AHA's Rural Podcast Series

Community Cornerstones: Conversations with Rural Hospitals in America

Half of all Medicare beneficiaries get their benefits through Medicare Advantage (MA) plans, which are offered by private companies and in theory should provide the same level of coverage of traditional Medicare. However, some MA plans have made the process of getting a claim covered a nightmare for patients, hospitals and health systems. In this conversation, Chris Barber, president and CEO of St. Bernards Healthcare, discusses the overwhelming problems certain MA plan practices can create for patients and their caregivers, especially for rural hospitals and health systems who face a unique set of challenges in caring for their communities.


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00;00;00;25 - 00;00;22;23
Tom Haederle
Today, half of all Medicare beneficiaries get their benefits through Medicare Advantage or "MA" plans. They're offered by private companies and supposed to provide at least the same level of coverage that traditional Medicare does. That's in theory, anyway. In practice, an alarming number of MA private insurers have made the process of getting a claim covered a nightmare for patients.

00;00;00;25 - 00;00;22;23
Tom Haederle
Today, half of all Medicare beneficiaries get their benefits through Medicare Advantage or "MA" plans. They're offered by private companies and supposed to provide at least the same level of coverage that traditional Medicare does. That's in theory, anyway. In practice, an alarming number of MA private insurers have made the process of getting a claim covered a nightmare for patients.

00;00;22;26 - 00;00;45;24
Tom Haederle
Policyholders report facing ever-higher administrative hurdles that resulted in long delays and inappropriate denials, while hospitals and other caregivers are being overwhelmed by all of the red tape. What can be done?

00;00;45;26 - 00;01;18;00
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle, with AHA Communications. In recent years, the growth of MA plans in rural areas has especially impacted rural and critical access hospitals, who already face a host of serious challenges as they strive to meet the health care needs of their communities. It's not overstating things to say that prior authorization, payment audits and delays and denials of patient care by some MA plans is threatening the financial solvency of our nation's rural safety net.

00;01;18;03 - 00;01;32;13
Tom Haederle
In this podcast, hosted by Michelle Millerick, AHA's senior associate director of health insurance coverage policy, one CEO of a rural health system describes the impact of the growth of MA plans on the communities it serves. Let's join them.

00;01;32;15 - 00;01;58;24
Michelle Millerick
Thanks, Tom. This is Michelle Millerick from the AHA Policy team and a senior associate director of health insurance coverage policy. And today, I'm joined by Chris Barber, who's the president and chief executive officer of St. Bernards Health Care in Jonesboro, Arkansas. Chris has been part of the leadership team at St. Bernards for over 30 years. So there's been tremendous on the ground experience and insight from the field to our conversation today about Medicare Advantage and some of the unique challenges facing our rural health care providers.

00;01;58;26 - 00;02;07;28
Michelle Millerick
So, Chris, I'm hoping we can start there. If you can tell us a little bit about yourself and more about St. Bernards and the types of patients and communities that you serve in Arkansas and Missouri.

00;02;08;00 - 00;02;32;09
Chris Barber
Thanks for having us, Michelle. During the malaria outbreak in the late 1890s, the brave women of the Olivetan Benedictine sisters followed their faith and responded to a desperate need by reaching out and inviting the sick into what was at that time was a six-room house referred to as St. Bernards to began a journey of sacrifice and unwavering service to others that has spanned over 123 years.

00;02;32;11 - 00;03;10;23
Chris Barber
Over that time, this small hospital has been transformed into the most extensive regional health system serving rural communities in northeast Arkansas and southeast Missouri, with a catchment area of approximately 624,000 individuals. The largest tertiary facility in the region of Saint Bernard Medical Center, which is a 454-bed facility, including a 74-bed behavioral health facility with multiple critical access hospitals under the umbrella, and recently transitioned a low-volume PPS hospital to the first Rural Emergency Hospital in Arkansas and one of the first rural pace programs in the country.

00;03;10;27 - 00;03;18;08
Chris Barber
The organization looks much different than it did in 1900, but our primary purpose and mission have transcended through time.

00;03;18;10 - 00;03;33;13
Michelle Millerick
Thanks, Chris. It's really helpful to hear more about your organization and especially the mission part of the work that you do and taking care of patients in your community. So as we think about Medicare Advantage and diving into our topic for today, you know, I think one of the reasons that this is so top of mind is that MA enrollment has been growing rapidly.

00;03;33;13 - 00;03;53;05
Michelle Millerick
As you now, you know, traditional Medicare for a long time was the predominant delivery system for Medicare coverage where most people were getting their Medicare coverage options. And now we've hit that tipping point this year where 50% of all Medicare beneficiaries are getting that care through Medicare Advantage and that enrollment is growing at about 8 to 10% per year nationwide.

00;03;53;08 - 00;04;15;01
Michelle Millerick
And I think, as you know, you know, we're really seeing sort of some of that growth in rural areas, in particular in a big way and perhaps as well some of the delays and denials and insurer practices that can be problematic for providers and patients that are following that. So I wonder if you can just tell us more about what you're seeing in Arkansas and Missouri in terms of MA growth and the impact that it's having on your organization?

00;04;15;03 - 00;04;50;25
Chris Barber
Sure. Similar to what's occurring nationally, we experience a rapid increase in Medicare eligible people choosing Medicare Advantage plans. These ongoing challenges with insurance companies over negotiations on reimbursement, prior authorization claims, denial and delayed payments have placed extreme financial pressures on hospitals in the state. The center of health care quality and payment reports revealed recently that 37 of our 49 rural hospitals, or 76%, are losing money in day-to-day operations of hospital services in Arkansas.

00;04;50;27 - 00;05;23;14
Chris Barber
Additionally, as more of these Medicare eligible population has transitioned to Medicare Advantage plans, our hospitals are reimbursed well below the rate of Medicare, resulting in a material financial impact on organization. This development of the shift in payer mix from Medicare to MA has had a profound effect on our organizations. For example, we have seen significant increases in our labor costs by just adding personnel to combat the massive number of claims, denials, pursue appeals and prior authorization.

00;05;23;16 - 00;05;32;13
Chris Barber
We are experiencing challenges just transferring patients to the appropriate level of care, often increasing length of stay in some of our acute care facilities.

00;05;32;15 - 00;05;50;07
Michelle Millerick
That's really striking, Chris, and especially some of the details you just shared on some of the financial impact of these shifts in the market. Do you have any data you can share with us just to help paint a picture as well about the environment and what you're seeing in MA? You know, certainly we're seeing some national trends with huge growth, but anything from from your market that you can share data wise?

00;05;50;14 - 00;06;19;19
Chris Barber
Yes, In our market, for St. Bernard’s Medical center, if you look at a ten year comparison of our percentage of charges for Medicare versus Medicare Advantage, it has changed dramatically. In 2015, Medicare represented 43% versus 9.5% of Medicare for our book of business. Our most recent records - 2024 percentage that Medicare Advantage is now more significant book of business than traditional Medicare.

00;06;19;21 - 00;06;46;19
Chris Barber
Medicare Advantage represents 29.8% versus Medicare, now 28.4%. Again, we've experienced these increased denials and payment delays and appeals. Our inpatient reimbursement for this population is roughly 7 to 9% below Medicare for this Medicare Advantage population. Additionally, we seeing an increase in self-pay with higher co-pays and deductibles in our market.

00;06;46;22 - 00;07;07;27
Michelle Millerick
That's really interesting, Chris, and I think consistent with what we're hearing from our members across the country. You know, I also think when you look at MA growth over the last decade or so, you see in rural areas, you know, ten years ago the uptake was pretty low. And it seems like in the last five or so years we've just seen a lot of dramatic growth, especially, you know, nationwide, but especially in rural areas, it's growing faster.

00;07;08;05 - 00;07;29;14
Michelle Millerick
And so I think some of the reasons that we're starting to see some of these pain points that that you alluded to, you know, really is correlated, especially with some increased growth and MA penetration in rural areas. So I wonder as we think about, you know, the bigger picture of what does this growth mean? You know, you've provided sort of an outline of some of the impacts on your organization, but I think a lot of this comes back to, especially for mission driven organizations like St. Bernards

00;07;29;18 - 00;07;46;17
Michelle Millerick
you know, what does this mean for patients and families? You know, there's real people behind delays and denials and, you know, people who are waiting for an authorization to be transferred to a rehabilitation facility or people who are told that they have cancer but need to wait for the treatment that might save their life while their insurer decides if they're going to cover it.

00;07;46;24 - 00;07;56;21
Michelle Millerick
And so I wonder if you can just talk a little bit about, you know, what some of these challenges translate to for patients and families that you serve and also for the clinicians and the nurses and doctors who are taking care of them.

00;07;56;23 - 00;08;21;08
Chris Barber
Absolutely. In terms of patients and their families, they can have a more exhausting experience when shopping for health insurance policies these days. They still have to educate themselves on common terms that we're all familiar with co-insurance, co-pays, deductibles and then what network. But these newer policies, however, may include some additional qualifiers or terms that may affect where and how individuals can receive care.

00;08;21;10 - 00;08;47;24
Chris Barber
If they don't meet all the criteria, they may have to pay more out-of-pocket penalties or a number of other requirements that were not present in older and more traditional policies. Anecdotally, many older individuals enroll in an MA   plan when they're healthy, seeing lower premium costs and additional benefits like dental and vision insurance. I know a recent report on NPR said those enrollees start feeling trapped as they encounter more health problems.

00;08;47;26 - 00;09;18;05
Chris Barber
They don't get to choose any doctor or hospital they want, like the traditional Medicare. To make matters worse, a recent federal review cited that more than half of MA plan directories contain inaccurate information on which providers they could see. You know, on the clinical side, we believe some insurance companies conduct business and write their clinical policies that has made it difficult for organizations to provide medical care and could jeopardize how, when and where individuals receive future care.

00;09;18;07 - 00;09;48;24
Chris Barber
Frequently, patients and families feel caught in the middle and really need trusted resources to provide honest and transparency and guidance. Clinicians are highly frustrated with the time required on the phone to receive a much needed test that has to be pre-authorized, thus creating unnecessary delays in determining a working diagnosis and appropriate treatment course. Again, we hear concerns about delays in transferring patients from the acute care setting to other levels of care.

00;09;48;26 - 00;10;14;11
Chris Barber
Finally, I would just add and underscore this point: these roadblocks to patient care really demonstrate the importance of community benefit and programs that not-for-profit hospitals and health systems play in addressing how rates of smoking, inadequate nutrition, substance abuse, help counter health risk assessments that we have in our communities. So it's imperative for us to continue to navigate these waters.

00;10;14;14 - 00;10;41;28
Michelle Millerick
Thanks, Chris, and I really appreciate your perspective on how some of these issues and trends affect patients. There's something you said that I want to just drill down on for a second. You know, particularly around some of the impact on clinicians and caregivers and how these policies are adding cost and burden to the health care system. You know, particularly as a system with rural presence, you know, workforce issues and shortages of health care providers is a national issue all over the country, but certainly something that's especially pronounced in rural areas.

00;10;42;00 - 00;11;01;10
Michelle Millerick
And as we think about, you know, peer-to-peers and the burden of prior authorization and clinician documentation and some of the things that play into insurer delays and denials or excessive use of prior authorization for things that are pretty routine. Can you talk a little bit more just about some of the workforce issues that you're seeing and maybe how some of your policies might play a role?

00;11;01;13 - 00;11;25;06
Chris Barber
Yes, this has certainly been a challenge, one, recruiting talent to rural communities. As you know, physicians primarily trained in urban markets. And we have to compete nationally on compensation, but also you have to have amenities to go along with that. So it is a challenge. We want to get physicians as well as clinicians to move to rural communities.

00;11;25;09 - 00;11;47;08
Chris Barber
So if they have a rural payback or program with physician training, that has certainly benefited some of our communities. It's also good to have a medical school, a residency that believes in rural medicine and encompasses that and provides rotations in a community. What we've found, if we can get them to the community, they can see what kind of quality medicine you can provide, an impact that you can have.

00;11;47;10 - 00;12;15;24
Chris Barber
It can be meaningful on a fulfilling career here, but is a challenge when you're trying to recruit to rural communities. Let me say some of the other aspects and critical access hospitals in regard to MA...timely payment in the payer mix of patients are essential to hospital survival. In many of these rural communities, we see less commercial insurance and more Medicaid and Medicare and now a significant percentage of Medicare advantage in our rural communities.

00;12;15;26 - 00;12;57;11
Chris Barber
You know, recently in the American Hospital Survey on Medicare Advantage plans, they have the highest denial rate at 19.1%. This significant operational challenges places organizations and exacerbate issues in smaller rural facilities that do not have either a dedicated resource for ongoing monitoring and continuously fighting to overturn these high number of denials. In many instances, Medicare plans are paying much less for critical access hospitals and Medicare, and we have one critical access facility that is receiving 37% less for inpatient reimbursement premiums for MAs, compared to Medicare, which is significant.

00;12;57;13 - 00;13;28;04
Chris Barber
Additionally, in specific markets, rural critical access hospitals are limited in their ability to negotiate a reasonable agreement with these large national insurers effectively. And as we all know, the margins on rural hospitals are extremely thin. And this shift in payer mix has dramatically impacted the financial deterioration of many hospitals with limited cash reserves. In our case, we're fortunate to have a system that helps some of these resources in alignment with our critical access hospitals.

00;13;28;06 - 00;13;38;01
Chris Barber
But in general, if there's no changes in the near future, unfortunately, I think we'll continue to see the deterioration of services and the number of providers in rural communities.

00;13;38;04 - 00;13;58;19
Michelle Millerick
Chris, that's really striking. And you know, I think when you describe one of your critical access hospitals getting 37% less than they would have under traditional Medicare...you know, you think back to 1997...Congress made a special payment designation for critical access hospitals to make sure in recognition of their unique status and their ability to ensure that people get access to health care services.

00;13;58;26 - 00;14;20;23
Michelle Millerick
I mean, rural areas that they get paid at 101% of their costs under Medicare. And so it's really striking, I think, an important policy question for us to think about, too, as Medicare Advantage continues growing and is rapidly becoming the predominant way that people get Medicare coverage. You know, it's really striking that that need perhaps isn't being met on the MA side in terms of what the reimbursement that critical access hospitals are getting.

00;14;20;23 - 00;14;36;12
Michelle Millerick
It doesn't match what Congress wanted them to get on the fee for service side. And then you add some of the other things that you're talking about in delays and denials of care and prior authorization. And that's that's really helpful perspective, Chris. You know, I want to think about sort of solutions and, you know, where do we go from here?

00;14;36;12 - 00;14;56;06
Michelle Millerick
And I think you've laid out what some of the issues are really well. You know, I think from a federal perspective, there's some good news, which is that these issues are getting a lot of attention from policymakers, from the media, and frankly, just from the public and people who are really worried about what's happening, you know, in open enrollment the last couple of months as people are out there making choices about Medicare coverage.

00;14;56;09 - 00;15;25;05
Michelle Millerick
There's been a lot of stories and attention on the impact on patient access to care for services that should be covered in MA and inappropriate denials. You know, in the last year or so, we've started to see a major government reports from the HHS Office of Inspector General raising concerns about inappropriate denials. The Centers for Medicare and Medicaid Services, which oversees the operation of the Medicare program, finalized a major new rule in April of this year that just went into effect January 1st

00;15;25;08 - 00;15;54;02
Michelle Millerick
that's really trying to better align coverage in May with traditional Medicare. So I think our voice is being heard and I think these perspectives are really being elevated and that there's consensus that something needs to be done. And, you know, I think from the AHA perspective this is really a full court press issue where we're actively working to develop policy solutions to help rural critical access hospitals and urging federal policymakers to continue increasing oversight and really focusing on enforcement and compliance of some of the new rules that just went into effect.

00;15;54;04 - 00;16;15;02
Michelle Millerick
But I wonder if, from your perspective, in leading a health system, Chris, you know, what else do you think was needed in terms of solutions? You know, what does your system, you know, need as you contemplate how to move forward and tackle this sort of new world that we live in and for rural hospitals in general, to be able to continue to be viable in serving their communities as this MA shift continues to take place?

00;16;15;05 - 00;16;38;17
Chris Barber
Well, first and foremost, I'd like to begin by applauding the AHA for the work done to date and the continued effort to advance this meaningful policy and regulatory oversight of the MA. And as you stated, it's important to let our voice be heard often and frequently. Please keep up the pace regarding the enforcement and compliance in calendar year 2024 of Medicare Advantage rule.

00;16;38;20 - 00;17;10;09
Chris Barber
We believe there are significant outstanding public policy issues and problems that need to be rectified for past underpayments to hospitals by MA, specifically the 340B remedy from 2018 to 2022. And as you stated, I want to underscore the significance. It'll be imperative to continue to explore payment mechanisms to secure essential services in rural communities while providing some organizational flexibility and selected markets where strategies that might work well in their area.

00;17;10;11 - 00;17;39;15
Chris Barber
Initially, when establishing the Critical Access Hospital designation, CMS recognized the need for cost plus payment mechanism for rural hospitals. In light of the current environment, we believe CMS should consider similar approaches to preserve our essential services in rural America. They need to be mindful of where we are and what's at risk at this point in time. We all are supportive of tighter alignment of the administration of these Medicare Advantage plans similar to that of traditional Medicare program.

00;17;39;18 - 00;17;51;19
Chris Barber
One example that has been identified is the appeal process, not having the plan conduct the appeal process, that you haved that QIO which would provide some benefit.

00;17;51;22 - 00;18;16;16
Michelle Millerick
Those are some great suggestions, Chris, And I think, you know, anything is on the table these days and totally agree that this is an area where this is ripe for opportunity. I think that's about all the time that we have for today. So I just want to thank you so much, Chris, for joining us on the Advancing Health AHA podcast and for all the work that you're doing on behalf of patients and families, especially for your willingness to tell your story about your organization and some of the challenges that you're facing.

00;18;16;16 - 00;18;30;15
Michelle Millerick
And, you know, I think as we try to tackle some of the big challenges of our time that our health care system is facing, it truly takes a village. So we look forward to our continued partnership with all of you and with your team at St. Bernards in 2024. So thanks again, Chris.

00;18;30;17 - 00;18;40;28
Chris Barber
Thanks, Michelle , for having us. And it's our pleasure to provide some contribution to the discussion. Please continue all the great work that you guys are doing. We look forward to an exciting 2024.

Attracting and retaining skilled health care workers in rural settings is more difficult than ever before, with increasing competition from other employers and dwindling applications. But rural health care leaders aren't throwing in the towel. In this conversation, Kevin Stansbury, CEO of Lincoln Health, Debra Rudquist, president of Amery Hospital, and Karen Cheeseman, CEO of Mackinac Straits Health System, discuss the new ways they are retaining their current workforce, and how they are forging new paths to attract future generations of health care workers.


