Toniann Richard, CEO of Health Care Collaborative (HCC) of Rural Missouri, is part of a lineage of crop and beef producers. Raised in Herington, Kan., just south of Junction City, her grandfather advocated for farmers and even ran for local office. At the time, her mother, a beauty salon owner, was a registered Democrat. “That’s when my mom said she changed her voter registration to Republican because ‘Grandpa was running for office and he couldn’t have me not be on his side,’” Richard said.
Although he didn’t win the seat, it’s evident that his penchant for advocacy is a trait his granddaughter shares. Richard’s role in community service began early. Although it came with some starts and stops, she’s managed to not only make a name for herself, but also for the Lexington, Mo.-based nonprofit she runs.
Hired and Fired
Back in Herington, a strong work ethic wasn’t something you talked about; it was something inherent. Richard, still in middle school when she landed her first job at her mom’s salon, learned the hard way there would be no free rides. “The deal was I had to answer phones, dust the retail shelves, sweep the hair, run errands, and not be a brat and argue with my mom,” she said. In return, Richard got part of the afternoon free to walk to the community pool and hang out with friends. Later in the afternoon, she’d return to the salon, help clean up and head home.
“For about a week, I was being a brat and she fired me,” Richard said. “At the time, I thought, ‘Sweet. I don’t have to work anymore.’ Well, I didn’t realize she was my ticket to town, which was kind of my pay. The tough thing about being fired is that I had to stay home and help my dad and brother on the farm and clean the house. That taught me a lesson – even my mom will kick me to the curb for being lazy.”
Richard was rehired a couple weeks later. “I worked my butt off,” she said. “I didn’t want to lose my ride to town to hang out at the pool with my friends.”
Richard’s ability to connect and create relationships was evident even at Herington High School, where she was student body president and winter homecoming queen. Although she came from a family of Kansas State University alumni, she deviated from Purple Pride and attended Baker University, a private Christian school in Baldwin City, Kan. Richard was a part of Baker’s education program, where she taught preschool for three years. By the time she approached practicums her junior year, Richard had a change of heart and switched to the business program.
This transition afforded the opportunity to work closely with Baker’s then vice president of development, Jerry Weakley. As a student intern, she watched how he cultivated relationships, a move that would serve her well later. After graduation, she landed her first job with the American Cancer Society (ACS), fundraising for its Relay for Life program. “This is where I met Stephanie Weiter, who is still a dear friend and close colleague,” Richard said. “She taught me how to develop cohesive teams and how to be a strong female leader in the workplace.”
After marrying her husband Pat, head football coach at Oak Grove High School in Missouri, Richard took a hiatus to figure out her next steps. “Pat and I had just gotten married, and I took a job at a daycare because I thought I wanted to open my own daycare facility,” she said. “Pat thought it would be a good idea for me to work for a daycare first to see if it was going to be a fit. I got a job managing a before-and-after school program. The kids and I had a blast, but it lasted 90 days. It wasn’t for me.”
Learning the Ropes
Soon after, Richard landed a position as membership director for an area YMCA. She later moved to an executive role at what was then the Clay-Platte YMCA, supervising the entire operation.
There, she met other strong mentors including former University of Central Missouri football coach Terry Noland, Gary Linn, who is still leading teams at the YMCA of Greater Kansas City, and Sarah Reese, who currently serves as area vice president for the YMCA of San Diego County. Richard watched Noland problem solve and navigate difficult situations. And Reese taught Richard that knowing her strengths is one thing but knowing her weaknesses is so much more valuable.
Fully vested in her role at the YMCA, Richard was hands-on even when she was out of the office. The YMCA was open from 5 a.m. until 10 p.m. It was also open seven days a week. “A blessing or a curse, I made myself available to people,” Richard said. “My daughter Grace was recognizing that whenever the phone rang, it was work…and that was going to take me away from whatever was going on with her. I was working evenings and weekends. I felt like my family was falling apart. I had walked away from things that mattered to me the most. I wasn’t involved in church like I had been previously. There was a distance from my family back at home because of the reality of working all the time. The big thing was, whenever the phone rang, Grace would lose it.”
It was apparent that something needed to change. “It was the weirdest thing. One night, I was driving home from work, thinking, ‘I just can’t do this,’” she said. “In the Richmond Daily News, there was an ad for an executive director position at HCC. I couldn’t figure out how to apply online, but there was a phone number. It was about 10 o’clock at night and I thought, ‘Well, I’ll call this phone number and leave a message and maybe get a call back the next day.’ Someone picked up and it totally caught me off guard because I was preparing the voicemail message in my head.”
The interim executive director who answered the phone also worked for a Lexington, Mo.-based law firm and had stepped in to keep the nonprofit going. “I can talk right now if you can,” she told Richard. They spoke for nearly an hour that night.
“That’s how fast it happened. And I remember being so excited about the potential for this job because there were so many possibilities. I could see the potential for me in a place like this,” Richard said. After interviewing three times and discovering she and then Lafayette Regional Health Center CEO, Bret Kolman, had an instant connection, Richard got the job and gave notice at the YMCA.
“In 2007,” Kolman said, “I was on the board of a small health care related nonprofit in Lafayette County. We had less than $250,000 a year in grants, no other revenue streams, and big ideas. We had less than 60 days cash on hand, and 2.5 FTEs (full-time employees). When our director left, I was on the committee that helped interview candidates. One person stood head and shoulders above the crowd: Toniann. I credit hiring Toniann as one of my best sales jobs and greatest hires in my career.” Kolman is now CEO of Independence, Mo.-based Centerpoint Medical Center.
