Advancing Health Podcast

00:00:02:28 - 00:00:25:19
Blake McLaughlin, D.O.
With an oasis, typically its water that comes from an aquifer, that is from mountain regions or other regions far, far away. We know that the challenges that our rural hospitals face and providing perinatal services, they're not isolated and they can't be cut off from their water source.

00:00:25:21 - 00:00:59:02
Julia Resnick
That was Dr. Blake McLaughlin, senior medical director of women's health services at Banner Health. His words capture something fundamental about rural maternal care. No hospital exists in isolation. Welcome Back to Frontiers, a podcast series from the American Hospital Association. I'm your host, Julia Resnick. Today, we're exploring the role larger health systems in tertiary medical centers can play in helping rural hospitals continue to provide maternal care and what it takes to make those partnerships work.

00:00:59:04 - 00:01:23:00
Julia Resnick
Emily Brayton is a perinatal outreach nurse at Dartmouth Health in New Hampshire. She also serves as director of operations for the Northern New England Perinatal Quality Improvement Network. Dartmouth Health's connected care partners with health care providers and facilities throughout northern New England, giving them access to the expertise of an academic medical center, regardless of whether they are part of the same health system.

00:01:23:02 - 00:02:02:00
Emily Brayton, R.N.
I think it's really important for systems to have an understanding of the integral role that inpatient obstetric services really serves for their whole entire hospital and their communities is one of those things that we're seeing across the country. New Hampshire experienced closures. It just really changes the communities and maybe who's coming into those communities. I can understand the concerns about settling in a rural place that maybe you have to go far for OB services.

00:02:02:01 - 00:02:23:02
Emily Brayton, R.N.
The strain that that puts on the local emergency departments and the local EMS crews are very, very hard. So I think really focusing on how to sustain inpatient OB services should be the job of every single health care system.

00:02:23:04 - 00:02:51:07
Julia Resnick
When a rural hospital loses inpatient obstetric services, the impact ripples into communities and nearby hospitals. So, if sustaining maternal care is a shared responsibility, what does that responsibility look like for large health systems? At Banner Health, Dr. Blake McLaughlin describes it as starting with a commitment to the communities the system serves and then using the resources of the health system to strengthen care across the entire network.

00:02:51:09 - 00:03:10:13
Blake McLaughlin, D.O.
One of the things that we do is we start from a heart posture, an attitude of care, of love. That is really what drives the work that we do, not fear. And so when we approach things with a scarcity mentality, with a fear mentality, really we're kind of starting on our heels and not from the best perspective.

00:03:10:14 - 00:03:37:08
Blake McLaughlin, D.O.
So our attitude moving into this work is we have a commitment. What we think about too is how do we leverage the benefits of the massive health care system that has a singular priority on safe moms, healthy babies to serve and resource these communities? There is this virtuous cycle that it creates, and it serves and it resources and elevates, really the quality of care,

00:03:37:09 - 00:03:42:19
Blake McLaughlin, D.O.
the standard of care, the entire culture within the whole health care system.

00:03:42:21 - 00:04:14:01
Julia Resnick
As we talked about in the previous episodes, distance can make access to specialty care a challenge for rural residents. But patients don't always have to travel to access specialized expertise. Sometimes the care can be brought to them. South Dakota based Avera Health has been doing this across the Upper Midwest for more than a decade. The system serves communities across a vast rural footprint where long travel distances, harsh winters, and limited access to specialty care are part of the reality for caring for mothers and babies.

00:04:14:03 - 00:04:24:13
Julia Resnick
Dr. Kimberly McKay, an OBGYN and medical research director for Avera Research Institute, says those geographic challenges are compounded by the needs of the communities themselves.

00:04:24:15 - 00:05:00:06
Kimberlee McKay M.D.
The challenge is really about geography, yes. Winter, yes. But also the further you get away from your urban center, you have your increased risk of chronic disease. Of social determinants of health like transportation, housing, food insecurities. You know, when you've got people who live in rural areas, who tend to have more chronic health needs within, especially in the setting of pregnancy, we're always trying to think of ways of how do we push out specialty services so we can keep folks local.

00:05:00:07 - 00:05:27:25
Julia Resnick
For Avera, the answer has been to push specialty expertise out into communities and keep patients local whenever it's safe and appropriate to do so. And it's technology that makes that possible. The work began more than a decade ago, with ultrasound. Using telemedicine to connect scans performed in rural communities with maternal fetal medicine specialists who could interpret that remotely. Today, Avera uses telehealth to bring specialists into rural communities virtually,

00:05:27:26 - 00:05:45:04
Julia Resnick
remote monitoring to stay connected with patients at home, and virtual consultations to give local clinicians another set of eyes when they need them. And there's a really important distinction here that technology isn't replacing local care, it's extending it.

00:05:45:07 - 00:05:52:27
Julia Resnick
In the Mountain West, Banner Health is also using technology to support local providers around the clock. Here's Dr. McLaughlin again.

00:05:53:00 - 00:06:17:14
Blake McLaughlin, D.O.
We have on call 24 over seven 365 OBGYN hospitalists. So those family medicine OB physicians in those rural hospitals, they can get any time a telehealth consult from those OBGYN hospital labor and delivery specialists. Sometimes that will just be a review of the medical record. Sometimes it will be a review of the fetal heart rate tracing. But we can actually provide the service where via tele cart

00:06:17:14 - 00:06:27:26
Blake McLaughlin, D.O.
so it really dissolves those geographic barriers and allows us to continue to keep folks in their community when it's safe and appropriate to do so.

00:06:27:28 - 00:06:50:19
Julia Resnick
Technology brings that second set of eyes into the room, without taking the local clinician or the local hospital out of the equation. The technology can only extend care if there's someone on the ground to deliver it. And in rural communities, that clinician may not always be an obstetrician. That's why Emily Brayton from Dartmouth Health describes rural obstetrics as a team sport.

00:06:50:21 - 00:07:15:15
Emily Brayton, R.N.
I fully believe that obstetrics is a team based sport, and kind of nobody really wants to be making choices fully on their own. But when you're the one obstetrician or midwife who's on, when you're one of two nurses and your other nurse is busy in another room, how nice would it be to pick up the iPad and initialize tele-OB?

00:07:15:18 - 00:07:28:20
Julia Resnick
Banner health has found another way to strengthen that connection, giving clinicians a shared framework for making decisions. And one morning in Wyoming, Dr. McLaughlin saw what that could mean in practice.

00:07:28:22 - 00:07:46:04
Blake McLaughlin, D.O.
They actually have a patient with a category two tracing. And they want to convene a virtual fetal safety team. Would you be willing to help? And I said absolutely. So went out to the desk and sat there with our nurses in Casper, Wyoming Medical Center. And virtually we connected with our team at Worland, and we reviewed the patient's tracing.

00:07:46:04 - 00:08:05:09
Blake McLaughlin, D.O.
We reviewed the algorithm, and according to the algorithm, the recommendation was to counsel the patient and proceed with a caesarian delivery. So we were able to support the team in doing that. They counseled the patient. They had an uncomplicated C-section. We had a healthy Banner baby girl after hours of eight and nine, and mom was so thankful and grateful that we intervened.

00:08:05:09 - 00:08:22:08
Blake McLaughlin, D.O.
The team felt so grateful that we were able to provide that support. So that's the real life stuff that's making a difference, that are keeping folks connected and really raising the bar in terms of quality, safety and the outcomes that we're looking for.

00:08:22:10 - 00:08:35:01
Julia Resnick
But there's another piece to this equation: the people who are there when the technology isn't enough. Dr. McKay from Avera sees that as an essential part of extending maternal care in rural communities.

00:08:35:03 - 00:09:01:28
Kimberlee McKay M.D.
So the technology to the patient, yes, is very important. But just as important is enabling the care teams in the small, the tiny towns. So we've been working with these small sites on not just simulation, but saying, what do you have in your house to be able to take care of pregnancies. So how do you sort of like figure out when you actually need the patient to come in for care or be seen in person?

00:09:02:01 - 00:09:22:27
Julia Resnick
The goal isn't for every hospital to provide every level of maternal care. It's for every team to know what they can safely manage, when they need more support, and how to reach it quickly. Years ago, Dr. Mackay got one of those calls. She was at her son's school conference when an OBGYN colleague from a small Minnesota hospital reached out for help.

00:09:23:03 - 00:09:34:06
Julia Resnick
A young patient had experienced a severe postpartum hemorrhage after delivery and the hospital had run out of blood. The physician caring for her needed help immediately.

00:09:34:08 - 00:09:54:09
Kimberlee McKay M.D.
You know, we face timed into the O.R., she's like, I don't know what to do. So I'm at my son's conference in the hallway of the elementary school, like, okay, like, yep, I'm going to find somebody to connect the dots with. And we got her evacuated. And, you know, just after a few phone calls because, again, the culture is just say yes.

00:09:54:12 - 00:10:16:09
Julia Resnick
For Dr. McKay, that experience helped shape Avera's work to strengthen transfer processes and build more formal support systems around maternal care. And when those types of connections extend beyond individual hospitals and providers, they can become something even more powerful - a regional system of care.