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00;00;00;26 - 00;00;22;20
Tom Haederle
In your combined years of experience, have you ever met a workforce challenge of the magnitude we currently face? That blunt question posed by John Supplitt, senior director of AHA’s Rural Health Services, to three veteran CEOs of rural hospitals and health systems, drives this podcast discussion of how to handle what everyone acknowledges is a national staffing emergency facing rural providers.

00;00;22;23 - 00;01;00;13
Tom Haederle
The panel's answers and their ideas about how to retain rural health care professionals and attract new ones hold profound implications for the roughly 20% of Americans who rely on their services. Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Retaining skilled health care workers in rural settings is more difficult than ever before.

00;01;00;15 - 00;01;23;26
Tom Haederle
There are many reasons for this, not the least of which is competition. Too many badly-needed health care pros are leaving the bedside to pursue other local options, including manufacturing, the hospitality field, even Walmart. The rise in remote work makes things even tougher. Rural health care providers have not thrown in the towel and are strategizing new ways to keep their people and groom a younger workforce for the future.

00;01;23;28 - 00;01;34;23
Tom Haederle
As one CEO puts it, we've got to do a better job of convincing young people that health care is a rewarding career. With that, let's join John and his guests.

00;01;34;24 - 00;02;05;07
John Supplitt
Good day, I'm John Supplitt, senior director of AHA Rural Health Services. And today, we’ll be discussing the chronic workforce shortage that’s plaguing rural hospitals across the country, and the potential solutions to this problem. I'm joined by three rural hospital CEOs who form our panel, and they are Kevin Stansbury, CEO, Lincoln Health, a 15-bed critical access hospital in Hugo, Colorado, located on the high plains midway between Denver and the Nebraska state line.

00;02;05;09 - 00;02;29;05
John Supplitt
Debra Rudquist, who's president of Amery Hospital and Clinic, and this is a 16-bed critical access hospital located in Wisconsin’s dairy land about an hour east of Saint Paul, Minnesota. And Karen Cheeseman, CEO of Mackinac Straits Health System in St. Ignace, a 15-bed critical access hospital with five clinics located in Michigan's Upper Peninsula. Welcome, Kevin, Debra, and Karen to our podcast.

00;02;29;09 - 00;02;30;09
Kevin Stansbury
Thank you, John.

00;02;30;12 - 00;02;31;21
Karen Cheeseman
Thank you, John. Thanks for having us.

00;02;31;26 - 00;02;32;22
Karen Cheeseman
Thank you, John.

00;02;32;24 - 00;03;05;00
John Supplitt
Health care careers are often a calling and a qualified, engaged and a diverse workforce is at the heart of America's health care system. However, and as you know, long-billed structural changes combined with the profound toll of COVID-19, have left rural hospitals and health systems, including post-acute care and behavioral health providers facing a national staffing emergency. Now, in your combined years of experience, have you ever met a workforce challenge of the magnitude that we currently face? Kevin?

00;03;05;25 - 00;03;18;07
Kevin Stansbury
Absolutely not. I've been in this business almost 40 years, and the combination of COVID with the rapid retirement of the boomer generation has really caused employment stresses unlike anything I've ever seen before.

00;03;18;09 - 00;03;18;23
John Supplitt
Karen?

00;03;18;28 - 00;03;24;16
Karen Cheeseman
John, I've not in my 20 plus years. These are unprecedented times, not experienced anything like it.

00;03;24;20 - 00;03;25;11
John Supplitt
How about you, Debra?

00;03;25;16 - 00;03;30;12
Debra Rudquist
No, absolutely not. In a 40-year career. I have not seen anything like it.

00;03;30;14 - 00;03;36;02
John Supplitt
So in this time of scarcity, from whom do you see the greatest competition for your employees? Debra?

00;03;36;23 - 00;03;52;17
Debra Rudquist

Well, John, that really depends on the type of employee. For example, our service workers, we are finding more intense competition from the manufacturing industry in our area. We have a number of them and they're paying very good wages. Also, the Walmarts of the world are competition for us.

00;03;52;20 - 00;03;53;24
John Supplitt
Yeah, the box stores. Karen?

00;03;54;01 - 00;04;10;22
Karen Cheeseman
For me in my area John I live in a highly-driven tourism area and we are experiencing a lot of competition right now in the hospitality field in which we haven't in the past. So competing, as Debra said, in those areas for our support teams has become a real challenge.

00;04;10;23 - 00;04;11;15
John Supplitt
How about you Kevin?

00;04;11;17 - 00;04;11;25
Kevin Stansbury
It's a combination

00;04;12;13 - 00;04;38;21
Kevin Stansbury
of things. This is a new economy that we're operating in and there's a lot more remote opportunities for people to live in rural and work really around the globe. So we're facing competition from employers around the world for the same employees that we used to be able to capture around being one of the larger employers. The other dynamic that's happening is we all live relatively close to the city and the competition for staff in the city is really increasing dramatically.

00;04;38;22 - 00;04;51;06
Kevin Stansbury
So wages are rising very rapidly. We just don't have the reserves to keep up with that. So folks that want to leave for higher pay can find a job in the city within an hour and a half with no problem whatsoever.

00;04;51;07 - 00;05;19;16
John Supplitt
Well, and it's interesting when you think about it, three different communities, three different perspectives, and you're experiencing this competition in three different ways. And I'm sure that's going to resonate with the folks who are listening. So there are several fundamental factors that are shaping the workforce, including continuing shortages of health care workers, the massive turnover, the need to support health workers, mental and physical well-being, inflation, demographic shifts, consumer expectations, the role of technology, reshaping care delivery.

00;05;19;16 - 00;05;28;15
John Supplitt
All these factors are really influencing the shape of the workforce moving forward. What are the forces that are driving the workforce challenges in your organizations? Kevin?

00;05;29;06 - 00;05;49;01
Kevin Stansbury
I think it starts with everything that we talked about in the previous question, but there's also this issue of health care. We've got to do a better job of educating young folks, junior high kids, high school kids, that health care is a rewarding career. Too often, as I speak to young people, one of the first things they talk about is I want to become a YouTuber.

00;05;49;02 - 00;05;59;07
Kevin Stansbury
So there's this idea of the Internet economy has really changed things a lot, and we have to think differently and how we approach young people to attract them into health care.

00;05;59;10 - 00;06;00;02
John Supplitt
How about you Karen?

00;06;00;09 - 00;06;20;12
Karen Cheeseman
One of the things we're really working on, John, is how we partner in a different way with our educational partners throughout the area. So how do we work collaboratively for them to build the programs that that we need to support the workforce? And once they're built, how do we sustain them so that we can continue to meet the supply and demand of the workforce?

00;06;20;13 - 00;06;27;28
John Supplitt
So you've got a four year university, you’re on the Upper Peninsula, four-year university to the north, a community college to the south. How are you working with them?

00;06;28;03 - 00;06;50;14
Karen Cheeseman
Correct. We're spending more time than we have in the past. We've always had the relationships and now we're really looking to have different levels of conversation. So pre-pandemic professionals had a calling to come in to health care, and now I feel as if there's a real level of hesitation, as John said, how do we get them back in, encourage them that these are rewarding and fulfilling careers?

00;06;50;21 - 00;06;59;26
John Supplitt
Debra let me aim this one at you. In which areas or services are you experiencing the greatest workforce shortages and to what do you attribute that problem?

00;07;00;05 - 00;07;26;02
Debra Rudquist
So certainly in our professional types of positions, primarily certified medical assistants, LPNs, R.N.s. We're also seeing intense competition and shortages for lab techs, radiology techs. So most of those areas that require technical and professional degrees, we are experiencing severe shortages. And so as Kevin and Karen have pointed out, we're looking at some very flexible work options.

00;07;26;02 - 00;07;48;14
Debra Rudquist
We're doing pipeline strategies. But one of the things I wanted to mention is how we've had to change in the way that we offer flexible options for our team members. We used to for our certified medical assistance, which is one of the areas of greatest shortage for us in our clinics. We used to primarily hire them to be full time and that meant a four ten-hour workweek, ten-hour day, four days a week.

00;07;48;21 - 00;07;58;03
Debra Rudquist
And now we're asking them what they want to work and trying to be very flexible and give them the types of hours when we can that meet the needs of they and their families.

00;07;58;05 - 00;08;21;05
Kevin Stansbury
Yeah, I agree with that, Debra, that the age of the 12-hour shift or the three eight-hour shifts is over and we have to be much more flexible in accommodating employees’ lifestyles and offering more flexible work assignments. The other thing I would say back to what Karen was saying on the relationship with the education programs, we have to get into our secondary schools, the junior high and the high schools.

00;08;21;08 - 00;08;43;00
Kevin Stansbury
We did a study of the high schools that serve our area. We found that there wasn't a single program, high school that was offering high school-level anatomy and physiology. Really tough to get kids to follow a health care career if they haven't been exposed to those sciences in school. So we hired a teacher to help the schools to rove around to the schools to offer those kinds of programs.

00;08;43;02 - 00;08;50;13
Kevin Stansbury
We have to get much more creative in what we do to extend that from the junior high level all the way up through the four-year education and beyond.

00;08;50;18 - 00;09;02;02
John Supplitt
And so when you're addressing this, it's not just support services and dietary, environmental, but it's also for clinicians, physicians, nurses, professionally-trained and certified clinicians.

00;09;02;08 - 00;09;03;03
Kevin Stansbury
That's correct.

00;09;03;06 - 00;09;03;27
Karen Cheeseman
It sure is.

00;09;03;29 - 00;09;04;22
Debra Rudquist
Absolutely.

00;09;05;00 - 00;09;28;07
John Supplitt
We often hear that to manage the shortage, health care organizations have to focus on programs to boost retention, to take a fresh approach to the skills and the current talent optimization, improve employee engagement, and then ensure the best experience for new staff during recruiting and onboarding. So in what ways have you responded to the need to refresh your approach to recruitment,

00;09;28;09 - 00;09;30;12
John Supplitt
onboarding, and retention of staff? Debra?

00;09;31;02 - 00;09;58;00
Debra Rudquist
Yes, so we invested in a full-time recruiter. We found that we were not aggressive enough in our workforce outreach, and so we now have a full-time recruiter who's in the schools, who's working with the local colleges, and we're very much quicker. We're using social media, we are making offers, same day interviews, we're offering orientation more often and just trying to be very quick and fast in the hiring process.

00;09;58;06 - 00;09;59;00
John Supplitt
Karen?

00;09;59;03 - 00;10;24;18
Karen Cheeseman
Similar to Debra, we're doing some of the things she mentioned and we're also looking as to how we grow our own internally. Again, looking at the supply and demand, what can we do internally? One of the things most recently we've done is we've launched an M.A. medical assistant apprenticeship program and that gives us a lot of flexibility in terms of how we grow and shape those individuals coming into health care.

00;10;24;22 - 00;10;25;16
John Supplitt
Kevin?

00;10;25;16 - 00;10;44;07
Kevin Stansbury
Yeah, I think this is an area where rural actually has an advantage over our larger colleagues in the urban areas. Culture trumps everything, John, and we have the opportunity within rural to really focus on retention and it's a lot easier to keep someone than to hire somebody in. So we're spending more time really talking with our employees about what it is that they need.

00;10;44;07 - 00;11;02;08
Kevin Stansbury
Becoming more engaged as both Debra and Karen referenced. We've got to figure out a way to create an environment where employees really do feel like they're fulfilling the mission of the local hospital. That's easier to do in the rural areas because so often the local folks were born in that hospital or their grandfather worked there or their grandmother.

00;11;02;11 - 00;11;13;10
Kevin Stansbury
So really building that culture of we're serving our community and the neighbors that they've lived with their entire lives really, really helps to kind of build your own, culture trumps everything.

00;11;13;13 - 00;11;20;17
John Supplitt
That does to give us an advantage for sure. I have to ask, is how you're addressing the mental health needs of your caregivers and staff? Debra?

00;11;21;12 - 00;11;38;24
Debra Rudquist
Yes, throughout the pandemic we were very creative and had a number of programs. We had stations or areas at each of our sites where people could decompress. And after that time, we've continued many of those. We have what we call “be well” programs and “be well” moments. And so we build into our daily huddles these “be well” moments.

00;11;38;24 - 00;11;55;01
Debra Rudquist
We actually have a catalog that managers can use of “be well” moments, that can be anything from short meditation to stretching. And so really focusing on those “be well” moments and offering, of course, the employee assistance program when it seems appropriate.

00;11;55;07 - 00;11;55;18
John Supplitt
Kevin?

00;11;55;25 - 00;12;23;13
Kevin Stansbury
Exactly. As Debra was just saying, we've invested in an app, a wellness app that we allow our staff to use for free. We allow their families to access it up to five members of their family, gives them a variety of resources to manage stress or depression, anxiety, financial counseling, health education programs, exercise programs, weight loss. So really trying to engage more and more outside of what normally we would worry about as employers.

00;12;23;16 - 00;12;30;06
Kevin Stansbury
We're really looking at the total health of the employee in order to keep them more engaged with their organization.

00;12;30;08 - 00;12;58;12
Karen Cheeseman
Similar for us, and I think it's important to recognize it's not a one size fits all, you know, model. I think we really have to recognize throughout the past three years what our employees have been through and how we respond appropriately to those situations. Perhaps, let's take childcare for a moment, right. In looking at our younger workforce and the constraints they face today with the lack of childcare and how that impacts their ability to get to and from work.

00;12;58;19 - 00;13;16;16
Karen Cheeseman
Many of our employees are caring for aging parents, so how do we take those things that are outside the typical norm right of the workday but recognize the importance they play in the employee's success and contributions to the organization and how do we help and support?

00;13;16;18 - 00;13;38;10
John Supplitt
Great. And we've touched on this already, but I want to dig a little deeper with respect to how you're motivated to look at new approaches toward introducing health care careers to the community. We've talked about apprenticeships, Karen, and tapping into the schools, high schools and middle schools. Have you explored new career paths to recruit employees in your organizations, and if so, what and why?

00;13;38;10 - 00;13;42;15
John Supplitt
And Karen, you mentioned apprenticeships. Maybe you can explain on that a little bit for us.

00;13;42;18 - 00;14;03;03
Karen Cheeseman
Sure. That was one of the areas that we were really struggling with and just didn't have the resources locally to support the program. So we spoke with another rural partner who had implemented it just over the past year and really learned what does it take, what type of resources do we need, what does it require of our leaders to support?

00;14;03;06 - 00;14;27;11
Karen Cheeseman
And our leaders became very engaged and jumped in at the opportunity to do that, because oftentimes we do have these programs available. The employees that are going through them, the students, rather, at the other locations, the competition's just too great. So if we can get them in the door early and get them exposed to our culture as Kevin mentioned, let them go and try out different areas and explore what we have.

00;14;27;13 - 00;14;32;25
Karen Cheeseman
I just think we have an earlier buy-in and our chance of success is greater.

00;14;32;27 - 00;14;51;08
Kevin Stansbury
You know, building on that, I think one of the important things and Karen, I agree, we've done a lot of the same things in terms of building apprenticeship programs. We've also had to invest more in leadership training and helping our existing staff understand what it means to be a mentor to a young person and what are the skills that they need to have.

00;14;51;10 - 00;15;06;03
Kevin Stansbury
We don't want to really encourage young people to come into our organization and then met with a resistant staff. So they really had to open up and we have to do more to train them on what's expected of them and helping to develop the future of our workforce.

00;15;06;06 - 00;15;34;14
Debra Rudquist
Yes. So in addition to clinical rotations, preceptorships, apprenticeships, another innovative program that we developed was a scholarship program for young people in our area who were not able to afford that one or two year of tuition. And so we, together with our foundation now fund two to four scholarships each year, and those are up to $10,000. And those recipients will have a guaranteed job with us after they complete their education.

00;15;34;20 - 00;15;42;18
John Supplitt
I have to say, the innovation that's coming from the three of you is pretty remarkable in terms of the way you're tackling this experience. Karen, you had a thought?

00;15;42;21 - 00;16;06;07
Karen Cheeseman
I think I wanted to add John is we were finding that our turnover in the first year as we brought new nursing staff in, that turnover was greater in the first year of employment. And so we really stepped back and said, what can we do differently during that time frame? And we partnered with our educational partners again and looked at and really developed a nurse resiliency program.

00;16;06;10 - 00;16;25;06
Karen Cheeseman
And so what that does throughout that first year is it establishes regular check-ins with the nursing team members. And if there are things that are getting slightly off course, it gives us an opportunity to have that check-in in that regular conversation to make sure that we can address any concerns early on.

00;16;25;13 - 00;16;37;06
John Supplitt
Have any of you looked at extending your workforce to include direct care workers such as personal care aides or community health workers or community connectors as an extension of your workforce? Debra?

00;16;37;28 - 00;16;44;25
Debra Rudquist
Not currently, but we've been exploring the idea of a community health worker, and that is something I have a great interest in pursuing.

00;16;45;00 - 00;16;45;10
John Supplitt
Kevin?

00;16;45;16 - 00;17;10;07
Kevin Stansbury
I agree. We've been evaluating different ways to get community paramedicine out into the community more doing wellness checks on our elderly residents, making sure that they're safe at home if we discharge them, how are we following up? How are they making sure that they're getting to their doctor's appointment or getting their prescription filled? And in the remote area in which we live, where it's often necessary to drive 40 or 50 miles to get to the next house,

00;17;10;09 - 00;17;19;18
Kevin Stansbury
we've really tried to figure out what's the best way to do that. And leveraging telemedicine, even if it's just a phone call, has really helped to reach out and do more.

00;17;19;18 - 00;17;47;29
John Supplitt
And that was the next area I wanted to explore. As we're looking at technology and telemedicine robots, any automation that's going to improve the productivity of our staff, including clinical documentations and artificial intelligence to expedite decision-making, it can't substitute for caregivers, but it can enhance their ability to practice efficiently. So do you see a more permanent role for the use of technology in your organizations

00;17;47;29 - 00;17;49;01
John Supplitt
and how would that occur? Kevin?

00;17;49;23 - 00;18;11;01
Kevin Stansbury
Again, back to the community paramedicine. I'm a big fan of our patient monitoring where if we can evaluate what's going on with a patient's blood sugar or their blood pressure, we can track that more regularly on a daily basis and then look when a patient might be starting to decline and then intervene quicker rather than waiting for them to just come to the emergency department.

00;18;11;03 - 00;18;18;24
Kevin Stansbury
So that's one small area where I think in rural that kind of technology is perfectly adapted for the environments in which we live.

00;18;18;29 - 00;18;20;23
John Supplitt
Do you see technology being a solution? Karen?

