Department of Health and Social Services (Division of Public Health) 
Delmarva Health Initiative 
Delaware Rural Health Plan 

Delaware Rural Health Plan June 2000 
Planning today to improve the lives of tomorrow 
Table of Contents 
Executive Summary 
Rural Health Plan – Context within Existing State and Local
Allocating Resources for Leadership Development and Staff
Acknowledgements 
Acronyms 
Section I. Introduction to the Rural Health Plan 
Plan Overview 
General Characterization of Sussex County
Rural Health Plan - Strategies 
Rural Health Plan - Process
Planning Efforts
The Rural Health Plan and Value Delivery
Components of the “Value Chain” for Rural Health
Section II. Environmental Analysis – Needs, Resources, and Gaps 
Needs Considered in the RHP 
Types of Resources Considered in the RHP 
Observations on Resource Sufficiency and Quality
Aligning Resources with Needs – “Where are the Gaps?” 
Section III. Strategic and Operational Improvements 
Introduction 
Lifecycle Recommendations 
Service Area Recommendations 
Special Considerations Recommendations 
Summary of RHP Recommendations 
Master Table of Suggested Policy Collaborators 
Section IV. Leadership and Staffing 
Introduction 
Stakeholders Defined 
Accountable Entities and Shared Responsibility 
Accountability in Sussex County 
Support 
Section V. Funding
Introduction 
Using the RHP to Finance Health Improvement
General Funding Strategy Process 
Sources of Funding
Section VI. Risks and Uncertainties
Introduction 
Potential Risks and Uncertainties
Section VII. Strategic Synthesis 
Introduction 
Principles/Tests of the RHP Strategy
Table of Contents Page i
Delaware Rural Health Plan June 2000 
Planning today to improve the lives of tomorrow 
Appendices 
Appendix A Medicare Rural Hospital Flexibility Program (MRHFP) 
Appendix B Northland Health Group (NHG) - Firm Background 
Appendix C Value Chain Detail 
Appendix D Stakeholders Contributing to the Rural Health Plan 
Appendix E List of Studies Relevant to the RHP 
Appendix F Summary of Notes for Policy and Initiative Development (DRAFT) 
Table of Contents Page ii 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Executive Summary 
In recognition of the unique and predominantly rural nature of Sussex County, the State of 
Delaware Department of Social Services - Division of Public Health (DPH) applied for Federal 
Office of Rural Health Policy grant funding to develop a Rural Health Plan (RHP). The Plan was 
designed to present an organized and strategic approach to improving the health of Sussex 
County residents. 
The RHP takes a community sensitive approach to addressing health status and access to services 
within Sussex County. The principal approaches employed in the RHP include: 
1. Recognizing and building upon the prior and anticipated future collective efforts of multiple
stakeholders to improve health status and access to health care services in Sussex County;
2. Balancing Sussex County health needs with existing and potential resources; and 
3. Developing recommendations for policies and implementable targeted initiatives, which
rely upon collaboration between government and community stakeholders.
The authors of the Plan believe that in order to be relevant, and to play an instrumental role in 
improving the health of Sussex County residents, recommendations must deliver value to 
citizens. The RHP therefore applies business concepts of value creation to the greatest degree 
possible in the context of recommendations for health care improvement. The RHP’s 
“customers” are the residents of Sussex County whose health status it addresses. 
The process of RHP development deeply involved committed and knowledgeable stakeholders. 
The Delmarva Health Initiative (DHI) served as Steering Committee for plan development. The 
Steering Committee itself met monthly with the consultants to review and critique interim 
findings and recommendations. Written documentation was supplemented by additional primary 
and secondary qualitative research, including more than 50 individual interviews with a diverse 
range of Sussex County stakeholders, stakeholder focus groups involving key constituencies, and 
finally, a working stakeholder retreat held at Dewey Beach, Delaware on May 22, 2000. Final 
recommendations were drafted only after the stakeholder retreat input focused on action planning 
was available. 
In Section II of the Plan, needs and resources are organized by lifecycle (Infant and Perinatal; 
Child and Adolescent; Adult; and Geriatric), by clinical service type (Primary Care; Dental Care; 
Behavioral and Mental Health; and Home Care) and additionally by certain special needs areas 
(Cultural, Minority, Racial and Ethnic Issues; Access to Resources; Leadership and Planning; 
and Infrastructure). 
Each of the ten recommended policies and ten suggested initiatives in Section III were matched 
to identified needs and resource gaps. These are summarized in Table III-1 (page 43). Both 
policies and initiatives are a focused and feasible set of recommendations that could lead to 
measurable implementation goals. The RHP focuses on the highest priority issues. In 
developing these recommendations, an active attempt was made to build on existing activities 
and infrastructure wherever possible. An effort was also made to avoid emphasis on those areas 
that are already being actively addressed in an organized and effective way. 
Executive Summary Page 1 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Prioritization and operational implementation planning will be the next task of the stakeholders. 
Leadership and staffing will therefore be key to successful implementation of RHP 
recommendations. Leadership issues are directly addressed in Section IV. The concept of 
“accountable entities” (stakeholders committed to “leading change”) is introduced in this section 
and should be viewed as applicable to suggestions for initial collaborators, which are provided 
with each recommendation. 
Section V addresses funding. The Plan stresses that while direct service resources require 
funding in order to focus on eliminating gaps, financial resources should also be directed toward 
training leaders, providing staff to develop and facilitate coalitions of stakeholders and 
accountable entities, and to supporting systems that can deliver county specific, statistical and 
other data essential to making sound decisions. The RHP has documented the significant need to 
leverage available resources through concerted shared responsibility. 
The RHP is not itself a grant application or a direct funding mechanism. Rather it is a potential 
guide to local or state agencies for setting funding priorities based on delivering value to Sussex 
County. Discrete initiative recommendations from the RHP can be extracted and enhanced for 
presentation as funding requests whereas policy recommendations may create the vehicle for a 
range of fundable opportunities. 
Risks and uncertainties detailed in Section VI denote potential barriers to successful 
implementation of the RHP. By recognizing these, proactive strategies may be undertaken to 
minimize risks of achieving less than full value through the RHP. While it is not possible to 
predict all the potential barriers to success for each initiative and policy recommendation in the 
RHP, it is worthwhile to focus some attention on major anticipated areas of risk and uncertainty 
for the RHP as a whole. 
Section VII contains a “strategic synthesis.” This is an opportunity to overview the RHP as a 
whole and ask 10 important questions which ensure that the rural health business plan considers 
and applies key strategic principles appropriately. These same questions can, and should, be reapplied 
to specific strategies and initiatives developed in the course of implementing the RHP. 
The RHP is presented jointly to the Governor and Sussex County Administration. It is submitted 
as a contribution to health planning for Sussex County. The Plan honors past accomplishments 
with both pride and respect. It offers sober and candid analysis regarding those challenges that 
remain. It embodies optimism regarding the real potential for positive change which can be 
realized by building on the collaborative spirit and energy which has characterized prior 
successes. 
Executive Summary Page 2 

Delaware Rural Health Plan June 2000 
Planning today to improve the lives of tomorrow 
Acknowledgements 
As principal collaborators in the development of the Delaware (Sussex County) Rural 
Health Plan, both the Delmarva Health Initiative and the Department of Social Services – 
Division of Public Health wish to recognize the Sussex County hospitals as well as 
numerous other agencies, organizations, institutions, and individuals who have 
contributed to improving the health of Sussex County residents in advance of this plan. 
Although it has been impossible to individually note each of these past contributions in 
the Rural Health Plan, the current effort to organize and coordinate efforts going forward 
would not have been possible without the important groundwork accomplished more 
informally in the past. Only through the continuation of such important and dedicated 
grassroots efforts will progress on the ambitious goals of the Rural Health Plan be 
successful. 
Steering Committee Members 
Prue E. Albright Division of Public Health 
Norene Broadhurst Beebe Medical Center 
Don Clark Nanticoke Health Services 
Barbara DeBastiani Division of Public Health 
Stephany Foster Electronic Data Systems Liaison to DE Healthy Children 
William Gallery, DVM 
Edward Goate Central Delaware Community Health Partnership, Inc. 
Reverend John Hird Beebe Medical Center Trustee 
Wallace Hudson Beebe Medical Center 
Paul Lakeman Bayhealth Medical Center 
Joe Liefbroer Johnson Wax 
Colonel Mike Martin Dover Air Force Base 
Bill Neaton Bayhealth Medical Center 
Gina Bianco Perez Division of Public Health 
Beverly Smith Division of Public Health 
Lois Studte Southern Delaware Community Health Partnership, Inc. 
Acknowledgements Page 3 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Acronyms 
Abbreviation/ 
Acronym Full Text 
AARP American Association of Retired Persons 
AHCRQ Agency for Health Care Research & Quality 
ALS Advanced Life Support 
AAPP Alliance for Adolescent Pregnancy Prevention 
BBA Balanced Budget Act 
BLS Basic Life Support 
CAH Critical Access Hospital 
CD/SA Chemical Dependency and Substance Abuse 
CDC Center for Disease Control 
CON Certificate of Need 
CTT Certified Therapeutic Technician 
DAAPD Division of Aging Adults with Physician Disabilities 
DADAMH Division of Alcohol, Drug Abuse and Mental Health 
DDAIC Delaware Dental Access Improvement Committee 
DHCC Delaware Health Care Commission 
DHI Delmarva Health Initiative 
DHSS Department of Health and Social Services 
DIDER Delaware Institute for Dental Education and Research 
DIMER Delaware Institute for Medical Education and Research 
DPH Division of Public Health 
DSCYF Department of Services for Children, Youth, and their Families 
DSS Division of Social Services 
EMS Emergency Medical Service 
FTE Full Time Equivalent 
HCFA Health Care Financing Administration 
HPSA Health Professional Shortage Area 
HRSA Health Resources and Services Administration 
LBW Low Birth Weight 
MCO Managed Care Organization 
MRHFP Medicare Rural Hospital Flexibility Program 
MVA Motor Vehicle Accident 
NASW National Association of Social Workers 
NHG Northland Health Group 
ORHA Federal Office of Rural Health Policy 
PCP Primary Care Physician 
RHP Rural Health Plan 
RWJ The Robert Wood Johnson Foundation 
SBHC School Based Health Care 
SCI Strong Communities Initiatives 
SEER Surveillance, Epidemiology, and End Results Program 
STD Sexually Transmitted Disease 
Abbreviations/Acronyms Page 4 

Section I 
Planning today to improve the lives of tomorrow 
Delaware Rural Health Plan 
Introduction to the Rural Health Plan 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
I. Introduction to the Rural Health Plan 
Plan Overview 
In recognition of the unique rural nature of Sussex County, Delaware, the Division of Public 
Health (DPH) applied for Federal Office of Rural Health Policy grant funding to enable 
development of an innovative Delaware (Sussex County) Rural Health Plan (RHP). The RHP 
takes a community sensitive approach to addressing the following aspects of health status and 
access to services in Sussex County (illustrated in Figure I-1): 
Figure I-1: IOM Model - Health Care Operating Environment 
• Health care resources; 
• Physical environment; 
• Social environment; 
• Disease prevalence; 
• Health and function; and 
• Well-being.1 
While addressing each of these issues at 
some level, the RHP focuses primarily on 
the issues of primary (characteristics of 
the population and health care delivery 
system) and secondary (environmental) 
Social 
Environment 
Physical 
Environment 
Genetic 
Endowment 
Well-Being 
Disease 
Health 
Care 
Individual 
Response 
Health 
and 
Function 
Prosperity 
determinants of health. Evans and Stoddard, 1990, “Producing Health, Consuming Health Care” 
The RHP is intended to create awareness for those who are relatively unfamiliar with the county 
(e.g., new residents and policy makers from other parts of the state), as well as deepen the 
understanding and perspective of established stakeholders within Sussex County. 
General Characterization of Sussex County 
Sussex County is unique among both its peer counties within Delaware (Kent and New Castle) 
and the bordering counties in Maryland to the south and east. Given its area of 950 square miles, 
Sussex is one of the largest counties east of the Mississippi River and accounts for nearly half of 
the state’s total area. The total population of approximately 141,000 is aggregated primarily 
around the county’s four cities: Georgetown, Lewes, Milford, and Seaford. Not unexpectedly, 
health care resources are also concentrated in these areas. 
Rural Health Plan - Strategies 
The principal strategies employed in the RHP include: 
1. Recognizing and building upon the prior and future collective efforts of multiple 
stakeholders to improve health status and access to health care services in Sussex County; 
1 Institute of Medicine. Improving Health in the Community. National Academy Press: 1997. 
Section I Page 5 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
2. Balancing Sussex County health needs with area resources, as reflected by a qualitative 
and quantitative understanding of existing assets and circumstances. This includes the input 
from government agencies, community groups, and individuals, representing health care 
providers, regulatory agencies, policy makers, social services, advocacy, and/or referral 
agencies; and 
3. Developing policy and strategy recommendations and implementing targeted initiatives, 
which rely upon identified lead agencies and organizations that can achieve success through 
collaboration with relevant and interested community stakeholders. 