00:10:16:12 - 00:10:31:02
Julia Resnick
At Dartmouth Health, perinatal outreach teams work with hospitals throughout northern New England, including hospitals outside the health system. And that collaboration doesn't end when a patient is transferred. The transfer itself becomes an opportunity to learn.

00:10:31:04 - 00:10:55:00
Emily Brayton, R.N.
We provide debriefs to teams that send neonatal patients to us to kind of talk through and walk through the patient's care while they were at their home hospital, but then also give that follow up of what happened here. We also work really hard on what we call transport conferences, which is where we sit down with our referring hospital teams.

00:10:55:01 - 00:11:07:19
Emily Brayton, R.N.
It's a collaborative approach with both our OB clinicians and our neonatology friends, and really talking about the whole care of the patient.

00:11:07:21 - 00:11:32:08
Julia Resnick
A transfer can be the end of one patient's episode of care, but for the clinicians involved, it can also be the beginning of a conversation. And when hospitals across the region are doing that together, those lessons become shared knowledge. Banner Health has built that kind of peer to peer learning into its rural network through the Rural Whisk Consortium, where nurse and physician leaders come together regularly to share what they're seeing on the ground.

00:11:32:15 - 00:11:35:19
Julia Resnick
Here's Dr. McLaughlin.

00:11:35:21 - 00:11:57:22
Blake McLaughlin, D.O.
We meet together virtually. We talk about best practices. We share and have potluck style about, hey, these are challenges we're facing, these are opportunities. Here's how we're solving for this problem. What do you guys think about that? And it is a tremendously valuable opportunity to really share that one team experience virtually. And so we're proud of that as well to keep folks connected.

00:11:57:24 - 00:12:22:16
Blake McLaughlin, D.O.
It's central to our DNA. It's the core of who we are. And so we want to make sure that that doesn't just end when, you know, we've transitioned from urban metro academic centers and folks out in the rural hospitals are just sort of fringe and out there. Even though we're geographically maybe located across large volumes of space and many miles, we want to make sure that there's one heart and one mind.

00:12:22:19 - 00:12:42:19
Julia Resnick
The value of the network isn't just what any one hospital can provide. It's what becomes possible when they learn together. At Dartmouth Health, regional coalitions bring hospitals and community partners together around the needs of the families they serve. Emily Brayton describes how those coalitions reach far beyond the walls of individual birthing hospitals.

00:12:42:21 - 00:13:11:04
Emily Brayton, R.N.
It really does take a village to raise a child or children or to have a family. And we know that. And so one of the ways that we're broadening the reach from outside of the hospital and leveraging our rural communities and making sure that everyone has what they need is through our regional coalitions. There are 11 of them that are centered around birthing hospitals.

00:13:11:04 - 00:13:42:02
Emily Brayton, R.N.
So if you're doing the math, we have 15 birthing hospitals, but only 11 regional coalitions. And that's because we have a couple hospitals that are close together in drive time. So we're really centering the coalitions around those hospitals, but extending the reach far beyond those hospitals and really getting the support of the community to understand what do families need in order to survive and thrive.

00:13:42:03 - 00:13:46:16
Emily Brayton, R.N.
Right? We don't want people just surviving. We want people thriving.

00:13:46:19 - 00:14:01:14
Julia Resnick
The goal goes beyond connecting rural hospitals to a tertiary medical center. It's about building a regional network around the needs of families, one that can draw on the strengths of hospitals, clinicians and communities.

00:14:01:16 - 00:14:15:01
Julia Resnick
The infrastructure may be technology protocols and transfer pathways, but what makes those systems work is the relationships between the people on both ends. Here's Dr. McKay from Avera Health and Emily Brayton from Dartmouth Health.

00:14:15:03 - 00:14:26:00
Kimberlee McKay M.D.
Technology doesn't foster the relationship. The culture fosters the relationship, which is, if you call me, I'm going to answer and I'm going to try to answer your question to the best of my ability.

00:14:26:02 - 00:15:02:03
Emily Brayton, R.N.
Relationships drive your ability to be productive. And so it's really about getting to know each other, getting to know the hospitals. We find that people are more willing to reach out to us and say, like, hey, we're kind of struggling with this thing. What do you guys think? Having lots of relationships outside of our referral teams really allows us to draw on that vast knowledge and expertise that's in our region, allows us to just be stronger by working collaboratively.

00:15:02:06 - 00:15:32:28
Julia Resnick
Providing maternal care in rural communities isn't easy. It takes grit. It takes commitment, and it takes a deep love for your patients in your community. But it can be isolating, and it doesn't have to be. And perhaps that's what makes Dr. McLaughlin's oasis metaphor so powerful. An oasis may appear to stand alone, but beneath the surface it's connected to something much larger a source of water far beyond what you can see.

00:15:33:01 - 00:16:04:03
Julia Resnick
And that has been the undercurrent for this entire series. Rural hospitals can thrive when they are connected, and so can families in rural America. Thank you for joining us for the special podcast series Frontiers. I've been your host, Julia Resnick. Visit the American Hospital Association's website to explore more stories from rural hospitals and health systems across the country, and discover how they are finding new ways to strengthen maternal care and keep it close to home.

00:16:04:06 - 00:16:22:15
Julia Resnick
This series is supported by the Commonwealth Fund, a national private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the author and not necessarily those of the Commonwealth Fund, its directors, officers or staff.

00:00:00:04 - 00:00:20:02
Tom Haederle
Welcome to Advancing Health. Many people may think of primary care and a visit to the hospital as distinctly different paths for their care needs. But as we hear in this month's Leadership Dialog podcast, more hospitals and health systems are investing in preventive primary care to keep patients healthy.

00:00:20:04 - 00:00:39:26
Marc Boom, M.D.
Greetings, everybody, and thank you for joining me today. I'm Mark Boom. I'm the president and CEO of Houston Methodist, and I'm the board chair of the American Hospital Association. As we continue with these discussions, we're going to focus today's conversation on something really near and dear to me as a primary care physician myself, which is the rise of primary care as a key strategy for so many hospitals.

00:00:39:27 - 00:01:00:13
Marc Boom, M.D.
Some may obviously not immediately think of very acute care hospital or health system when thinking of primary care, but increasingly our hospital field is getting much more involved and for very, very good reasons. Because our core mission is to keep people healthy. And certainly that means providing very high quality care when a patient is sick and inside our organizations in the hospitals,

00:01:00:13 - 00:01:21:17
Marc Boom, M.D.
but even more so, it means helping patients access preventive services that keep them healthy and out of the hospital in the first place. There's tremendous value for everyone in ensuring that patients and communities have access to primary care clinicians and clinics for screenings, wellness care, as well as a trusted care team to help with chronic disease management and other drivers of health.

00:01:21:18 - 00:01:43:24
Marc Boom, M.D.
So investing in primary care prioritizes a patient's overall health and helps avoid costly or unnecessary emergency department visits. I'm joined today by a guest whose health system really understands these reasons of why investing in primary care is good for patients. David Banks is here today. He is the CEO of AdventHealth, an integrated health system that serves communities across nine states.

00:01:43:25 - 00:01:47:12
Marc Boom, M.D.
David, thank you so much for joining us. And let's get started.

00:01:47:15 - 00:01:50:09
David Banks
Yeah, thank you for having us. It's really an honor to be here.

00:01:50:10 - 00:02:05:20
Marc Boom, M.D.
Well, I'll start very broadly. I'd love to just...tell us very briefly about AdventHealth as a whole, and then talk to us about how AdventHealth thinks about primary care as a strategic priority and how you thereby support primary care and all of those communities that you serve.

00:02:05:22 - 00:02:43:08
David Banks
Yeah. So, AdventHealth, our roots go back to the late 1870s, the sanatorium movement, and actually John Harvey Kellogg. And so this notion of staying healthy has been at the core of our organization's founding. And so fast forward to today, AdventHealth serves over 10 million people in nine states, as you mentioned. Initially were a hospital centric company, but we decided in 2023 that we needed to fundamentally reset our primary care strategy. In order to have exactly what you open with the most pervasive community impact,

00:02:43:09 - 00:03:01:21
David Banks
we knew we needed to get outside the walls of the hospital and really create care relationships at a community level that could be longitudinal and help people really live at the top of their health care potential. And we think primary care is an essential component to get that done.

00:03:01:22 - 00:03:18:16
Marc Boom, M.D.
Well that's fantastic. So talk about a further role in terms of how primary care plays expansion to access. Talk about how you make decisions, about how you invest, because there's different ways and explain some of those different ways and where you invest in primary care.

00:03:18:19 - 00:04:07:09
David Banks
Yeah. So the key decision we made in 2023 was to really take apart what was our physician network, move it into its own operating division, not a hospital division, but an operating division that had as its focus primary care. And so for us that spans created better definition for four ways we seek to connect with our communities. And that ranges from virtual 24 hour access, primary care all the way up through really complex senior care models for older individuals that may have a variety of clinical conditions, that with the right level of primary care and turn in primary care, really allows them to manage the complexity of their chronic conditions in a way that

00:04:07:12 - 00:04:25:24
David Banks
keeps them out of the hospital, keeps them from bouncing between doctors and really having a coordinated experience. So we realize primary care is not one thing. For some folks it's same day access, don't need a longitudinal relationship. Just trying to solve a problem to more middle range, which is the primary care I like. I want to know my provider.

