The Future of Rural Hospitals and Health Systems

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Tom Haederle
Some 57 million rural Americans - about 17% of our population - depend on their hospital as an important source of care, as well as a critical pillar of their area's economic and social fabric. As we observe National Rural Health Day on November 16th this year, now is a good time to take stock of the stresses and challenges that continue to confront rural care providers, but also to explore some trends, creative ideas and new approaches to help rural hospitals and health systems continue to provide the essential services that patients rely on.

00;00;39;11 - 00;01;11;17
Tom Haederle
Welcome to Community Cornerstones. Conversations with Rural Hospitals in America. I'm Tom Haederle with AHA Communications. In today's podcast, two senior health care leaders with years of experience serving rural populations take a deeper dive into the future of rural hospitals and health systems in the U.S. Host Michelle Hood is executive vice president and chief operating officer of the AHA, and her guest, Dr. Joanne Conroy is president and CEO of Dartmouth Health in New Hampshire, as well as chair elect of the AHA Board of Trustees.

00;01;11;19 - 00;01;17;18
Tom Haederle
Dartmouth Health, by the way, is the most rural academic medical center in the country. Let's join them.

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Michelle Hood
Good day. My name is Michelle Hood, and I have the pleasure of serving as the executive vice president and chief operating officer of the American Hospital Association. Joining me today is Dr. Joanne Conroy, president and CEO of Dartmouth Health and chair elect of the AHA Board of Trustees. We are here to discuss the future of rural hospitals and health systems.

00;01;41;05 - 00;02;09;01
Michelle Hood
But first, let us establish our rural credentials. Nobody disputes that Maine is a rural state. In fact, some of the state is designated frontier. As the former president and CEO of Eastern Maine Health Care, now Northern Light Health, headquartered in Brewer, Maine, I worked with and on behalf of rural hospitals, including critical access hospitals that were system members across the entire state.

00;02;09;03 - 00;02;22;01
Michelle Hood
Likewise, nobody disputes that New Hampshire is a rural state. Dr. Conroy, you also are familiar with rural health care as both a clinician and administrator. Please share with us your rural credentials.

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Joanne Conroy
Well, I started my career in South Carolina, which at least from the Medical University of South Carolina we took care of a number of people in both rural South Carolina as well as Georgia. And since 2017, I've had the pleasure of being president and CEO of Dartmouth Health, which is the most rural academic medical center in the country.

00;02;43;15 - 00;03;02;12
Joanne Conroy
And not only have I had an appreciation about how rural New Hampshire, Maine and Vermont are, but also the fact that our relationship with our rural partners is shifting dramatically during COVID. And you can see the future change even more.

00;03;02;15 - 00;03;23;15
Michelle Hood
For those listening, just know that meeting rural challenges and opportunities is near and dear to both of our hearts. Our commitment to those providing care to those living in rural America is steadfast. Dr. Conroy, please share with us some of what is unique about Dartmouth Health and how you are working to meet the challenges of rural health care.

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Joanne Conroy
Historically, academic medical centers depended on creating a network of hospitals to deliver a volume of patients to their facility created this inflow. But what Dartmouth Health has been trying to do is create an outflow, meaning to direct patients to receive care in their community and or go to those specific community hospitals where we've established the expertise to give patients care

00;03;50;28 - 00;04;14;11
Joanne Conroy
close to home. That's a little bit of a different model than we've had historically with an academic medical center seated within a network of facilities. I have to say that COVID actually accelerated this, but it was already part of our plan, which was everything didn't need to come to the academic medical center. Only those really high acuity patient care issues.

00;04;14;14 - 00;04;15;25
Michelle Hood
Meet people where they are.

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Joanne Conroy
That's right. And I have to say that we have really a deep appreciation for what those communities actually are doing. All health care is local and there's no anonymity. So when I'm in Hanover, we solve our problems in all three of the co-op. But if I'm in Keene and I'm visiting Cheshire Medical Center, I have the same level of recognition from the people in the community as I do up in Hanover.

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Joanne Conroy
And it's just a broad footprint that you learn to appreciate and value.

00;04;46;18 - 00;05;05;05
Michelle Hood
Yeah, love it. I couldn't fill up my car with gas without somebody coming to talk to me about their latest experience with the health care system. So, you know, we're getting ready to come out of this public health emergency May 11. It is officially over. So what do you see as some of the greatest challenges as we enter this new phase?

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Joanne Conroy
Well, there are a lot of things the American Hospital Association has advocated for that are going to help us, even though the PHE actually sunsets. They have managed to extend some of the telehealth provisions. But there are other things that are happening coincident with the public health emergency sunsetting that cause me some concern. The federal government had talked about moving people off Medicaid.

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Joanne Conroy
I find that incredibly concerning. Certainly our rural patients, the number of people that actually are have bankruptcy from medical debt is actually been decreasing because we've expanded Medicaid and yet we're going to reverse a lot of that as states, and this is a state decision, decides whether or not to move people off their Medicaid rolls. That creates incredible challenges for rural America.