Although the distinctive geographic and demographic characteristics of Sussex County may not 
easily permit comparisons to rural areas in other eastern states, many of those states have 
completed RHPs focused on improving the quality of, and access to, health care in rural areas. 
These strategies have generally focused on facilitating the designation of Critical Access 
Hospitals (CAH), small facilities (with up to 15 acute care beds) which agree to certain size and 
activity limitations in exchange for generally favorable Medicare reimbursement. While this 
option has been explored in Delaware, it does not currently apply to any of the three existing 
Sussex County hospitals. The state’s approach to considering possible CAH development is set 
forth in Appendix A. The Delaware (Sussex County) Rural Health Plan therefore focuses on 
community-based health improvement rather than hospital-specific strategies. 
Through the Delaware State Office of Rural Health, DPH has shared responsibility for 
developing the RHP with the Delmarva Health Initiative (DHI), a county-wide collaborative of 
health care providers and advocates largely derived from past Sussex County Health Summits. 
DHI identified the need for technical assistance to facilitate RHP development and selected the 
Maine based Northland Health Group2 (NHG) to research and author the Plan. 
Rural Health Plan - Process 
DHI met monthly as the Steering Committee for this effort. DHI reviewed and critiqued interim 
findings and recommendations based on a review of existing need assessments and resource 
descriptions. This analysis was supplemented by additional primary and secondary qualitative 
research, including more than 50 interviews with a diverse range of Sussex County stakeholders. 
Complete listings of interviewees and documentation reviewed are provided in Appendices D 
and E. NHG also visited certain key community sites, government and community agencies, and 
provider facilities. Interviewees provided meaningful contributions to the understanding of key 
opportunities, challenges, and barriers addressed by the Plan. 
Rural Health Plan - Context within Existing State and Local Planning Efforts 
Lessons learned from historical public health planning efforts reveal an important balance for the 
RHPs users to appreciate. From one perspective, the Plan could be expected to be “allencompassing” 
so that the interests of all stakeholders are meaningfully represented (e.g., “wide 
representation and participation”). From another point of view, the Plan must be focused on high 
priority and high impact issues, and must contain clear and specific guidance for policy and 
2 For NHG qualifications and firm background please see Appendix B 
Section I Page 6 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
action (e.g., “less is more”) with value derived from focusing attention on a limited number of 
issues. 
Figure I-2: Context for Rural Health Plan 
RURAL 
2010 
/ 
HEALTH 
PLAN 
HEALTHY 
DELAWARE 
ALL OTHER 
STATE-WIDE 
PLANNING 
SERVICE 
AREA OR 
COMMUNITY 
PLANNING 
CITY 
PLANNINGCOUNTY SUB-
DIVISIONS 
In either circumstance, successful development of the 
RHP must create a contextual “fit” between existing state 
and community-level planning processes and activities 
(illustrated in Figure 2). The RHP does not replace, but 
rather complements, initiatives targeted to individual 
community needs or “at-risk” populations in particular 
areas. It provides a strategic and advocacy focus, at all 
levels of policy and implementation, for issues relevant to 
Sussex County. It can inform collaborative action across 
communities and can guide both policy makers and 
funders on pressing county-wide issues. At the broadest 
level, the RHP can serve to create relevant connections 
among state planning initiatives such as Health Delaware 2010, the Delaware Institute for 
Medical Education and Research (DIMER), and the Delaware Health Care Commission (DHCC) 
as well as multiple new and ongoing agency specific initiatives. 
The Rural Health Plan and Value Delivery 
In order to be relevant and to play an instrumental role in improving the health of Sussex County 
residents, projects and initiatives must deliver value to citizens. The model for understanding 
value delivery is found in commercial businesses, which regularly focus on the importance of 
value for attracting and retaining customers. This focus supports the ability of any business to 
operate efficiently, responsively, and profitably and thus be durable in its marketplace. 
The RHP applies the business concept of value creation to the greatest degree possible in the 
context of health care improvement. The RHPs “customers” are the residents of Sussex County 
whose health status it addresses. Additionally, however, customers could include the hospitals 
and other direct service providers, community based social service agencies, businesses, the state 
of Delaware itself, and perhaps many others who will use the RHP and benefit from its vision of 
policy and project opportunities. 
Components of the “Value Chain” for Rural Health 
The top value chain model seen below (Figure I-3) is presented to illustrate the components of 
value production for a manufacturing firm that produces goods from raw materials. Primary 
production activities are those that are easily recognizable as components of selling, 
constructing, or delivering a manufactured product. Support Activities and Processes are the 
“back room” functions that are necessary to support the primary activities but which are 
sometimes overlooked when measuring value. Both primary production and support activities 
are necessary. Each category expresses functionalities that are provided by the firm or delivered 
collaboratively with partnering organizations (e.g., subcontracted activities, joint ventures, etc.). 
Section I Page 7 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Figure I-3: Classical Manufacturing Value Chain Model 
) 
(((
) 
(
/
Primary Production Activities 
Operations 
Infrastructure 
Staff and Leadership 
R & D 
Informational Technology 
Outbound 
Logistics 
Marketing 
and Sales 
Support Processes and Activities 
Service Inbound 
Logistics 
(Customer 
AcquisitionRaw Material 
Procurement) 
Fabrication) Delivery and 
FulfillmentPost-Sales 
Service and 
Support) 
Facility, Plant, Finance, Systems, etc. 
HR Functions: Recruitment, Training , etc. 
Product Development and Improvement 
InternalExternal Communications, Analysis, etc. 
Effective 
Product 
Marketing 
and Sales to 
Customers 
The value chain expresses the way in which different components of a business system 
complement each other to create value for “end users” or “customers.” A value chain adapted to 
rural health care is represented below (Figure 4). For each element of rural health care (i.e., 
dental health, primary care, and home health care), analogous Primary Activities (Projects and 
Initiatives) contribute in a linear fashion to program execution or delivery of services. This can 
be compared to an assembly line in a manufacturing production process for making “widgets.” 
Similarly, Support Activities (Policies and Structures) are essential enablers of the primary 
activities and the system, but do not directly play a role in production or delivery of services. 
Figure I-4: Rural Health Plan Value Chain Model 
) 
Projects and Initiatives 
Provision of 
Direct 
Services 
Infrastructure 
Leadership/Staffing 
Planning 
Communication 
Discharge, 
Referral, 
Placement 
Public 
Awareness, 
Education, 
Information 
Policies and Structures 
Surveillance, 
Assessment, 
Monitoring, 
Prevention 
Access, 
Intake, 
Registration Value = 
Optimal Health 
Status for Sussex 
County Residents 
(CustomersFinance, Environmental Factors 
Accountability, Stakeholders, Recruitment, Training 
Project Development, Improvement, and Pilots 
Coordination, Partnering, Information Sharing, IT 
The concept of RHP “value delivery” therefore encompasses all of the components required for 
successful accomplishment of recommended projects and initiatives. The model is used 
throughout this document to analyze needs and resources as well as to target policies and 
initiatives to yield the most effective impact on community health status. 
Section I Page 8 

Section II 
Planning today to improve the lives of tomorrow 
Delaware Rural Health Plan 
Environmental Analysis - Needs, 
Resources, and Gaps 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
II. Environmental Analysis – Needs, Resources, and Gaps 
Needs Considered in the Rural Health Plan 
After reviewing existing needs studies, NHG generally focused on those studies that were no 
more than three years old and contained specific, quantitative information regarding Sussex 
County issues. The focus on county-level studies limited the amount of available information. 
While there was no shortage of analytic studies and monographs for review, many contained data 
and observations that were aggregated and reported at the state level. Using these studies to plan 
at the county level would have required an assumption that Sussex County residents have the 
same needs and characteristics as Kent and New Castle Delawareans. However, this is not the 
case. For example, a review of data that is available for Sussex County (e.g., vital statistics) 
reveals that patterns of health, disease, and behavior differ dramatically in Sussex County when 
compared to the state as a whole or to Kent and New Castle Counties. 
Types of Resources Considered in the Rural Health Plan 
Multiple resources contribute to the Sussex County health care delivery system. In the Plan, 
resources are categorized into three types: 
• Direct Health Care Providers (providers of direct clinical health care services) 
• Human Service Providers (community or state agencies providing social services) 
• Service Integrators/Advocates (organizations providing referrals and/or problem 
solving assistance to clients across a broad range of needs) 
Each resource type contributes uniquely to the health status of rural Delawareans through 
delivery of components such as: health care services, health education, basic needs assistance, 
advocacy, and/or financial support. 
Observations on Resource Sufficiency and Quality 
Different methods for determining resource quality and utility are required to consider the three 
categories of resources addressed by the Plan. Direct Health Care Providers represent the only 
area for which accepted planning benchmarks exist, and for which estimates for the number of 
professionals required to serve a population are even moderately available. Even in this 
relatively limited context, the use of quantitative measures is controversial and problematic due 
to problems such as geographic distribution and lack of access. Therefore, assessment of 
resource adequacy, and the potential for resources to meet community needs, must be both a 
quantitative and qualitative exercise. In this plan, alignment between resources and needs has 
thus been determined by structured, qualitative assessments provided by individuals experienced 
with an “on the ground” perspective. To the extent possible, additional objective data (e.g., 
surveys, quantification, studies on access, etc.) have been used to further inform this process. 
Aligning Resources with Needs - “Where are the Gaps?” 
The sections that follow provide both narrative descriptions and schematic representations of 
Section II Page 9 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
resource adequacy considered in three dimensions. A life cycle perspective (perinatal, 
child/adolescent, adult, and geriatric) and a provider or clinical service perspective (primary care, 
dental, behavioral health, home health) are both included as is a “special considerations” section. 
Each resource is examined in the context of its perceived performance in meeting existing needs 
and in delivering value. The graphics are used to represent alignment that does (or does not) 
exist among Sussex County’s resources. 
The RHP uses a “traffic light” scoring approach to depict resource adequacy at points along the 
value chain. Red indicates that gaps between needs and available resources are so significant 
that the system is “stopped;” yellow is a “warning” of incomplete functionality; and green means 
that the system operates smoothly, hence a “go.” Thus, a green marker denotes points where 
resources fully meet needs, yellow indicates questionable or sub-optimal resources, and red 
denotes a significant and potentially problematic gap between needs and resources. From a 
planning perspective, the most critical areas to address are the red markers or “gaps.” 
Figure II-1: Gap Analysis Example 
(5) For each needs dimension analyzed, overall “degree of 
alignment” or “performance” is summarized by a value chain 
component, and supporting notes and key points are indicated. 
(2) Population Group or 
Resource/Service Type 
being analyzed 
Significant Gap in Resources 
Questionable Resource Sufficiency 
Fully Sufficient Resources 
(4) Resource Alignment Legend 
Inf a nt s/ Perinat a l 
Lifecycle - Infants and Perinatal (3) Components of Value Chain 
being tested for alignment 
Summary of Findings: Infant and Perinatal Resource Alignment 
(1) Needs Dimension 
(“Gap Analysis” Topic) 
Each value chain component is evaluated and assigned a 
color that indicates its current “degree of alignment” or 
“performance”; if a color was not assigned, insufficient 
information existed to make the evaluation. 
Overall 
Status 
Information 
Intake 
DirectService 
Referrals 
Monitoring 
Infrastructure 
Leadership/ 
Staffing 
Planning 
Communication 
Section II Page 10 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow 
Lifecycle #1- Needs of the Infants and Perinatal Population 
June 2000 
Source for all data below is Delaware Vital Statistics Annual Report (1998) 
• Key outcome indicators of infant and perinatal health care effectiveness are the 
neonatal/infant mortality and low birth weight (LBW) rates. In Sussex County, neonatal and 
infant mortality have risen for the past two 5-year cycles as compared to state. The LBW 
fraction has risen from a favorable level (pre-1995) to approach the higher state rate: 
7 
8 
1987-19911988-19921989-19931990-19941991-19951992-19961993-19971994-1998 
) W 
DelFiii4 
5 
6 
7 
8 
9 
10 
/iiUS 
e 
IIlity byii7 
8 
9 
10 
11 
12 
13 
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DelNCC 
IIPerce nt of LBW Births 
Sussex v De law are 
6.5 
7.5 
8.5 
5 Ye ar Pe riod 
Perce nt (%of LBaw are 
Sussex 
gure II-4 Neonatal Mortality by 5 Year Perod 
US v DE v Counte s 
19871991 
19881992 
19891993 
19901994 
19911995 
19921996 
19931997 
19941998 
5 Year Period 
Deaths1,000 Lve Brths 
DelawarKent 
NCC 
Sussex 
Figure-3 
Infant Morta 5 Year Perod 
US v DE v Countes 
19871991 
19881992 
19891993 
19901994 
19911995 
19921996 
19931997 
19941998 
5 Year Perod 
Deaths/1,000 
aw are 
Kent 
Sus sex 
Figure-2 
• Sussex County and Delaware are now higher than US in neonatal mortality (see Figs. II-2 
and II-3). The rise in Sussex County infant mortality over the past two 5-year periods is 
unexplained and is of concern. Statewide LBW rates are generally driven more by births to 
teens and African American females; however, in 
Sussex County, teens and white births are the drivers. Figure II-5 
Births to Single Mothers by County 
Among the white population in Sussex County, the (1994-1998)
percentage of LBW infants exceeds both the US and 
the state. 