00:04:25:24 - 00:04:41:24
David Banks
I want a longitudinal relationship - up to that more chronic care, complicated levels of primary care that really require care coordination across multiple specialties to ensure peak health for folks that are dealing with a number of issues.

00:04:41:26 - 00:04:49:26
Marc Boom, M.D.
I'm curious, do you have people move from one of those different type of channels to another? Does that happen frequently?

00:04:50:01 - 00:05:15:04
David Banks
We do. In our traditional primary care offering, if you will, as they start to age into Medicare, we encourage them based on their clinical conditions, the support they need - they can either stay put or maybe they the senior care model really is a better model for them. There's just a lot of consumer choice that's built in in all of the models that that we have, and we realize that was essential.

00:05:15:04 - 00:05:45:26
David Banks
What was so interesting to us when we started is how few people really had a longitudinal relationship with their primary care doctor. And when we investigated that as to why it really came down to a question of value, we realized we needed to change our offering, support our clinicians better, and create more comprehensive clinical models that really allowed them to engage more fully with their patients and create more solutions for their patients in a way that the patients could find more value.

00:05:46:01 - 00:06:08:09
Marc Boom, M.D.
And I assume that the clinicians in those different kind of channels, I mean, they embrace the fact that there's differences. It's interesting you talking about so few having that longitudinal model. I still practice a tiny bit. And that's like the most valued thing for me, not to mention I think patients that I see is just known him for a quarter of a century or more many times, and it really helps with caring for them.

00:06:08:09 - 00:06:33:22
Marc Boom, M.D.
And I will say sometimes as people get older and very complicated, those senior type clinics can be a really much more logical place for somebody. So how do you navigate that sometimes? Does a clinician actually sometime raise his or her hand and say, you know, I love you, I've been taking care of you for 20 years, and I think you're going to actually be better over here because you're so complicated.

00:06:33:25 - 00:06:35:21
Marc Boom, M.D.
Does that get pretty fluid there?

00:06:35:27 - 00:07:00:01
David Banks
Yeah, we've actually had that exact case happen. And it takes a lot for the clinician to want to maybe give up that 25 year longitudinal relationship. But when the patient has, as you know, five specialists involved in their care, maybe some home based care, the senior clinics with the wraparound services from social work and other in-home support, some of the remote monitoring, it just makes more sense.

00:07:00:01 - 00:07:21:18
David Banks
And usually the families are so appreciative because it takes a lot of the burden off of that adult child, if you will. And we've all been in that situation of really having to be a clinical quarterback between a primary care provider and five specialists and trying to keep med rec straight and all those sorts of things, they really need to be in a more intensive setting when that happens.

00:07:21:18 - 00:07:26:15
David Banks
And the benefits are so clear that usually that transition is not a difficult thing.

00:07:26:18 - 00:07:39:27
Marc Boom, M.D.
Fascinating discussion. Give us an idea of scale and scope across AdventHealth. How many primary care physicians? And I'm sure you have nurse practitioners and physician assistants and others in that realm as well. But how many are we talking about?

00:07:40:00 - 00:08:13:18
David Banks
Yeah. So if we look at the state of Florida, for example, probably 700 employed providers in our model, majority of those physicians, although we have been really adding to our APP complement. We know they're really a great augmentation to care. Right levels of care from the right provider really allow reach. What we've really been able to do in our model in Florida is we've opened up since we started this, almost a quarter of a million more appointments for patients to be seen because access was such a major problem.

00:08:13:18 - 00:08:38:10
David Banks
And so by increasing the number of employed physicians we have up in that seven, really about 700 range actually relocated and redesigned our clinics. We again, I don't think we're atypical in this, but in our health system, we ended up with 100 doctors in 100 sites. And so we really built primary care pavilions that allowed an aggregation of up to ten providers.

00:08:38:10 - 00:08:57:27
David Banks
That allows then the other support services to be aggregated there as well. And so that's really created about a quarter million visit gain in the last two years. Because if you can't get in to see your doctor, it doesn't really matter. You know, that's really the thing that matters most. We're taking this strategy now out into what we call our multi-state division.

00:08:57:27 - 00:09:24:28
David Banks
So Chicago, Dallas-Fort worth, Kansas City, Colorado, where we have, again, large, large employed. In Colorado, we probably have close to 500 employed primary care providers. And so we've made a big investment in this simply because I don't think, like I said, we can have the community impact if we just stay within the walls of the hospital. We have to be able to ideally get people under a care plan that allows them to optimize health.

00:09:25:00 - 00:09:40:10
David Banks
Our hospitals are there when you when you need that level of acute support. But most of our interactions happen away from the hospital, so those need to be clinically robust, consumer focused, you know high value opportunities for the patients we have.

00:09:40:12 - 00:10:01:20
Marc Boom, M.D.
So sometimes the economics can get in the way like how much of this is in a fee for service type of environment? How much of this is in more of a value based or global care or some version of financing? And then as you talk about the economic side of the benefits, and we're gonna come to the other more important clinical and others, you know, how does that mesh with all of that?

00:10:01:24 - 00:10:36:15
David Banks
Yeah. So two ways we think about it. I like the idea of value based care in that, giving additional resources to primary care physicians to provide more longitudinal support. So we're active participants. We have about 900,000 lives in some sort of government program. We've been very active participants in reach. We've done work with MA providers as well. We like those models because it puts more resources into the clinic, and it allows us to be able to help people stay at the right level of care to get what they need.

00:10:36:16 - 00:10:59:25
David Banks
Additionally, what we've done in our own employee base, because the real pressure point for this comes for the self-funded employers. We've created a very high value. It's actually a high actuarial value option for our employees that is really primary care centric. So we have traditional insurance, we have the high deductible plans. We created a mid-level plan that is really a primary care centric plan.

00:10:59:25 - 00:11:23:10
David Banks
First year we had 9000 enrollees of our employees. This year it grew to almost 18,000. And really trying to understand can we get better care and can we see better economics? Because the thesis is if you see your primary care doctor, you should have a less financial burden because your care is being managed. And so we're testing that inside of our own employee base.

00:11:23:10 - 00:11:39:26
David Banks
And we're seeing some very good results in terms of access to care and some of those early indicators, some of those, those health factors we want to see from early screenings, chronic care as well as inpatient hospital admission avoidance.

00:11:39:26 - 00:12:03:00
Marc Boom, M.D.
So, what do you see in terms of total cost of care at this point then? Are you seeing ER visits going down in that population? Are you seeing better and less frequent hospitalizations in a chronic disease management group? Are you managing, I imagine some of these senior clinics you're managing complex end of life issues. You're managing complex dimension and neurodegenerative disease issues.

00:12:03:00 - 00:12:04:20
Marc Boom, M.D.
What are you seeing in that realm?

00:12:04:25 - 00:12:28:00
David Banks
Yeah, probably the most compelling statistic to me - and this would be true in our Reach program with CMS, as well as what we see in our employees. For those of our patients that are stratified in that rising risk or high risk category, when they're under care management, they're avoiding about $6,200 of cost a year. So you think about the expense of those patients at the top of your pop health pyramid.

00:12:28:03 - 00:12:49:15
David Banks
You know, those often are 30 to $40,000 a year type expenditures. So getting $6,000 a year of expense off of that group is a material gain. On the front end, we saw a 90% utilization rate of primary care in our employee base that are in that high value plan, and so we think that's going to pay dividends long term.

00:12:49:15 - 00:13:11:10
David Banks
And as I mentioned with our care management program, we put into our ERs. This year we've already diverted 511 admissions. And the way we were able to do that is we knew their providers, we knew their plan of care, and it allowed us to say, look, clinically, this is a this is safe to send this person back to this level of care.

00:13:11:10 - 00:13:31:06
David Banks
They don't need to be admitted. As you know, hospital admissions carry their own benefit and risks. And so we've seen those benefits across the board and we've seen those CMS benchmarks we've been able to come underneath them at 2%, you know. So those benchmarks are at 13,000 per member per year. So we're starting to see some early numbers.

00:13:31:06 - 00:13:35:15
David Banks
But we have a lot more to go, I think, to really prove out the case.

00:13:35:18 - 00:13:57:04
Marc Boom, M.D.
Well, I want to end with one last question of, you know, you've got many others watching this saying, you know, we need to go there. We haven't gone there. We're a very legacy like hospital system and different types of economic models and environments and things. What are the lessons learned? What would what advice would you give to somebody like that who leads a system and says, I think we need to go embark on a journey similar to this?

00:13:57:08 - 00:14:25:27
David Banks
I think we've learned two things. One is maybe it was unique to us, but we were losing subsidizing about $225,000 per primary care doc pre this this model. We've been able to cut that in half. So just the financial burden or expense if you will. We've been able to become more efficient through again redesigning the model, putting primary care out front, optimizing the way our practices flow, supporting with different resources.

00:14:25:27 - 00:14:49:27
David Banks
Our subsidy costs actually been cut in half, not to zero yet, but in half. Additionally, we've seen more access for that investment. And like I mentioned, we're starting to see some of those early pop health indicators coming. So it's the better organization just created a better expense management structure. And we're seeing patients use primary care at a rate they weren't using it before.