00;18;21;10 - 00;18;41;23
Karen Cheeseman
I sure do John. One of the things we are preparing to launch here later this summer is a telehospitalist program that will serve our hospitals. So, you know, when you look out in the ability for the rural areas to recruit and retain hospitalists for the lower volume census that we tend to run in the smaller critical access hospitals.

00;18;41;25 - 00;19;09;07
Karen Cheeseman
And you know, you look at the expense that you incur and it's really not doable anymore. So we're looking at how we leverage the technology to support that need remotely. And we're seeing and learning from our partners who have launched this already that they're seeing improvements in admissions and improvements in response times and the overall quality. So I think this is just one example of how we leverage technology moving forward.

00;19;09;14 - 00;19;09;24
John Supplitt
Debra?

00;19;09;29 - 00;19;30;18
Debra Rudquist
Yes. So in addition to telehospitals, virtual visits, all of those things that we've all been working on throughout the pandemic, two innovative areas that we've explored, and one of them we've launched is a telerespiratory therapy service. So one of the areas of greatest workforce shortages for us has been respiratory therapy, and that became very acute during the pandemic.

00;19;30;20 - 00;19;50;03
Debra Rudquist
And so we contracted and we work with a company now for the off hours and the weekends that we have respiratory therapy through the use of telemedicine so our nurses can consult with a respiratory therapist. And that then requires us not to have a respiratory therapist on call. That was one of the biggest issues, was finding people who would do quite a bit of call.

00;19;50;04 - 00;20;07;00
Debra Rudquist
So that was an innovative program we began about a year ago. Thing that we're working on right now is what we call teledoc. It's a service that will allow us to connect with the neonatologists in the Twin Cities. So we continue to maintain an obstetrics programs — very difficult in our environment. I'm sure it is for you as well.

00;20;07;00 - 00;20;23;26
Debra Rudquist
We have just about 80 to 100 deliveries a year, but given our location, we feel that that's an important service to continue. And so having that connection, that real-time connection with the neonatologist available has been a real comfort to our family medicine physicians who do obstetrics.

00;20;24;02 - 00;20;24;14
John Supplitt
Kevin?

00;20;24;16 - 00;20;49;16
Kevin Stansbury
Yeah, I completely agree with that. There's a whole range of specialties that we're now going to be able to make available in our hospital, whether it's telestroke, telehospitalists, teleneonatology. The other thing though, I think going the other way out to our patients’ behavioral health, telemedicine has been a huge boon for behavioral health, especially in rural areas where the stigma of having someone's vehicle parked outside the mental health clinic is a restrictor for them accessing that care.

00;20;49;18 - 00;20;55;18
Kevin Stansbury
If they can make that call from home or off of their cell phone, then that really helps to improve care and access.

00;20;55;20 - 00;20;56;03
John Supplitt
Karen?

00;20;56;10 - 00;21;25;14
Karen Cheeseman
One other thing I would add that we're currently looking at, we're partnering with our group and that supplies our ER physician coverage. And they just recently rolled out an artificial intelligence model that allows them to accurately predict volumes in the emergency room, and so as we look at models like that and we look at nursing resources in how we staff our units, that's something we'll be taking a close look at and in endeavoring upon here in the future.

00;21;25;17 - 00;21;43;06
Karen Cheeseman
So, for example, if we look at an ER time that's predicted to have a lower volume, perhaps I can take that nurse and work with our team to shift that nurse to a different area that may have a greater need on a given area. So really we’re looking at efficiencies and how we move those resources appropriately to meet the needs of the care team.

00;21;43;13 - 00;22;03;04
John Supplitt
You know, this has just been a fascinating discussion on an extremely important subject and I think what we've come to conclude is that the landscape has shifted significantly. But it didn't just happen overnight. It was accelerated by the COVID pandemic, but it has been building for some time. And now it's really in front of us.

00;22;03;04 - 00;22;28;29
John Supplitt
And so it is calling upon us to make some very creative and innovative solutions to a problem that has to be fixed in order for us to continue to deliver the highest quality of care to the people who live in our rural communities. Thank you very much for sharing your insights. Is there a final message that you would like to share with our listeners with respect to the way in which you're approaching workforce and how you see it moving in the next few years?

00;22;29;06 - 00;22;29;18
John Supplitt
Kevin?

00;22;29;23 - 00;22;49;16
Kevin Stansbury
Again, I think rural has an advantage in that we tend to be more nimble. We can take creative ideas and operationalize them very, very quickly and we have the ability to reach out and connect with our employees on a more personal basis. And so I think we need to leverage that advantage to really make workforce success going forward in rural areas.

00;22;49;19 - 00;23;08;17
Karen Cheeseman
I would add on to Kevin's comments, I think that collaboration is more important than ever to sit back and think, well, this is how we've always done it is no longer the case. I think it requires a very collaborative effort and you've got to step outside your comfort zone. These are very different times. And how do we work through them?

00;23;08;19 - 00;23;17;25
Karen Cheeseman
Our communities rely on us. It's our mission, right, to provide that care in our community. And it's going to take a very concerted effort here over the next several years.

00;23;17;28 - 00;23;35;07
Debra Rudquist
I think that growing our own has the major emphasis in our rural areas. It's going to be critical and we have plenty of examples in our medical center where we have staff who started as a dietary aid, patient access assistant, CNA who've now completed their careers and professional degrees.

00;23;35;09 - 00;23;44;10
Debra Rudquist

And that's through our support of that, through assistance with tuition reimbursement and through the pipeline strategies of getting into the high schools and even the middle schools.

00;23;44;14 - 00;24;08;29
John Supplitt
Well, this has been a great discussion of the magnitude of the challenges being faced by rural hospitals and the way that you have stepped up to meet these challenges through your resourcefulness and innovation. I want to thank my guests, Kevin Stansbury, CEO, Lincoln Health, Hugo, Colorado. Debra Rudquist, president Amery Hospital and Clinic in Wisconsin. And Karen Cheeseman, CEO of Mackinac Straits Health System in St. Ignace, Michigan.

00;24;09;01 - 00;24;32;10
John Supplitt
Your perspectives on the workforce crisis, its sources and solutions are much appreciated. And as rural hospitals continue to battle with these workforce challenges, we're going to be looking to you and your colleagues for continued insights into what works and how we can improve access, quality and outcomes for our patients and the communities we serve. I'm John Supplitt, senior director of Rural Health Services.

00;24;32;12 - 00;24;38;08
John Supplitt
Thank you for listening. This has been an Advancing Health podcast from the American Hospital Association.

Rural Emergency Hospitals (REHs) officially became a new type of care provider on January 1, 2023, expanding the scope of services that rural providers can offer. In this conversation, Laura Appel, executive vice president of the Michigan Health and Hospital Association, and Christina Campos, CEO at Guadalupe County Hospital, discuss what’s involved in converting to and meeting the eligibility requirements of a Rural Emergency Hospital, and what patients stand to gain from it.


View Transcript
 

00;00;00;21 - 00;00;22;27
Tom Haederle
Nearly 20% of Americans rely on rural hospitals and health systems as the sole provider of their health care needs. An important regulatory step taken at the start of this year has expanded the scope of services that rural providers can offer. Stay with us to learn more about this welcome step forward and how it's working out so far.

00;00;22;29 - 00;00;48;06
Tom Haederle
Welcome to Community Cornerstones Conversations with Rural Hospitals in America. I'm Tom Haederle with AHA Communications. Rural Emergency Hospitals officially became a new type of care provider on January 1st, 2023. The new designation means that for the first time, Medicare will pay for emergency department and other outpatient services without requiring the facility to meet the current definition of a hospital.

00;00;48;08 - 00;01;08;05
Tom Haederle
In today's podcast, John Supplitt, senior director of AHA Rural Health Services, speaks with a hospital CEO and a public policy expert, from New Mexico and Michigan respectively, about what's involved in converting to and meeting the eligibility requirements of a rural emergency hospital and what patients stand to gain from it.

00;01;08;07 - 00;01;34;13
John Supplitt
Good day. I'm John Supplitt, senior director of AHA Rural Health Services. And joining me is Christina Campos, CEO of Guadalupe County Hospital in Santa Rosa, New Mexico. And Laura Appel, executive vice president of government relations and public policy at the Michigan Health and Hospital Association. And we're here to discuss rural emergency hospitals and its evolution as a new model of payment and delivery.

00;01;34;15 - 00;02;10;14
John Supplitt
Welcome, Christina and Laura. It's great to have you on our podcast. So effective January 1st of 2023, rural emergency hospitals are a new provider type and it allows Medicare to pay for emergency department and other hospital outpatient services in rural areas without requiring the facility to meet the current Medicare definition of a hospital. You each are bringing a unique and important perspective to the formation of rural emergency hospitals, and I want to set a baseline for our listeners regarding your interest in this opportunity.

00;02;10;16 - 00;02;41;20
John Supplitt
And first, Christina, you are a CEO of a ten-bed sole community hospital in eastern New Mexico on the Pecos River, midway between Albuquerque and the Texas border. It's also where Interstate 40 historic U.S. Route 66 and two other federal highways converge. And you are the only hospital for more than 4500 people living in an area of 3000 square miles. And the topography, high plains and natural lakes.

00;02;41;27 - 00;02;44;03
John Supplitt
So you are out there, you're remote.

00;02;44;05 - 00;02;55;26
Christina Campos
Yeah, we're about 60, 65 miles from the nearest hospital. And it's not a hospital that has a higher level of care. It's similar care. So for advanced care, you already have to drive 120 miles.

00;02;55;29 - 00;03;08;18
John Supplitt
It's significant and I think people get the picture. So what does the community expect from Guadalupe County Hospital and what are the challenges you face as an acute care hospital in this unique setting?

00;03;08;22 - 00;03;30;08
Christina Campos
Yeah, well, interestingly, acute care worked for us. Sole community hospital, our hospital specific rate worked for us for the last 20 years. It's no longer working for us and we know that critical access reimbursement will not work for us. It would be less than what our rate has been, but our community expects us to provide life saving care.

00;03;30;11 - 00;03;53;07
Christina Campos
And I think in the years that I've been involved with the AHA and with one of the original task force for ensuring access to vulnerable communities, and we kind of surveyed the field to see what does that mean. Emergency care was at the top of the list and inpatient care was not. But the money was in inpatient care and our ED was a loss leader.

00;03;53;14 - 00;03;53;23
John Supplitt
Right.

00;03;53;24 - 00;04;19;20
Christina Campos
So being able to come up with a new designation, a new model of care and reimbursement that actually fits the way we are providing care, especially as we get better at chronic care management and preventive care and start really reducing the need for inpatient care. We've been working on reducing readmissions and for years I teased we're committing a slow suicide as a hospital.

00;04;19;22 - 00;04;23;13
Christina Campos
This is a lifeline that is being thrown out to my hospital.

00;04;23;15 - 00;04;51;21
John Supplitt
Yeah. Yeah, it's interesting. I mean, the concept of a rural emergency hospital has been around probably since 2016, if I'm not mistaken. And now that it has gotten traction, it's been legislated and codified, it's an opportunity that you really can consider seriously. Now, Laura, for this new model to take effect, states have to have in place legislation that will allow the licensing, certification and payment of this new provider type and service.

00;04;51;23 - 00;05;03;04
John Supplitt
And Michigan was among the first four states to pass enabling legislation. Please share with us why this is a priority in your state and how it came to pass.

00;05;03;05 - 00;05;32;07
Laura Appel
Sure. Like you just mentioned, John, this concept has been around for quite a while and we've been paying attention to it all along for the reasons that Christina mentioned. Eliminating inpatient utilization was important because we were recognizing that that was the way to go with health care. At the same time, the reimbursement model just wasn't following that. So we've been informally asking our members, you know, how does this look to you?

00;05;32;07 - 00;05;56;05
Laura Appel
What might you do with this? And then when it became a reality, probably like many other states, we had at least one member for whom this was financially significant to get this done and started right away. And so we moved on this to get this legislation done last session and have it be signed by the governor asap so that we could jump on it.

00;05;56;07 - 00;06;02;08
Laura Appel
And we are assisting a member in particular to move forward with this as quickly as possible.

00;06;02;13 - 00;06;04;04
John Supplitt
That was a really aggressive timeline.

00;06;04;06 - 00;06;27;19
Laura Appel
Very aggressive timeline. And in Michigan in particular, our Certificate of Need program, it does not allow for what the federal statute allows for essentially banking your beds and having a do over, if you say within the first five years, this doesn't work for us. That was not allowed in Michigan statute in any way. And the way our certificate of need works, we don't have any designated bed need.

00;06;27;21 - 00;06;40;04
Laura Appel
So there was no going back if we didn't get that law change and we really needed to do that. We also didn't have a mechanism for a licensure provision for a rural emergency hospital, and we had to create that as well.

00;06;40;05 - 00;07;08;23
John Supplitt
Right. So let's fast forward now to November of 2022. CMS has finalized the roll emergency hospital conditions of permit participation and the payment rates that will apply to the emergency department and hospital outpatients services in connection with the 2023 hospital outpatient PPS final rule. So then in January of this year, CMS published guidance on this rulemaking and you've both seen and read the CMS rule and the guidance.

00;07;08;25 - 00;07;23;02
John Supplitt
The question I have is, is it what you expected? And can you work within this framework? And Laura, let's start with you. Was the final rule in January guidance what you expected? And is this a framework in which you can work?

00;07;23;03 - 00;07;45;22
Laura Appel
Yeah. I'm going to say generally we can work with this, of course. And I'm sure that Christina will have a comment on this as well. You know, to not have these types of hospitals eligible for 340B makes the financial calculation much more complex, I think. The other thing that we're very disappointed in is the opportunity for swing beds.

00;07;45;25 - 00;08;24;17
Laura Appel
We had many more opportunities to think about how to use swing beds during the recent pandemic, and we are particularly interested, we're very much looking at the example of what they've been doing at Dayton General Hospital in southeastern Washington State. They're using their swing beds for substance use disorder and other complex patients, people that need skilled nursing facilities, but also have the problems of mental illness or, you know, general difficulties of anxiety and other things, things that make it very difficult for us to place those patients in nursing and other nursing home settings.

00;08;24;23 - 00;08;31;19
Laura Appel
And we need that flexibility. And so to not have that be a part of the program, that's a disappointment.

00;08;31;21 - 00;08;55;17
John Supplitt
Well, and I think you bring up something that's really important, that's flexibility. And the limitation of a statute that codified rural emergency hospitals doesn't allow for a lot of flexibility. And as much as we have commented and tried to reach some sort of accommodations through CMS, there's only so much that they can do. So it remains a work in progress without a doubt.

00;08;55;20 - 00;09;03;00
John Supplitt
But Christina, the same question then: Was the CMS guidance what you expected and can you work within this framework?

00;09;03;07 - 00;09;21;29
Christina Campos
Well, you know, ironically, you would think that the transition would actually be easier for a critical access hospital than for an acute care hospital, but it's not. Critical access hospitals have been giving certain leeway with the swing beds where it's reimbursed on a cost basis. I don't have a swing bed at my facility because the equation wasn't good.

00;09;21;29 - 00;09;44;28
Christina Campos
It didn't work for us. So I'm not giving up swing beds. Interestingly, I don't have 340B either because in my community the primary care center is a partner. But a separate organization. So they are the 340B provider and my pharmacy at the hospital is A 340B pharmacy. So I do have an interest in it, but I am not prohibited from that aspect of it.

00;09;44;29 - 00;09;46;18
John Supplitt
Well, that's very unique.

00;09;46;20 - 00;10;14;07
Christina Campos
So I'm not losing funds for 340B, I'm not losing funds for SNF or for swing beds and having to become a SNF, which is cost prohibitive, I think. And then you have to have two administrative, separate entities. So I think for me in particular, it's a really, really great fit. But I do recognize that many of the other hospitals in New Mexico, the math doesn't quite work out for them because they are losing swing bids and because they are losing that 340B money. for

00;10;14;07 - 00;10;33;02
Christina Campos
So I think this might be a foot in the door. Yeah, but there's going to have to be a lot of work done to make it a viable option for many, many more hospitals. Right. In terms of the legislative process, New Mexico was not ready. I think my hospital is the one that put it on the radar for the state and said, hey, this came up.

00;10;33;04 - 00;10;51;27
Christina Campos
We looked at it in October. Our state hospital association put out the cost analysis for us. And, you know, when I saw what the base payment was, we did the math right away and says, this works for us. This will work for us. To date this year, we've lost already $1.8 million under our current structure. This will make up that difference.

00;10;51;28 - 00;11;18;16
Christina Campos
Wow. And we're also comparing current to pre-pandemic and the numbers that came out were pre-pandemic. So the difference is huge. But my state was not ready and my legislature was not going to go into session until January. It ended in March. So I spent, you know, a good amount of the last two months prior to April in Santa Fe advocating this was very much my bill.

00;11;18;18 - 00;11;40;07
Christina Campos
It was signed just a couple of weeks ago on on Good Friday, which made it a very good Friday. And it does not go into effect until June 16th because it did not have an emergency clause in it. However, even that makes sense for me. We're we're financially stable. We're okay. We're losing money now. But we knew that the day was coming and we had saved for it.

00;11;40;09 - 00;11;57;05
Christina Campos
But we're going to be able to become an REH on July 1st, which is going to be great because we're not going to do two separate cost reports or a cost report structure based on one payment mechanism. And then in half of the year or portion of the year based on the other. But the timing was weird. The timing was weird.

00;11;57;07 - 00;12;04;07
John Supplitt
But that's very exciting news then. So congratulations on getting the legislation passed. And so now you're going to hit the ground running on July one.

00;12;04;08 - 00;12;04;23
Christina Campos
July one. 00;12;04;23 - 00;12;05;13 John Supplitt Exciting.

00;12;05;16 - 00;12;09;20
Laura Appel
Yeah, it makes me grateful to have a full time legislature.

00;12;09;22 - 00;12;10;17
Christina Campos
Yeah, right.

00;12;10;18 - 00;12;14;04
Laura Appel
Not always, but in this case, it was good luck.

00;12;14;06 - 00;12;37;24
John Supplitt
Well, and of course, the payment, as you both have mentioned, has been a major focus of the providers and policymakers regarding the viability of rural emergency hospitals. And to review, CMS is going to pay an additional 5% over the payment rate for the hospital outpatient prospective payment for REH services. And they'll also pay an additional annual facility payment in 12 monthly installments.

00;12;37;26 - 00;12;59;17
John Supplitt
And for 2023, that monthly payment is $272,000 and change. So for 2024 and each year after then it will increase by the hospital's market basket percentage increase. So the question is, Christina, and you may have answered this, but we'll ask it again, will this payment be sufficient for you to maintain services in your communities as an REH?