• Sussex County has more births to single mothers 
(43.7) compared to the state (35.79%) and other 
Delaware counties (Figure II-5). 
ll 
le 
County % Births to Single Mothers 
Delaware - A35.7% 
New Cast33.4% 
Kent 36.0% 
Sussex 43.7% 
• Prenatal care adequacy in Sussex County is lower than the state in the aggregate and in 
each racial/ethnic subgroup measured. While Sussex is not alone in this regard, the 
comparison between non-urban New Castle County and Sussex County is striking. 
Figure II-6 
Births to Mothers Receiving Adequate Prenatal Care by Race 
DE 
Kent 
NCC 
Wilmington 
Sussex 





WhiBlack 
te 
All Races 
) 
47.1 
66.9 67.4 
81.2 
71 
0 
10 
20 
30 
40 
50 
60 
70 
80 
90 
% 
Prenatal Care Adequacy by Delaware County (1998KENT SUSSEX WILMINGTON BAL. NCC DEL 
County 
by Category of CareAdequate 
Intermed 
Inadequate 
Unknown 
Figure II-7 
10 20 30 4050 60 7080 90 
Percentage ofTotalBirths
Section II Page 11 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Lifecycle #1-Resources for the Infants and Perinatal Population 
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T 
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Status 
Summary of Findings: Infant and Perinatal Gap Analysis 
• Awareness (of Resources): Good for some populations (white, insured), poor for others (Hispanic, 
Black, disadvantaged); More hospital-based education is needed; State Service Centers provides 
clearinghouse function. 
• Access to Care: Delmarva Rural Ministries has a mobile van and is expanding beyond migrant 
population; Geographic access/transportation problematic for fixed site resources; Generally more 
bilingual capacity needed; Social Service availability to disadvantaged and racial and ethnic minority 
populations needs improvement; new health center to open in Georgetown. 
• Direct Service: Physicians up-state support down-state providers with specialty care; Each hospital 
provides labor and delivery services with comparable service levels; Linkage of social services with 
direct clinical services needs improvement. 
• Referral: More lay support (resource fathers/mothers) needed; Child Development Watch is an 
important resource re: coordination of care and case management; Home visiting for first time parents 
provides opportunity to follow the family and observe in their own environment. 
• Monitoring: United Way and Child Development Watch are monitoring outcomes; Perinatal mortality 
is rising -reasons are not well understood; No systematic appreciation of health status on a county 
level. 
• Infrastructure: There are three duPont Pediatric Clinics (Milford, Georgetown and Seaford) that serve 
infants, and children and adolescents (up to 19 years) with family income up to 200% of poverty on a 
sliding fee scale basis. Transportation is a significant limitation to receiving infant and perinatal 
services for those who live a distance from these sites. 
• Leadership: The Perinatal Board has been very effective in providing system level leadership, however 
the social service sector does not have focused leadership in addressing this population. 
• Planning: Services for children with special health care needs, appear to be a strong potential resource 
but are currently under-funded; Perinatal Board is an important planning resource, helped raise 
Delaware’s ranking infant mortality from worst to 25th in country. 
• Communication: Provider-provider communication is spotty; 53 separate agencies on teen pregnancy; 
The symposium “Cradle of Hope” was effective. 
Section II Page 12 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow 
Lifecycle #2 - Needs of the Child and Adolescent Population 
June 2000 
• While meaningful Sussex County specific data is lacking on younger childhood needs, 
extrapolation of state level data suggests that injury prevention, asthma, and special needs 
support services areas all may require attention. 
• As articulated in Delaware’s Maternal and Child Health Grant application, the following 
needs are apparent in Sussex County for special needs children: 
– Insufficient services for OT, PT, and speech therapy needs; 
– Child care needs for the population may be insufficient and currently under study; 
– Care coordination is insufficient for children > age 3 with special needs; 
– Culturally compatible specialty care access is insufficient. 
• Sussex County teen live birth rates are well above the US and state rates for both younger 
and older teens. For white teen mothers, the rate is rising whereas the US rate is falling for 
this group. African-American teen birth rates are falling at a rate similar to US and are 
decreasing faster than the state rate. Teen live birth rates in several census tracts 
(Bridgeville, Selbyville, and Laurel) stand out as extraordinarily high. 
Dierrtes 
0 
5 
10 
15 
7983 
8084 
8185 
86 
8387 
88 
8589 
90 
8791 
8892 
8993 
9094 
9195 
9296 
9397 
9498 
iod 
US 
Difference (in %) 
ffence BetweenTeen (15-19)and GeneralLive Bih RatSussex County v.US v.DE (1978-1997) 
(20) 
(15) 
(10) 
(5) 
8284865 
YearPerDEL 
SUS 
Figure II-8 
Figure II-9 
Five-Year Average Teenage (15-19) Fertility Rates 
U.S., Delaware and Counties, 1978-1998 
90 
80 
70 
60 
50 
40 
30 
DE 
NCC 
liU.S. 
Kent 
Sussex 
Sources: 
Deaware Health Statistics Center 
National Center for Health Statstics 
78-82 79-83 80-84 81-85 82-86 83-87 84-88 85-89 86-90 87-91 88-92 89-93 90-94 91-95 92-96 93-97 94-98 
Five-Year Intervals 
Source for above data is Delaware Vital Statistics Annual Report (1998) 
• School Based Health Centers (SBHC) are in all Sussex County high schools; based on 
interviews and SBHC data, teen primary health care needs are characterized as “largely 
unmet.” Teen mental/behavioral health needs are also not adequately being met due, in part, to 
a lack of providers serving this population. In addition, for both primary care and mental 
health needs, transportation is inadequate and conflicts with access and confidentiality needs. 
Approximately 35% of SBHC visits are for mental health concerns. 
• Self reported substance use in older Sussex 
County adolescents exceeds state rates. The 
need for improvement is particularly apparent 
from the increase in use reported between 
grades 8 and 12, which greatly exceeds the 
state as a whole. 
8th v 11th Grade Self Reported Substance 
Use Grade 8 Grade 11 Change 
Sussex % % % 
Cigarettes 22 39 17 
Alcohol 25 53 28 
Marijuana 15 25 10 
Delaware % % % 
Cigarettes 24 33 9 
Alcohol 29 47 18 
Marijuana 19 25 6 
Section II Page 13 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Lifecycle #2 - Resources for the Child and Adolescent Population 
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IMPROVED CHILD
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Overall 
Status Summary of Findings: Children and Adolescents Gap Analysis 
• Awareness: State Service Centers are primary resources for reproductive health including education and 
services for family planning and sexually transmitted diseases (STD); YMCA resource centers and Boys 
and Girls Club disseminate information; SBHCs provide treatment for STD but do not provide broader 
family planning services in most districts; Resource guide is published for resources serving children with 
special needs 
• Access: Poor access to behavioral health, mental health, primary care, and family planning; Few 
transportation options; the Delaware Healthy Children Program (children’s health insurance) is an 
important resource; Access van is expanding awareness/access; Limited services for special needs children 
remains a problem; Adolescents access into family planning services remains problematic (e.g., 
confidentiality, lack of SBHC services, transportation and clinic hours were cited as barriers). 
• Direct service: Quality can be very good when services are available, with possible exception of teen 
OB/GYN services; Language and socio-cultural barriers impact patient-provider communication; Patientphysician 
communication problems make direct service quality less than ideal. 
• Referral: Little county level data is available to determine resource or care adequacy. 
• Monitoring: School nurses, especially at elementary and middle school levels, and SBHC are important 
resources, especially in the area of prevention, but little evaluative data is available; Outcomes 
measurement under development at United Way but not active. 
• Infrastructure: duPont Pediatric Clinics provide direct services; Resource infrastructure is not sufficient to 
meet behavioral health needs for this population; Direct state contracting has may have unintentionally 
reduced providers and decreased access; Head Start is an important resource; Feedback from mothers 
concerned about access/adequacy of special needs services for children. 
• Leadership: Leadership: Despite a proliferation of services, coordination of efforts to meet needs may be 
lacking; Community health partnerships have been initially successful, but more work is to be done. 
• Planning: Not clear if resources are equally available to Hispanics; Additional planning is needed, re: the 
stage of intervention for children, especially in areas of behavioral risk factors (e.g., prevention of 
substance use between 8th and 11th grade). 
• Communication: When children graduate, there is insufficient communication between SBHC and private 
health care systems to assure that primary care is in place; Although the role of SBHC is not provision of 
primary care, their role in assuring a medical home “drops off” precipitously upon graduation; Insufficient 
communication among providers; Agency collaboration is rising. 
Section II Page 14 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow 
Lifecycle # 3 - Needs of the Adult Population 
June 2000 
• Delaware cancer mortality rates are the second highest in the US (1992-1996 SEER data). 
Mortality from prostate, colorectal, cervical, and lung cancers are extremely high in state. 
County rates are indistinguishable from state in vital statistics data for individual cancers due to 
small populations numbers. African-American men (lung, prostate, colorectal) and African-
American women (cervical) predominate in excess mortality. Hospitals have been instrumental 
in developing integrated cancer care and support programs. 
• Sussex County exceeds Delaware and US mortality rates for all adult age groups except ages 
35-44. Mortality is apparent across all age groups particularly for cancer, heart disease, and 
motor vehicle accidents (MVA). 
Figure II-10 
y Age () 
p 
US 
Dea t h Ra te s B All Ca u sesSu s s e x Co u nty v. DE v. US (1992-1996) 
0.0 
200.0 
400.0 
600.0 
800.0 
1000.0 
1200.0 
1400.0 
1600.0 
25-34 35-44 45-54 55-64 
Age Ba nd 
De a th R ate pe r 100,000 po 
Delaw are 
SUS SEX 
Source for above data is Delaware Vital Statistics Annual Report (1998) 
• Sussex County death rates from congestive heart disease exceed state rates. Cardiac disease is 
also the most frequent cause for hospitalization in Sussex County. Lifestyle and controllable 
risk factor issues predominate as predisposing factors: 
– Smoking – Motor vehicle accidents 
– Overweight – No seat belt use 
– Hypertension – Operating under the influence of alcohol 
• County specific Behavioral Risk Factor Survey data are not currently available. State level 
data is shown in Fig. II-11. Figure II-11 
Delaware Adults at Risk from Selected 
• All racial and ethnic groups in Sussex County 
exceed US mortality rates in diabetes. African-
American females in Sussex County have a 
strikingly high mortality (greater than 50 per 
100,000) which exceeds both the state (40 per 
Percent of Adults 
18 and Older 
40 
30 
20 
10 
Behavioral Risk Factors, 1997 
100K) and US (28 per 100K). 
• Sussex County rates for STDs such as syphilis, 
gonorrhea, and chlamydia exceed state rates 
which themselves are high compared to US 
rates. 
Binge Drinkers 
"Poor Health" 
No Health 
Ins.
Diabetic 
High BP 
No Safety Belt 
Overweight 
Smokers 
Drink & 
Drive 
Chronic Drinkers 
With These Risks Factors 
Section II Page 15 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Lifecycle # 3 - Resources for the Adult Population 
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Status Summary of Findings: Adult Gap Analysis 
• Awareness: Good for those highly familiar with the system, but relatively poor for all others; Delaware 
Help Line serves primary referral function providing general state level information; Database is extensive, 
but the use by (and focus on) Sussex County population is unclear; Mixed to poor impressions by other 
providers; Awareness of multiple other resource directories is low. 
• Access: Primary care provider numbers appear adequate for population when federal shortage area criteria 
are applied BUT this may not result in operational access if practices are closed to new patients, certain 
payer types or do not have accessible hours or geographic sites for special populations; Dental access is 
limited, even for populations able to pay, joint planning is trying to address this; Lack of transportation 
infrastructure is a long standing problem; Managed care networks limit access to some physicians. 
• Direct service: Direct medical and dental care service quality is acceptable for adults by report, however, 
the availability of such services may be significantly limited for many residents who encounter access 
barriers (see above). 