00:14:49:27 - 00:15:10:02
David Banks
I think the real lesson is give it its own leadership and focus. Tucking it up under a hospital. You and I both know a hospital just sucks all the air out of the room. And there's when you think about community based care, it's just hard for them to compete for the time, attention and resources. It's worth creating the special focus so they can thrive.

00:15:10:02 - 00:15:19:22
David Banks
And it's really one of the best decisions we've made, giving them their own focus. And I'm excited to see what this will produce for us in the coming 2 or 3 years.

00:15:19:25 - 00:15:41:12
Marc Boom, M.D.
Really fascinating discussion. Like I said, near and dear to my heart. Love seeing this impact that you've made. I mean, think about all the wins there, most importantly for your community in terms of access, in terms of coordination of care, all those different things. And things like lower subsidies, which of course enable the sustainability of health care and the affordability of health care for everybody.

00:15:41:12 - 00:15:48:27
Marc Boom, M.D.
And I would imagine you've got some pretty darn happy primary care physicians in that, in that model as well when you're building that structure around them.

00:15:49:02 - 00:16:16:04
David Banks
They definitely feel more seen and heard and valued. And they are. Listen, hospitals are great at rescue care. The longitudinal impacts, though are going to be outside the walls of the hospital. And to me, we believe it's built on a robust primary care. They're scientists, they're clinicians, they're compassionate. They care about their patients. That's just such a powerful model for community health that we just fully believe in.

00:16:16:07 - 00:16:34:20
Marc Boom, M.D.
David, thank you very, very much for your time today. This is fascinating conversation. I know a lot of valuable insights for our listeners. And you may be getting some calls for some, some help from some out there who want to go this way. So to all of our viewers, thank you for listening. And I'll be back next month for another one of our Leadership Dialog conversations.

00:16:34:20 - 00:16:36:26
Marc Boom, M.D.
Thanks, everybody for listening.

00:16:36:28 - 00:16:45:22
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:18 - 00:00:10:16
Ashley Blake, D.O.
You have to love it. You have to love your job. You have to love your community. And really, it helps if you just think your feet in and embrace it.

00:00:10:19 - 00:00:32:28
Julia Resnick
Welcome back to Frontiers, a rural maternal health podcast series from the American Hospital Association. I'm your host, Julia Resnick. Voice you just heard was Dr. Ashley Blake, an OBGYN in Cynthiana, Kentucky. In our first episode, we heard from rural hospital leaders who made the choice to invest in maternal care and keep it close to home. But leadership alone isn't enough.

00:00:33:01 - 00:00:49:15
Julia Resnick
Even the most committed leaders can't sustain maternal care without the people to provide it. Today, we'll hear how rural hospitals are rethinking the maternal care workforce so that they are prepared to care for the next generation of rural families.

00:00:49:18 - 00:01:18:00
Julia Resnick
In rural communities, maternal care is deeply personal. Providers care for neighbors, coworkers, and oftentimes generations of the same families. Those relationships create a sense of purpose and connection. Many of the rural clinicians we spoke with chose rural medicine because of those relationships. At the top of this episode, you briefly heard from Dr. Ashley Blake, an OBGYN at Harrison Memorial, her hometown hospital.

00:01:18:02 - 00:01:20:09
Julia Resnick
Here's Dr. Blake.

00:01:20:12 - 00:01:43:02
Ashley Blake, D.O.
One of our labor nurses - I now see her sister, I see her mother in law, I see her cousins. They send pictures of me delivering her babies. They're three year-olds now that I delivered. Or color me pictures and bring me in gifts. You know, it's just like that is a reward and a benefit that no one like prepares you for how much of an impact it has.

00:01:43:07 - 00:01:54:21
Julia Resnick
In our first episode, you also heard from Jill White, chief nursing officer at Hutchinson Regional Medical Center in Kansas. She returned to her hometown to continue caring for the community that helped shape her.

00:01:54:24 - 00:02:19:13
Jill White
So I grew up here in Hutchinson, moved here at a very young age and spent my growing up years here through high school. I did move away, but quickly found that I missed it and wanted to move home and be back close to family. And as I've spent my adult years here, there's so much value in the size of the community that we are in raising a family here.

00:02:19:14 - 00:02:29:26
Jill White
I'm friends with people I work with, and we see each other, you know, outside of work, and there's so much to be said for that. It really is a big family.

00:02:29:28 - 00:02:40:13
Julia Resnick
If big families and relationships are what make rural medicine so rewarding, how do you help clinicians and training see the value of practicing in rural communities? Here's Dr. Blake again.

00:02:40:18 - 00:03:04:23
Ashley Blake, D.O.
I think that that is probably our biggest struggle, because all of the training takes place in these large cities that have targets, and they have Starbucks and they have malls and all the things that you need. And then you get your med school occurred there, your residency occurs there. And then the thought of going to somewhere without those things, I think, is sometimes hard for some physicians.

00:03:04:24 - 00:03:10:27
Ashley Blake, D.O.
The thing that makes it work the best is if you just plant your roots and, you know, embrace it and enjoy it.

00:03:11:00 - 00:03:26:10
Julia Resnick
But for rural hospitals to build a sustainable maternal health workforce, they have to create opportunities for students and trainees to experience rural practice firsthand. At Western Wisconsin Health, CEO Eilidh Peterson has made building that pipeline a strategic priority.

00:03:26:13 - 00:03:28:15
Eilidh Pederson
That pipeline starts at

00:03:28:15 - 00:03:57:27
Eilidh Pederson
different levels of training, so we do host rural residents. That's a wonderful opportunity to expose new physicians to rural medicine. We partner with all of our local colleges and universities to host midwifery students, to host medical students. And then recently, we've actually expanded the way in which we've hosted students to create that passion for rural medicine, namely obstetrical care.

00:03:57:27 - 00:04:22:10
Eilidh Pederson
So we do host high school students through our local scrub pumps. And then we started mentoring middle school students. We call it Mentored in Medicine. They are exposed to various careers in healthcare. And of course, we're going to talk to them about obstetrical care and the joys of entering into that practice. So we're starting early, but really through many channels and pipelines.

00:04:22:13 - 00:04:44:21
Julia Resnick
The future of rural maternal care is multidisciplinary teams where patients receive the right care from the right provider at the right time. For many rural hospitals, building that kind of team may be one of the most important strategies for sustaining maternal care into the future. Eilidh Peterson believes that diversity within the workforce has been one of the keys to strengthening maternal care at Western Wisconsin Health.

00:04:44:28 - 00:05:12:06
Eilidh Pederson
A diverse workforce has really been the number one solution for us. Not putting all of our eggs in one basket, but making sure that we have a number of different professionals for patients to choose from. To extend and expand our pipeline from where we can get qualified obstetrical providers has really been key. And a diverse workforce is really critical. For us

00:05:12:06 - 00:05:23:13
Eilidh Pederson
that looks like certified nurse midwives, obstetricians, family medicine with OB, and we'd love to hire our family medicine with OB and C-section.

00:05:23:15 - 00:05:51:07
Julia Resnick
One important member of that multidisciplinary team is the family physician with obstetrical training, often called an FMOB. In many rural communities, these physicians provide prenatal care, deliver babies including C-sections, and care for entire families, making them an important part of a sustainable workforce. Benjamin Anderson, CEO of Hutchinson Regional Medical Center, has become a strong advocate for expanding high quality training opportunities for FMOBs.

00:05:51:09 - 00:06:19:22
Benjamin Anderson
This is a passion point for me and I've seen the very best of full scope family medicine. There are a handful of residencies, maybe a dozen or two dozen residences in the United States that are consistently graduating board certified family physicians that are ready to do surgical OB. it's important to know the difference, and a lot of them are in training in what are called unopposed family medicine programs, where they're not competing against any other specialty for their numbers.

00:06:19:22 - 00:06:42:27
Benjamin Anderson
They're graduating with 200 deliveries and 101 hundred plus primary C-sections, where they are the surgeon, the primary surgeon on that. And so those are programs where there's a strong relationship between the OBGYN department and the family medicine residency. So they're getting that kind of exposure and that kind of direct, hands on experience. And so those are the ones from which we recruit.

00:06:42:27 - 00:07:02:21
Benjamin Anderson
And so there is a need to grow the number of unopposed family medicine slots in the United States. And there's some rural hospital transformation funds that are focusing on that to, to the program's credit. But those are the ones that it's really important to, to, to look at. We're looking for the Peyton Manning and Serena Williams of that. In Hutchinson

00:07:02:21 - 00:07:14:07
Benjamin Anderson
we're a larger community to accommodate full scope family medicine. But right on the right, right on the brink, we believe we have the capacity for and the volume to accommodate both.