00;12;59;25 - 00;13;19;08
Christina Campos
Yeah, you know, when they first started talking about the REH concept and they were the only thing they identified at that time was that 5% increase in patient services that wasn't going to do it for me. It absolutely was not. As a sole community hospital, we were already getting about us. I believe our cost report prepared. So it was somewhere about a 7.5% add on.

00;13;19;10 - 00;13;39;02
Christina Campos
So we're going to forfeit that by a couple of percentage points. But when we got that number and it was a little bit lower when it first came out in October and then it was adjusted because of low volume adjustments and other mathematical equations that went to it. It's $3,274,000. And I mean, I know the amount because I've had to apply it and reapply it.

00;13;39;03 - 00;13;59;12
Christina Campos
We just finished our preliminary budget, which will be hopefully approved at my board meeting next week. This week, in fact. And it's not going to show us, we're not going to be rich off of this. We're absolutely not going to be rich off this. We're going to have a positive margin, very slim, positive margin, which is, you know, de facto for all rural hospitals, but a survivable margin.

00;13;59;12 - 00;14;20;02
Christina Campos
And then we'll work on expanding outpatient services for our community in a wise way that will hopefully improve margins over time. But we're going to be able to quit concentrating on our lowest volume of services, which was inpatient and concentrate on our high volume, which is outpatient and emergency department services.

00;14;20;05 - 00;14;52;18
John Supplitt
I want to dive into something that you brought up and that was the involvement of your board. So you're a county hospital and so you have a public board, and so you've been working with them for the better course of two years, almost two years to try to condition them towards this conversion. Help us understand what that experience has been like from the moment where you started to consider this transition to rural emergency to the point now where you're actually going to approve a budget that will go into effect July one?

00;14;52;20 - 00;15;20;08
Christina Campos
Well, you know, at first when when the concept of REH, I was not paying attention to it because I didn't know what the base payment was. And that made all the difference. So I kind of ignored it. You know, it was it was on my radar, but it didn't seem to be the solution for us. And when those numbers first came out in in, you know, August, you know, early early numbers came out, and then when the final number came out in November, we did have a board retreat and discussed with the board, this is an opportunity for us to do it.

00;15;20;10 - 00;15;49;16
Christina Campos
And in fact, you know, when people say, what about the transition? Well, it's not. We've been transitioning into this over the last four or five years easily. Our inpatient census is almost nothing. Even our length of stay because of the quality of care that's given on the outpatient services, because of the quality of care, even on an inpatient service, that you can get your normal rural admissions like COPD, pneumonias, everything that's treated medically because we don't have surgical services.

00;15;49;19 - 00;16;13;12
Christina Campos
We're struggling to keep them a second midnight because people are turning around so much more quickly. Mm hmm. So the transition is really a financial transition, a document transition. Semantics. So even discussing it with my board, it's the same conversation that we're having with the community. We're really not changing our clinical way of providing care. We've already done this.

00;16;13;14 - 00;16;27;13
Christina Campos
We're going to change the way we build and the way we're reimbursed. But the same high level of quality of care will stay still in effect, and patients, rather than being admitted, will be opposed. So we're just going to be billing part B instead of part A.

00;16;27;15 - 00;16;52;29
John Supplitt
Well, and let me pull that thread a little bit, too, because CMS has also established rules regarding access, safety and quality of care for rural emergency hospitals. And they closely align with critical access and ambulatory surgical centers but you're a sole community PPS. Among these requirements is a quality assessment and performance improvement program. So Cristina, do you see any challenges in meeting these requirements upon conversion to an REH?

00;16;52;29 - 00;17;14;29
Christina Campos
Do you know what I see as a challenge is that people are going to assume that we can be lax because we were already having to do HCAPS, we are already having to do all the quality measures, you know, compared the same ones that the huge hospitals were doing on a micro level with a ten-bed hospital. So what I'm telling my employers that we are not going to change the quality of care, we're not going to do HCAPS anymore.

00;17;15;06 - 00;17;37;03
Christina Campos
We're going to ED CAPS. We're still going to have the same measures in terms of of, you know, diabetic patients that are kept overnight or re managing that carefully or hospital acquired infections, everything else. But we'll document a little bit differently. We're still going to want a care plan because patients might stay one night, maybe two nights on the off chance.

00;17;37;06 - 00;17;49;17
Christina Campos
So I'm going to be challenged and making sure that we keep that same high level quality care and know that we are going to be just as as scrutinized, if not more so, than we were as an acute care hospital.

00;17;49;20 - 00;18;10;13
John Supplitt
Those are really great insights. Thanks for sharing there. So Laura, given what we know about the REH payment and rules for quality assurance and patient safety, do you foresee hospitals in Michigan moving towards this new model of payment delivery? That is, do you anticipate critical access hospitals or others converting to a rural emergency hospital?

00;18;10;16 - 00;18;42;12
Laura Appel
This is such a different question now than it was three years ago. I think that this was really anticipated for a while. Again, you mentioned that this was a conversation starting in 2016, but during the pandemic, I do not know of a hospital in Michigan that didn't have a sizable number of inpatients compared to their bed availability. Everybody had a high census. Places that had a four patient census average census places had two.

00;18;42;14 - 00;19;02;20
Laura Appel
All of a sudden they were full or maybe they were at, you know, 70%. Things that had been unheard of in the past. And that just so changes your frame of reference. It's so hard now to look around for some people and say, Yeah, we were transitioning away from that and we can return back to that mindset and think about REH and that mechanism.

00;19;02;22 - 00;19;33;22
Laura Appel
We are seeing people shifting back to that, but it was not, you know, when when the bill was signed and even last year when you were saying that the first numbers came out, there were few organizations that would say, Yeah, we might have somebody for that, but really very little objective interest in it. And now I'm just now starting to see compared to, I would have thought five or maybe even ten critical access hospitals would've been absolute candidates for this.

00;19;33;25 - 00;19;56;13
Laura Appel
I think the the thing that really appeals to me about it is: there's no secret about it, Michigan has lost population in our rural areas. The prediction is we will continue to lose population, but our population that remains there will be older. So we will have a group of people who really do need services at the same time that we don't have that many people to spread the cost over.

00;19;56;14 - 00;20;23;03
Laura Appel
So we have these fixed costs that are required to keep an ED open and to have those observation services. And yet at the same time we, you know, you can't make it up on volume when you just don't have very much volume there. So I think that the model of having those fixed payments is so important. And again, we're told all the time hospitals and health care need to become much more innovative, but the payment policy almost never kept up with it.

00;20;23;09 - 00;20;27;19
Laura Appel
I really see this as being a step in the right direction by the the federal government.

00;20;27;20 - 00;20;52;17
John Supplitt
Well, it really is fascinating to see how the landscape has changed, as I call it, in ways that we might have not have anticipated. But now, as we're learning more how these opportunities might still be important to rural hospitals. Well, my last question, Laura, we'll start with you. What opportunity does conversion to rural emergency hospital mean to your hospitals and the rural residents in Michigan?

00;20;52;19 - 00;21;20;19
Laura Appel
Well, we don't have the same landmass as some of the super large states like Texas or Alaska. But the Upper Peninsula, for example, is very large and only has 300,000 people in it. And we really need to be able to have a number of different facilities spread across that area. And yet you just don't have enough people to support it at the rates that are currently paid.

00;21;20;21 - 00;21;43;25
Laura Appel
And I understand why folks don't want to see higher payment rates necessarily, but you can only drive down the fixed costs so far. We really do need emergency services spread across our state and that includes our rural areas. Our rural residents serve that kind of health care just as much as the people in our suburban and urban areas.

00;21;43;28 - 00;22;12;12
Laura Appel
So I think over time, this is going to become a much more popular model and it is going to keep access to the most vital, emergent and typically used health care services. Like Christina said, already folks drive if you need cancer care or bypass surgery or things like that. We're already driving for those services anyway. But this is going to keep those emergency services much closer to the community.

00;22;12;12 - 00;22;14;29
Laura Appel
And I'm very excited about that.

00;22;15;01 - 00;22;34;19
John Supplitt
This is a really fantastic discussion. Yeah, this is a work in progress, but there's a lot from which to work and so there is a great deal of hopefulness here. Christina, the same question: What opportunity does conversion of Guadalupe County Hospital to a rural emergency hospital mean to the community from both a medical and economic perspective?

00;22;34;24 - 00;22;53;27
Christina Campos
Do you know this is a survival mechanism. This will allow my hospital to stay open. It will allow us to continue to save lives. You know, we're an incredibly remote area, small population. But as you mentioned at the beginning of the podcast, you know, we've got I-40, we've got Route 66, U.S. 84, U.S. 54 there all converge in that community.

00;22;53;27 - 00;23;12;11
Christina Campos
So a ton of traffic. We do get a lot of motor vehicle accidents. So and we have scuba diving. Go figure. We have scuba diving in our communities. So we do have a lot of lakes. But, you know, without a hospital my community probably would little by little disappear. So it's critically important to the community. There is a lot of work that needs to be done.

00;23;12;11 - 00;23;33;23
Christina Campos
I just found out a week or two ago that my hospital will not qualify for the flex program because it's for hospitals with inpatient services and it's meant for critical access hospitals and small rural hospitals. So that's going to have to be changed, I believe, because these rural emergency hospitals are just a step away from critical access. So there's a lot, a ton work to be done.

00;23;33;23 - 00;23;53;08
Christina Campos
And I really hope that 340B fix is in there and I hope that maybe the possibility of not, you know, maybe a minimal amount of inpatient care. My concern is end of life care. Yeah, other hospitals are not going to take our patients that are that are, you know, facing end of life. We do not have a nursing home in my community.

00;23;53;08 - 00;24;13;12
Christina Campos
We do not have SNF. We do not have, you know, home health care. We have one hospice nurse in the entire county. I need to crack that nut and figure out how we're going to offer that end of life care. And there is flexibility within it because it's a 24 hour average of all of your visits. Most of our E.R. visits are, you know, 3 hours max.

00;24;13;12 - 00;24;32;27
Christina Campos
And that's from the time they walk in to the time they walk out. You average out with all our our so-called inpatient or OBS visits? We're going to stay well beyond that, no matter what. But we want to make sure that we're doing it right and that we offer the care that my citizens and my community, including my family and my neighbors, need.

00;24;32;29 - 00;25;03;04
John Supplitt
Yeah. You know, I can't imagine Santa Rosa or Guadalupe County without a very strong medical presence, given the convergence of three federal highways. So it'll be very interesting to see how this emerges. But I again, I think we all are quite hopeful. I want to thank my guest, Cristina Campos, CEO of Guadalupe County Hospital in Santa Rosa, New Mexico, and Laura Appel, executive vice president of government relations and public policy at the Michigan Health and Hospital Association.

00;25;03;07 - 00;25;28;24
John Supplitt
Your perspectives on emergency hospitals as a new model of payment and delivery are very greatly appreciated. And as this model continues to evolve, we will be looking to you and your colleagues for continued insights as to what works and how we can make this model better for patients, hospitals and the communities we serve. I'm John Supplitt, senior director of Rural Health Services at the American Hospital Association.

00;25;28;26 - 00;25;32;17
John Supplitt
Thank you for listening. This has been an Advancing Health podcast.

An estimated 57 million rural Americans depend on their hospital as an important source of care and critical pillar of their community. In this conversation, Joanne Conroy, M.D., president and CEO of Dartmouth Health and board chair-elect at the AHA, discusses the future of rural hospitals and health systems in the U.S., and the possible solutions to providing quality and cost-efficient care for the communities that need it most. November 16 is #NationalRuralHealthDay.

Visit www.aha.org/national-rural-health-day to learn more about Rural Hospitals in America.


 

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00;00;01;01 - 00;00;39;09
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.

00;01;17;20 - 00;01;41;03
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.

00;02;22;03 - 00;02;43;13
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.

00;03;23;18 - 00;03;50;28
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.

00;04;15;28 - 00;04;41;12
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.

00;04;41;12 - 00;04;46;16
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?

00;05;05;07 - 00;05;32;04
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.

00;05;32;11 - 00;05;58;01
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.

00;05;58;02 - 00;06;16;21
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.

00;06;48;14 - 00;07;11;02
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?

00;07;11;04 - 00;07;39;25
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.

00;07;39;25 - 00;08;03;27
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.

00;08;03;27 - 00;08;30;19
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.

00;08;56;12 - 00;09;04;27
Joanne Conroy
So creating a hospital at home is far easier when your hospital at home geography might be five miles. You know.

00;09;05;00 - 00;09;07;01
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.

00;09;44;27 - 00;10;00;20
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?

00;10;00;22 - 00;10;24;10
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.

00;10;53;22 - 00;11;15;06
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.

00;12;03;11 - 00;12;04;01
Joanne Conroy
Thank you, Michelle.

People of American Indian and Alaska Native descent, also known as Indigenous, are twice as likely to experience pregnancy-related deaths as white women. In this conversation, Tina Pattara-Lau, M.D., maternal and child health consultant with the Indian Health Service Office of Clinical and Preventive Services, and Johnna Nynas, M.D. obstetrics and gynecology specialist at Sanford Bemidji Medical Center, explore common disparities and systemic barriers Indigenous people experience in pregnancy and postpartum, and ways hospitals and health care organizations can combat these challenges to provide culturally-focused care. November is #NativeAmericanHeritageMonth.


 

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00:00:00:28 - 00:00:40:18
Tom Haederle
According to the Centers for Disease Control and Prevention, people of American Indian and Alaska Native descent, also known as indigenous, are twice as likely to experience pregnancy related deaths as white women. Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. November is National Native American Heritage Month, and November 16th is National Rural Health Day.

00:00:40:20 - 00:01:09:08
Tom Haederle
Making this a fitting time for this podcast discussion of the experiences of American Indian and Alaska Native Communities indigenous to the United States. In this podcast, Julia Resnick, AHA's director of Strategic Initiatives, is speaking with Dr. Dr. Tina Pattara-Lau a maternal and child health consultant with the Indian Health Service Office of Clinical and Preventive Services, and Dr. Johnna Nynas, an obstetrics and gynecology specialist from Sanford, Bemidji Medical Center.

00:01:09:10 - 00:01:26:02
Tom Haederle
The group explores some of the common challenges, disparities and systemic barriers indigenous people experience in pregnancy and postpartum, and discusses ways hospitals and health care organizations are combating these challenges to provide adequate and culturally competent care.

00:01:26:04 - 00:01:45:25
Julia Resnick
Welcome, Dr. Pattara-Lau and Dr. Dr. Nynas. We're so happy to have both of you here today to talk about maternal health for American Indian and Alaska Native communities. So let's start with Dr. Pattara-Lau. Can you share with our listeners some background and recent statistics on the state of maternal health for indigenous communities in America?

00:01:45:27 - 00:02:07:23
Dr. Tina Pattara-Lau
Thank you and thanks for the opportunity to elevate this important topic today. We know that maternal morbidity, mortality for American Indian and Alaska Native birthing persons is usually 2 to 3 times that of the white non-Hispanic population. And we see these disparities when we provide care in the community. But several new studies have recently highlighted some inequities among indigenous birthing persons nationwide.

00:02:07:25 - 00:02:31:18
Dr. Tina Pattara-Lau
I'll note that while some studies do use gender specific pronouns, IHS is inclusive of all birthing persons. So last year, a CDC report from the State Maternal Mortality Review Committee found that 93% of American Indian and Alaska Native pregnancy related deaths were preventable. 64% occur postpartum. The leading causes of death included mental health conditions such as death by suicide or overdose, as well as hemorrhage.

00:02:31:20 - 00:02:58:18
Dr. Tina Pattara-Lau
And earlier this year, two studies published in JAMA found that while maternal deaths in U.S. hospitals have declined. So there more maternal morbidity has actually increased. And specifically, American Indian and Alaska native mortality decreased over the study period, but pregnant patients still experienced a higher risk of maternal death compared with white patients. In a second study found that severe maternal mortality in more states was higher among American, Indian and Black populations.

00:02:58:20 - 00:03:18:07
Dr. Tina Pattara-Lau
And so while the data doesn't provide us with the full story, we need to acknowledge that there are systemic gaps and barriers to maternity care that contribute to the inequities for indigenous birthing persons. And so IHS, along with other health care systems, have turned to innovative approaches and increasing care in the community and support before, during and after pregnancy.

00:03:18:09 - 00:03:29:20
Julia Resnick
That is absolutely heartbreaking and thinking about those communities, what are some of the common challenges or barriers to getting proper pregnancy care and postpartum care?

00:03:29:22 - 00:03:56:13
Dr. Tina Pattara-Lau
Certainly the effects of historical trauma, including systemic racism, can actually last generations. And so together with adverse childhood experiences or aces and social determinants of health such as transportation, housing or access to electricity or clean running water, they disproportionately affect American Indian and Alaska native birthing persons. And so this can contribute to a higher rate of co-morbidities during pregnancy, including the mental health conditions and substance use.

00:03:56:15 - 00:04:21:06
Dr. Tina Pattara-Lau
I must acknowledge that this history does contribute to mistrust as well as avoidance seeking care within institutionalized health care systems. And as a non-native provider, I have learned it's important to be open and curious and practice humility. Acknowledge the trauma and the bias across generations, along with resiliency of cultural practices to help build trust and provide culturally safe care. Specifically in the rural setting

00:04:21:09 - 00:04:44:06
Dr. Tina Pattara-Lau
significant barriers the closure of rural obstetric hospitals. March of Dimes reports that one third of U.S. counties are considered maternity care deserts. 300 birthing units are closed since 2018, about 70 in the last year. Many American Indian and Alaska Native families live in rural communities. So 13% delivery, maternity care, deserts and about a quarter of babies are born in areas of limited or no access to maternity care.

00:04:44:09 - 00:05:06:09
Dr. Tina Pattara-Lau
So while IHS provides care to the 574 federally recognized tribes, births occur in all 50 states and the District of Columbia, and 25% of those American Indian Alaska Native births occur at an IHS or tribal facility, which means that 75% occur outside our system. So we've worked to maintain rural access by working in close collaboration with family practice physicians, midwives.

00:05:06:11 - 00:05:43:21
Dr. Tina Pattara-Lau
We realize that birth is commonly attended by relatives, including elders and aunties. So indigenous birth workers also have an important role to play in providing care. And then in urban areas, about 70% of Americans or Alaska Natives reside in those communities, often living apart from family and traditional cultural environments. And that presents a mental and physical challenge. So urban clinics will try to meet the needs of the community by incorporating culturally specific activities or provide things like mandatory health care, community-based outreach programs like health fairs, and then afterschool programs for youth who are focused on nutrition and fitness or native arts and crafts dance.