• Referral: Most problematic for mental health; Hospitals provide referrals to physicians; Most frequent call 
is for family practice physicians accepting Medicaid; Awareness for referral opportunities may limit 
otherwise functional systems. 
• Monitoring: Little county level data is available to determine resource or care adequacy. 
• Infrastructure: Many services focused on adult population; State funding mechanism lowers incentive to 
collaborate and may lead to inter-agency competition; Mental health access or infrastructure (too few 
providers) is a problem; Transportation remains problematic, particularly for residents of more rural and 
less densely populated portions of the county. 
• Leadership: Leadership and joint planning among direct providers are of mixed quality -some good 
examples, but many more opportunities for improvement; Division of Volunteerism not functioning well 
or meeting potential as an integrator. 
• Planning: Community/state supports multiple referral services and resource directories which could be 
coordinated better -it is not clear if funding is adequate to support all; Good coordination of resources in 
rehab (DE Association of Rehabilitation Facilities); Less joint planning/coordination in other areas; Should 
look at cost and efficiency issues for long range. 
• Communication: Hospitals serve catchment areas well however there is minimal operational collaboration 
across hospital services and staffs; Increased coordination of services and resource inventories represents 
an opportunity to improve their advocacy/service integration role. 
Section II Page 16 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Lifecycle # 4 - Needs of the Geriatric Population 
• As a result of both the aging of the population and an increasing retiree population, the Sussex 
County elderly population is anticipated to grow rapidly through 2010. The greatest growth 
rate will be in the over 85 age group. 
Figure II-12 Figure II-13 
) 
0 
Projl 
Elderly Population Growth Estimates(1999-202010,000 
20,000 
30,000 
40,000 
50,000 
60,000 
70,000 
80,000 
90,000 
1999 2000 2005 2010 2015 2020 
Year 
ected Populati on > Age 60 
New Cas te Cou nt y 
Kent Count y 
Sussex County 
Est. % G ro wth in Elderly Pop ulation Segments 
Sussex County(2000-2020) 
160% 
140% 
% 
Gr 120% 
ow 
th 100% 
(20 
0020 
80% 
20) 
60% 
40% 
20% 
0% 
Over 60 Over 75 Over 85 
Age Band 
• Mortality rates for elderly population in Sussex County exceed state and US in the greater 
than 65 age groups in the aggregate: 
All causes 65-74 75-84 85+ 
US 2578.7 5851.5 15280.2 
Delaware 2731.5 6209.4 17297.2 
Sussex Co. 2597.8 6362.8 17126.3 
and, significantly, for the following specific conditions: 
– Pneumonia and influenza 
– Motor vehicle accidents 
• Other than basic mortality data, despite an anticipated explosive geriatric population growth, 
there is a striking lack of data to support the identification of needs for this population. This 
data is required for a thorough understanding of needs and for resource development. 
Anecdotal and qualitative data suggests needs in the following areas: 
– Primary care 
– Geriatric medical specialists 
– Home care 
– Transportation 
– Social activities 
• Coordinated and long range planning for this population appears to be lacking at the county 
level. 
Section II Page 17 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Lifecycle # 4 -Resources for the Geriatric Population
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IC SERVICES
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Status 
Summary of Findings: Geriatric Gap Analysis 
• Awareness: Population is bypassing integrators and working directly with providers. 
• Access: Access to prescription medication is a problem; “Pill Bill” may increase access to prescription 
drugs for low income; Not clear if adult day care is meeting need or is appropriately located; CHEER and 
senior centers are key resources; Vans believed to have significantly alleviated transportation problems for 
the geriatric population, but individuals requiring multiple services or living in low population density 
areas continue to experience transpiration related limitations. 
• Direct service: Difficult population to serve due to cultural and access issues; Home Health is an important 
support and is in short supply; Geriatric medical specialists are not readily available in Sussex County. 
• Referral: Discharge planning is working well, but limited by a resource availability or knowledge; 
Adequacy of discharge largely depends on the area -many services in the Beebe area; Out-referral 
hampered by lack of Sussex County geriatricians (see above). 
• Monitoring: Division of Aging and Adults with Physical Disabilities (DAAPD) does not have current 
health status or needs/resource assessment for geriatric population; Unclear if CHEER adequately meets all 
need or if it is serving a large enough percentage of the population; Senior Summit indicated that resources 
are not meeting needs. 
• Infrastructure: State directory of geriatric services indicates many resources are present but sufficiency is 
unknown; CHEER and Senior Centers are important resources (e.g., providing immunizations, focus for 
day activity, housing, recreation); Assisted living increasing, but not clear if demand supports increase in 
housing units; Information on the advocate/service integrator area is limited; Transportation options 
inadequate. 
• Leadership: Centralized funding may be a threat to these organizations; Seniors benefit from some 
advocacy through AARP; Leadership shown by DHSS/DAAPD limited by lack of planning data. 
• Planning: With no data, planning is insufficient; Each agency is perceived as doing its own thing, no joint 
planning; Some believe direct services are not prepared for rapid growth of this population (migration to 
Sussex) or the aging of the population; Additional work in the planning of services is needed; Social 
service agencies should work with direct service providers to plan for improved geriatric services. 
• Communication: Better communication with direct service providers can improve services. 
Section II Page 18 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Service Area #1: Primary Care Needs 
• Substantial data and analysis from Division of Public Health University of Delaware Survey 
(1998) and DIMER report (10/99) are available to support an understanding of primary care 
needs. 
• The estimated need for additional primary care providers differs when taking a "by the 
numbers" view versus documenting the experience reported by individuals related to “limited 
practical access or availability” of numerically adequate providers. Sussex County is 
currently designated a medically underserved area. Northern Sussex County is designated as a 
primary care shortage area. Designation is based in part on the overall number of full time 
equivalent (FTE) physicians. However, contradictory information exists regarding true 
operational capacity (consumer perceptions and experience of practitioner availability) for the 
following reasons: 
– Practices may be closed to new patients; 
– Practices may accept limited insurance or network participation; 
– While the federal criteria for FTE (hours of practice per week) are met, productivity is 
not considered (i.e., low productivity would effectively reduce capacity); 
– Typical hours of operation (no evenings or weekends) may effectively limit access for 
certain populations; 
– Lack of knowledge or skill in the care of special populations (e.g., disabled, 
child/adolescent, AIDS, and geriatrics) may limit the effective availability of providers; 
– Sussex County has the lowest use of non-physician clinicians (e.g., physician assistants, 
nurse practitioners and certified nurse midwives) in the state, thus limiting the 
“extendibility” of practices; 
– The primary care capacity is clustered around hospitals, especially for OB/GYN 
services, thus making access geographically difficult for some citizens - particularly 
those lacking private transportation. This geographic problem is institutionalized, to 
some degree, by hospital credentialling rules requiring physicians to live within 30 
miles of the hospital; and 
– Cultural accessibility (Hispanic population) and multi-lingual capacity are limited. 
• The general orientation of primary care in Sussex County is toward acute/sick care rather than 
“wellness” or preventative care. This may affect the impact of lifestyle-related conditions as 
well as early diagnosis of serious disorders (such as cancer) which may result in higher 
mortality. Contributing factors include: 
– Availability: In situations of limited practitioner availability, both providers and consumers 
reserve their use to the most acute needs rather than preventive services; and 
– Cultural Attitudes: The generally conservative Sussex County population holds a “take care of 
yourself” ethic that supports receiving care only when ill. 
• As public health clinics have transitioned away from direct primary care services, private 
providers have become the only resource for care such as maternal and child health services. 
This may have resulted in an unintended negative impact on primary care availability. 
Section II Page 19 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Service Area #1: Primary Care Resources 
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Status Summary of Findings: Primary Care Gap Analysis 
• Awareness: Hospitals make medical staff directories available and provide information through 
the hospital on available primary care practices; Telephone directories contain listings only; Little 
systematic information on a county-wide basis that provides practice details. 
• Access: Improvements have been made to access/intake; Sussex County has numerically adequate 
capacity; but problematic geographic distribution; fewer than 37% of PCP sites have Spanish 
bilingual capacity; 25% of Sussex County PCPs do not participate in a managed care network; 
Primary care access for special populations is problematic; Few providers are open to Medicaid; 
Recruitment of healthy individuals to receive primary “well care” remains problematic. 
• Direct service: As public health clinics have transitioned away from direct services, private 
providers are the only source of primary care; Quality of care from primary providers is 
perceived as acceptable. 
• Referral: Linkages with behavioral health, geriatric specialists, and dental services remain 
questionable. 
• Monitoring: School nurses and SBHC support surveillance of children and adolescents by 
monitoring vaccinations and “medical homes”; Minimal County level measurement or monitoring 
of the quality or accessibility of primary care; DIMER has a statewide role. 
• Infrastructure: Hospital bylaws require physicians reside within 30 miles of hospital; Sussex 
County has lowest use of mid-level providers in state. 
• Leadership: Hospitals, DIMER, and Physician Organizations are providing leadership. 
• Planning: DIMER has taken a coordinating role in planning and recruitment; DHCC has reported 
planning related data. 
• Communication: Insufficient data to determine resource adequacy. 
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Section II Page 20 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Service Area #2: Dental Care Needs 
• Delaware Institute for Dental Education and Research (DIDER) data and interviews confirm 
Sussex County meets Dental Health Professional Shortage Area (HPSA) criteria for dental 
care (1998 Dentists in Delaware Report). 
• There is a substantial capacity deficit in Sussex County dental services for treating both 
insured and non-insured populations. Shortages are particularly acute in western Sussex 
County, from Bridgeville to Laurel. There is also a shortage of culturally compatible dentists 
for certain populations (Hispanic, African-American). Many dental practices are closed to 
new patients. Further, the capacity of dentists is likely to deteriorate due to planned 
retirements. One in five dentists was uncertain if s/he would be in practice in five years in 
Sussex County. 
• Sussex County dentists reportedly have heavier workloads than industry standards. Improved 
access may require a change in office hours, but this is difficult to reconcile with their current 
workload. Those patients that are seen in Sussex County primarily receive urgent care. 
Preventative dentistry is not emphasized like in other parts of the state. 
• Employers report an increased cost of dental coverage resulting from the need to allow 
network access outside of the local (Sussex County) area. It is not uncommon for insured 
patients to travel to Kent or Wilmington counties for a dentist. Most uninsured travel to 
Wilmington County for care at one of the dental clinics. 
• There are a number of ongoing initiatives focused on attracting dental resources to Sussex 
County. These have been associated with some success to date. The response to the dental 
crisis indicates a capacity for effective crisis planning. The Delaware Dental Access 
Improvement Committee (DDAIC) report (Spring, 2000) articulated a coordinated approach 
to improvement. As proposed, activity intended to attract dentists to Sussex County has begun 
and includes a recruitment campaign, indicating that proactive planning to address the dentist 
shortage has begun. Current efforts are focused on addressing infrastructural issues (including 
licensing regulations) that constitute barriers to additional recruitment: 
– Training and licensure requirements are restrictive; 
– Delaware has its own testing program and does not grant license reciprocity to other states; 
– Dental hygienists are not permitted to practice preventative dentistry other than under the direct 
supervision of a dentist; and 
– There is no dental school in Delaware. The General Practice Dental Residency Program and 
dental hygiene education programs are both located in New Castle County. 
• Although there has been substantial effort to focus on and improve the dental issue, those 
involved say it is too early to tell what the final outcomes will be, but progress has been made 
and they continue to be optimistic. 
Section II Page 21 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Service Area #2: Dental Care Resources 
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All Resource Types 
Infants/Perinatal 
/Adolescents
Children
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Geriatrics 
Overall 
IMPROVED DENTAL CARE SYSTEM
Status 
Summary of Findings: Dental Care Gap Analysis 
• Awareness: There is no organized way for the population to know if there is a new provider or 
resource; Little or no prevention related education to general population. 
• Access: Of the few practices available, many are closed to new patients; Strategies to improve 
access by expanding office hours are difficult to reconcile with current workload; Medicaid 
children have limited access through public health clinics, with less than one-third of eligible 
children receiving services each year. Children above the Medicaid threshold have problematic 
access, with affordability being a primary barrier. 
• Direct service: Sussex County dentists have heavier workloads than industry standards - despite 
this, wait times (in office) are low; Quality of dental providers is perceived as adequate. 
• Referral: There is a lack of dental sub-specialists located in Sussex County. 
• Monitoring: Preventative care is not a high priority, many practices do not send reminders for 
regular care and checkups; Dental health status to date has not been measured on a population 
basis - plans are underway for Fall 2000. 
• Infrastructure: Sussex County is under-served; shortages particularly acute in western Sussex 
County; One in five dentists was uncertain if s/he would be in practice in five years in Sussex 
County; Efforts are underway to attract dental resources to Sussex(e.g., recruitment campaign, 
training programs); State licensing regulations are a barrier in increasing the number of dentists 
(e.g training requirements are restrictive Delaware has its own testing program, no reciprocity 
with other states, etc.). 