00:07:14:09 - 00:07:38:25
Julia Resnick
Certified nurse midwives are another example of how rural hospitals are expanding the maternal care workforce. Working alongside physicians and nurses, certified nurse midwives provide prenatal, labor and delivery, post partum, and well woman care. Let's meet Samantha Crouch, a certified nurse midwife and director of the nurse midwifery program at University of Arkansas for Medical Sciences, also known as UAMS

00:07:38:27 - 00:07:40:16
Samantha Crouch, DNP
Midwifery care

00:07:40:19 - 00:07:42:01
Samantha Crouch, DNP
is, I mean, the

00:07:42:01 - 00:07:43:10
Samantha Crouch, DNP
reason that people are drawn

00:07:43:10 - 00:07:44:15
Samantha Crouch, DNP
To it,

00:07:44:15 - 00:08:14:26
Samantha Crouch, DNP
for a few different reasons. Really, the art of midwifery and the midwifery model of care, which places a really big emphasis on building trusting relationships within the health care provider and patient relationship. We spend a lot of time focusing on social determinants of health. And what's the holistic picture here for this patient? Not just checking in on mom and baby and what are the vital signs and what do the heart tones sound like.

00:08:14:27 - 00:08:51:26
Samantha Crouch, DNP
But really, how are you feeling about, you know, how is your partner feeling? What does your support system look like? What things are you nervous about? And really diving into some of the more emotional and psychological components of pregnancy. That really comes through for a lot of people and translates really well to rural health, because we do have a lot of specialized training in providing community based health care and providing continuity of care, which builds trust and builds partnerships and improves outcomes as well.

00:08:51:28 - 00:09:14:16
Julia Resnick
Recognizing the important role midwives can play, UAMS is investing in the next generation of the profession. This fall, they are launching the state's first publicly funded nurse midwifery education program to help address the growing need for maternal care providers and expand access to midwifery services across rural Arkansas, including many communities where midwifery services are not currently available.

00:09:14:19 - 00:09:57:27
Samantha Crouch, DNP
I have spent a lot of time looking into and kind of reflecting on as we've built is how to create better recruitment and better awareness about nurse midwifery as a career path in our areas across the state that don't currently have exposure to midwifery within the workforce. Trying to find ways where we can get certified nurse midwives practicing in some capacity, even just a day or two a week, so we can create exposure for the nurses and for the families of these rural communities, so that we can then recruit them into our program and send them back to their communities to practice.

00:09:58:00 - 00:10:11:22
Julia Resnick
The greatest impact comes when these professionals work together as a team. For Hutchinson Regional, building those connections across disciplines has transformed the way they deliver maternal care. Chief Nursing Officer Jill White shares more.

00:10:11:25 - 00:10:36:16
Jill White
OB itself can't sustain the health system. So how do we layer that to where you know someone who has that family med background, they can care for that entire life continuum, starting with OB and newborns, building that practice, building that relationship with their with their patients and families. And that really has had a huge impact in our delivery numbers as well.

00:10:36:19 - 00:10:41:02
(Dr. and Baby Background)
Okay. Next contraction. I think you're going to have a baby.

00:10:41:04 - 00:11:01:01
Jill White
We are on pace for over 100 more deliveries this year than we did even just last year, with onboarding of some new providers and working closely with the nurse midwives and getting them actual privileges to bring their patients on site. If they have that patient who, you know, can't deliver at the birth center, but they want their nurse midwife to follow them, great.

00:11:01:01 - 00:11:21:28
Jill White
We can do that here. The people that we serve are better the more that we serve. And so it's so important that we really maintain frequent touchpoints with patients like this, keeping those skills up, keeping our presence up. You know, it's so much about trust and relationship building in that patient population.

00:11:22:01 - 00:11:48:18
Julia Resnick
In low birth volume hospitals, providers may encounter obstetric emergencies less often than their colleagues in larger hospitals. That makes ongoing training, simulation, and peer learning especially important because every team needs opportunities to practice for the moments that matter most. Dartmouth Health partners with rural hospitals in northern New England to facilitate simulation drills. Emily Brayton, a perinatal outreach nurse, shares how that works.

00:11:48:20 - 00:11:52:15
Julia Resnick
You'll hear more about Dartmouth Health's work in the next episode.

00:11:52:18 - 00:12:28:27
Emily Brayton
Simulation and skills has been really beneficial to teams. We have one hospital in the North Country that has done a lot of work with a group at DHMC. We are teams that are kind of existing together, but we're not necessarily the same exact team. They are well supported, and so being able to go into that hospital and provide those teams with dedicated time with a neonatologist, and it really said it all with the people that showed up.

00:12:29:00 - 00:12:43:06
Emily Brayton
We didn't just have people who were there from their inpatient unit. We had all of the people who come and help when there's an emergency happening, regardless of whether it's happening on the OB side or with the baby.

00:12:43:08 - 00:13:09:21
Julia Resnick
Simulation is one way to maintain clinical skills. Another is creating opportunities for rural clinicians to spend time in higher volume settings, and then bring that experience back to their communities. At Banner Health that idea has become the rural OB pathways program. Here's Dr. Blake McLaughlin, an OBGYN and senior medical director of women's services at Banner Health. You'll also hear more from Dr. McLaughlin in the next episode.

00:13:09:24 - 00:13:36:27
Blake McLaughlin, D.O.
So something that we have done within Banner, we've created what's called the rural OB pathways program. And so what we do is we offer this program that folks can opt into where they will come from a rural facility like Paige, Arizona, or from Washakie, Wyoming, and they will come to one of our large volume facilities in Phoenix, and they'll spend seven, ten, 14 days embedded with that obstetrics team on labor and delivery.

00:13:36:27 - 00:14:06:06
Blake McLaughlin, D.O.
So they'll get high volume, high complexity of all of the things. But particularly they're focusing in on their optimization of their surgical skills and their obstetric skills. So we have had tremendous positive feedback from everyone involved in those experiences. Both for the physicians that are going and being embedded in that team, they're able to go back to their facilities and their communities that they came from, and they just have maintained that skill set and optimization.

00:14:06:08 - 00:14:17:14
Julia Resnick
Dr. McLaughlin believes that the same philosophy should begin during residency. Rather than asking clinicians to choose between urban and rural training, Banner is intentionally connecting the two.

00:14:17:16 - 00:14:38:12
Blake McLaughlin, D.O.
Those interns will spend their first year at the mothership there at the North Colorado Medical Center in Greeley, and they really get that foundational direction and education and training that they need. And then they'll go out to rural communities like our hospital in Sterling. So Sterling Regional Med Center, and they'll spend their last two years of their residency program embedded in that role community.

00:14:38:12 - 00:14:57:01
Blake McLaughlin, D.O.
And so they're really anchoring their heart, their mind, their attitude, their perspectives to rural medicine, but they're staying directly connected to that source program where they're getting that premier residency and fellowship equivalency training. Really ingrained them then, this connectedness.

00:14:57:03 - 00:15:27:08
Julia Resnick
Building a strong workforce is about creating a continuum of learning from early exposure and multidisciplinary teams to ongoing training and mentorship throughout a clinicians career. Together, these investments are helping ensure that role providers have the knowledge, skills and support they need to care for mothers and babies close to home. But no rural hospital can do it alone. Even the strongest workforce benefits from connection to colleagues to specialists, and to partners who can help expand what's possible.

00:15:27:10 - 00:15:52:03
Julia Resnick
That's where we'll go next. Join us for the final episode of Frontiers, as we explore how regional collaboration, digital tools, and new models of care are helping role communities strengthen maternal care for the future. This series is supported by the Commonwealth Fund, a national private foundation based in New York City that supports independent research on healthcare issues and makes grants to improve healthcare practice and policy.

00:15:52:10 - 00:15:59:10
Julia Resnick
The views presented here are those of the author and not necessarily those of the Commonwealth Fund, its directors, officers or staff.

00:00:19:07 - 00:00:44:25
Chris DeRienzo, M.D.
Hi, this is Dr. Chris DeRienzo, the chief physician executive of the American Hospital Association. Welcome back to Advancing Health. We've got a really interesting conversation today with a colleague of mine at Banner Health. Joining us on the podcast is Dr. Corey Casper. He's the senior vice president and chief research officer, the inaugural chief research officer at Banner Health and also a professor of medicine and clinical translational science.

00:00:44:25 - 00:01:02:21
Chris DeRienzo, M.D.
I had to try that one. I had to practice it a couple of times to get it right. Professor of medicine and clinical translational science at the University of Arizona. And we are very lucky to have him on the podcast today to talk about some of the interesting work they're doing to integrate research findings into a large community health system.

00:01:02:21 - 00:01:05:07
Chris DeRienzo, M.D.
Corey, thank you so much for being on the podcast.

00:01:05:13 - 00:01:10:14
Corey Casper, M.D.
What an incredible mouthful to begin with. But thank you for having me and I really look forward to our conversation.

00:01:10:19 - 00:01:28:21
Chris DeRienzo, M.D.
Well, you know, I think it would be helpful, for starters, to just help our listeners understand the arc that brought you out of what I might describe as a more traditional background in academic medicine into this unique partnership that Banner has with its academic partner at University of Arizona.

00:01:28:27 - 00:01:49:14
Corey Casper, M.D.
Yeah, thanks for asking that question. You know, there's a dirty secret, which is that every single healthcare worker working in the United States right now essentially has to come through an academic medical system to get to where they are. It's the way you become a health care worker. And so we all are very used to a very traditional academic medical system, and it works really well for lots of things.