Richard’s journey at HCC began in November of 2007 in a small office inside of the Lexington 4Life Center. The organization consisted of one other employee. However, there was a hitch: Her position was funded for only one year. A grant application had been submitted to the Health Resources and Services Administration (HRSA) on HCC’s behalf for a three-year round of funding. The HCC board felt confident about its chances of getting funded.
“I showed up my first day and had no idea what to do,” she said. “I soon realized my job was to figure out how to make this thing go.” Richard, three months into her first year at HCC, and two other colleagues were returning from a meeting in Jefferson City when she learned that the promising grant application sent to HRSA was denied – certain areas in Lexington were not recognized as rural.
“I remember sitting in the back seat on the drive back thinking, ‘Oh no! What are we going to do?’” But in the car with Richard was someone who happened to be an expert in licensing and accreditations for health departments. (At the time, Lafayette County Health Department was HCC’s fiscal agent.) “She called HRSA and said, ‘What do you mean we aren’t rural? I’m looking out of my window and all I see are cows!’ I remember thinking, ‘This woman is so brave. She just called Washington, D.C., and read these people the Riot Act.’”
Richard contacted current HCC Human Resources Director Brook Balentine, who at the time was working for Senator Claire McCaskill. Once apprised of the situation, McCaskill, the late Senator Ike Skelton, and former Senator Kit Bond agreed to fight HRSA’s rurality score for Lexington.
They won. HCC received its first substantial grant award of $540,000. “We got a lot of momentum out of that,” Richard said. “I also saw that it’s okay to ask questions and push back.”
The Making of a Rural Health Network
HCC found itself on the fast track after that. In 2009, President Barack Obama signed into law the American Recovery and Reinvestment Act (ARRA). Title XIII of ARRA, called the Health Information Technology for Economic and Clinical Health Act (HITECH), allocated $19.2 billion toward health internet technology (IT) development. The goal was to improve health care delivery by incentivizing the implementation of electronic health records (EHRs) for use in meaningful ways.
The HITECH funds HCC received enabled the organization to forge relationships with Carroll County Memorial Hospital, Lafayette Regional Health Center, Fitzgibbon Hospital and the recently closed I-70 Hospital in Sweet Springs.
“This is when we started making a name for ourselves in D.C.,” Richard said. “People were impressed that hospitals were working [together] to share data. This was at a time when rural leaders were having a hard time getting on board with technology. We were lucky because our partners embraced it and met on a monthly basis to figure things out.”
HCC had managed to create a group of health IT experts. Richard admits the learning curve was grueling. “We brought technology leaders to the table and I couldn’t understand what they were talking about,” she said. “I would go home at night and just google words to try and figure out what they meant.”
The other challenge was internet connectivity – or lack of it – that often hampers rural areas. The very first telemedicine equipment HCC purchased cost $125,000. Unfortunately, the area’s broadband issues made the technology virtually impossible to use. At the time, DSL was slowly making its debut into the rural commercial space.
Even with these challenges, HCC was bringing technology leaders and health care professionals to the same table. This caught HRSA’s attention coupled with the fact that HCC was one of the only vertically integrated networks, where community-based programming was the driver.
Setting a Place at the Table
With help from the Health Forward Foundation (formerly known as the Health Care Foundation of Greater Kansas City) and REACH Healthcare Foundation, along with other funding sources, HCC found its financial footing and started expanding its programming and staff to accommodate direct services.
“The potential for opening a clinic came when we started seeing the push and pull between hospitals and clinics,” Richard said. “The conversation at the national level was hospitals don’t really get along with clinics. I thought that was dumb. They don’t even do the same thing. Why wouldn’t they get along? Do we not serve the same purpose?”
These issues were discussed at length with HCC’s board. What they found was people didn’t understand that hospitals and clinics each bring different value to the table. With that, HCC focused on service delivery — particularly the appropriate time and place for individuals to receive services regardless of socioeconomic factors. The complexities of payment reform were layered on top of that.
“It just made sense,” Richard said. “When we started thinking about the clinic and then looked at opportunities with the board to actually open one, the focus was around making sure people had access to what they needed.”
With that, the table was set. HCC’s comprehensive programming and direct service model has played a crucial role in helping individuals not only navigate the health care system, but also receive social services and other community resources. From creating a complex rural health network, to owning and operating four federally qualified health centers (FQHCs), HCC has created the framework for others to follow.
Recognized as a National Leader
Today, HCC is a formidable player in rural health care policy on a national scale. “We looked at the National Rural Health Association (NRHA) and tried to model their strategic plan, mission and values because we knew they were an industry leader.”
Richard regularly works with research and policy leaders around the country who are focused on reform. Those ideas are recycled on the local level and leveraged to drive health policy that precisely impacts direct services at HCC’s Live Well Community Health Centers in Buckner, Carrollton, Concordia, and Waverly as well as other rural health care entities statewide.
“We work with high level research and policy experts,” she said. “I love the fact that we can talk about the challenges of just being working parents living on limited resources in rural communities and it not be used to compromise us as rural leaders. We are saying this is the realty of how we live and we’re proud of it.”
Recently, the National Opinion Research Center (NORC), an affiliate of the University of Chicago’s Welsh Center for Rural Health Analysis, published a report as a part of the National Association of Community Rural Health Centers’ implementation guide for hospital collaboration. The report consisted of two case studies – HCC was one – making the Network and its FQHCs a national model.
Under Richard’s leadership, HCC has grown from 2.5 FTEs in 2007 to nearly 75 FTEs and has raised nearly $16 million in grant funds. Its Live Well Centers have also earned the distinction of Patient-Centered Medical Homes (PCMH) from the National Committee for Quality Assurance.
“When it comes down to achievements, we’re going in the direction God wants us to go,” Richard said. “I get validation from being a servant-leader. And that’s all that I feel I need.”