• Leadership: Effort to get water fluoridated in under-served communities was successful; Western 
Sussex Health Coalition has been active; DDAIC report (Spring, 2000) articulated coordinated 
approach to improvement. 
• Planning: The response to the dental crisis indicates orientation toward crisis-focused planning, 
and the beginning of proactive planning; Planning has resulted in effective policy advocacy (e.g., 
allowing hygienists limited practice outside of dentist’s office); DIDER/DDAIC are focal. 
Recruitment campaign is underway. 
• Communication: Little communication between dentists and other health care providers; Few 
newspaper articles describing needs or calling attention to problem. 
Section II Page 22 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Service Area #3: Mental/Behavioral Health Needs 
• Behavioral health needs were characterized and documented in the 1999 DIMER report as 
inadequate. DIMER documented a "severe shortage" of mental health practitioners in Sussex 
County. However, Sussex County lost its federal Mental HPSA designation in 1998. Data 
analysis is underway at DPH to determine if HPSA designation can be reinstated. 
• Based on interviews and a review of limited Sussex County data available from the Division of 
Alcohol, Drug Abuse and Mental Health (DADAMH): 
– Ambulatory chemical dependency and substance abuse services (CD/SA) appear to be 
insufficient; 
– Child and adolescent services are insufficient; 
– Specialty geriatric mental health services are virtually non-existent; 
– SBHC staff report significant access problems to mental health services for children and 
adolescents: 
• No formal process is available for adolescent behavioral health referrals or 
for linkages between primary care and behavioral health resources; 
• There is 0.5 FTE child psychiatrists in the county, located on the coast; 
There are no pediatric or adolescent behavioral health inpatient units nor 
hospital services in Sussex County; 
• Knowledge of, and linkages between, resources (communication) in the 
child and adolescent population are lacking; 
• Transportation/data from schools confirm that access for adolescents is a 
real problem; and 
• Needs data reveal high suicide rates (although small absolute numbers) 
among teens. 
• Hospital personnel report a significant proportion of emergency room use is directly related to 
behavioral health needs and that providers do not feel they can provide optimal care for these 
problems in the emergency room setting. Sussex County has no involuntary admission 
capacity, patients are taken to the state hospital in New Castle County, often utilizing suboptimal 
transportation arrangements (most often transported in police cars by on-duty 
officers). 
– Managed care organizations as well as other payers are emphasizing outpatient treatment, 
BUT 
– Credentialling limitations limit use of non-physician providers. 
• For many Sussex County individuals, there are cultural issues driving a hesitancy to use 
mental health and substance abuse services. For example, the adult and geriatric population 
associates a stigma with the use of mental health treatment. Some faith communities may also 
discourage or minimize the potentially beneficial role of mental health professionals. 
Leadership, planning, and communication for those populations which can be reached needs 
to be improved, especially addressing dual diagnosis, isolation and depression, and stigma 
associated with seeking mental health care. 
Section II Page 23 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Service Area #3: Mental/Behavioral Health Resources 
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Summary of Findings: Mental/Behavioral Health 
• Awareness: Easter Seals produced a study on information for adult awareness/information; Geriatric 
population barriers are cultural and related to the stigma associated with mental health treatment; 
Differences in awareness may be related to geography (closer to hospitals = higher awareness); Western 
Health Council is actively investigating issues of awareness and access. 
• Access: “By the numbers,” Sussex is not classified as a HPSA for mental health care; One part-time child 
psychiatrist in Lewes is the only one in the county and is involved mostly in crisis work; Significant access 
to specialized child, adolescent and geriatric providers was consistently reported; Transportation/data from 
schools complicate access for adolescents creates a real problem. 
• Direct service: A significant portion of emergency room use is directly related to behavioral health needs; 
Direct providers are perceived as doing an “average” job under these circumstances; Reimbursement levels 
for providers are well below average and may impact quality; Providers perceived as not knowledgeable 
about special needs for geriatric population. 
• Referral: No formal process for adolescent referral or linkages between resources; Adult population may 
know what is needed, but may take multiple calls to arrange for services. 
• Monitoring: Needs data reveal high suicide rates (although small overall numbers) in several age groups; 
External outcomes measurement is beginning (United Way, Managed Care, DHSS/DADAMH); Burden of 
“non institutionalized” mental health is not well understood at the county level; Mental Health Parity Law 
passed in 1999, regulations under development. 
• Infrastructure: No involuntary admission capacity within Sussex County; Transportation of involuntary 
patients is inadequate; Licensing and health plan credentialling regulations problematic for non-physician 
providers; Inadequate CD/SA services. 
• Leadership: Sussex County could benefit from more support from state; agencies doing “best they can;” 
Seaford area initiative (Western Health Council ) has recently begun to assess mental health needs 
regionally. 
• Planning: Need more focus on outpatient care; Looking more at parity in mental health benefits for adult 
population; More focus on geriatric population, especially in the areas of dual diagnosis, isolation, mental 
health stigma. 
• Communication: Linkages among providers serving adolescent population are lacking; Interagency 
Council is helping increase communication. 
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Section II Page 24 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Service Area #4: Home Health Needs 
• Home health services are an increasingly important part of the health care system as delivery 
is transitioned away from hospital inpatient care. Based on a population over age 65, (approx. 
26,250) it is projected that there will be 2,339 annual users of home health care services in 
Sussex County. Special population groups (perinatal/infants, special needs children, 
convalescing and chronically debilitated individuals, and older adults) may be 
disproportionate users of home health services and further stress capacity. Anecdotally, there 
is a general belief that currently, people who need services most urgently are receiving them. 
However, others with less acute or urgent needs, but who could benefit from home health 
services for preventive or disease management benefits are unlikely to receive services. It is 
unclear whether or not home health resources can keep pace with the population growth. At 
this time, there is no quantitative data on Sussex County’s present or future home care 
capacity or requirements. The following interim conclusions appear warranted: 
– Home health resources are not positioned to accommodate growing population: 
• Ancillaries, supportive services, and chronic disease management resources are 
minimal and have not been studied as to adequacy of focus and distribution; 
– The limited labor pool creates both staffing and quality of care issues. Home health 
agencies are facing staffing needs and shortages. With low unemployment and 
competitive employers able to pay more competitive wages, agencies are having a 
difficult time retaining staff and paying competitive wages. Some believe this may 
threaten the quality of services. 
• Home health service access and infrastructure focused on treating the Medicare population are 
at risk due to severe decreases in funding from the federal government. Across the country, 
this makes the future and long term viability of home health agencies uncertain. Specific to 
Sussex County, there is a concern that resources are progressively less able to meet needs and 
that the situation is getting worse. General categories of need were identified as: 
– Skilled nursing; 
– Homemaker services; 
– Personal care services; 
– Child aide services for special need children; 
– CTT services in behavioral health; 
– Services for special needs populations; and 
– Coordination and communication of services for geriatric population. 
Section II Page 25 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Service Area #4: Home Health Resources 
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Summary of Findings: Home Health Gap Analysis 
• Awareness: Population understanding of home health services is variable by ethnic status; Much 
information is distributed via the hospitals as part of the discharge planning process. 
• Access: Threatened by changes in Medicare reimbursement; General belief that people who need 
services most urgently are served; Care can be accessed for most urgent needs, but sometimes it 
takes a “long time;” Services for chronic disease management, special needs and subacute needs 
may be more difficult to access. 
• Direct service: Service is considered of acceptable quality, except in geriatrics where there is 
room for improvement in considering this population’s special needs. 
• Referral: Chronic disease patients may return to the hospital more frequently due to lack of access 
to a primary care provider linked with good home health supports. 
• Monitoring: No monitoring systems or performance data were known; No quantification of 
population need for home health services; Lack of outcome monitoring is a problem, particularly 
for infant/perinatal and geriatric populations. 
• Infrastructure: Viability of home health providers is threatened by decreasing Medicare 
reimbursement; Long term viability is uncertain; Labor pool shortages aggravate the situation; 
Anticipated worsening of situation as rapid retail growth continues. 
• Leadership: Labor shortage is making it difficult for agencies; Recruiting home health staff is 
getting harder and more expensive; No clear leadership on this issue. 
• Planning: No clear consensus that resources can keep pace with growing need; resources are 
perceived as having a more difficult time meeting needs and the situation is getting worse, not 
better. 
• Communication: Coordination and communication of services for geriatric population is a real 
need. 
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Section II Page 26 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Special Considerations: Hispanic Population Needs 
Hispanic Population 
The identifiable and rapidly growing Hispanic population in Sussex County prompted a specific 
focus on needs in that community. In the first large scale attempt to characterize Hispanic 
population needs, DPH in conjunction with La Esperanza/La Red, conducted a survey in 1999. 
While there have been multiple initiatives and efforts to provide health services for the Hispanic 
community in the past several years, concern remains regarding the level of health care services 
accessible to Hispanics in Sussex County. Key findings are summarized below: 
• Qualitative information from some providers, employers, and community agencies suggesting 
there are generally adequate levels of health care services, but the Hispanic population itself 
perceives that services are not available. 
• Most of the Hispanic population is resident rather than migrant. According to the survey, 
about one-third of Sussex Hispanics consider themselves migrant. Most respondents have 
been in the area for less than five years but more than one year. The majority of the Sussex 
County Hispanic population lives in Georgetown, followed by Seaford and Milford. 
• Nearly 88% of the population surveyed speak Spanish only. Improved access to care, 
therefore, requires substantial bilingual capabilities at provider sites. In addition, 
transportation and reduced financial barriers were prioritized as needs by respondents. 
• Most of the population is single, but live in a group environment with annual household 
incomes of less than $20,000. Most of the employed Hispanic population works in a high risk 
environment for occupational injuries, such as farming and poultry industries. 
• In order to enroll in financial and medical assistance programs, individuals must present 
evidence that they are “legal.” The need to verify “legal” status adds a layer of complexity to 
accessing many services. This does not apply to Medicaid eligibility for children. 
• More migrants reported receiving “no care” than reported using a “clinic” site for care. 
Longer term residents appear to be more likely to receive care in private practice or hospital 
settings. 
• There is an indication that services for Hispanic children are more adequate than for adults 
due to existing resources and Medicaid eligibility (for children who are US citizens and whose 
parental income qualified them for Medical Assistance). Too often, however, undocumented 
parents do not apply for Medicaid for their otherwise eligible children due to fears of 
deportation. 
• There is much less evidence that services for adults are accessible. Nearly one half of 
respondents reported being denied medical care, or avoiding seeking that care, during the past 
12 months; approximately one quarter specifically cited denial of medical care due to inability 
to pay or avoidance of seeking services for financial reasons. Few survey respondents 
reported seeking preventive medical care. All interviewees indicated that access to dental care 
was a significant problem. 
Section II Page 27 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Special Considerations: EMS and County Infrastructure 
EMS 
• Including Emergency Medical Services (EMS) in the RHP recognizes the special role prehospital 
care plays in Sussex County health delivery. 
– Early intervention (improved outcomes); 
– Safe, appropriate, and timely transport (stabilization/reduce pain and anxiety); 
– Maximized effectiveness within available resources (cost and staffing). 
• EMS issues for Sussex County identified in interviews include: 
– Sussex County is large and sparse; 
– The 911 system is, in some senses, a victim of its own success in achieving broad public 
awareness - “misuse of 911;” 
– EMS dispatchers regularly make social service referrals to 911 callers - there is an important 
message here that is not necessarily the same as misuse; 
– EMS representatives are aware of, and concerned about, adequacy of response times; 
– Historically separate systems between the county (ALS) and the local services (BLS); and 
– Measuring the quality of pre-hospital care remains a challenge despite positive steps taken 
within the system. 
• The Fitch Report and Delaware Emergency Medical Services Improvement Committee Report 
studied EMS needs and specified state-level policy recommendations, e.g.: 
– Illustrated need for development of better data and tracking systems. 
– Led to creation of a new board to oversee EMS operations and improvements. 
Infrastructure Needs 
• Sussex County demographic characteristics: High poverty rate, high percentage of citizens 
who have not completed high school (50-55% of African American adults have not completed 
high school); Better estimates for the status and needs re: Hispanic populations are needed. 
• Eight Sussex County communities were identified in the Strong Communities Initiative (SCI) 
as high risk for health and safety due to significant infrastructural deficiencies. 
• The purpose of the SCI was to assist the eight unincorporated, rural Sussex County 
communities to become self sufficient and to create a working partnership between the 
communities, state, county, local governments and businesses: 
– Many of the Strong Communities (neighborhoods) had experienced deterioration; single-parent 
families lived amidst the highest rates of violence, drug trafficking, teen pregnancy and 
substandard housing; 
– Critical issues included crime, water quality, septic/sewer, trash and dumping, etc. continue to 
impact quality of life and, possibly, health in these communities and others. 