00:01:49:15 - 00:02:23:27
Corey Casper, M.D.
I mean, it's incredibly the best in the world for training healthcare workers. It's exceptional at generating great research and often it's the source of amazing care. So when the model works well, it's incredible. I think what I was seeing in my career, after almost 25 years in a very traditional academic medical setting, is that there are increasing pressures and strains on that traditional model that make it more and more challenging to translate the incredible research that we're doing into teaching, and, more importantly, to every patient who needs to access care in this country.

00:02:23:28 - 00:02:38:13
Corey Casper, M.D.
You know, we're in such a golden age of research where research findings are accelerating and becoming so much more impactful, but getting them to every patient that needs them. And that's why I was so excited about the opportunity to join Banner as their first inaugural chief research officer.

00:02:38:14 - 00:02:52:07
Chris DeRienzo, M.D.
Let's build for a moment on what exactly does Banner look like? Many of our listeners might not be familiar with the reach of Banner as a health system, much less the nature of its partnership with your academic partner.

00:02:52:09 - 00:03:12:20
Corey Casper, M.D.
It's a great question. I wasn't familiar with all of the ins and outs of Banner either before joining about a year and a half ago. So Banner Health is an integrated healthcare delivery system, and we're one of the largest in the country. So we operate 33 hospitals, literally hundreds of clinics. We are the largest employer in the state of Arizona, employing over 65,000 individuals.

00:03:12:20 - 00:03:40:21
Corey Casper, M.D.
And we reinvest $1 billion a year back into our communities as a nonprofit healthcare delivery system. So it's a very large, very unique system that's run incredibly well. The way that we provide high quality care to so many people in so many areas, rural areas, urban areas, at our partner referral hospitals, you know, at our rural referral hospitals is through highly standardized, highly quality driven care.

00:03:40:24 - 00:04:05:09
Corey Casper, M.D.
You know, that is the hallmark of what we do at Banner, and that's all incredibly exciting. But what really attracted me as our chief research officer was kind of taking that next step. So, sure, we have 1.2 million patients under care. We have large health care system that is integrated with an insurance plan, as well as with ownership partly of Quest Labs in our region.

00:04:05:09 - 00:04:35:21
Corey Casper, M.D.
And so a truly integrated system of data that you could really begin to make some important observations using research about health outcomes and how to improve them. But what was really exciting too is some of the traditional partnerships that we've had for many years. So for over a decade, our academic partner has been the University of Arizona. So it's two colleges of medicine in Phoenix and Tucson are our partners in our delivery, and we oversee all of the clinical and translational research at the University of Arizona.

00:04:35:21 - 00:04:54:14
Corey Casper, M.D.
And we partner with them to deliver care and to train the next generation of healthcare workers. So it's an incredibly strong partnership. We're also, I think and I don't know this for sure, but I think we're one of the only, if not the only, large health care delivery system that's partnered with two NCI designated comprehensive cancer centers.

00:04:54:16 - 00:05:15:07
Corey Casper, M.D.
So the University of Arizona has a comprehensive cancer center in Tucson. And then we partner with MD Anderson in Houston to provide our cancer care in all regions other than Tucson. So it's an incredible embarrassment of riches that we have in terms of our partnerships. And that's really one of the things that hallmarks, you know, what makes us so successful.

00:05:15:09 - 00:05:48:04
Chris DeRienzo, M.D.
Well, let's build on those partnerships and to help our listeners understand, given the footprint that you've described, with a huge reach across 33 hospitals into the communities, but also this this fairly robust research pillar that you that you now lead. How are you bridging that gap from the discoveries that happen in labs, you know, at Banner. But all over the country, this bleeding edge of research with a community health system that is using your words, they're reaching 1.2 million patients a year.

00:05:48:04 - 00:05:55:03
Chris DeRienzo, M.D.
That is that is not a small gap. And my guess is the translational part of your title is exactly where that lives.

00:05:55:06 - 00:06:13:00
Corey Casper, M.D.
Yeah. Thanks so much. So there's three ways that I think we really try and address taking the research gains that we make and translating them to every single patient that we have. And I'll talk about these three ways and give you some examples because I think they're really quite exciting. So first and foremost our research is really focused or strategic.

00:06:13:00 - 00:06:37:18
Corey Casper, M.D.
So, you know, having been at the University of Washington, trained at the University of California, San Francisco, you know, went to medical school at Cornell, at New York Hospital. These are huge academic health systems that well, reputed and really do lots of things really well. I'm not saying that we don't, but for an organization that's primarily a healthcare delivery organization that also does some very good research, it's really important to focus.

00:06:37:18 - 00:06:57:04
Corey Casper, M.D.
So one of the first things that we really did was to think about where are those areas where we're making unique contributions and unique contributions within our region that really benefit our patients, but we can also learn from those patients. And so obviously, we operate our headquarters is in Phoenix, Arizona. We operate out of the southwest. Before coming to Phoenix

00:06:57:04 - 00:07:14:04
Corey Casper, M.D.
I often thought that, you know, Phoenix was sort of the home of some of the oldest people in the country, but that's actually not true. I learned that our median age is actually not that dissimilar from New York or other cities, but we do definitely have a bimodal distribution where we have many elderly people and many young people.

00:07:14:07 - 00:07:40:19
Corey Casper, M.D.
So a lot of our research is focused on diseases again in our patient population. So what are the diseases that are common that we focus on? We have a huge program in neurological diseases, especially memory and movement disorders because that's a huge problem in our region. As I mentioned, we have two large, you know, partnerships and a large research program in cancer because, you know, oncology is a critical portion of our part of the world. Cardiovascular disease,

00:07:40:19 - 00:08:04:22
Corey Casper, M.D.
so, you know, again, a disease that's often associated with aging, but structural heart disease, rhythm disorders and coronary heart disease. Fourth is our programs and orthopedics. Again, you know, our bones are what tend to fail us as we start to get older. And so we focus on how to keep them healthy and rehabilitate them when they're not. And then lastly, we have a very large program because of our breadth and transplantation.

00:08:04:22 - 00:08:22:21
Corey Casper, M.D.
And so how do we sort of make sure that these gains that we're making in transplantation are available to everyone? So first one way we just make sure that our research is getting to as many people as possible is we focus on the areas in our region and in those areas that we think can be applicable to the world.

00:08:22:25 - 00:08:43:18
Corey Casper, M.D.
The second way that we really do this is that we are laser focused, like our like, mission in the world right now is to think about the types of research that will change the practice of medicine. What we're really good at is protocolizing and standardizing the practice of medicine. So if we can define a best practice we can get that out there.

00:08:43:18 - 00:09:05:12
Corey Casper, M.D.
And so our research is laser focused on that. And I'll give you a couple of examples. So we have a preeminent Alzheimer's Institute, probably one of the best in the world. Scientists that are Alzheimer's Institute helped to develop one of the first blood tests to early detect Alzheimer's disease. We're very much, in part, developed and finalized or finished at Banner.

00:09:05:14 - 00:09:35:04
Corey Casper, M.D.
Terrific. Like wonderful that there's a blood test that's available. But what we then recognized is that still there's gaps in people's ability to get this test. So our researchers took it a step further. What if you could develop a device that would collect a small sample of blood at home and allow that blood to be shipped to a central laboratory where you can get a test for dementia that is as accurate right now as a spinal tap and as a, you know, MRIs that you used to need to get PET scans to diagnose Alzheimer's disease.

00:09:35:06 - 00:09:55:14
Corey Casper, M.D.
That test can now come to your home. So we've now allowed that test to go to people's homes in all sorts of rural parts of Arizona, and even a collaboration in rural parts in sub-Saharan Africa. So it's a great example of how we take technology, we develop new technology and make it fit for purpose. But more than that, we find a way to democratize it.

00:09:55:14 - 00:10:20:09
Corey Casper, M.D.
So we find a way to get that technology to every person who needs it. And I'll take that example one step further. We had a huge NIH grant to develop an imaging center where we actually developed some of the first ways PET scans to image people's brains, to look for dementia and other memory disorders. Fantastic. But very few people can travel to our quaternary care hospital, to our premier research clinic and get that test.

00:10:20:09 - 00:10:51:01
Corey Casper, M.D.
So what did we do? We worked with some other investigators in the Phoenix region from some of our collaborating institutions, and we came up with - it sounds crazy - but essentially behind a little RV, we were able to build this thing that kind of looks like a portable pizza oven, and it's a portable MRI machine. And this machine to rural communities throughout the southwest and offers people the ability to get scans, brain scans, to diagnose and to prevent deterioration in brain health.

00:10:51:01 - 00:11:00:15
Corey Casper, M.D.
So, again, a way that we're taking the research we've made at a sort of highly specialized referral center and making sure they're available to every person out there.

00:11:00:18 - 00:11:20:24
Chris DeRienzo, M.D.
And to me, these are examples that highlight exactly the connection we're trying to lift up. You know, there are only a handful of academic medical centers in America relative to the 6000, I think 51 at last count, total hospitals in the country. But I've seen this strength in community health systems of getting to execution. And in the communities they serve,

00:11:20:26 - 00:11:29:00
Chris DeRienzo, M.D.
what I'm hearing you describe is a model that really links the leading edge of research with the populations who can most need it.

00:11:29:01 - 00:11:30:08
Corey Casper, M.D.
That's exactly right.