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Joanne Conroy
And we forget that there's tremendous poverty in a lot of our rural geographies. And along with poverty, affordable health care is a component of it. It's not the entire solution, but it certainly is a lifeline for a lot of those families and patients and certainly the communities.

00;06;16;28 - 00;06;48;11
Michelle Hood
Yeah, for sure. So I know that you're very familiar with the AHA strategic plan that we're currently in year two of a three year plan. Our key priorities are providing better care and greater value, advocating for the financial stability of hospitals and health systems. Everybody's number one concern addressing workforce challenges and designing strategies to support our members. And in that work across the U.S.

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Michelle Hood
Enhancing innovation, especially as it relates to meeting consumer demands and changing consumer demands, and then finally rebuilding and enhancing public trust and confidence in America's health care system. So it's a flexible but broad strategic plan. And how do you see that aligning with the needs of rural hospitals and health systems?

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Joanne Conroy
Let's talk about workforce first. That's what keeps most people up at night. And rural geographies have a greater challenge than urban geographies. We simply don't have the available workforce to recruit. New Hampshire has the lowest unemployment in the country. And on top of that, the geographies are a lot more attractive for people to live in the southern part of the state, where we have over 600,000 people in New Hampshire on the seacoast. And then the rest of the state is relatively rural.

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Joanne Conroy
So how do you recruit people to those areas of the state that need that workforce? And then how do you retain them? It's interesting. Most rural communities are now talking about their big issue is housing and affordable housing for their employees. You know, our roles have changed in communities. We can no longer actually limit our involvement to the walls of our facility.

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Joanne Conroy
We actually have to get out into the community and be very, very involved. And we've led an effort that's focused on vital communities in the Upper Valley in New Hampshire, where we are creating a low interest investment fund so developers can come in and build single family homes because we know that's the pathway for the future. So workforce is rough across the country, but it's really bad in rural geographies.

00;08;30;22 - 00;08;56;10
Joanne Conroy
I would say the second aspect that we need to consider is the fact that what works in urban and suburban geographies does not work in rural health care. Most of our value based programs do not work in rural health care. There are so many different obstacles, like if I want to do a hospital at home, it's six miles down a gravel road and they don't really have a reliable internet and sometimes not reliable electricity.

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Joanne Conroy
So creating a hospital at home is far easier when your hospital at home geography might be five miles. You know.

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Michelle Hood
With good broadband.

00;09;07;04 - 00;09;13;24
Joanne Conroy
Broadband. So I think people think that everything is easily translatable, but it's actually not.

00;09;13;26 - 00;09;44;25
Michelle Hood
I think that's the power of the work that we're doing with our members and the board in particular around trying to find different pathways to the future. I mean, maybe that future will intersect at some point, but we all are going to have different ways of getting there. Last thing I wanted to talk to you about is that, you know, our mutual and shared interest in advocating for women leaders and there are quite a few women CEOs in rural health care and beyond.

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Michelle Hood
And I know that you're a founding member of Women of Impact and have worked to increase the leadership opportunities for women in health care. So how do you see our ability to collectively open more doors for women leaders?

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Joanne Conroy
So first of all, I start with the data, is that we've got 15 years of data across Fortune 500 companies that when you have a diverse leadership teams and diverse boards, you make better decisions. So there's plenty of evidence to say that we should invest in creating diverse teams. And part of diversity is gender diversity. As we track the increase in women leaders across the country, you know, it's going to take

00;10;24;14 - 00;10;26;22
Michelle Hood
100 years to see parity in the C-suite.

00;10;26;22 - 00;10;53;18
Joanne Conroy
So we've got a lot of work ahead of us. I would say that hospitals and health systems need to think about a couple of things. Number one, investing in leadership programs for women. KPMG has actually done that quite successfully. Invest in them. They will pay you back in multiples. The second thing is make sure you create career paths for women and that there is an element of sponsorship within your organization.

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Joanne Conroy
Even if you sponsor a woman and that means put her name forward at an organization outside of your system, you are still advancing that individual's career and it helps all of us. Those are things that I think are really important, and I get the pushback from a lot of my male colleagues. They say, well, why are you doing something for women?

00;11;15;06 - 00;11;29;05
Joanne Conroy
Why don't you do it for men? I said, listen, when we have parity, we can talk about equal balance of programs. But right now we've got 100 years where we need to catch up. And so let's not argue about how we do it. Let's just start doing it.

00;11;29;10 - 00;11;57;16
Michelle Hood
Yeah, that's great. So I want to thank Dr. Conroy. I thank you for sharing your thoughts on the future of rural hospitals and health systems and and lastly, the challenges that must be overcome to assure a viable and robust rural health care delivery system. And also, of course, share your passion around advancing women in health care leadership. I know our listeners appreciate the credibility that you bring through a lifetime of experience as a physician and leader in rural health care.

00;11;57;19 - 00;12;03;05
Michelle Hood
I am Michelle Hood, EVP and CEO of the American Hospital Association. Thank you for listening.

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Joanne Conroy
Thank you, Michelle.