• Only 77% of respondents in the Strong Communities Survey reported that they had health 
insurance. 
• A total of over 30 additional and similar communities exist in Sussex County for which 
environmental/infrastructural issues predominate as health concerns. 
• Significant leadership, planning and monitoring needs remain: 
– County-wide and local data regarding nature and adequacy of infrastructure; 
– A county-wide representative body to lead and evaluate initiatives; and 
– Initiatives that will engage the public more broadly to solve infrastructural problems. 
Section II Page 28 

Section III 
Planning today to improve the lives of tomorrow 
Delaware Rural Health Plan 
Strategic and Operational Improvements 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
III. Strategic and Operational Improvements (Broad Policy and TargetedInitiative Recommendations) 
Introduction 
The value chain presented in Sections I and II demonstrated that for the RHP, broad policies and 
targeted initiatives represent the direct value generating activities. Each of the ten recommended 
policies and ten suggested initiatives detailed below were matched to identified needs and 
resources (from Section II) through an iterative process consisting of documentation review, site 
interviews, DHI Steering Committee workgroups, stakeholder focus groups, and finally, a 
working stakeholder retreat held at Dewey Beach, Delaware on May 22, 2000. This conference 
had a broad invitational list and was attended by over 70 stakeholders. For ease of reference, the 
key components of each recommendation are summarized in Table III-1 at the end of this 
section. The DHI Steering Committee determined that the Plan should have a focused and 
feasible list of implementation recommendations. While recognizing that enough input would be 
obtained to create an exhaustive array of possible projects and studies, the Committee wisely 
recognized that this could be paralytic and that later accomplishments could be more easily built 
on a platform of early and significant successes. The RHP honors this approach by providing a 
sufficiently broad, but quantitatively and scope limited, initial menu of policy and 
implementation recommendations for each area of analysis from Section II. A more detailed 
compendium encompassing the broader input and learning obtained is recorded and reported in 
Appendix F. 
In developing recommendations, an active attempt was made to build on existing activities and 
infrastructure wherever possible. Simultaneous efforts were made to avoid emphasis on those 
areas which are already being actively addressed in an organized and effective way. 
Recommendations are organized according to key needs and resource areas defined in the 
preceding section. 
Section III Page 29 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Lifecycle Needs Recommendations 
Infants and Perinatal 
Needs Addressed: Infant mortality and low birth rate trends 
improving infant and perinatal outcomes. 
Policy Recommendation 1: Support and enhance existing initiatives focused on 
• The RHP endorses current activities being performed under the auspices of the 
Perinatal Board and the Alliance for Adolescent Pregnancy Prevention (AAPP); 
• These activities should be enhanced and publicized widely in Sussex County in order 
to increase enrollment and participation; and 
• Encourage expansion and support for “resource mothers” and “resource fathers” 
programs. 
Policy Recommendation 1 
Suggested Policy Collaborators Should Include: 
• Agencies/Advocacy Groups 
• Department of Health and Human 
Services (DHSS)/Department of Health 
(DPH) 
• Hospitals 
reforms that eliminate barriers to the provision of prenatal care in the first trimester 
for eligible and presumptively eligible pregnant females. 
· School Districts 
Policy Recommendation 2: Implement Medicaid reimbursement and procedural 
• Reimbursement rules for obstetric practitioners that do not penalize providers of care 
to pregnant women who may experience first and second trimester fetal losses; 
• Procedures for presumptive eligibility voucher use which are well understood by 
practitioners and clients and which result in a favorable pattern of use and care 
delivery; 
• Enforce existing rules and mandates requiring presumptive eligibility to be honored 
by practitioners and facilities; and 
• Expand voucher availability and acceptability for individuals who are not 
presumptively eligible but require first trimester pregnancy care. 
Policy Recommendation 2 
Suggested Policy Collaborators Should Include: 
• DHSS/DSS (Division of Social Services) and DPH 
• Sussex County medical providers 
Section III Page 30 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Children and Adolescents 
Needs Addressed: Children and adolescents at risk for abuse and neglect, chemical or substance 
abuse, teen pregnancy, and behavioral problems. 
community focused initiatives to support family unity and child and adolescent healthy 
lifestyles. 
Policy Recommendation 3: Actively plan, implement, and promote family and 
As a matter of public policy, stress and prioritize funding for community and family oriented 
projects in such areas as: 
• Family communication; 
• After school recreational and social activities; 
• Day care; 
• Behavioral health information and education; 
• Parenting classes and parent-parent mentoring initiatives; 
• Adult-child mentoring initiatives; 
• Diversity training and education; 
• After school activities and recreational opportunities; and 
• Job initiatives for teens. 
Policy Recommendation 3 
Suggested Policy Collaborators Should Include: 
• DHSS/ Department of Services for Children, Youth, 
and their Families (DSCYF) 
• Faith Communities 
• School Boards and Parent Teacher Associations (PTA) 
• State Police 
system for Sussex County teens. 
Initiative Recommendation 1: Implement and market a peer support and advisory 
• Teen Advisory Panel to serve as a problem solving resource and forum for policy 
discussion and feedback; 
• Teen Crisis Line to respond to confidential inquiries and concerns of teens; 
• Teen Peer Counseling Program to enable peer-peer problem solving, support, and 
relationship building; 
• Extend services to younger teens (middle school level); 
• Enhance emphasis on social, family support, and behavioral health services; 
• Actively collect and analyze encounter level data and use it to measure outcomes and 
plan services; 
• Address rise in substance abuse between grades 8 and 11; and 
Section III Page 31 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
• Seek, to the maximal degree possible, to leverage SBHC services to diminish teen 
pregnancy. 
Initiative Recommendation 1 
Suggested Initiative Collaborators Should Include: 
• Boys’ and Girls Clubs 
• Chambers/Employers 
• County Administration 
• DHSS/DPH 
• Faith Communities 
• School Districts 
• YMCA 
of SBHC services. 
Initiative Recommendation 2: Support the expansion, depth, and optimal utilization 
• Extend services to younger teens (middle school level); 
• Enhance emphasis on social, family support, and behavioral health services; 
• Actively collect and analyze encounter level data and use it to measure outcomes and 
plan services; 
• Address rise in substance abuse between grades 8 and 11; and 
• Seek, to the maximal degree possible, to leverage SBHC services to diminish teen 
pregnancy. 
Initiative Recommendation 2 
Suggested Initiative Collaborators Should Include: 
• DHSS/DPH 
• Faith Communities 
• Hospitals 
• Legislature 
• School Districts 
Section III Page 32 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Adults 
Needs Addressed: Unintentional injury prevention and diabetes mortality. 
prevention education efforts targeting motor vehicle crashes, workplace injuries, and 
substance use related injuries. 
Initiative Recommendation 3: Undertake intensive and coordinated injury 
• Leverage existing Trauma Center designations to provide enhanced analysis and 
trending of injuries, follow up education, community and workplace based education 
and prevention programs; and 
• Identify best practices and develop interventions through a multi-disciplinary task 
force of hospitals, EMS, ER physicians, nurses, etc. 
Initiative Recommendation 3 
Suggested Initiative Collaborators Should Include: 
• Community Colleges 
• DHSS/DPH (Healthy Delaware 2010) 
• Emergency Medical Services (EMS) 
• Hospitals 
• High Risk (for injury) Employers 
• State Police 
diabetes mellitus health 
improvement initiative. 
Initiative Recommendation 4: Undertake intensive 
• Components to include screening, education, self care and monitoring components as 
well as enhancing access to specialty care; and 
• White males and black females should be targeted. 
Initiative Recommendation 4 
Suggested Initiative Collaborators Should Include: 
• American Diabetes Association 
• DHSS/DPH 
• Faith Communities 
• Hospitals 
• Managed Care Organizations (MCOs) 
Section III Page 33 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Geriatric 
Needs Addressed: Planning and geriatric specialty clinical resources. 
initiative, with a specific Sussex County and local community focus, to better 
understand the health and social service needs of elderly adults currently and for the 
next decade of anticipated high geriatric population growth. 
Initiative Recommendation 5: Undertake a formal data collection and planning 
• Data obtained should provide information about: 
• Demography and epidemiology; 
• Burden of illness/morbidity; 
• Service use patterns; 
• System capacity; 
• Quality of life; 
• Functional status; and 
• Other health status measures. 
• Analysis and planning based on this data should be ongoing; broad review and 
goal setting should be accomplished at an annual Sussex County Geriatric 
Summit. 
Initiative Recommendation 5 
Suggested Initiative Collaborators Should Include: 
• AARP 
• CHEER 
• DHSS/Division of Aging and Adults with Physical 
Disabilities (DAAPD) 
• Hospitals 
execute a recruitment strategy for geriatric specialists, physician extenders, and 
primary care physicians with an interest in caring for the elderly, to Sussex County. 
Initiative Recommendation 6: Use the output obtained from the above to inform and 
Ensure that current and future analytic and planning activities through the DAAPD are 
structured to provide specific information and recommendations for Sussex County: 
• Ensure that there is coordination between accountable and advocacy groups 
representing the elderly. 
Section III Page 34 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Initiative Recommendation 6 
Suggested Initiative Collaborators Should Include: 
• CHEER 
• DHSS/DAAPD 
• Hospitals 
• Sussex County medical providers 
Service Area Needs Recommendations 
Primary Care 
Needs Addressed: Quantity and distribution of primary care practitioners in Sussex County. 
The RHP strongly recognizes the critical importance of improving primary care 
access in Sussex County. Needs in this area are currently being addressed through 
DIMER and DHCC analyses and recommendations that are both adopted and 
endorsed by the RHP. Area hospitals play a significant role in improving access to 
physician resources. 
Dental Care 
Needs Addressed: Quantity and distribution of dental practitioners in Sussex County. 
The RHP strongly recognizes the critical importance of improving dental care 
access in Sussex County. Needs in this area have been addressed through Dental 
Care Access Improvement Committee analyses and recommendations which are 
both adopted and endorsed by the RHP. 
Mental/Behavioral Health 
Needs Addressed: Quantity and distribution of mental and behavioral health practitioners in 
Sussex County. 
well as an active recruitment and retention strategy, for mental and behavioral health 
practitioners for Sussex County, which ensures adequate provider staffing and access 
for county residents. 
Initiative Recommendation 7: Develop a behavioral health provider staffing plan, as 
• Target recruitment to ensure addressing needs by age, geographic location, service 
requirements, racial, cultural, and ethnic compatibility; 
• Given the scarcity of behavioral health resources, provider recruitment should ensure 
the maximum potential to share these resources across hospital service areas; 
• Use the models of dental and primary care manpower assessment and recruitment to 
guide development of a customized approach to behavioral health recruitment; and 
Section III Page 35 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
• Seek to integrate recruitment and retention activities with payment reform and payer, 
as well as employer network reform, to ensure sufficient and balanced incentives to 
achieve goals. 
Initiative Recommendation 7 
Suggested Initiative Collaborators Should Include: 
• Agencies 
• DHSS/ DSCYF 
• Hospitals 
• MCOs 
network credentialling requirements with the goal of permitting, and enabling 
reimbursement for, the supervised practice of behavioral health counseling and 
therapies by qualified pre-licensees during their periods of practical professional 
training. 
Policy Recommendation 4: Review practitioner licensure regulations and MCO 
Enable the practice and reimbursement of otherwise license eligible, fully educated, Masters’ 
level counselors and therapists while they are under professional licensed supervision in the 
process of obtaining required practical experience. 
Policy Recommendation 4:
Suggested Policy Collaborators Should Include:
• DHSS/DPH 
• Employers 
• Legislature 
• MCOs 
• National Association of Social Workers 
(NASW) 
• State Board of Social Work Examiners 
Home Health 
The RHP notes, with concern, potential limitations in resource availability and 
current reimbursement structure in this area. There was insufficient planning data 
and topical expertise among the stakeholders to support specific recommendations 
at this time. This area should be revisited in light of the activities recommended in 
the geriatric section above. 
Section III Page 36 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Special Considerations Needs Recommendations 
Cultural, Minority, Racial and Ethnic Issues 
Needs Addressed: Issues of cultural barriers to care for racial, ethnic, and other minority 
residents of Sussex County. 
between key employers of ethnic and racial minority residents and their workers in 
health planning activities; Solicit multilateral long term participation in strategy 
development. 
Policy Recommendation 5: Establish dialogue and a mutually receptive environment 
• Emphasize the intersection and shared benefit from improved health status of ethnic 
and minority residents of Sussex County; 
• Ensure bilingual and culturally compatible access to such meetings, as appropriate; 
and 
• Use meetings as a means for bilateral education and consciousness raising. 