00:05:43:24 - 00:05:50:29
Julia Resnick
That's wonderful to hear. So turning to you, Dr. Nynas, can you talk to us about your hospital and the communities you serve?

00:05:51:01 - 00:06:21:06
Dr. Johnna Nynas
Sure. So I work for Sanford Health in Bemidji, Minnesota, which is located in the far northern part of the state. And we have three surrounding American Indian reservations that patients do receive care from our facility in coordination with their local facilities at their IHS site. And within our region, we're basically located in one of the most socially kind of deprived and poorest regions of the state and also very geographically isolated.

00:06:21:07 - 00:06:50:12
Dr. Johnna Nynas
So in keeping with the national trends that we're seeing, we face the same kind of barriers. We're seeing a lot of adverse impact related to those social determinants of health, high rates of poverty, substance use, domestic violence, trauma in the home. Subsequent issues related to generational trauma. The geographic isolation is particularly problematic. Thinking of northern Minnesota, we're heading into winter and in addition to just distance being a barrier, a weather is a huge barrier for us.

00:06:50:13 - 00:07:12:23
Dr. Johnna Nynas
So when you have a patient that travels 60 miles to get to an appointment and has transportation difficulties and then we throw a snowstorm in the middle, that's a completely unseen barrier that other places of the country don't have to consider. And then again, within the community, we're working really hard to acknowledge that there is still systemic racism within the community and implicit bias.

00:07:12:26 - 00:07:40:02
Dr. Johnna Nynas
And we're really trying to be mindful of our role within that. And again, be curious and ask those questions and really make some efforts to train our staff and our our nurses and collaborate not just within the health care systems themselves, but also with community organizations that are supporting indigenous birthing persons and improving our own cultural competence, if you will, within the community and try to rebuild that trust.

00:07:40:05 - 00:08:00:12
Julia Resnick
Yeah. So I want to dig into some of those opportunities because you both really outlined what the challenges are. But as we're seeing is we're talking to health care organizations. I'd love to hear more about what you think hospitals and health care organizations can do to address those challenges and disparities when they're treating American Indian and Alaska Native individuals.

00:08:00:14 - 00:08:03:01
Julia Resnick
Dr. Pattara-Lau I will start with you.

00:08:03:03 - 00:08:27:13
Dr. Tina Pattara-Lau
Well, we know pregnancy is a stress test for the body, you know, physically, mentally and spiritually. And underlying comorbidities, mental health conditions may become more acute. Some examples of where the additional stressors can affect American-Indian, Alaska Native populations are that in some states, substance use during pregnancy can result in involvement of the legal system, including incarceration or child protective services.

00:08:27:16 - 00:08:58:15
Dr. Tina Pattara-Lau
There is a mistrust of the health care and legal systems, and that's a barrier to establishing prenatal care, but also to timely interventions such as treatment to prevent congenital syphilis. So some families are fearful there will be hurt by their health care provider due to this underlying systemic racism. The CDC also recently released a report: one in five women reporting mistreatment while receiving maternity care, one in three of black, Hispanic, multiracial women watching this treatment and 45% women held back from asking questions or sharing concerns.

00:08:58:17 - 00:09:19:01
Dr. Tina Pattara-Lau
So what can we do? Well, while we hope all pregnant, postpartum patients are treated with respect, we know this is not always the case. And so starting with the patients, I share with my patients as well, please continue to advocate for yourselves and your relatives. You know your body best. When something feels wrong, tell someone, get help. Bring a trusted family member or friend.

00:09:19:04 - 00:09:42:25
Dr. Tina Pattara-Lau
Many patients, as Dr. Nynas mentioned, have access to tribal MCH programs and organizations such as the Alaska Native Birth Workers Community or the Navajo Breastfeeding Coalition to provide that support. And then looking at ourselves within our care systems, what am I doing to promote cultural safety? Am I elevating Indigenous leaders, elders, members of the community to create systems by the people for the people they serve?

00:09:42:27 - 00:10:10:09
Dr. Tina Pattara-Lau
Am I talking about things like first foods and medicines, indigenous birth and traditional healing practices. And so you may be familiar with the CDC's HRSA campaign that was launched in January for American Indian Alaska Native people provide resources and education, specifically from tribal communities as well as urgent maternal warning signs. But also as a society, as we begin to share more of our stories around mental health and reducing the stigma around mental health and seeking support. HRSA

00:10:10:09 - 00:10:39:25
Dr. Tina Pattara-Lau
recently launched last year, the Maternal Mental Health Hotline for 20/7 confidential support before, during and after pregnancy. It's available to patients and families with call or text translation services in 60 languages, including Navajo. Their number is 1-833-TLC-MAMA. So again, just some examples of the community and the national level support that we can find for our patients in the field.

00:10:39:27 - 00:10:56:06
Julia Resnick
And that national maternal mental health hotline started by HRSA, really crucially important. So, Dr. Nynas can you talk more about what you're doing at your hospital to increase access and availability of resources to improve maternal health outcomes for Indigenous women in your community?

00:10:56:09 - 00:11:45:05
Dr. Johnna Nynas
Sure. We've been really fortunate. Back in 2021, a group of health care providers within northern Minnesota, which included Sanford Health, as well as our IHS partners at Red Lake Nation and Leech Lake Nation and several community organizations came together and developed a program that we're calling Families First. And we were the 2021 recipient of a rural maternity and obstetric management services grant from HRSA to support development of this collaborative to really look at how we can target those issues that contribute most to adverse maternal outcomes, particularly among American Indian women within our region, and also how to create a foundation and to keep this sustainable for years to come.

00:11:45:08 - 00:12:07:23
Dr. Johnna Nynas
And so what came out of this is we've partnered together with several organizations to make sure that we are providing high quality and culturally related health care for moms and their families. We're trying to build trust and basically ensure that the care that these patients deserve is available. And our goal is for the next seven generations. So within that, there's several different moving programing pieces.

00:12:07:25 - 00:12:32:02
Dr. Johnna Nynas
The most critical one has been establishing high risk OB care coordinators at all of the sites that are providing obstetric care services. So we created the position and provided the initial funding for these positions and really what they're responsible for is their nurses who know all of the high risk patients within provider services and really kind of does the double checking to make sure nobody falls through the cracks.

00:12:32:04 - 00:12:50:01
Dr. Johnna Nynas
So if a patient hasn't been sending in their blood sugars or has missed an appointment with a consultant or missed an ultrasound, they're reaching out to the patient to find out what was that barrier that was difficult for you to come in for that appointment or to finish that part of your care and get them reconnected with care.

00:12:50:08 - 00:13:18:26
Dr. Johnna Nynas
And as we are seeing just a nationwide shortage of real health care providers and in particular a significant shortage of rural obstetric care providers, we need to support our practices in any way we can, and this has been a helpful way to do that. One of the extensions of this is increasing our home visiting nursing program capacity. One of the extensions of that was a partnership with Bemidji County Public Health to increase home visiting nursing programs.

00:13:18:26 - 00:13:40:18
Dr. Johnna Nynas
And so they established a goal of trying to complete 40 in-home visits for 2023. And as of June of this year, they had completed 143 home visits going way beyond their goal. And that is the direct result of the work that our high risk OB care coordinators are doing. For transportation barriers, obviously, that's a huge issue in our region.

00:13:40:20 - 00:14:07:03
Dr. Johnna Nynas
We have purchased a van that is going to be providing transportation for patients to appointments and ultrasounds. We are taking some lessons we've learned from Sanford Bemidji Behavioral Health Program, which did a similar program where they would provide transportation. What they found was when you provide the transportation for the patients, you can operationalize the cost of the van and the driver by decreasing your no-show rates.

00:14:07:06 - 00:14:32:21
Dr. Johnna Nynas
So that's something that we're going to implement for prenatal care and hopefully use that as a model for other health care agencies and also within our health care system as well. We are developing a specific, culturally competent group prenatal care program within our IHS site. So that prenatal care is a different model of providing traditional prenatal care. Patients still have their individual assessments.

00:14:32:21 - 00:15:13:23
Dr. Johnna Nynas
They still receive the American College of OB-GYN recommended evaluations and testing at the appropriate intervals, but they also get an additional 2 hours of education on any topic related to pregnancy and postpartum. So we're using that as an opportunity to weave together kind of traditional beliefs of birthing and child care and postpartum and those customs that exist within our tribes, along with the teachings that are out there and accepted by the national organizations as best practice. And weaving them together in a way. And also helping to really foster some support within the community itself,

00:15:13:25 - 00:15:35:24
Dr. Johnna Nynas
so women are also working together and supporting each other to keep those relationships going. And it's really about not only educating the individual person, but also making sure that they have the tools. So if they have a friend down the road or someone they know reporting symptoms, hey, that sounds like preeclampsia. You should really call your doctor. Maybe we should get you to the E.R. that's familiar to me.

00:15:35:26 - 00:16:17:01
Dr. Johnna Nynas
And that's where we can really make an impact, is improving health literacy and knowledge within our communities and then improving our access to virtual care. Broadband access can be really limited in rural areas, can be cost prohibitive for many people. And we are looking at putting infrastructure into some of the satellite clinics within our region to improve access for virtual visits, to decrease some of those transportation needs and really bring obstetric care to where women live rather than expecting all patients to come to us. And then internally we're doing a lot of work surrounding trauma stewardship and trauma informed care, a lot of education for our staff and our nurses education regarding low intervention, birth

00:16:17:01 - 00:16:49:06
Dr. Johnna Nynas
processes and how to support a low intervention birth. And we're really starting to see some improvement in some of our outcomes since doing those. And we've seen from 2017 to 2023, we've seen a 77% decline in CPS holds for babies for cases of neonatal abstinence syndrome in maternal substance abuse. We've also implemented within our hospital a different way of monitoring for neonatal abstinence when women have been using substances in pregnancy called eat sleep console.

00:16:49:08 - 00:17:15:06
Dr. Johnna Nynas
And what we're seeing coming out of that is we're seeing decreased neonatal length of stay, fewer admissions to our special care nursery for morphine administration. And we're seeing a higher number of referrals of women to drug and alcohol treatment programs and increased use and referrals to medication assisted therapy programs. So many good outcomes coming out of multifaceted work that we're doing as a collaborative team within our community.

00:17:15:09 - 00:17:30:10
Julia Resnick
That's wonderful and I love hearing about how you're weaving together traditional practices alongside medical ones to really meet the needs of the pregnant people in your community. I wonder if you have any stories that you can share that can really bring this program to life for our listeners.

00:17:30:12 - 00:17:54:18
Dr. Johnna Nynas
We're still in the phases where we're building the programing, but this is the idea. Where it came from is if I can have a patients who might be seeing a provider up in Red Lake with her local provider receiving group prenatal care up there, forming relationships with other women in her community and then transition to our hospital, which is the regional kind of birthing hub for our region.

00:17:54:20 - 00:18:17:25
Dr. Johnna Nynas
She's coming in basically having appropriate screenings. Any chronic medical conditions have been addressed and are controlled going into her pregnancy and delivery? We are doing a lot of work around what are some of those spiritual practices and cultural practices that are really important to me? Who are the people who are going to support me during my birth process and what should that look like?

00:18:17:28 - 00:18:44:22
Dr. Johnna Nynas
And sending that with the medical record, as we would lab results or other test results, because it's an important part of the care piece. And when those patients come to us for that transition of care and delivery, making sure that we're incorporating those practices at the bedside and providing those necessary resources. And the goal is that when all of our patients end up delivering, we're going to see better outcomes for moms, better outcomes for babies.

00:18:44:22 - 00:19:31:15
Dr. Johnna Nynas
We're working to get good coordination so those women can be seen by their initial OB provider at their IHS clinic locally within two weeks of delivery for that supportive postpartum care. We're also working with other community groups who do similar work. Some Indigenous doulas, lactation consultants within the region to really support that in-home care that happens postpartum. And we can identify those women who are at risk for postpartum depression, substance abuse, relapse, who may have different needs just within their own household, be it access to water, to heating, to clothing, shelter and meeting those needs and ultimately graduating them from the program with an established primary care provider to manage their ongoing medical concerns for

00:19:31:15 - 00:19:43:21
Dr. Johnna Nynas
the rest of their lives. And that's the work that takes a lot of time and effort in the short term. But the long term game is what's going to really move that needle in terms of maternal outcomes overall.

00:19:43:24 - 00:20:05:20
Julia Resnick
Absolutely. So as we wrap up, I want us to look forward towards the future and thinking about what are some things that our hospitals and health care systems should consider doing when serving pregnant and postpartum Indigenous individuals. So, Dr. Pattara-Lau, I'll ask you to answer that from the national perspective. And Dr. Nynas I'll ask you to address that from your hospital community's perspective.

00:20:05:22 - 00:20:08:03
Julia Resnick
Dr. Pattara-Lau, I'll start with you.

00:20:08:05 - 00:20:28:22
Dr. Tina Pattara-Lau
So at the national level, in response to the closure of rural labor and delivery units and the decline in birth national birth volumes, IHS has developed an obstetric readiness in the emergency department. We're calling it OB-Red, for short, manual and training programs. This is a collaborative, multidisciplinary team effort across our service areas Phenix, Navajo, Great Plains.

00:20:28:22 - 00:20:49:02
Dr. Tina Pattara-Lau
And we actually had some input from Alaska. We're fortunate enough to travel to South Dakota recently to provide some on new ground training as well. It provides a site, some maternity care deserts where an OB provider is not readily available with readiness checklists, quick reference protocols and training curriculum essentially for safe triage, stabilization, transfer of pregnant patients and newborns.

00:20:49:04 - 00:21:16:01
Dr. Tina Pattara-Lau
And so, as I mentioned, several IHS areas have implemented O.B. Red and demonstrated increased confidence with both triaging management of patients and newborns. We're also working as well to increase access to care during that critical pregnancy and postpartum transition period by piloting a maternity care coordinator program or MCC. And similar to what Dr. Nynas described, this is really an way to utilize telehealth and home visitation support, some of which does exist.

00:21:16:04 - 00:21:46:18
Dr. Tina Pattara-Lau
Alaska is a great example in the interior. Utilizing StarLink, we're able to increase broadband access. While not perfect, but certainly increases the amount of specialty care that you can get into the rural space. And really utilizing those approaches to increase screening education intervention, including the distribution of self-monitoring blood pressure cuffs, which we know can often save patients the time to schedule an appointment or obtain child care, gas for the car and then transport themselves to the clinic.

00:21:46:20 - 00:22:08:25
Dr. Tina Pattara-Lau
During the pandemic, we also expanded our virtual echo curriculum, which was a vital way for us to essentially reach providers across IHS to provide continuing education, but also specialty consultation. And we'll be partnering with the Northwest Portland Area Indian Health Board to launch a monthly Indian country, Echo on care and access for pregnant persons. And our goal is to bridge traditional practice with evidence based care models.

00:22:08:28 - 00:22:30:19
Dr. Tina Pattara-Lau
So our first webinar will highlight the work of one of our first Indigenous midwives and teachers. And so we invite you and your listeners to visit our website, newly launched with last month. www.ihs.gov/ach and to learn more about resources available for American-Indian, Alaska, Native communities and the people who provide care for them. So thank you again for the opportunity to share with you today.

00:22:30:19 - 00:22:33:06
Dr. Tina Pattara-Lau
And thank you to Dr. Nynas as well for the work that you do.

00:22:33:06 - 00:22:38:13
Julia Resnick
That’s wonderful. Dr. Nynas, turning to you for some final thoughts.

00:22:38:15 - 00:23:05:13
Dr. Johnna Nynas
Yeah, we're piggybacking on that exact same work. We are hoping to launch what we're calling an OB virtual hospitalist program to bring kind of a telemedicine view similar to telestroke into our regional EHRs to support those local providers in stabilization and assessment in an emergency situation, because I can't function as a successful OB-GYN if I don't have a provider who can successfully stabilize a patient prior to our transfer.

00:23:05:14 - 00:23:37:15
Dr. Johnna Nynas
So thank you for all the work that you're doing, Dr. Pattara-Lau, it's wonderful. In thinking about how to move forward for communities, I think really important part of this is improving our knowledge and understanding of trauma, informed care and implicit bias training for your team. I think that is a really critical part, not only to acknowledge the historical trauma and the disparities that exist within our community, but to move forward with it from a place of humility and trying to understand those barriers and respond to them appropriately.

00:23:37:15 - 00:24:06:13
Dr. Johnna Nynas
So I think that's really critical for hospital systems to consider. I would also encourage health care providers and hospital systems to really look within their own regions and communities and who else is providing this work and really working to form those collaborative relationships within your region. And they're going to look different place to place. But the more that you develop that collaborative team and that strong relationship and promote referrals back and forth between agencies.

00:24:06:16 - 00:24:24:03
Dr. Johnna Nynas
I would encourage meetings face to face, if you can, at least a couple of times a year to keep each other informed. But that has been really critical in trying to move the needle in terms of outcomes and connect patients to the right resources in care. And you can't do that unless we know what's out there and what everyone's trying to do without recreating the wheel.

00:24:24:06 - 00:24:45:21
Dr. Johnna Nynas
And then the other thing that I really learned throughout this process is we need to stop the the mindset of we're trying to solve this problem right now. And that's happening today. What we're trying to do is set the foundation of what our options to sustain this care for 20 years. What do I want the outcomes to look like 30 years from now?

00:24:45:21 - 00:25:08:11
Dr. Johnna Nynas
What is this going to look like in seven generations? Because that's really the changes we want to make is really improve the health of our communities over time. So we're really trying to think about this is what should this look like 50 years from now down the road to support women and birthing persons and also that culture. So I think really having that forward thinking mindset is really critical.

00:25:08:13 - 00:25:34:12
Julia Resnick
Absolutely and I think that's a big part of why we're here to build that foundation so that over the next years, months, years, generations ahead, we can provide better care for our American Indian and Alaska Native pregnant people. So I want to thank you, Dr. Pattara-Lau and Dr. Nynas for your time for sharing your expertise and insights and for all the work that you are doing to improve outcomes for indigenous moms in your communities.

00:25:34:15 - 00:26:00:17
Julia Resnick
And to our listeners, you've heard us mention a few different resources over the past few minutes. So I encourage you to visit CDC’s Hear Her campaign specific for America Indian and Alaska Native Communities. The campaign offers educational information and tools for pregnant and postpartum indigenous women, their partners, friends and families, and for health care providers as well. You also heard us mention HRSA's National Maternal Mental Health Hotline.

00:26:00:19 - 00:26:10:06
Julia Resnick
Again, that number is 1-833-TLC-MAMA. So thank you again to both of you for joining us and your expertise. And to all of you for listening in.