00:11:30:09 - 00:11:33:26
Chris DeRienzo, M.D.
I want to make sure we get to your third. And so what's the third one?

00:11:34:02 - 00:11:55:25
Corey Casper, M.D.
Yeah. So the third thing that we're doing is we're trying to make sure that we can do this research as quickly and efficiently as possible. Now, why is that important? I mean, I'm sure, you know, with you doing the work that you do, you speak with a lot of people. And I'm sure you've heard a lot about all of the medical research now in the United States, funding cuts, changes in priorities, changes in the regulatory landscape.

00:11:55:26 - 00:12:18:07
Corey Casper, M.D.
It is not an easy road to navigate right now. But one thing that is really clear is that given all of those uncertainties and given the challenges, you need to have a laser like focus on the research that you do and you need to do it efficiently. What we've done is we've really established a new program to rapidly open clinical trials and have them available to our to our patients.

00:12:18:08 - 00:12:39:00
Corey Casper, M.D.
We are working towards a goal of getting new clinical trials open within 40 days of being approached by a sponsor. Like, that's incredible. Like, if we can do that, and we're making, you know, we've already reduced the time to activating a clinical trial at Banner fourfold. So we're making huge strides towards that. But it's such a simple example of something that we take for granted,

00:12:39:01 - 00:13:05:20
Corey Casper, M.D.
right? Like if, if our value proposition in the world as being a, you know, a health system with a strong academic partner and doing academic clinical research, if that's our value proposition, then we've got to get these studies to the patients who need them by doing them quickly and by doing them as distributably as possible. So right now, our research, we don't just do at our primary quaternary referral hospitals, we do them across our network.

00:13:05:20 - 00:13:22:14
Corey Casper, M.D.
So if you're in Northern Colorado and you're at one of our more rural sites, you have that same access that someone in downtown Phoenix has. And so to us, that's a model of research that we feel like truly will be able to bring the gains that we're making in medical research now to every patient and needs them.

00:13:22:16 - 00:13:45:06
Chris DeRienzo, M.D.
Corey, this has been a spectacular conversation. If I could read back what I'm hearing, I think your combination of focus, of depth and of reach is really what's driving this translation of research out into the 1.2 million patient community who you serve at Banner. Again, most folks on our podcast or listening to our podcast aren't going to be based in an AMC.

00:13:45:06 - 00:14:12:08
Chris DeRienzo, M.D.
So my last question for you. We've only got about a minute or two left, and I'd love to ask it of everybody who I get to interview for our show is if you had one thing that you would hope our listeners take away that they can bring back to possibly their rural hospital in Mississippi or in western Oregon and say, I want to help my home get better at translating this cutting edge research to reach my communities.

00:14:12:08 - 00:14:19:02
Chris DeRienzo, M.D.
What guidance would you give them? What first step should they take after they finish listening to our conversation?

00:14:19:04 - 00:14:43:24
Corey Casper, M.D.
Such a great question. I mean, I have an easy answer to that. I think we overcomplicate research, right? We think about it as a as a highly falutin academic exercise that is often frustrating and inaccessible to many. But research is simply the process of sitting at the bedside, recognizing a question that's important, and asking the question in a way that's answerable, measurable, and impactful.

00:14:43:26 - 00:15:08:10
Corey Casper, M.D.
If your eyes are open, if you see the problems that you're confronting at your health center, no matter how big or how small, single bed, clinic, hospital, tiny clinic, whatever it is, find a way to ask and answer those questions because it'll be to the benefit of your patients. And there's lots of people out there, whether they're at large academic medical centers or whether it community networks like ours that are there to partner with you.

00:15:08:10 - 00:15:22:13
Corey Casper, M.D.
So keep your eyes open. Look for those questions that present to us every day as clinicians. Ask those questions and find ways to answer them efficiently, impactfully. Because all of our patients and all the world will benefit from it.

00:15:22:15 - 00:15:28:28
Chris DeRienzo, M.D.
Corey, thank you so much for joining the podcast. Listeners, thank you for tuning in. This has been a lot of fun.

00:15:29:01 - 00:15:37:24
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:20:09 - 00:00:26:08
Eilidh Pederson
There's one way we all come into this world.

00:00:26:10 - 00:00:46:18
Eilidh Pederson
And the safest and best way to do that is in hospital. And so it is so important that we preserve rural obstetrical care. For us, it's not just been about preserving, it's been about growing and thriving. And to do the right thing in the face of adversity.

00:00:46:20 - 00:01:13:14
Julia Resnick
You just heard from Eilidh Pederson, CEO of Western Wisconsin Health, a critical access hospital in Baldwin, Wisconsin. It's an agricultural community with three stoplights, where a traffic jam means you're waiting behind an Amish buggy. In just the past few years, six hospitals in her region have closed their labor and delivery departments. Workforce shortages, financial pressures and declining birth volumes have created extraordinary challenges for rural hospitals.

00:01:13:16 - 00:01:36:07
Julia Resnick
We set out to better understand how rural hospitals are sustaining maternal care in the face of these challenges. Again and again, we heard the same message. For rural hospital leaders, maternal care is more than a service line. It's a commitment to the families they serve and an investment in the future of their communities. Welcome to Frontiers, a new podcast series from the American Hospital Association.

00:01:36:08 - 00:02:00:09
Julia Resnick
I'm your host, Julia Resnick. Throughout this series, we'll explore how rural hospitals across the country are working to sustain maternal care in their communities through committed leadership, workforce innovation, and regional collaboration. Our story begins with the leaders who make the choice to invest in maternal care. Even when the path forward isn't easy.

00:02:00:12 - 00:02:28:08
Julia Resnick
When we talk about rural America, it's easy to picture a single kind of place. But rural communities are incredibly diverse. Some are surrounded by farmland, others by mountains, deserts, rivers, or forests. They vary in size, geography, and the opportunities and challenges they face. Before we explore the future of rural maternal care, let's take a moment to meet some of the communities at the heart of this story.

00:02:28:14 - 00:02:37:04
Julia Resnick
We'll start in upstate New York with Sinéad Ingersoll, chief operating officer of Canton Potsdam Hospital in the Saint Lawrence region of Rochester Regional health.

00:02:37:07 - 00:02:41:00
Sinéad Ingersoll
The Saint Lawrence County is the largest, most geographically

00:02:41:00 - 00:03:12:25
Sinéad Ingersoll
isolated county in New York State. We're 30 minutes from the border. We are by two to 2.5 hours away from the nearest highest level of care - tertiary care - that's either going into Vermont or south to Syracuse. We are the main provider of health care services in this broader community. There's about 110,000 people that live in this county, and they are scattered throughout this huge county, which also presents as you can imagine, unique challenges and very harsh winters, kind of want to throw that in there as well.

00:03:12:25 - 00:03:15:16
Sinéad Ingersoll
So we get a lot of snow up here.

00:03:15:19 - 00:03:29:09
Julia Resnick
Next, we'll head to the heart of the Sunflower State, Kansas. I spoke with two leaders from Smith County Memorial Hospital: Sarah Ragsdale, the CEO, and Laken Lyon, the chief nursing officer. Here's Lakin.

00:03:29:12 - 00:03:30:02
Lakin Lyon
We are

00:03:30:03 - 00:03:46:28
Lakin Lyon
in the middle of nowhere. We're 12 miles from the center of the contiguous 48 states. We're a rural community. We're out in the middle of an OB desert. We don't have a lot of facilities around us that deliver anymore.

00:03:47:04 - 00:03:47:13
Lakin Lyon
And

00:03:47:13 - 00:04:00:15
Lakin Lyon
some of that has been recent changes. So it's at least one hour of travel time to the nearest OB facility from us in any direction that you go.

00:04:00:18 - 00:04:04:16
Julia Resnick
Here's Sarah Ragsdale, CEO of Smith County Memorial Hospital.

00:04:04:19 - 00:04:08:12
Sarah Ragsdale
Critical Access Hospital here where we labor, deliver and

00:04:08:12 - 00:04:10:21
Sarah Ragsdale
do postpartum all in one room.

00:04:10:24 - 00:04:11:10
Sarah Ragsdale
We're very

00:04:11:10 - 00:04:22:04
Sarah Ragsdale
patient-centered here. You feel like if we didn't have that, those maternity services here, that we may lose the families coming to our rural health clinic.

00:04:22:07 - 00:04:34:03
Julia Resnick
One thing you'll hear from leaders across rural America is how deeply connected they are to the communities they serve. This is Dr. Ashley Blake, an ob/gyn at Harrison Memorial Hospital in Kentucky.

00:04:34:06 - 00:04:59:20
Ashley Blake, D.O.
I live in central Kentucky in a small community, Salvia, Kentucky. We do around 200 deliveries a year. Sometimes we get to the 250 mark, and sometimes we're right below the 200 mark. Salvia is a very small community. We all went to school together. We all know your grandmother and your children and your siblings. All of our children play ball together.

00:04:59:20 - 00:05:15:10
Ashley Blake, D.O.
So we work together, and we also go to the ballparks together and support our kids together. Our kids play on the same very small travel soccer or softball or baseball community. We all go to church together. It's a very, very small community.