Policy Recommendation 5 
Suggested Policy Collaborators Should Include: 
• Advocacy Groups/Agencies 
• Chambers/Employers 
• Community Colleges 
• County Administration 
• DHSS/DPH 
• Faith Communities 
• Hospitals 
community forums for communications between consumers and accountable entities. 
Initiative Recommendation 8: For minority and ethnic populations, develop regular 
• Use this input for gaining knowledge about needed resources and services; 
• Use input as a basis for innovative development of new services; 
• Develop approaches for meeting non-traditional family units; and 
• Forums should be bilingual, as appropriate to constituencies. 
Section III Page 37 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Initiative Recommendation 8 
Suggested Initiative Collaborators Should Include: 
· Agencies/Advocacy Groups 
· Community Colleges 
• County Administration 
• DHSS/DPH 
• Faith Communities 
• Hospitals 
The following recommendation is applicable to both the minority and access needs areas: 
non-traditional access to health care services attractive to racial and ethnic minority 
as well as non-minority residents of Sussex County. 
Initiative Recommendation 9: Actively support, pursue, and create opportunities for 
• Non-traditional siting of service facilities (i.e., employment sites, shopping malls, 
mobile units, community centers); 
• Culturally compatible physical space, staffing, and language; and 
• Create access which encourages service use by all members of non traditional family 
and living units. 
Initiative Recommendation 9 
Suggested Initiative Collaborators Should Include: 
• Agencies/Advocacy Groups 
• Chambers/Employers 
• County Administration 
• DHSS/DPH 
• Faith Communities 
• Hospitals 
Section III Page 38 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
Access to Resources 
Needs Addressed: Linking consumers and referring professionals and agencies with resources. 
Policy Recommendation 6: As a matter of public policy, encourage the statewide 
consolidation and reorganization of existing resource compendia and directories into 
a master directory of services. 
• Standardize content to reflect key information required for timely and appropriate 
referrals for services; 
• Organize and index in a geographically and service friendly fashion to enable easy 
identification of local and appropriate resources; 
• Commit to publication in, and access from, a variety of media, including electronic 
and web based, to extend availability to the public more broadly; 
• Update on a frequent basis; 
• Provide “real time” access to the directory by key referral resources (such as EMS 
dispatch, hospitals, key agencies, Delaware Help Line); and 
• Consider the creation of centralized toll free referral “hot line(s)” with compendium 
access to respond to telephonic requests for local and appropriate resources and 
referrals. 
Policy Initiative 6 
Suggested Policy Collaborators Should Include: 
• DHSS 
• Legislature 
• State Service Center Office 
Leadership and Planning 
Needs Addressed: The lack of available data to support leadership in health planning and 
implementation of change in Sussex County. 
Policy Recommendation 7: As a matter of public policy, mandate the collection and 
distribution of all statewide health (including vital statistics) demographic, 
epidemiologic, and sociologic data on at least a county level and preferably on a ZIP 
code level. 
• Given the significant disparities in population and demography between northern and 
southern Delaware, regional and local data is essential to understanding the 
population of Sussex County and using that understanding to plan for resources and 
services; 
Section III Page 39 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
• A model exists for the differential collection and reporting of New Castle County and 
Wilmington area data for this reason. 
• Although data integrity may be compromised by relatively small numbers of 
observations in Sussex County, knowledge of this potential pitfall can result in 
appropriate corrections and offsets when necessary and should not prevent the 
collection of county specific data. 
Policy Recommendation 7 
Suggested Policy Collaborators Should Include: 
· County Administration 
· DHSS 
· Legislature 
Policy Recommendation 8: As a matter of public policy, support and encourage 
leadership development within ethnic and non-ethnic communities of Sussex County. 
• Seek opportunities to engage community constituencies in planning and problem 
solving forums; 
• Develop opportunities to engage residents across age, racial, and ethnic groups; 
• Sponsor leadership development experiences (i.e., seminars, retreats, school 
curriculum, committee and initiative participation) which include both identified and 
potential new leaders from the community; and 
• Ensure that language and cultural diversity is not a barrier to engaging Sussex County 
residents in leadership experiences. 
Policy Recommendation 8 
Suggested Policy Collaborators Should Include: 
• Community Colleges 
• County Administration 
• DHSS 
• Faith Communities 
• First State Community Action 
• Legislature 
• School Districts 
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Delaware Rural Health Plan 
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Policy Recommendation 9: As a matter of public policy, commit to ongoing 
collaborative planning and strategy for health improvement in Sussex County. 
• Build and expand upon the positive experience of DHI by encompassing a larger 
representative constituency including County Administration, DIMER, MCOs, 
employers/business; School Districts, faith communities, and consumers. 
Policy Recommendation 9 
Suggested Policy Collaborators Should Include: 
· Chambers/Employers 
· County Administration 
· DHI 
· DHSS 
· Faith Communities 
· Hospitals 
· School Districts 
Initiative Recommendation 10: Set, and monitor progress towards, specific 
improvement goals for health status, access, planning, and implementation for Sussex 
County related to key recommendations in the RHP. 
• Using the value chain model, create and monitor specific metrics of effectiveness and 
implementation to inform stakeholders and enable assessment of progress; and 
• Regularly measure against these to provide feedback to planners and funders 
regarding the effectiveness of goals. 
Initiative Recommendation 10 
Suggested Initiative Collaborators Should Include: 
• All stakeholders, coordinated by DHI and 
DPH 
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Delaware Rural Health Plan 
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Infrastructure 
Needs Addressed: The ongoing need for upgrading and maintaining roads, sanitation, public 
safety, telecommunications, and transportation in Sussex County. 
Policy Recommendation 10: As a matter of public policy, continue support of 
community infrastructure improvement initiatives, including ongoing planning and 
upgrading based on a sound understanding of the growth and use characteristics of 
the region. 
• Continue to support, and expand as needed, community improvement and decay 
prevention programs such as the SCI; and 
• Develop a mechanism to assess and report on the “state of infrastructure” of Sussex 
County on a regular basis with the goal of ensuring that evolving infrastructure 
matches developing needs based on growth, innovation, and natural obsolescence of 
infrastructure. 
Policy Recommendation 10 
Suggested Policy Collaborators Should Include: 
· Chambers/Employers 
· County Administration 
· DHSS 
· Department of Transportation 
· EMS 
· First State Community Action 
· State Planning Authorities 
· State Police 
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Delaware Rural Health Plan 
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Table III-1: Summary of RHP Recommendations 
Category Initiative 
# 
Policy 
# 
Page 
# 
Brief Description 
1 30 Support and enhance existing initiatives focused 
on improving infant and perinatal outcomes. 
Infants/Perinatal 2 30 Implement Medicaid reimbursement and procedural reforms 
that eliminate barriers to the provision of prenatal care in the 
first trimester for eligible and presumptively eligible pregnant 
females. 
Child/Adolescent 3 31 
community focused initiatives to support family unity and 
child and adolescent healthy lifestyles. 
Child/Adolescent 1 31 Implement and market a peer support and advisory system 
for Sussex County teens. 
Child/Adolescent 2 32 Support the expansion, depth, and optimal utilization of 
SBHC services. 
Adults 3 33 Undertake intensive and coordinated injury prevention 
education efforts targeting motor vehicle crashes, workplace 
injuries, and substance use related injuries. 
Adults 4 33 Undertake intensive diabetes mellitus health improvement 
initiative. 
Geriatric 5 34 Undertake a formal data collection and planning initiative, 
with a specific Sussex County and local community focus, to 
better understand the health and social service needs of 
elderly adults currently and for the next decade of anticipated 
high geriatric population growth. 
Geriatric 6 34 Use the output obtained from the above to inform and 
execute a recruitment strategy for geriatric specialists, 
physician extenders, and primary care physicians with an 
interest in caring for the elderly, to Sussex County. 
Mental/Behavioral 7 35 Develop a behavioral health provider staffing plan, as well as 
an active recruitment and retention strategy, for mental and 
behavioral health practitioners for Sussex County, which 
ensures adequate provider staffing and access for county 
residents. 
Mental/Behavioral 4 36 Review practitioner licensure regulations and MCO network 
credentialling requirements with the goal of permitting, and 
enabling reimbursement for, the supervised practice of 
behavioral health counseling and therapies by qualified prelicensees 
during their periods of practical professional 
training. 
Cultural/Minority 5 37 Establish dialogue and a mutually receptive environment 
between key employers of ethnic and racial minority 
residents and their workers in health planning activities; 
Solicit multilateral long term participation in strategy 
development. 
Infants/Perinatal 
Actively plan, implement, and promote family and 
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Delaware Rural Health Plan 
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Cultural/Minority 
and Access 
9 38 Actively support, pursue, and create opportunities for nontraditional 
access to health care services attractive to racial 
and ethnic minority as well as non-minority residents of 
Sussex County. 
Access 6 39 As a matter of public policy, encourage the statewide 
consolidation and reorganization of existing resource 
compendia and directories into a master directory of services. 
Leadership and 
Planning 
7 39 As a matter of public policy, mandate the collection and 
distribution of all statewide health (including vital statistics) 
demographic, epidemiologic, and sociologic data on at least a 
county level and preferably on a ZIP code level. 
Leadership and 
Planning 
8 40 As a matter of public policy, support and encourage 
leadership development within ethnic and non-ethnic 
communities of Sussex County. 
Leadership and 
Planning 
9 41 As a matter of public policy, commit to ongoing collaborative 
planning and strategy for health improvement in Sussex 
County. 
Leadership and 
Planning 
10 41 Set, and monitor progress towards, specific improvement 
goals for health status, access, planning, and implementation 
for Sussex County related to key recommendations in the 
RHP. 
Leadership and 
Planning 
10 42 As a matter of public policy, continue support of community 
infrastructure improvement initiatives, including ongoing 
planning and upgrading based on a sound understanding of 
the growth and use characteristics of the region. 
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Delaware Rural Health Plan 
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Table III-2: Master Table of Suggested Collaboration 
Agencies/Advocacy GroupsCDCCHEERChambers/EmployersCounty AdministrationDHIDHS/DAAPDDHSS/(all other)
DHSS/DPHEMSFaith CommunitiesHospitalsLegislatureMCOsSchool DistrictsState PoliceOther 
Initiatives 
1 x x x x x x 
2 x x x x x x 
3 x x x x x x x 
4 x x x x x 
5 x x x x x 
6 x x x x x 
7 x x x x x 
8 x x x x x x 
9 x x x x x x x 
10 x x x x x x x x x x x x x x x x x 
Policies 
1 x x x x x 
2 x x x 
3 x x x x x 
4 x x x x x x 
5 x x x x x x x x 
6 x x x x 
7 x x x x 
8 x x x x x x x 
9 x x x x x x x 
10 x x x x x x x 
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Planning today to improve the lives of tomorrow 
Delaware Rural Health Plan 
Section IV 
Leadership and Staffing 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
IV. Leadership and Staffing 
Introduction 
Leadership and staffing are key to successful implementation of policies and targeted initiatives 
developed as a result of the RHP. Leadership must provide overall vision, direction, and 
guidance for initiatives, while project staff attends to day-to-day operational issues. Without 
capable leadership, projects will either fail to “get off the ground” or will be limited in their 
effectiveness. Issues of leadership simultaneously constitute the key to success, as well as the 
greatest potential vulnerability for the RHP. 
Staffing community-based initiatives may take various forms. For large-scale projects, a 
dedicated program staff may be necessary. For shorter term or smaller initiatives, volunteers or 
contributed staff time from supporting organizations may be sufficient. 
Developing leadership for community-based programs is challenging. Collaboration and joint 
action, while advantageous in bringing organizations together, may also lead to unintended 
consequences such as diffusion of responsibility, or alternatively stated, a lack of clear 
accountability. 
Stakeholders Defined 
For the purpose of the RHP, “stakeholders” may be defined as organizations and individuals that 
have an interest in the health of a community’s population and share responsibility for 
monitoring, assessing, and improving community health. As a group, stakeholders may include 
consumers, providers, businesses, government, and other relevant sectors of the community. 
Entities comprising stakeholders may expand or contract in number, and membership may 
change, to reflect shifts in health issues and strategies that present themselves. 
Accountable Entities and Shared Responsibility 
Accountable entities are stakeholders or groups of stakeholders that are clearly identified as 
“leading change” and which are expected to achieve specific results as part of the community’s 
strategy for addressing health issues. Realizing the true benefits of collaborative efforts requires 
a paradigm of shared responsibility supported by all stakeholders. Shared responsibility in the 
context of health care planning begins as individuals and organizations explicitly take ownership 
for improving health status, show commitment to collaboration focused on measurable goals, and 
assume mutual accountability for creating change. 
The process of creating responsibility for actions in the form of specific accountable entities will 
differ from problem to problem, from strategy to strategy, from time to time, and from place to 
place. The basis for designating a stakeholder as an accountable entity may include regulatory 
requirements, legislative mandates, social pressures, market forces, lobbying, voluntary 
initiatives, enlightened self-interest or, most likely, a combination of these and/or other factors. 