In the United States, behavioral health and physical health can sometimes be treated as if they are unconnected, usually involving separate sites of care. One small, rural health system decided to override the usual way of doing things and provide a care model that reconnects treatment to the whole person. In this podcast, Charlie Forbush, chief administrative officer at Western Wisconsin Health, describes their hospital's behavioral health expansion within the schools and community, and how it made a difference in patients’ access to whole-person care.


Millions of women across the United States have no access to maternal health care, particularly in rural areas that lack obstetric services. In this episode, leaders from St. Anthony Regional Hospital in Carroll, Iowa, discuss their newly piloted "Center for Excellence" and the Center's success in bringing care to infants and mothers within their community and beyond.
 


 

View Transcript
 

00;00;01;00 - 00;00;22;00
Tom Haederle
As in many areas of the country, maternal health access is a real issue in rural Iowa, where an increasing number of counties have seen reduced services or none at all. St Anthony's Regional Hospital in Carroll, Iowa, has stepped it up to address that gap.

00;00;22;02 - 00;00;54;28
Tom Haederle
Welcome to Community Cornerstones: Conversations with Rural Hospitals in America, a new series from the American Hospital Association. I'm Tom Haederle with AHA Communications. St Anthony's response to the shrinking access to maternal health care services throughout the six counties it serves in rural Iowa can be described in three words: The Birth Place. This grant-funded Center of Excellence has not only expanded and improved health outcomes for moms and their babies, it has also helped ignite the passion for health care in students and future providers.

00;00;55;00 - 00;01;02;28
Tom Haederle
Three leaders from The Birth Place sat down with the AHA’s Julia Resnick to discuss the tactics and strategies that are making a difference.

00;01;03;01 - 00;01;27;16
Julia Resnick
This is Julia Resnick, director of Strategic Initiatives at the American Hospital Association, coming to you from the Rural Health Leadership Conference. I'm here this morning with three outstanding leaders from Saint Anthony Regional Hospital in Carroll, Iowa. We have Allen Anderson, president and chief executive officer, Virginia Uhlenkamp, OB, director at Thr Birth Place, and Ashleigh Wiederin, OB outreach coordinator at The Birth Place. Allen, Virginia,

00;01;27;16 - 00;01;50;03
Julia Resnick
Ashley, thank you so much for joining me this morning to talk about maternal health. So I know for a lot of our hospitals, maternal health access is a real issue. And that's no different in Iowa, where many of your counties don't have obstetric services. So it's my understanding that you've piloted the Center for Excellence in the last year as the hospital's way of bringing care to infants and moms within your area.

00;01;50;06 - 00;01;55;28
Julia Resnick
So, Allen, can you talk about the impetus for starting the center and the elements of the the Center of Excellence program?

00;01;56;03 - 00;02;19;14
Allen Anderson
Sure and thanks for having us. This work was really started prior to the Center of Excellence. We wanted to set a foundation. We had a governance, our governance board that really supported this work. We identified this as an issue because of the access, because of some of the quality initiatives regarding maternal health, OB services. And so really, that foundation was set before the Center of Excellence.

00;02;19;14 - 00;02;38;06
Allen Anderson
The Center of Excellence really was just something that came after that allowed us some funding to be able to continue the work. So it's really exciting. We see more and more facilities around us get out of doing OB and labor and delivery services. And so it is important work for us to preserve that access for our patients.

00;02;38;08 - 00;02;42;19
Julia Resnick
So Ashleigh can you tell us about what happens at The Birth Place? What is this program like?

00;02;42;21 - 00;03;07;12
Ashleigh Wiederin
So for the Center of Excellence, our goals were really centered around increasing that access to care and also implementing things that improve the health outcomes for our moms. So we've been able to expand prenatal appointments to a few of our outreach clinics and then use some of our partnerships to improve those outcomes. Kind of include activities that really enhance that overall patient experience.

00;03;07;14 - 00;03;15;18
Julia Resnick
That's really wonderful. And now that you've been implementing this program for a few months, can you share some of the learnings or challenges you're experiencing? Ginny, I'll turn to you.

00;03;15;23 - 00;03;41;02
Virginia Uhlenkamp
Yeah, some of the learnings that we've had is, number one, for me as a nurse to learn about the complexities of health care and kind of looking at that big picture. We've learned a lot about what happens at the legislative level, both in federal and state, and how to bring that focus and goals for maternal health down to the bedside and, you know, to let our nurses know that indeed, our federal and local leaders do care about maternal health and what they do matters.

00;03;41;05 - 00;04;01;29
Virginia Uhlenkamp
Challenges, of course, we're going to talk about workforce issues. I think it's important to find the right people for the right position or place at the table, and that involves some of our outreach activities. And then to the students to ignite that passion for health care, to encourage and expose those students. You know, there are people out there that have a passion for health care

00;04;01;29 - 00;04;06;15
Virginia Uhlenkamp
we just have to bring them into the circle and light that fire, I say.

00;04;06;17 - 00;04;14;06
Julia Resnick
And maternal health is so one of those like, passion issues that, like a lot of people have it in their hearts and like to really want to support moms and babies.

00;04;14;06 - 00;04;14;24
Virginia Uhlenkamp
Exactly.

00;04;15;01 - 00;04;26;14
Julia Resnick
That's exciting. So what about the outcomes that you're seeing from this new program? Have you seen any improvements to date? And like, what are the metrics that you're measuring to help, you know, if you're making progress? Ashley I'll turn it to you.

00;04;26;16 - 00;04;47;10
Ashleigh Wiederin
Sure. So our first year of kind of rolling out the Center of Excellence, the focus there was on relationship building and partnership engagement. We had really great success with that and were able to create documented partnerships. That was something that the grant required as a deliverable, and we were successful in that with partnerships in all six counties in our service area.

00;04;47;13 - 00;05;07;27
Ashleigh Wiederin
As we moved into the second year, our our focus kind of shift on that patient engagement, like I said, improving those outcomes. And one of the things that we've noticed is a sharp increase in our class attendance. We kind of restructured some of the educational offerings that we had, and more specifically, our participation in our postpartum support group.

00;05;07;29 - 00;05;26;14
Ashleigh Wiederin
That has really increased not just in the number or the volume, but in the longevity. So moms are coming to group and then they're continuing to show up. That's once a week. And we see moms that are now coming through their entire maternity leave and then they're building a community and caring those relationships when they go to work.

00;05;26;14 - 00;05;38;03
Ashleigh Wiederin
We hear "we met for dinner" and they'll send us photos of their babies and the moms getting back together. So that's been a really great thing to see. And one of the really positive outcomes that we've noticed.

00;05;38;05 - 00;05;54;20
Julia Resnick
That's so cool to hear about how you're building community. Absolutely. Love that story. And I just want to congratulate all of you for the work that you're doing. It's really exciting and so important in our rural communities. Before we wrap up, Alan, I want to ask you what's next for this program and for St. Anthony's work in the maternal health space?

00;05;54;20 - 00;06;16;14
Allen Anderson
The easy answer is we do not know. A lot of this is being reactive to some of those external pressures. So as more and more of those facilities get out, we have the opportunity to grow in this area. So what we've been really focused on is setting that foundation. That foundation will help us realize those growth opportunities as some of those external pressures come to fruition.

00;06;16;15 - 00;06;22;08
Allen Anderson
So the easy answer again is we don't know, but we're setting our foundation to be able to be successful in the future.

00;06;22;13 - 00;06;34;22
Julia Resnick
Well, thank you to your commitment to maternal health in the rural setting. I'm sure that your your community really appreciates that. And I want to thank all of you for joining me this morning to talk about this important issue. Thank you so much. Thank you.

Building a robust nursing workforce is hugely important in providing quality care to patients, but poses unique challenges in rural Ohio. In this conversation, Fisher-Titus’s Stacy Daniel, director of clinical programs, and Katie Chieda, chief nursing officer, share how their team concentrated on recruiting international nurses to ensure that they remained a strong, independent health system for years to come.


 

View Transcript
 

00;00;01;05 - 00;00;35;00
Tom Haederle
Ensuring a robust nursing workforce in rural Ohio poses unique challenges. Equipped with a broad plan to retain their current workforce and recruit additional team members, the team at Fisher Titus Health concentrated on recruiting international nurses to their community to ensure they remain a strong, independent hospital for years to come.

00;00;35;02 - 00;01;03;23
Tom Haederle
Welcome to Advancing Health, a podcast brought to you by the American Hospital Association. I'm Tom Haederle with AHA Communications. In today's episode, Elisa Arespacochaga , AHA’s vice president of Clinical Affairs and Workforce, sits down with Stacy Daniel, director of clinical programs with Fisher Titus Medical Center, and Katie Chieda, chief nursing officer with Fisher Titus, to discuss their approach to building and sustaining a rural health care workforce.

00;01;03;26 - 00;01;26;07
Elisa Arespacochaga
Welcome to another podcast in the AHA's ongoing series where we focus on important issues facing clinician leaders. I'm Elisa Arespacochaga, vice president of Clinical Affairs and Workforce. I'm joined today by Stacy Daniel, director of Clinical Programs, and Katie Chieda, chief nursing officer for Fisher Titus Medical Center. Today we're going to talk about their approach to building and sustaining a rural health care workforce.

00;01;26;09 - 00;01;35;18
Elisa Arespacochaga
So, all right, to get us started and Stacey, I'll start with you here. Tell me a little bit about yourself and your organization and then I'll ask Katie to chime in as well.

00;01;35;21 - 00;02;02;18
Stacy Daniel
So I have served as the director of clinical programs at Fisher Titus since 2021. I earned my Bachelor's of Arts and Biology from Ohio State in 2008 and my Bachelor's of Science in Nursing from Ashland University in 2014. I began my nursing career at Fisher Titus in 2014 as a staff nurse. Since then, I've held various positions throughout the organization, including church nurse, hospital supervisor and manager of nursing operations.

00;02;02;21 - 00;02;25;24
Stacy Daniel
As director of clinical programs, I serve as a liaison between Fisher, Titus Health and the clinical education programs. Ensuring continued development and successful recruitment and retention of our clinical staff, as well as leading international recruitment efforts. I also lead our clinical education department in initial and continuing education requirements and opportunities throughout our health system.

00;02;25;27 - 00;02;37;27
Elisa Arespacochaga
Great. So you really have a sense from the ground up of where how the nursing team works and how to support it. So, Stacey, a little bit about you and Fisher, Titus.

00;02;37;29 - 00;03;07;21
Stacy Daniel
Yes. So Fisher Titus Health is an independent rural community health system, and we're located in north central Ohio. We have a 99 of that acute care hospital, which includes a level three trauma center, level two cath lab and certified stroke center. And we also have a 69-bed skilled nursing facility, a 40-unit assisted living facility. We have a home health center employed ambulatory physician group that provides primary and specialty care across 18 different sites.

00;03;07;23 - 00;03;17;03
Stacy Daniel
We also have a diverse ancillary outpatient services, which includes lab imaging, and we have a robust adult and pediatric rehab services at our facility. And Katie,

00;03;17;05 - 00;03;22;13
Elisa Arespacochaga
a little bit about your your background and how you came to this position.

00;03;22;15 - 00;03;54;25
Katie Chieda
Thank you. I am Katie Chieda and I serve as the chief nursing officer for Fisher Titus Health. I have served in this position since 2016. I originally joined Fisher Titus in 2013, holding many different leadership roles. Prior to the role I'm in today. As Chief nursing officer, I oversee nursing, ancillary and post-acute services across the health system. I started my nursing career at the Cleveland Clinic, serving as a bedside nurse prior to taking on nursing leadership roles.

00;03;54;27 - 00;04;15;19
Katie Chieda
I also play an active role in the Ohio Organization of Nursing Leaders, serving as the committee chair for the engagement committee, as well as a seat on the board of directors for OONO. In addition to the state level involvement. I'm also a member of the American Organization of Nurse Leaders and serve on the Huron County Mental Health and Addiction Services Board.

00;04;15;21 - 00;04;28;26
Elisa Arespacochaga
Great. Thank you. So, Katie, let's talk a little bit about how the pandemic and the nursing shortage really impacted your organization. Can you tell me a little bit about how that has gone for you?

00;04;28;29 - 00;04;58;14
Katie Chieda
Yeah. Before the pandemic, Fisher Tigers did not utilize contract labor. We were blessed that that wasn't something that we had to to turn to to staff our organization. Fortunately, we started the evaluation of international nursing in 2018-2019. As an independent community hospital surrounded by large tertiary centers. Our challenge with the nursing shortage was really just beginning at that point.

00;04;58;16 - 00;05;25;11
Katie Chieda
Our team examined the market, our current ability to recruit and retain optimal staffing along with state and national trends, to identify strategies for recruitment and retention. Our findings indicated the growing nursing shortage, even before the pandemic. So we knew we had to start to find different solutions with that growing shortage. With the pandemic, of course, those nursing needs intensified quickly.

00;05;25;13 - 00;05;49;20
Katie Chieda
We expanded our med search bed capability as well as doubled the size of our ICU facilities across the state. We're nearing maximum capacity, which often meant that patients could not be transferred to other facilities. And that made our focus on really how do we maintain patient care here in the community, knowing that we may not be able to get those patients out. 

00;05;49;22 - 00;06;15;20
Katie Chieda
We did look at contract labor premium pay, of course, for our internal staff, but they were tired as well. So we wanted to ensure that we had the staff that we needed for the long term and we were able to, of course, as many hospitals across the nation did, decrease or hold elective services. We reallocate allocated resources from across the organization, ensuring that we were still providing the best care to our patients.

00;06;15;22 - 00;06;40;15
Elisa Arespacochaga
Yeah, I know you took a look at a number of different approaches. You mentioned several of them to support your own workforce. In addition to looking to see how you could bring additional workforce in which in a rural area where you have a little more challenge doing that. Can you talk a little bit about some of those additional approaches that you looked at in addition to looking at bringing in international nurses?

00;06;40;17 - 00;07;04;04
Katie Chieda
Recruitment retention was a strategic priority before the pandemic, and of course it continues to be today. Our goal is to continue as an independent community hospital. So now myself and our chief of h.r. As well as Stacy and a few other members of the team, we meet on a monthly basis to review new opportunities for consideration for recruitment and retention.

00;07;04;07 - 00;07;23;29
Katie Chieda
In the past, it definitely held a place on our strategic plan, but it didn't get monthly attention to shift. But some of the things that we do or we've identified as opportunities, we looked at an updated nursing compensation structure, which as soon as you look at it and make a change, you probably need to look at it again.

00;07;24;01 - 00;07;57;04
Katie Chieda
We also did focused educational assistance to ensure that we were spending the dollars allocated organizationally on our biggest challenge areas from a workforce standpoint. We identified and strengthened our clinical school partnerships. We expanded our clinical ladder program and that program is truly to keep the experts at the bedside. And we looked and we developed and then expanded a nursing residency program continually to look at the nursing compensation structure, as I mentioned at the beginning.

00;07;57;06 - 00;08;04;28
Katie Chieda
We also looked at nontraditional nursing hours and international recruitment in addition to those other items.

00;08;05;00 - 00;08;29;12
Elisa Arespacochaga
Great. Yeah, I think it's going to take a lot of different approaches to really make this effective. And it sounds like you've had a full suite of activities. Stacy, let me turn to you now to talk a little bit about how you sort of rethought some of the nursing programs and focused on some of the international opportunities and some of those education and support activities that you lead.

00;08;29;14 - 00;08;51;11
Stacy Daniel
Yes. So when we decided we were going to begin down the road with international recruitment, one very important consideration we had was identifying a partner and then also determining whether we wanted to do direct to hire or contract staff. So we wanted to make sure the nurses were part of the Fisher Titus family and that they feel like they're part of our community.

00;08;51;11 - 00;09;17;19
Stacy Daniel
So we did opt for the direct-to-hire nurses. We identified our partner in late 2019, which was PRC Global, and then we began our road to recruitment. At the time, we recognized that it would take a minimum of about a year for them to come on. But with complications with immigration and the pandemic slowing down the process, it really extended it to about 18 months some times.

00;09;17;22 - 00;09;44;18
Stacy Daniel
So we strongly believed in finding the right individuals and building the right onboarding structure and felt like that was very critical to our success. So we developed a comprehensive interview process so that involved frontline leaders, frontline staff, and then they had a final interview with Katie, the chief nursing officer. Throughout this process, we not only identified the right person by skill and fit, we also shared the support system we had built to ensure our mutual success.

00;09;44;25 - 00;10;02;25
Stacy Daniel
So this included community mentor program, peer mentor, preceptor program, our general onboarding, and then also cultural diversity classes that we had for existing staff as well as our new international nurses and teambuilding events that we would have with the nurses when they arrived.

00;10;02;28 - 00;10;24;01
Elisa Arespacochaga
That sounds great. Really important to make them feel like they they have come to a community that's really welcoming of them. I know when you shared this with me, you've shared some pictures of some of the different activities and welcoming them, which I just think is a great idea, even to meeting them at the airport too, to make sure they feel connected to your organization.

00;10;24;03 - 00;10;31;05
Elisa Arespacochaga
Katie, let me ask you, what are some of the challenges that came along with this as you started getting it off the ground?

00;10;31;07 - 00;10;52;20
Katie Chieda
I would say the biggest challenge was getting our clinical leaders comfortable with the fact that they were identifying an individual that was going to join their team 12 to 18 months from now. Generally speaking, when you talk about recruitment of a nurse, we're filling a position that's open today and you're looking for the skillset to meet that need.

00;10;52;22 - 00;11;17;14
Katie Chieda
So we we had to shift their thinking on that. Some just that you're identifying somebody that fits with your team, that brings the skillset that you need for the team, but you're not necessarily identifying someone for a specific position. That was interesting. I think we had to keep them connected with the nurses throughout the time frame from when they identified and hired that individual through the date of arrival.

00;11;17;14 - 00;11;43;10
Katie Chieda
And Stacey did a really great job of ensuring that that connection happened. That was probably the biggest challenge in the beginning. Once we did have an arrival date for those nurses that were joining us, then it was working with our h.r. Team to ensure a seamless onboarding process. There is a quick turnaround from the date that the nurse arrives to the date that the nurse has to start.

00;11;43;10 - 00;12;12;09
Katie Chieda
It's within one week. So all that pre hire paperwork and any prep that we could do in advance of them arriving, we needed to do so we could meet that deadline of a week. The second challenge that we identified were the minor differences in the general nursing practice. And although we had discussions with our nurses when we hired them in discussions with our partner PRS Global, some of those things weren't identified until our nurses arrived.

00;12;12;09 - 00;12;47;07
Katie Chieda
And we really relied heavily on our preceptors and our clinical education teams to work collaboratively and identify and addressing those differences as the nurses joined us. And really they we, we've we've grown since our first nurse arrived to where we are today, incorporating monthly education and just listening to every member of the team, the preceptor, the nurse who joined us and our clinical education team to ensure that we were providing them the best education.