00:05:15:13 - 00:05:37:08
Julia Resnick
While these communities may differ. One thing is remarkably consistent. In many places, the local hospital has cared for generations of the same families and is woven into the fabric of community life. That sense of connection shapes the decisions hospitals make. Across the country, leaders are committed to ensuring families can welcome a child into the world safely and close to home.

00:05:37:09 - 00:05:46:06
Julia Resnick
And that commitment starts at the top with hospital executives and governing boards. Here's Eilidh Pederson again from Western Wisconsin Health.

00:05:46:08 - 00:05:49:07
Eilidh Pederson
A hospital really has to make a decision

00:05:49:08 - 00:05:51:04
Eilidh Pederson
on where you're going to put

00:05:51:04 - 00:05:53:24
Eilidh Pederson
your funding and your priorities.

00:05:53:24 - 00:06:00:28
Eilidh Pederson
And at our hospital, we said, if we're going to be here for our community, truly from the start,

00:06:00:28 - 00:06:01:14
Eilidh Pederson
it

00:06:01:14 - 00:06:27:03
Eilidh Pederson
means we have to make obstetrical care a pillar and a foundational element in our hospital operations. And for us, that starts with our board of directors. They have helped us at the Foundation for we are going to provide obstetrical care. We're going to do it well. And to do that, we're going to put funding in place. We're going to ensure safe staffing.

00:06:27:10 - 00:06:49:15
Eilidh Pederson
We're going to ensure that we have all of the resources and equipment that we need to do this to the best of our ability. And so that's where it's really started, is at the board and indicating to everyone out there that obstetrical care is worth fighting for. And to do that well you must make it a priority.

00:06:49:18 - 00:07:11:20
Julia Resnick
For many rural hospital leaders, sustaining maternal care comes down to a choice. When Benjamin Anderson became CEO of Hutchinson Regional Medical Center, the organization was at a crossroads. Rather than scale back, he and his leadership team made the decision to invest in and strengthen maternal care. Here's Benjamin and Chief Nursing Officer Jill White describing why they chose that path.

00:07:11:24 - 00:07:15:19
Julia Resnick
You'll hear more of their story in our next episode.

00:07:15:21 - 00:07:33:14
Benjamin Anderson
At Hutchinson our obstetrics program...go from 800 plus deliveries a year down to 270 last year. We'd seen a lot of outmigration around OB. We had to decide, are we going to do this? Because if we're going to do it we need to do it well, and if we're going to do it well, we need to do it often. And we've got to double down and invest

00:07:33:14 - 00:07:54:24
Benjamin Anderson
and so rather than saying how much money can we make through this service line, we say, because we've already decided we're going to do it well, how do we sustain it? But the moral decision, ethical decision was already made and then we back in from there. And so it's important because birth rates are important. It's important because it's connected to community growth and health.

00:07:54:25 - 00:08:02:04
Benjamin Anderson
It's important because moms are important. We all have a mom. And it's important because through mothers we connect with everyone else in the community.

00:08:02:07 - 00:08:21:01
Jill White
If women don't have that place that they can start that healthcare journey for their families, they'll seek it elsewhere and they may lose it. You know, they're not going to return back for maybe family care or pediatrics or where are they going to refer their mom or their dad or sister or whoever it might be in their family that needs care.

00:08:21:01 - 00:08:35:07
Jill White
It's going to be wherever they've established and had that great interaction and relationship. And so it really is a very foundational stepping block for what you build an entire health care system and really community off of is those young families.

00:08:35:09 - 00:08:51:25
Julia Resnick
Sustaining maternal care takes more than financial investment or clinical expertise. It takes leaders who are willing to champion it. Not just within their own hospitals, but across the communities in rural America. Let's hear from Sinéad Ingersoll again. It's not just a service.

00:08:51:27 - 00:08:52:26
Sinéad Ingersoll
You know,

00:08:52:28 - 00:08:53:22
Sinéad Ingersoll
women's health

00:08:53:22 - 00:08:54:07
Sinéad Ingersoll
is really

00:08:54:07 - 00:09:00:02
Sinéad Ingersoll
essential to the survival of your community. If families don't feel safe delivering locally,

00:09:00:09 - 00:09:00:22
Sinéad Ingersoll
they may

00:09:00:22 - 00:09:01:16
Sinéad Ingersoll
not stay.

00:09:01:18 - 00:09:28:26
Sinéad Ingersoll
And, you know, it requires really intentional investment even when your volumes are low. Strong, team based care models, I think are really important. But it also means looking beyond maternal care like I just talked about and looking at that full women's health journey from preventative care to behavioral health to chronic disease management. You know, pregnancy is just one moment in that continuum.

00:09:28:28 - 00:09:40:01
Julia Resnick
Eilidh Pederson also speaks to how rural healthcare leaders can balance strategy with advocacy, making thoughtful decisions for their organizations while championing maternal care for their communities.

00:09:40:03 - 00:10:02:03
Eilidh Pederson
It's important that we think about obstetrical care in a different way. What does that mean for your region? What does that mean for care for the entire family? So often where you have your baby is where you will make your medical home. It's where you're seen for your prenatal care, where you'll have your lab work done, your imaging studies, surgeries down the road.

00:10:02:03 - 00:10:29:00
Eilidh Pederson
So it's truly a front door moment. So administrators to think about obstetrics care not just as a financial loss on the balance sheet, but what does it really mean for your region and for the hospital as a whole? Number two is advocacy work. As hospital administrators, I believe it is our duty to fight for the right things, to be the voice of those who don't have a voice.

00:10:29:00 - 00:10:55:03
Eilidh Pederson
And to do that in the space of obstetrical care, we must advocate. We must have conversations like this to bring awareness. We must speak with our lawmakers. We must speak with insurance companies and payers to bring about reimbursement reform. Because at the end of the day, that's what's needed. And then the third thing is to set up an infrastructure for obstetrical care, where the number one priority is quality.

00:10:55:06 - 00:11:19:07
Eilidh Pederson

This is a very risky specialty. There are deep clinical concerns that can come with having a baby, and it's our role as administrators to ensure that the team is as well prepared as they can be, that they can train where they fight, so to speak, and that they can practice as often as they can those maneuvers that bring about healthy outcomes.

00:11:19:09 - 00:11:39:04
Julia Resnick
After listening to these leaders, one thing becomes clear. The decision to sustain maternal care is about so much more than keeping a service open. It's about investing in families, strengthening communities, and ensuring that the next generation has the opportunity to grow and thrive close to home. Here's Sarah Ragsdale from Smith Center, Kansas.

00:11:39:07 - 00:12:02:03
Sarah Ragsdale
It shows thriving and growing communities, and it just shows sustainability across the system. You know, we're all here to take good care of people. We want to keep access local, and the more services we offer shows that we're a thriving facility and thriving community. All goes back to just giving back.

00:12:02:06 - 00:12:15:03
Julia Resnick
Which raises an important question what is at stake, not just for patients and families, for the future of rural communities if this care disappears? Here's Sinéad Ingersoll again.

00:12:15:06 - 00:12:34:18
Sinéad Ingersoll
So you know what would be lost? It's kind of hard to even articulate that. You know, when you think about women's health and I always think about people talk about, you know, OB services, maternal health, I think about women's health as  a continuum. It's a journey. And you know, it's not just access that will be lost, right?

00:12:34:19 - 00:13:01:24
Jill White
It's trust. It's safety. It's the ability for families to build their lives here. You know, we have four colleges that are within a ten mile radius of this little community. We need to have strong, high quality services to attract folks to move to this area, to want to stay in this area. And so, you know, this really our whole community hinges in my opinion on our ability to safely provide these services.

00:13:01:26 - 00:13:10:28
Julia Resnick
The challenges are real, but so are the opportunities. Here are Sinéad and Eilidh on why they are optimistic about the future of rural maternal care.

00:13:11:01 - 00:13:29:09
Sinéad Ingersoll
What gives me most hope is the people you know, rural teams are incredibly resilient. They're deeply committed to their communities. And rural health care has always been very resourceful. And I think now we're becoming resource enabled. And that's where I think you could really see real transformation happen.

00:13:29:12 - 00:13:54:03
Eilidh Pederson
It takes all of us fighting for the same thing, really working from the same playbook. And that's what the rural Wisconsin hospitals have done. We've seen great success to date, and I'm excited about what the future holds. There are about 50 rural hospitals in the state of Wisconsin, and we are all working together on quality outcomes, on reimbursement reform and workforce enhancement.

00:13:54:06 - 00:14:16:27
Julia Resnick
At the heart of these stories is a simple idea. Rural maternal care does not happen by accident. It happens because leaders choose to prioritize it. They make that choice because they understand what is at stake, not just for their hospitals, but for the families and communities they serve. The leadership commitment must be backed by the people who make maternal care possible -

00:14:17:02 - 00:14:43:12
Julia Resnick
skilled care teams who support patients throughout pregnancy, labor, delivery and postpartum. Join us for the next episode of Frontiers for a look at how rural hospitals are strengthening their workforce and creating new pathways to ensure maternal care is available for generations to come. This series is supported by the Commonwealth Fund, a national private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy.

00:14:43:19 - 00:14:50:18
Julia Resnick
The views presented here are those of the author and not necessarily those of the Commonwealth Fund; its directors, officers or staff.