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Delaware Rural Health Plan 
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Accountability in Sussex County 
Section III (Strategic Approaches to Improvement – Policies and Initiatives) identifies 
“suggested initial collaborators.” These represent those accountable entities which must be “at 
the table” to begin to discuss and advance the RHPs recommended policies and/or initiatives. 
They are not, in themselves, responsible for staffing or funding recommendations but without 
their commitment and support, it is unlikely that forward motion can be attained. The following 
accountable entities are anticipated to play key roles in multiple policies and initiatives and 
deserve special mention in this discussion: 
• Delmarva Health Initiative: DHI emerged from the Health Summit of 1998. Its very 
existence is a reflection of the county-wide appreciation of the value of accountable and 
collaborative leadership. The membership of DHI is currently composed primarily of hospital 
affiliated representatives – equally balanced between Bayhealth Medical Center, Beebe 
Medical Center, and Nanticoke Health Services representatives, including both 
administrative staff and board members. In addition, a number of state and independent 
agencies are represented, including the United Way. DHI’s primary role may be 
characterized as the overall convener of county-wide planning, and thus the “keeper of the 
RHP.” Going forward DHI will need to take central accountability for advancing RHP 
recommendations. 
• Regional/Community Health Coalitions: Other coalitions, such as the regional Health 
Councils as well as various hospital-affiliated community health boards, provide additional 
leadership. Ideally, these organizations would maintain active participation with DHI. 
• Hospitals: The three Sussex County hospitals play a pivotal role both in the communities 
they serve as well as throughout the county through shared accountability for most urgent 
care and substantial non-urgent care. Each hospital provides a full range of acute care 
services and leadership support to projects impacting their distinct service areas. The 
hospitals are also committed to improving overall health in Sussex County and fully 
recognize that impacting community health is dependent on many more factors than the 
delivery of direct hospital sponsored services. Participation in DHI by the hospitals 
underscores the ability of otherwise competitive entities to collaborate on a larger vision of 
health improvement. 
• Other health care providers: Development of leadership among physicians, other medical 
and dental care providers, behavioral health providers, and other providers is an important 
strategy for promulgating policies and initiatives that directly impact their practices or 
agencies. Minimally, these categories of stakeholders need to play a role in project 
development, from designing the initiative to recruiting participation from consumers who 
are their clients, and finally to monitoring and interpreting outcomes. 
• State Agencies: In the course of developing the RHP, interviewees representing both 
community organizations and state government indicated that Sussex County is often 
“overlooked,” “ignored,” and/or “not considered,” in state level planning or by state 
agencies. This occurs even though DPH hosts both the state’s Office of Rural Health and 
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Delaware Rural Health Plan 
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Southern Health Services which have provided valuable support to Sussex County 
development. 
• Sussex County Administration: Local government has a major stake in improving health 
care, social services, and both employment and commerce within the county. It has 
supported DHI from its inception and is expected to be an important influence on any 
county-wide initiatives going forward. 
• Faith Community Leaders: Faith leaders can play important roles in supporting both 
individual healthy behaviors and enhanced community activism. Indeed, they have 
demonstrated positive influence on health and infrastructure issues, particularly in the 
African-American and Hispanic communities. Clergy and clergy-led community efforts can 
also be influential at the policy level, as exemplified by the Strong Communities' success in 
drawing attention to inadequate infrastructure. 
Allocating Resources for Leadership Development and Staff Support 
Resources allocated toward strategies identified in the Plan should be balanced between direct 
services and supporting structures (e.g., leadership development, communication, infrastructure, 
etc.). Indeed, the need for leadership development was highlighted in Section III of the RHP. 
While direct service resources are focused on eliminating gaps, funding should also be channeled 
to training leaders, providing staff to develop and facilitate coalitions of stakeholders and 
accountable entities, and to supporting systems that can deliver county specific, statistical and 
other data essential to making sound decisions. The RHP has documented the significant need to 
leverage available resources through concerted shared responsibility. RHP objectives will be best 
met if leadership is multi-disciplinary, cross-organizational, and inclusive of ethnic, racial, and 
minority populations. 
Section IV Page 48 

Section V 
Planning today to improve the lives of tomorrow 
Delaware Rural Health Plan 
Funding 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
V. Funding
Introduction 
Consistent with the themes for the RHP, applying business concepts is a useful mechanism to 
help consider, as well as enable, funding strategies. The RHP is not itself a grant application or a 
direct funding mechanism. Rather it is a potential guide to local or state agencies for setting 
funding priorities based on delivering value to Sussex County. Discrete initiative 
recommendations from the RHP can be extracted and enhanced for presentation as funding 
requests whereas policy recommendations may create the vehicle for a range of fundable 
opportunities. 
The funding necessary to support new initiatives stemming from the RHP can be considered as 
similar to “startup capital” in the business world where firms seeking to implement new ideas (or 
“dot.com” strategies) compete for initial funding from external investors (“venture capitalists”). 
In business, sustained funding is derived from returns on ongoing operations. Sustained funding 
for rural health initiatives must be justified on the basis of a return on funding which takes the 
form of improved health outcomes and diminished public spending on illness, accident, or 
addiction services. The parameters of funding competition thus remain: value, capacity to 
execute, and potential for “return on investment.” 
Using the RHP to Finance Health Improvement 
Firms seeking capital develop business plans and then seek the support of venture capital 
investors who perceive a potential for a favorable return. Similarly, projects and initiatives 
identified in the RHP also require “venture/startup capital.” Sources of such funding include 
private foundation grants as well as both state and federal government grants and allocations. 
The RHP supports project development by contributing to the justification and/or demonstration 
of the effectiveness of a program. Funders increasingly require ongoing program evaluation to 
ensure that programs meet initial expectations. The outcomes can be expressed as improved 
health status and translated into “dollars saved” in unnecessary health care costs, reduced 
employer benefit costs and enhanced profitability for business, decreased loss of work capacity, 
increased worker productivity, and enhanced attractiveness of Sussex County to new residents, 
businesses, and professionals. Dovetailing initiatives with Healthy Delaware 2010 objectives, 
for instance, can represent a credible and “pre-qualified” return opportunity. 
The “grants as venture capital” analogy thus creates a useful framework. The community 
program or initiative becomes a “business” and external funding sources become “investors.” 
This approach is particularly relevant in addressing the issue of long-term sustainability. Few 
external funders are interested in contributing resources indefinitely to sustain projects that are 
appropriately funded as “pilots.” This reality often leads grantees to focus significantly on the 
time frame of the grant, whereas the “business planning” frames a longer-term perspective that 
identifies stakeholders and benefits and seeks internal sources of funding or enhance sustained 
fundability from external sources. 
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Delaware Rural Health Plan 
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General Funding Strategy Process 
Steps towards a general funding strategy process are as follows: 
1. Identify a community need based on observation, data, and an understanding of resource 
gaps along the value delivery continuum; 
2. Understand and communicate the impact of that need in the context of what target customers 
value and the potential return on investment as described above; 
3. Develop a project, service, or intervention that is targeted to address a specific problem (e.g., 
relieve a “bottleneck” in the value delivery chain) and which “fits” or complements the other 
initiatives; 
4. Define and clearly state the project’s goals, objectives, deliverables, etc. and determine an 
appropriate budget and return; 
5. Identify potential funding sources (e.g., foundation grant, local stakeholders, and federal or 
state grants or allocations) for whom value delivery is a priority and, therefore, whose goals 
are complementary to the project goals; pursue multiple funding vehicles if possible and 
permitted; consider seed funding with “follow-on” sustained funding based on demonstrated 
return; 
6. Receive funding, implement the program and develop a sustainability plan; and 
7. Monitor and report performance against goals using metrics that are directly relevant to 
measurement of return and value delivery and, thus, to enhancing and assuring sustainability. 
Stakeholders should plan to use the understanding of Sussex County needs, value creation, and 
gaps in resources, presented in the RHP, to support funding requests. Focusing on these 
elements will support responsive project development and will increase the likelihood of 
receiving funding from competitive sources seeking optimal value for invested funding. 
The process of defining the projects and initiatives is well underway. Section III of the RHP 
(Strategic and Operational Improvements [Broad Policy and Targeted Initiative 
Recommendations]) provides broad policy and specific implementation recommendations as 
they were identified in the development of the RHP. Additional focused planning may be 
required to create specific business plans for these and to bring them to the implementation 
phase. 
Sources of Funding 
Since value delivery is largely measured in terms of achieving population and health system 
goals, governmental (federal, state, or local) funding sources should be sought for sustained 
direct support, in anticipation of population-wide returns or benefits. In addition, private 
foundations often support the development of effective, efficient, and exportable models for 
health improvement. The unique “value orientation” of the Delaware RHP, and of projects 
spawned by it, can provide competitive advantage in obtaining such funding. Consistency with 
Healthy Delaware 2010, CDC initiatives, and other consensus improvement efforts can support 
the appropriateness of funding requests. 
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Delaware Rural Health Plan 
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Pursuing grant dollars may be expensive in terms of the “person hours” required between 
developing the grant and securing the funding decision. Not every grant application is successful 
– few grant writers achieve “hit rates” over 50 percent. Local alternatives to grant funding are 
appropriate and desirable to seek including, but not limited to, private contributors, grassroots 
fundraising, and cost sharing from collaborating agencies. 
• Federal Programs: A wide array of federal programs focused on health already exists. 
Three major sources of funding are the Health Resources and Services Administration 
(HRSA)1, the Federal Office of Rural Health Policy (ORHP)2, and the Agency for Health 
Care Research and Quality (AHCRQ)3. Staff to Delaware’s US Representative and/or 
Senators may also be able to assist in identifying and facilitating opportunities at the federal 
level. 
• State and Local Government: Significant state funding is directed at Sussex County 
through direct service programs and insurance (e.g., Medicaid, Children’s Health Insurance, 
etc.). The state has also created the Delaware Health Fund, which provides significant 
resources to support community health initiatives. Local government may also be positioned 
to provide financial support to efforts that will result in improved health for local citizens. 
Healthy Delaware 2010 is funded by DPH and federal sources. The Behavioral Risk Factor 
Survey is funded through grants. 
• Private, State or Local Foundations: The duPont/Nemours philanthropies distribute funds 
for child health in Delaware, operate clinics, and may have an interest in providing additional 
support to Sussex County. The Robert Wood Johnson (RWJ) Foundation4 is the largest 
private foundation making grants exclusively in health care and has historically funded 
demonstration programs. Current areas of interest include access, care of chronic conditions, 
and harm reduction strategies – all of which link directly to Sussex County needs as 
identified in this RHP. Information on other foundations can be found though the Foundation 
Center5. 
• Local Industry and Business: Depending on the issue, local businesses may be willing to 
contribute to initiatives. For example, the employer may underwrite a work site wellness 
program by emphasizing benefits such as reduced absenteeism or lower health care costs. 
Similarly, promoting access to state health insurance programs for dependents of low 
income, part time, or non-benefited employees may be advantageous to businesses. 
Hospitals, under their charitable giving programs, may be willing to contribute to seeding 
direct service or infrastructural initiatives which directly or indirectly enhance their 
community mission, benefit residents of their catchment areas, and/or indirectly enhance 
their attractiveness to a referral base. 
• Individuals: Support from individuals may take one of two forms: large gifts from wealthy 
contributors or smaller gifts from broader community fundraising. Expenses associated with 
fundraising from a broader base of individuals may be significant in terms of “person hours,” 
mailing, phone calls, etc. Raising money from individuals also may put one in “competition” 
with agencies that use fundraising as their main source of income and support (e.g., United 
1 Internet address: www.hrsa.gov
2 Internet address: www.nal.usda.gov/orhp/
3 Internet address: www.ahcpr.gov/
4 Internet address: www.rjwf.org
5 Internet address: www.fdncntr.org
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Delaware Rural Health Plan 
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Way) and which also address health care or social service missions. This speaks for careful 
consideration of collaborative initiatives rather than stand-alone competitive grassroots 
fundraising. 
Section V Page 52 

Section VI 
Planning today to improve the lives of tomorrow 
Delaware Rural Health Plan 
Risks and Uncertainties 

Delaware Rural Health Plan 
Planning today to improve the lives of tomorrow June 2000 
VI. Risks and Uncertainties 
Introduction 
Risks and uncertainties denote potential barriers to successful implementation of the RHP. By 
recognizing these, proactive strategies and planning may be undertaken to minimize risks of 
achieving less than full value through the RHP. While it is not possible to predict all the 
potential barriers to success for each initiative and policy recommendation in the RHP, it is 
nonetheless worthwhile to focus some attention on major anticipated areas of risk and 
uncertainty for the RHP as a whole. As specific projects are planned in more depth, stakeholders 
should determine which of the following concerns apply,