00;12;47;08 - 00;12;53;12
Katie Chieda
So at the end of their orientation, they could be a successful member of the nursing team.

00;12;53;15 - 00;13;11;10
Elisa Arespacochaga
That's great. It sounds like you've really created a an ongoing welcome, if you will. Stacey, let me ask you, what are you working on to sustain this effort to keep those connections beyond what Katie already covered? And how do you see your process going forward?

00;13;11;13 - 00;13;33;05
Stacy Daniel
Yeah, so we have open communication with the nurses and we've developed additional education to support the differences that we have noted in practice between the United States and the Philippines. We have team building events that are scheduled. We try to do them quarterly and encourage that the nurses build relationships with their mentors, both within the hospital and also within the community.

00;13;33;11 - 00;13;59;26
Stacy Daniel
We really want them to have that tie to the community and feel like they're part of Norwalk. So we truly believe that the key to success is ensuring that the nurses feel like they're that part of the community and the Fisher Titus family. These nurses are signing a three year agreement with us. So we hope that the environment we create here within the hospital and within the Norwalk community encourages them to remain here for many years to come.

00;13;59;28 - 00;14;20;02
Elisa Arespacochaga
Great. Let me ask you, Katie. Now, looking back on the last I guess it's been for almost five years, what advice would you share with others who might be thinking about either bringing in international nurses or taking a look at some of the the ways that they're supporting their nursing teams?

00;14;20;05 - 00;14;50;07
Katie Chieda
I definitely would say ensuring that you have a comprehensive program to support the nurses joining, but then also the nurses supporting them and the community members that step forward. For us, it was the support of those key stakeholders that truly created our, I believe, made our program stand out for the international nurses. That includes the frontline staff. We did get our buy in from our board of directors and our community members.

00;14;50;09 - 00;15;14;16
Katie Chieda
And truly, I would tell you, our community members made this experience for our nurses. Many of our nurses came with their spouses or their families, and they've been hired by companies in our community that are providing them just as much support as we are. In addition, I would tell people the more work you can complete in advance of their arrival, the better.

00;15;14;18 - 00;15;36;29
Katie Chieda
We had the opportunity with the pandemic and the immigration process to have 18 months to prepare. That created a challenge of keeping connected with those individuals. But it also gave us plenty of time to tell the story. So by the time our first nurse arrived, I can tell you our staff was super excited for them to be here as were our community mentors.

00;15;37;01 - 00;16;09;16
Katie Chieda
It's important to remember that these individuals are leaving everything that they knew and helping them understand what they can expect when they arrive. It's very important for their transition. And then you want to get those nurses, those individuals integrated into the community as much as you can as well. So when we did our matching with the community mentors, we identified key hobbies...or church attendance or families with children ages.

00;16;09;18 - 00;16;31;28
Katie Chieda
And we made sure that the people that we connected that with them with could provide them the support that they needed outside of working hours. Sometimes those three 12-hour shifts as a nurse, seems like you spend most of your time at the hospital. But for somebody who left there, their family and the community that they were used to, there's a lot of hours to fill outside of that.

00;16;31;28 - 00;16;44;22
Katie Chieda
And having that community mentor to go to the grocery store with or attend a family event with or celebrate the holidays with, really made the experience for our nurses that much better.

00;16;44;25 - 00;17;11;09
Elisa Arespacochaga
I'm sure and just even all the little things that you don't think of that just are a little bit different in a new country. Having that support to really help you, you know, make those connections, I think it's got to be a huge part of this. Well, Katie, Stacy, I want to thank you for your time and for sharing your story, not only at our Rural Leadership Conference, but also with our broader audience on this podcast.

00;17;11;12 - 00;17;23;13
Elisa Arespacochaga

Thanks for joining me.

 

Health equity is a discussion that is often framed only around race, but it means so much more. In this discussion, two heads of rural health systems explain how they're working to reach underserved communities, and the steps they're taking to get to full equity.


 

View Transcript
 

00;00;01;02 - 00;00;24;27
Tom Haederle
Rural America has a seat at the health equity table. Until now, it seems rural America has been excluded from the inclusion discussion. Not only does that lead to resentment, it leads to apathy. Those words are from a rural health care provider who refused to accept the status quo about the relevance of health care equity in his community.

00;00;24;29 - 00;00;50;00
Tom Haederle
Welcome to Community Cornerstones: Conversations with Rural Hospitals in America, a series from the American Hospital Association. I'm Tom Haederle with AHA communications. We hope these episodes will shed new light on the challenges, triumphs and issues facing rural health care providers who are a health lifeline for approximately 20% of Americans. Health equity is a discussion that's often framed only around race.

00;00;50;02 - 00;01;06;18
Tom Haederle
But it means much more. In today's podcast, recorded at AHA's 2023, Rural Health Care Leadership Conference, two heads of rural health systems explain the stake that their organization is have in working towards equity and the steps they're taking to get there.

00;01;06;20 - 00;01;33;13
Leon Caldwell
Hello, everyone. I'm Dr. Leon Caldwell, senior director for Health Equity Strategy and Innovation at the American Hospital Association's Institute for Diversity in Health Equity. I'm joined here this podcast being taped, as we say, is old school word "tape," being streamed here at the AHA's Rural Conference. This is an exciting lineup. I have here two of my favorite rural leaders.

00;01;33;16 - 00;01;47;00
Leon Caldwell
Nothing against the other ones, I know. I have with me Terry Scroggins from Titus Regional Medical Center in Texas, and Ben Anderson from the Colorado Hospital Association. Welcome to both of you.

00;01;47;02 - 00;01;47;20
Ben Anderson
Thanks for having us.

00;01;48;04 - 00;01;49;25
Terry Scoggin
Thanks for the opportunity to tell our story.

00;01;49;26 - 00;02;19;25
Leon Caldwell
Yeah, this is really a fun thing for me. You know, I like both of you quite a bit. We've had great conversations around health equity, in particular health equity in rural areas. You both do exciting work and will continue to do exciting work in this space. So one thing that's always been kind of in the back of my mind is that, you know, we do health equity kind of an injustice to some extent in rural spaces because we don't really define it well enough.

00;02;19;27 - 00;02;50;04
Leon Caldwell
And we often times put this racial spin on health equity and it can miss the mark, because it allows some of our rural leaders to say, well, you know, we don't have the many of those people in our community or we're just 90% white or whatever it may be. Right. But reality is, equity, if we think about it, is not just about race and ethnicity, it's about human differences and providing the services as people need them, right, across whatever the spectrum is.

00;02;50;06 - 00;03;05;25
Leon Caldwell
And both you've done some really phenomenal work in that space, inclusive of kind of race and ethnicity, but much broader. What brought you to that work? Like how did you get there as leaders in rural America thinking about equity?

00;03;05;27 - 00;03;26;09
Ben Anderson
I was in a health care delivery science master's program at Dartmouth College, and I had a classmate from Boston, Massachusetts, challenged me. I really had shared some of the skepticism that you just described, Dr. Caldwell, around "am I really invited into this conversation? Is this really my work to do as a rural white man?"

00;03;26;16 - 00;03;44;00
Ben Anderson
And her challenge to me was, go home, take what you're already measuring and divide it by people group and see what happens. And she said, race is not the only denominator. It's an important, even defining denominator in our generation. But it's not the only one. So I went back and we engaged our community kind of to prove her wrong.

00;03;44;01 - 00;04;11;16
Ben Anderson
Engaged our community, got 85% of our households to respond to a community engagement survey that essentially asked people how do they define their health and wellness? Who do they believe is responsible? Is it the health system? Is it their own choices? Is it the environment as a whole? And then in the major sectors of society, health care, public health, early childhood development, research and extension, faith community, employers, community as a whole in each of those sectors, what services from a list would they be aware of that would help them improve their health?

00;04;11;16 - 00;04;33;19
Ben Anderson
And what would they like to see more of? And they answer those questions in 10 minutes. They got $10 in in local chamber bucks. You had to spend in a local business, which of course, was a win at home. And when we divided that data by between white folks and and Hispanic folks, the numbers were different. And the reality was for me is we couldn't unsee that.

00;04;33;22 - 00;04;39;03
Ben Anderson
And once we knew about it, of course, we have an ethical obligation to do something about it. So that drew me into the work.

00;04;39;10 - 00;04;41;00
Leon Caldwell
Right. Great. Terry, about you.

00;04;41;07 - 00;05;03;22
Terry Scoggin
So I'm an East Texas boy, doc, and, you know, my father drove me into it. So growing up, my dad took care of anybody. My dad was one of the purest people I ever met, ever knew. And he didn't see color. He didn't see income levels. He just saw people. So I grew up watching that. So as I'm raising my boys and as I continue my career, you look for opportunities to help   people, and health care is that.

00;05;03;27 - 00;05;30;14
Terry Scoggin
Titus is in Mount Pleasant, Texas. So we're in the northeast corner of Texas and we are rural. Everything you want to describe in rural: older, Medicare, poverty. Have a chicken processing plant, our largest employer. 44%. Hispanic. 43% white. 10% African-American. We've got all the challenges in rural. So we were a melting pot. So when you talk about equity and you talk about that piece, it's what we live in every day.

00;05;30;17 - 00;05;49;05
Terry Scoggin
So what we're doing is I want to repeat, it has nothing to do with race and ethnicity alone. There's so many pieces. And Benjamin talks about the opportunities he has to study. And he actually encouraged me to go back to college. And I'm going to a program, the University of Texas, right now for the health transformation course at the Value Institute.

00;05;49;08 - 00;06;12;17
Terry Scoggin
And it's opening my eyes on a daily basis just to see segments of people not race, not age, not gender, but break down those segments. And it might be race, it might be the ethnicity. But there's so many pieces when you start breaking it down to make things equal and reduce disparities, you can't treat everybody the same. I want to say that again, right?

00;06;12;19 - 00;06;31;18
Terry Scoggin
You and me have talked about that we can't treat everybody the same. That's wrong. We've got to learn the cultures. We've got to learn the history. You got to tell the story and hear the story. Most importantly, we have to hear the story as health care administrators, we need to shut up and listen. It's people say all the time, God gave us two ears,

00;06;31;18 - 00;06;33;19
Terry Scoggin
one mouth, take into consideration.

00;06;33;25 - 00;07;03;28
Leon Caldwell
Yes, it's really important this notion of equity making a distinction between equity and equality. Right. Like and you guys have we've had these conversations. You've been around our work as we launch the health equity roadmap. And we've we've talked about this notion of, you know, treating people, giving them what they need. Right. And actually them telling us what they need, not always us just giving them what we think they need.

00;07;03;28 - 00;07;18;18
Leon Caldwell
Right. Versus just giving everybody the same thing in your work, right? You've had to make some decisions and make probably some stance to change the minds of folks who may not have understood that. Tell me about that experience.

00;07;18;20 - 00;07;55;06
Ben Anderson
Yeah, one lesson a couple lessons that come to mind. One is this epiphany that rural America has a seat at the health equity table. And until now, it seems as though rural America has been excluded from the inclusion discussion. And not only does that lead to resentment, it leads to apathy. Maybe this isn't my conversation. Maybe I'll just check out of it when we when we exclude ourselves from that conversation or feel thaat we're excluded from the conversation, we lose the opportunity for a very important 20% of the United States to engage in what we believe is the most important work of our generation.

00;07;55;08 - 00;08;20;03
Ben Anderson
So that's the first lesson I think I'd take away from it. I think it is so crucial to know not only that we have a place in this conversation, but where that place is. And that we find we find our role in it. I don't believe this is optional. I think when we looked at that data that I mentioned earlier, Dr. Caldwell, the phrase we use in West Kansas where I was living at the time is, that ain't right. Nothing about that is right.

00;08;20;10 - 00;08;37;21
Ben Anderson
Looking at those numbers that were different and so, well, then what are we going to do about it? Because we can't leave it there. And so we just knew we have to do something about that. And so I think the next lesson that comes to mind is it's so crucial that we know or that we ask patients for their biography before we collect their biology.

00;08;37;23 - 00;08;59;10
Ben Anderson
First, we learn their story. To Terry's point earlier, and when we know their story and when we ask them questions about what they need, they will tell us if we're willing, if we have a humility to ask and not assume that we know. And one of the cardinal mistakes in this work is to assume we know without asking. Nothing about us, without us.

00;08;59;12 - 00;09;02;00
Ben Anderson
So if we start by asking how we get to good places.

00;09;02;04 - 00;09;02;24
Leon Caldwell
Yeah.

00;09;02;27 - 00;09;21;17
Terry Scoggin
So rural health care's late. Benjamin's right. We're late to the table. We've got a lot of ground to make up. But once you see that data, you can't unsee it. And the data is not just numbers or graphs or infographics. The data is people. It's people you talk to, people you listen to, and when you hear their stories, you can't unsee it.

00;09;21;20 - 00;09;42;26
Terry Scoggin
So as I've changed myself, I've been in health care now ten years. I've been in industry for 32 years. And what you're seeing and hearing today, and once you look at these numbers and you look at what's happening in maternal births and pre needs, all the prenatal work that's going on, talk about diabetes, you know, we have 9% African-American population in our county.

00;09;42;26 - 00;10;13;26
Terry Scoggin
That was our largest hindrance during COVID. As far as getting that number down. We had the highest Covid per hundred thousand in northeast Texas in our county, the lowest mortality rate. Unfortunately, African-American population suffered more deaths than our white population and Hispanic population. So working with those church officials and government leaders and going door to door to make changes. The community of color is part of rural and rural has to understand that.

00;10;14;03 - 00;10;35;08
Terry Scoggin
And if we want to make a difference in rural, we can't leave the door shut any longer. And I think when health care administrators start realizing that and getting into it and see it, they're not going back. This is an easy decision. It's not a hard decision. Once you start having these conversations. I'm a believer. And meeting Benjamin...

00;10;35;10 - 00;10;45;21
Terry Scoggin
meeting you, meeting your team, it just fires us up more. And I think as other rural, administrators learn that and it's it goes to the organization quickly. People want to hear it.

00;10;45;23 - 00;11;05;16
Leon Caldwell
You know, it's interesting to hear your take on this and that to some extent rural has been possibly a little late in, you know, Benjamin's point, we haven't really included you in the conversation. So to some extent we've allowed you to be excluded. The question I have is how do we become more inclusive of roles? 

00;11;05;21 - 00;11;12;27
Leon Caldwell
What is the role that, you know, whether it's HHS or other organizations, how do we support you differently?

00;11;13;03 - 00;11;36;00
Ben Anderson
I'd love to take a stab at that one. I think - And I visited with folks around the country, probably 30 or 40 states at this point - specifically on the subject of rural health equity. And I believe the answer to that question, Dr. Caldwell, is you start with their pain. We can talk about the pain of of the urban person of color, and they can't relate to that because it's so distant from them.

00;11;36;08 - 00;12;07;25
Ben Anderson
But when we talk about a rural American dying 50% more often due to unintended injury than an urban American, that registers. We talk about people dying sooner due to avoidable circumstances or chronic illnesses. And the challenge that I think we ask is does that make us, as rural Americans, dumber, less sophisticated, less responsible, caring less about our health or are there structures in place that are driving those disparities? And undoubtedly there are structures that are driving them.

00;12;07;25 - 00;12;38;11
Ben Anderson
Well, if there are structures that are driving rural health disparities, then could there also be structures that are driving, say, racial disparities in health outcomes? Well, absolutely there could be. But we start with the pain that they can feel. And when we go and talk about white privilege, for example, with a dairy hand, a dairy worker who's making $14 an hour without health insurance in Syracuse, Kansas, on the edge of nowhere, and we start talking about white privilege, that doesn't that doesn't register with them.

00;12;38;13 - 00;12;41;24
Ben Anderson
But when we start with their pain, they start feeling the pain of others.

00;12;41;26 - 00;12;42;26
Leon Caldwell
Understood.

00;12;42;28 - 00;13;00;23
Terry Scoggin
When they hear that and when they have the conversations, you start talking to your community. Rural people are good people. And when rural people hear that pain that you are talking about. Benjamin, rural people want to make a difference. So real people want to jump in. So you ask, how do we get that message out? We've got to go where they're at.

00;13;00;28 - 00;13;22;12
Terry Scoggin
We've got to continue this forum today. We've got to have these conversations. AHA conference here today and tomorrow has quite a bit equity discussions. This is not racial discussions, it's equity. And they've got to build that in. If we want to stay independent, we have to address this issue. We want to remain an independent health system. We have to address the equity situation in rural America.

00;13;22;19 - 00;13;37;23
Terry Scoggin
It's the only way we're going to get an outcomes based data. You can't argue outcomes based data. You can look at mortality that Benjamin talks about. You can talk to all the different things related to health outcomes. That's going to open people's eyes so that health outcome data is going to be key.

00;13;37;26 - 00;13;39;27
Leon Caldwell
How did you white guys get into this work?

00;13;40;00 - 00;14;03;23
Terry Scoggin
It's personal. In rural America, it's personal. One Saturday, we were having a health fair at the hospital, and I found that one of our African-American churches was having a Black History Month. Didn't know about it. They were having a presentation and talking about the midwives history in northeast Texas. So I left my health, went over to the health fair, went over to that with the head of my rural community group, and there's 25 people there.

00;14;03;25 - 00;14;21;22
Terry Scoggin
Majority of them were over 55-60. But we listened. We had the conversation and somebody was there talking about Medicare and confusing him. And I just stood up and said, you know what, half this room has my cell phone. If you have problems, text me. In rural America, it's personal. We see these people. Our kids grew up with these people.

00;14;21;25 - 00;14;36;16
Terry Scoggin
So I'm not looking at that skin color, Hispanic, African-American, poor, rich. It doesn't matter. We treat people the same. And that's what we got to continue to do. And as far as my mission and our vision is our health system, our community.

00;14;36;18 - 00;14;57;11
Ben Anderson
I got invited in by a gay black guy from Atlanta. He called me, cold called me on the phone and said, "Do you want to be part of the Leadership Advisory Council for the Institute for Diversity Health Equity?" And I thought, what in the world is this guy calling me for? I don't belong in this conversation. And he said to me is, as health equity has risen to the center of the national conversation, it has largely overlooked the disparities between rural and urban Americans.

00;14;57;18 - 00;15;13;24
Ben Anderson
And we tend to villainize white people, white guys especially. And neither of those are right. Both heard the long term work, he said. Rather than calling you out for being a white guy, I'm calling you into the most meaningful work of our generation. I'm asking you if you have the courage to be the only straight white guy on a board of 20 people.

00;15;13;27 - 00;15;29;02
Ben Anderson
And I had to process that because I was I was expecting to be judged. And he called me and invited me into something better. And I mean, it just was 100% consistent with my values, and I couldn't ignore that. And so I'll spend the rest of my life at some level in this space.

00;15;29;02 - 00;15;51;20
Terry Scoggin
And him requesting Benjamin to be on that drove me because when I met Benjamin and heard Benjamin speak, it drove me to even go further in looking at this. Because that one person calling Benjamin and asking Benjamin to serve thing, look what it's doing. Northeast Texas will never be the same because of what Benjamin went through and that small step.

00;15;51;22 - 00;16;10;26
Leon Caldwell
Yeah. Thank you, guys, both of you guys. But you point to so this could be like a two hour session with you both. And really data, I hear both you saying data and different types of data, not just quantitative, but telling the stories of folks so you can hear their pain and also meet them where they are is critical pieces of us being more inclusive in this work.

00;16;10;28 - 00;16;37;11
Leon Caldwell
So, you know, on behalf of the Institute for Diversity and Health Equity, I thank you both for your time. And in closing, all this work, it seems to start, was consistent with an invitation. An invitation to be humane and to respect humanity and to share our gifts with each other. So I thank both of you for sharing your gift with me, this time with AHA and look forward to continued partnership and working with the Institute for Diversity in Health Equity.

00;16;37;15 - 00;16;39;01
Leon Caldwell
And we'll talk later.

00;16;39;03 - 00;16;41;03
Ben Anderson
Thanks. Dr. Cole. Well, thanks for the opportunity.

Mergers, acquisitions and affiliations. Most health care leaders agree that the future, especially for rural providers, will involve more cooperation and partnerships. In this podcast, three leaders from rural health care systems agree that every community must find its own unique way to maximize its health care resources while maintaining the best possible care for patients.


 

View Transcript
 

00;00;00;22 - 00;00;21;20
Tom Haederle
For a rural hospital with a strong community identity, one that may have been serving its community for a hundred years or more. The thought of merging or affiliating with another care provider can be pretty daunting. So many important questions. How will it work? How do we guarantee a high level of care? And what does it mean to partner with another without losing our sense of identity?

00;00;21;22 - 00;00;29;23
Tom Haederle
Today, let's hear three outstanding leaders of rural hospitals talk it through.

00;00;29;25 - 00;01;03;19
Tom Haederle
Welcome to Community Cornerstones. Conversations with Rural Hospitals in America. A new series from the American Hospital Association. I'm Tom Haederle with AHA Communications. Mergers Acquisitions and Affiliations. Most health care leaders agree that the future, especially for rural providers, will involve more cooperation and partnerships. In this podcast, three leaders from rural health care systems agree that every community must find its own unique way to maximize its health care resources while maintaining the best possible care for patients.

00;01;03;21 - 00;01;19;27
Tom Haederle
Often that's going to mean new partnerships. They're not always easy, but as one of today's experts says, I think the marketplace, the regulatory arena, the macro economics of health care is absolutely calling us to walk through this conversation. So let's join them.

00;01;19;29 - 00;01;49;17
Julia Resnick
Hello. I am Julia Resnick, director of strategic initiatives at the AHA and I'm so pleased to be here at AHA’s Rural Health Care Leadership Conference with three outstanding rural CEOs and hospital leaders. So today we're going to be talking about the question of mergers and acquisitions and affiliations and what the future looks like for rural hospitals. So I'm here today with Russ Johnson, who's the president and CEO of LMH Health in Lawrence, Kansas, Erik Thorsen, who's the chief executive officer of Columbia Memorial Hospital.

00;01;49;17 - 00;02;10;06
Julia Resnick
in Astoria Oregon, and Dawn Trompeter president of OSF Saint Elizabeth Medical Center and OSF Saint Paul Medical Center in Ottawa, Illinois. Such a pleasure to be with all of you. I would like to kick things off, giving you a minute to introduce yourself and your background and a little bit about your hospital and community. So, Dawn let's start with you.

00;02;10;11 - 00;02;33;27
Dawn Trompeter
Okay. So as you mentioned, I'm president at Saint Elizabeth Medical Center in Ottawa, Illinois, and that's a town of about 20,000. We have a hospital that's licensed for 97 beds. We also have inpatient behavioral health and a safety net hospital and I'm also president at Saint Paul Medical Center in Mendota, Illinois. As part of all of this, as part of our loss of health care.

00;02;33;29 - 00;02;37;05
Dawn Trompeter
And that's a critical access hospital, smaller town.

00;02;37;07 - 00;02;39;29
Julia Resnick
Wonderful. Russ, tell us about your hospital and community.

00;02;40;01 - 00;03;02;21
Russ Johnson
Thank you. Lawerence Kansas is sandwiched between Kansas City and Topeka. We're about 30 miles. Equidistant from both elements is a small community hospital a little larger than typical when we think about small and rural, but still not a large medical center and have about 150 physicians on our active medical staff.

00;03;02;24 - 00;03;04;04
Julia Resnick
Wonderful. And Erik?

00;03;04;06 - 00;03;31;12
Erik Thorsen
Well, I'm in Astoria, Oregon, a fishing and timber community right at the mouth of the Columbia River, right at the end of the Lewis and Clark Trail. We run a small critical access hospital in Astoria, one of the larger critical Access hospitals in the state. We have a great relationship with academic Medical Center. OHSU. Have about a 750 employees, an operating revenue budget somewhere in about $180 million range.

00;03;31;18 - 00;03;47;18
Julia Resnick
Wonderful. And it's great having hospitals from all over the country so we can get those different perspectives on what you're experiencing. So in the rural health care space, there is this tension between whether you stay independent versus aligned with a health care system. So how are each of your hospitals thinking about that issue?

00;03;47;21 - 00;04;15;18
Russ Johnson
I'll jump in there. I think it's important that we sort of acknowledge that tension and some of the legacy of that tension being, you know, what we thought of as health care and what we thought of as our purpose, which was being this fiercely independent community hospital that maybe has served our community for 100 years or more. And then what does it mean to partner with somebody and to collaborate with somebody without losing our sense of identity?

00;04;15;21 - 00;04;36;17
Russ Johnson
I think the marketplace, the regulatory arena, just the macroeconomics of health care is absolutely calling us to walk through this conversation and to think about it honestly and openly. And that can be that can be uncomfortable and just acknowledging that it can be uncomfortable. But I think it's really necessary right now.

00;04;36;24 - 00;05;08;05
Erik Thorsen
I think for Columbia Memorial, you know, we're an independent or private, not for profit independent organization with a community led board. And we really wanted to grow services inside of our service areas and needed a partner to do that. So for us, we started looking for partners who would allow us to retain our independence, allow local control, but yet bring services into the community that would help us achieve, you know, a joint vision around growth in our community.

00;05;08;08 - 00;05;51;09
Dawn Trompeter
And I'll say we were a community independent community hospital. And I'm speaking of Saint Elizabeth now in Ottawa first. And we probably 13, 14 years ago really started looking at where health care was going in the future and really needed to partner. We were coming from a point of strength, a lot of dollars in our funding, appreciation, etc., but really wanted to maintain health care within our communities long term and really identified that we had a lot of hospitals in our rural area, probably too many hospitals that weren't all going to make it, and we wanted to really make sure we were at the forefront of that and really partnering with a good partner to

00;05;51;09 - 00;05;53;14
Dawn Trompeter
sustain health care for years to come.

00;05;53;18 - 00;06;23;18
Russ Johnson
You know, I've really enjoyed this conversation with Eric and Don because they're they're ahead of this curve from where my organization is. And I think they're sort of showing what we all need to think about, which is it doesn't have to be an existential threat to who we are as an organization and to our legacy and our place in the community and our heritage to think about how we can partner with someone that extends and maintains and even grows and expands our mission.

00;06;23;18 - 00;06;32;08
Russ Johnson
And I just think framing it up like that as how can this be a component of our success rather than a mark of failure somehow?

00;06;32;15 - 00;06;57;05
Dawn Trompeter
I would agree too, because as we've talked before, it really, whatever the relationship looks like, it's really about having a partner that is really aligned with strategy and the mission and really what you're trying to accomplish for your community and I think that's really what it's about is really finding the right partner regardless if it's an acquisition, a partnership, affiliation, whatever that looks like.

00;06;57;07 - 00;07;11;22
Erik Thorsen
And really, I think understanding what you want out of that partnership as you go in so you can make sure that vision and values relationships are all aligned with the larger partner that you seek.

00;07;11;24 - 00;07;21;16
Julia Resnick
Mm hmm. And what I'm hearing from all of you is that there are different ways of going forward, but really maintaining your sense of individualism and like the culture of your community is such an important piece.

00;07;21;21 - 00;07;57;08
Russ Johnson
That's super important and I think, you know, one of the things that I've learned from Dawn and Erik and their conversation and and what rings true for us is that time upfront to really understand who you are and what you are and what what those things are. Julia, to your point that make you who you are, whether that's an organizational culture or it's even your service lines or it's your governance and being super clear about that so you don't compromise those things in maybe a journey of a partnership that does adjust some other aspects of your organization that are less central to who you are.

00;07;57;11 - 00;08;11;17
Julia Resnick
The health care field is certainly changing and we have to change along with it, even when that's a little uncomfortable. So I do a lot of work in the value based care space, and a lot of it is talking about how we shift from, you know, the traditional models of care to new models of care in the rural context.

00;08;11;17 - 00;08;31;06
Julia Resnick
How that enables you to continue to have access to care in rural communities without may be different from the traditional inpatient model. So how are you thinking about those alternatives to traditional hospital models that would allow you to maintain that access, access to care services? And what is that looking like in your communities? Erik, I'm going to throw out to you.

00;08;31;08 - 00;09;00;09
Erik Thorsen
Well, I think our relationship that we developed with OHSU lends itself nicely to answer that question that we have seen the shift in care. Certainly the inpatient outside the patient setting, we've tried to tackle it from bringing specialists into our community. We really wanted to limit the amount of basically services our community had to leave the community for and bring them local as best we could.

00;09;00;09 - 00;09;28;16
Erik Thorsen
And we found a great partner who didn't require a merger, who didn't require us to change EMR, who didn't require us to give up local control, but yet supplied and helped us recruit a number of specialists into our community that we would not have otherwise been able to do. So, You know, 80% of our work now is done on the outpatient side in clinical or ambulatory settings.

00;09;28;18 - 00;09;53;02
Erik Thorsen
That's worked well for us. Our hospital has thrived. We've added jobs, we've gained confidence in our community with the services that we provide, which is just a big snowball that helps our organization continue to thrive and grow. And that's our vision. A little different maybe than a true merger, but a little different model that is working well for us and our community.

00;09;53;05 - 00;10;17;20
Dawn Trompeter
And I think for us, you know, we have a great innovation center as well as a digital health platform. And so really looking at that care model development and we cannot continue to serve as we've served. How do we change that? Where's telehealth come in? Where some of the e-services and our digital platform that we use, how do we really think differently?

00;10;17;23 - 00;10;36;16
Dawn Trompeter
We just don't have the resources from staff to physicians to be able to continue to have everything exactly how we've had it. So how do we really level up and still provide great quality services and be more efficient and give our providers and our staff a better work life balance?

00;10;36;18 - 00;11;01;19
Russ Johnson
I would jump in on that too, Julia. I think the reforming of our financing and delivery system and the shift to risk is by definition outside of the capability of a small institution. When you think about, you know, sharing risk across a bigger organization and actuarial, even large organizations that we used to think of as large are no longer seen as scaled enough to bear risk.

00;11;01;21 - 00;11;23;19
Russ Johnson
And so we have to think about as smaller institutions, how do we come alongside a partner that can bear that risk and or who collectively we can? And I think it's I think it's to Dawn's point around expertise, and I think of data and analytics and development of new process models and the clinical integration that Erik spoke about.

00;11;23;21 - 00;11;46;09
Russ Johnson
Those are things that are all bigger than a small independent community hospital. And the literature and the forecast for the future is not a return to fee for service, it's a continuation away from that to more risk bearing. And it just not being a good steward of our institution to think we can bear that kind of risk and be successful through it.

00;11;46;12 - 00;11;57;11
Julia Resnick
And I think even if the value based payment model isn't fully ingrained in a lot of rural hospitals, you can still take on those care models that allow you to improve value and can help move your communities forward.

00;11;57;12 - 00;11;57;21
Russ Johnson
Yeah.

00;11;57;23 - 00;12;06;05
Julia Resnick
So I'll close with one final question I like. I like to think big picture at the end. So what is your vision for the future of rural hospitals and what's it going to take to get us there?

00;12;06;10 - 00;12;28;12
Dawn Trompeter
I think it's collaboration and partnerships. You know, how do we work together? We're not necessarily competing with everyone. It's really we have to join together for the better of all to be able to take care of our patients, to make it economically sustainable and really to drive quality and the care that we provide. We need to have those partners to be able to do so.

00;12;28;19 - 00;12;59;15
Erik Thorsen
Yeah, I agree and I'm anxious to see how the Rural Emergency Hospital model plays out in some of the communities that don't have the scale to, you know, offer the full array of acute care services. I think every community is unique. They have their own unique needs. They need to determine how and what they need to do to meet those needs and what they can, I think, safely do at a high level of quality in their community.

00;12;59;15 - 00;13;10;13
Erik Thorsen
And maybe that model will transform some small community hospitals into something a little different. And I'm really anxious to see if that plays out the way people think it will.

00;13;10;20 - 00;13;46;06
Russ Johnson
I think to start with something really simple, which is we have to find a way to continue providing excellent clinical care in rural communities. And maybe that's a statement of the obvious. But the other reality that we're facing is the trajectory of the current financing and delivery system really isn't compatible with that. And so I think taking those two forces really brings the work of AHA in promoting what are the alternative delivery models.

00;13;46;11 - 00;14;20;10
Russ Johnson
You know, so much of rural health care came out of forties and fifties era Hill Burton funding in a fundamentally different financing and health care environment, a different clinical environment, even a different demographic population environment. Well, we're not going back to that. So to me it's around to to steal from my colleagues here. It's around innovation and innovation at the local level, maybe letting go of some of the things that used to be scary, which are being independent and not being able to partner with somebody.

00;14;20;13 - 00;14;33;06
Russ Johnson
But I think also at the macro level, we have to support our association and each other because we've got to find a different delivery model that's sustainable. The local hospital can't do that on its own.

00;14;33;08 - 00;14;50;10
Julia Resnick
So what I'm hearing from all of you are that partnerships are key and that they are going to continue to be key in developing those new care models that will allow rural hospitals to thrive in the future. So we're lucky to have such great leaders like the three of you who are thinking about what the future looks like and really impacting the health of the communities you serve.

00;14;50;10 - 00;14;53;08
Julia Resnick
So I want to thank you for your time today. Really appreciate it.

00;14;53;12 - 00;14;54;01
Russ Johnson
Thank you, Julia.

00;14;54;05 - 00;14;54;21
Erik Thorsen and Dawn Trompeter
Thank you.

 

 


AHA's Rural Report Podcast Series

Recently, AHA published “Rural Report: Challenges Facing Rural Communities and the Roadmap to Ensure Local Access and High-quality, Affordable Care.” This podcast series is built around the AHA Rural Report. Meaning, it highlights a rural health challenge and shows how the field responds to the call to action.


Using Community Health Workers to Expand Access in Rural Areas - March 4, 2020

16:21 minutes

On this Advancing Health podcast, John Supplitt, AHA senior director, speaks to two rural hospital leaders about the importance of implementing an effective community health worker program to expand health care access.


Using Artificial Intelligence to Reach Rural Patients - January 15, 2020

12:30 minutes

In this AHA Advancing Health podcast, John Supplitt, senior director of AHA Rural Health Services, talks to Rachelle Schultz, CEO of Winona Health, about clinicians using artificial intelligence to identify and diagnose illnesses and injuries and recommend customized treatment plans, making primary care more accessible to those isolated by distance, weather or transportation.


How Rural Hospitals Are Responding to Challenges – July 17, 2019

15:20 minutes

Earlier this year, AHA published a rural report called “Challenges Facing Rural Communities and the Roadmap to Ensure Local Access and High-quality, Affordable Care.” The report outlines specific legislative and policy recommendations to address the persistent, recent and emergent challenges facing rural communities and the hospitals that serve them. In this podcast, AHA rural health experts explore the purpose of the Rural Report and its Call-to-Action for rural health providers and advocates alike.


Behavioral Health – May 23, 2019

13:53 minutes

On this podcast, we examine the challenge of behavioral health services for rural Americans and report the ingenuity and resourcefulness of the field in responding to this challenge.

Dr. Carrie Henning-Smith is an assistant professor and deputy director at the University of Minnesota Rural Health Research Center in Minneapolis. Joining her is Shelly Rivello, director of integrated care at J.C. Blair Health System in Huntingdon, Pennsylvania.

Our experts will share an evidence-based model to increase access to mental health services, as well as an evidence-based practice to integrate behavioral health services into primary care clinics.

 


More Rural Podcasts 

Partnering to Improve Rural Birth Outcomes - September 15, 2020

17:02 minutes

Many rural hospitals have been challenged with maintaining obstetric services but are now partnering with others to improve birth outcomes for mothers and babies. In this podcast highlighting successful maternal and child health efforts, care team members from Kearney County Hospital in Lakin, Kan., discuss the importance of a growing OB unit and the impact of Kearney County’s Pioneer Baby program. 


Doulas Enhance the Birthing Experience - August 19, 2020

17:01 minutes

Aisha Syeda, Program Manager at the American Hospital Association is speaking with Mary Schwaegerl, an Obstetrics Director and Julia Yoder, a Marketing & Public Relations Director at Brookings Health System, as they share the impact of their volunteer doula program at Brooking’s New Beginnings Birth Center.


Rural Hospital Offers Flexibility to Recruit Physicians - January 29, 2020

23:19 minutes

In this AHA Advancing Health podcast, Elisa Arespacochaga, vice president of the AHA Physician Alliance, talks with Benjamin Anderson, former CEO of Kearny County Hospital in Lakin, Kan., about how his hospital took a chance on an unorthodox approach to recruit physicians, including offering four-day work weeks and limited on-call commitment.


Rural City Part of Groundbreaking Heart Disease Prevention Initiative - June 12, 2019

28:05 minutes

On this AHA Advancing Health podcast, The Value Initiative series continues with a four-way conversation discussing how the Heart of New Ulm project in Minnesota aims to reduce heart disease and prevent cardiovascular problems before they appear. Guests include Julia Resnick, senior program manager, AHA; Carisa Bugler, director of operations, New Ulm Medical Center; and two others from the partnership.

Advancing Health Podcast logo